Nokea
When developing the plan of care for a child who is unconscious after a serious head injury, in which of the following positions should the nurse expect to place the child?
- A. Prone with hips and knees slightly elevated.
- B. Lying on the side, with the head of the bed elevated.
- C. Lying on the back, in the Trendelenburg position.
- D. In the semi-Fowler's position, with arms at the side.
Correct Answer: B
Rationale: Side-lying with the head elevated reduces intracranial pressure and maintains airway patency in an unconscious child.
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When developing a teaching plan for the mother of an asthmatic child concerning measures to reduce allergic triggers, which of the following suggestions should the nurse include:
- A. Keep the humidity in the home between 50% and 60%.
- B. Have the child sleep in the bottom bunk bed.
- C. Use a scented room deodorizer to keep the room fresh.
- D. Vacuum the carpet once or twice a week.
Correct Answer: C
Rationale: Using a scented room deodorizer can irritate airways and trigger asthma symptoms. The nurse should advise against this to reduce allergic triggers, while recommending measures like dust mite control and avoiding strong odors.
After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to consent to the recommended vaccinations. The nurse should first ask the parent:
- A. Did you know that vaccinations are required by law for school entry?
- B. What personal beliefs or safety concerns do you have about vaccinations?
- C. Would you prefer that fewer vaccines are given at a time?
- D. Can you please sign this vaccine waiver form?
Correct Answer: B
Rationale: Addressing the parent's specific concerns fosters trust and encourages informed decision-making.
A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide the treatment and
- A. Administer an aspirin-containing compound.
- B. Institute Rest, Ice, Compression, and Elevation (RICE).
- C. Begin physical therapy with active range of motion.
- D. Initiate skin traction.
Correct Answer: B
Rationale: RICE reduces swelling and bleeding in hemophilic joint bleeds. Aspirin worsens bleeding, active motion is harmful, and traction is inappropriate.
After teaching the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home, the nurse determines that the teaching has been successful when the parent states which of the following?
- A. We will keep the restraints on continuously except when checking the skin under them for redness.
- B. We will keep the restraints on during the day while he is awake, but take them off when we put him to bed at night.
- C. After we get home, we won't have to use the restraints because our child does not suck on his thumb.
- D. We will be sure to keep the restraints on all the time until we come to see the physician for a follow-up visit.
Correct Answer: A
Rationale: Elbow restraints should be worn continuously but removed periodically to check for skin irritation, ensuring both safety and comfort.
After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the father states which of the following?
- A. There is no rectal opening for stool to pass.
- B. There is a tube between the trachea and esophagus.
- C. The nerves at the end of the large colon are missing.
- D. The muscle below the stomach is too tight.
Correct Answer: C
Rationale: Hirschsprung's disease is characterized by absent nerve cells in the distal colon.