Nokea
When developing the plan of care for an infant with a cleft lip before corrective surgery is performed, which of the following should be a priority?
- A. Maintaining skin integrity in the oral cavity.
- B. Using techniques to minimize crying.
- C. Altering the usual method of feeding.
- D. Preventing the infant from putting fingers in the mouth.
Correct Answer: C
Rationale: Altering feeding methods is critical to ensure adequate nutrition and prevent aspiration due to the anatomical defect of a cleft lip.
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A child diagnosed with Wilms' tumor undergoes successful surgery for removal of the diseased kidney. When the child returns to the room, the nurse should place the child in which position?
- A. Modified Trendelenburg.
- B. Sims'.
- C. Semi-Fowler's.
- D. Supine.
Correct Answer: C
Rationale: Semi-Fowler's aids breathing.
A mother calls the clinic to talk to the nurse. The mother states that a physician described her daughter as having 20/60 vision and she asks the nurse what this means. The nurse responds based on the interpretation that the child is experiencing which of the following?
- A. A loss of approximately one-third of her vision.
- B. Ability to see at 60 feet what she should see at 20 feet.
- C. Ability to see at 20 feet what she should see at 60 feet.
- D. Visual acuity three times better than average.
Correct Answer: C
Rationale: 20/60 vision means the child sees at 20 feet what a person with normal vision sees at 60 feet.
An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifies which of the following as a result of using the same site?
- A. Unstruction of the fat tissue and poor absorption.
- B. Destruction of nerves and painful neuritis.
- C. Destruction of the tissue and too-rapid insulin uptake.
- D. Development of resistance to insulin and need for increased amounts.
Correct Answer: A
Rationale: Repeated injections at the same site cause lipodystrophy, leading to poor insulin absorption. Nerve damage, rapid uptake, or insulin resistance are not primary consequences.
A child undergoes rehydration therapy after having severe gastroenteritis. After teaching the parents about dietary management, the nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet?
- A. Regular.
- B. Clear liquid.
- C. Full liquid.
- D. Soft.
Correct Answer: D
Rationale: A soft diet is appropriate post-rehydration to ease digestion.
When developing the ongoing plan of care for the parents whose infant died of sudden infant death syndrome (SIDS), the nurse should plan to accomplish which of the following on the second home visit?
- A. Allow the parents to express their feelings.
- B. Have the parents gain an understanding of the disease.
- C. Assess the impact of the infant's death on their other children.
- D. Deal with issues such as having other children.
Correct Answer: A
Rationale: On the second home visit, allowing parents to express their feelings supports their emotional processing of grief, which is a priority in early bereavement care.