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When developing the plan of care for a child with early Duchenne's muscular dystrophy, which of the following nursing goals is the priority?
- A. Encouraging early wheelchair use.
- B. Fostering social interactions.
- C. Maintaining function of unaffected muscles.
- D. Prevent circulatory impairment.
Correct Answer: C
Rationale: Maintaining function of unaffected muscles is the priority to prolong mobility and independence in early Duchenne's muscular dystrophy.
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A nurse is teaching an obese child about portion control. Which strategy should be included?
- A. Eat only prepackaged meals.
- B. Use smaller plates.
- C. Skip breakfast daily.
- D. Drink soda with meals.
Correct Answer: B
Rationale: Smaller plates help control portion sizes visually. Prepackaged meals may be unhealthy, skipping breakfast can increase hunger, and soda adds empty calories.
A child with cystic fibrosis is receiving gentamicin. Which of the following nursing actions is most important?
- A. Monitoring intake and output.
- B. Obtaining daily weights.
- C. Monitoring the client for indications of constipation.
- D. Obtaining stool samples for hemoccult testing.
Correct Answer: A
Rationale: Monitoring intake and output is critical when administering gentamicin, an aminoglycoside, to detect early signs of nephrotoxicity, a common adverse effect.
While caring for a neonate with an imperforate anus, the nurse assesses the neonate's urine output for which of the following?
- A. Meconium.
- B. Blood.
- C. Bile.
- D. Acetone.
Correct Answer: A
Rationale: Meconium in the urine may indicate a rectourinary fistula, a common complication of imperforate anus.
A nurse is teaching the parents of a child diagnosed with a urinary tract infection secondary to vesicoureteral reflux. How should the nurse explain how the reflux contributes to the infection?
- A. It prevents complete emptying of the bladder.
- B. It causes urine backflow into the kidney.
- C. It results in painful bladder spasms.
- D. It causes painful urination.
Correct Answer: B
Rationale: Reflux allows bacteria to reach kidneys.
An adolescent female is prescribed amoxicillin for an ear infection. The nurse should teach the adolescent about the risks associated with her concurrent use of:
- A. Antacids.
- B. Oral contraceptives.
- C. Multiple vitamins.
- D. Protein shakes.
Correct Answer: B
Rationale: Amoxicillin can reduce the effectiveness of oral contraceptives, increasing the risk of unintended pregnancy. The nurse should educate the adolescent about this interaction and suggest additional contraceptive measures during antibiotic therapy.