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When developing the plan of care for a toddler who has taken an acetaminophen overdose, which of the following should the nurse expect to include as part of the initial treatment?
- A. Frequent blood level determinations.
- B. Gastric lavage.
- C. Tracheostomy.
- D. Electrocardiogram.
Correct Answer: A
Rationale: Frequent blood level monitoring guides acetylcysteine therapy. Gastric lavage is less effective than charcoal, and tracheostomy or ECG are not typically needed unless complications arise.
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Which of the following statements obtained from the nursing history of a toddler should alert the nurse to suspect that the child has had a febrile seizure?
- A. The child has had a low-grade fever for several weeks.
- B. The family history is negative for convulsions.
- C. The seizure occurred with a necessary arrest.
- D. The seizure occurred when the child had a respiratory infection.
Correct Answer: D
Rationale: Febrile seizures are associated with acute fever, often during infections like respiratory infections, in young children.
When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which of the following for the parents?
- A. Affection for their child.
- B. Responsibility for their child's welfare.
- C. Understanding of their child's disability.
- D. Confidence in their ability to care for their child.
Correct Answer: D
Rationale: Building parental confidence empowers them to manage their child's needs effectively, fostering positive outcomes.
The nurse is caring for a child in Bryant’s traction (see fi gure). The nurse should:
- A. Adjust the weights on the legs until the buttocks rest on the bed.
- B. Provide frequent skin care.
- C. Place a pillow under the buttocks.
- D. Remove the elastic leg wraps every 8 hours for 10 minutes.
Correct Answer: B
Rationale: The traction is positioned correctly; the nurse should provide frequent skin care to the back and shoulder areas. The hips and buttocks should be lifted off the bed to provide counter traction; the nurse should not adjust the weights. The nurse should not place a pillow under the buttocks as this would prevent counter traction. The elastic wraps should remain on the legs unless permitted by the physician.
After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which of the following?
- A. Decreases pain at the surgical site.
- B. Keeps the new urethra from closing.
- C. Measures his urine correctly.
- D. Prevents bladder spasms.
Correct Answer: B
Rationale: The catheter keeps the urethra open.
When developing the teaching plan for parents using the Pavlik harness with their child, what should be the nurse's initial step?
- A. Assessing the parents' current coping strategies.
- B. Determining the parents' knowledge about the device.
- C. Providing the parents with written instructions.
- D. Giving the parents a list of community resources.
Correct Answer: B
Rationale: Determining the parents' knowledge about the Pavlik harness is the initial step to tailor teaching to their understanding and needs.