Nokea
When developing the teaching plan for the parents of a 12-month-old infant with hypospadias and chordee repair, which of the following should the nurse expect to include as most important?
- A. Assisting the child to become familiar with his dressings so he will leave them alone.
- B. Encouraging the child to ambulate as soon as possible by using a favorite push toy.
- C. Forcing fluids to at least 2,500 mL/day by offering his favorite juices.
- D. Preventing the child from disrupting the catheters by using soft restraints.
Correct Answer: D
Rationale: Restraining prevents dislodgment of catheters.
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The mother of an 8-year-old with diabetes tells the nurse that she does not want the school to know about her daughter's condition. The nurse should reply:
- A. I think that would be a good idea.'
- B. What is it that concerns you about having the school know about your daughter's condition?'
- C. It would be fine not to tell your daughter's friends, but the teacher must know.'
- D. In order to keep your daughter safe, it is necessary for all adults in the school to know her condition.'
Correct Answer: B
Rationale: Exploring concerns builds trust and allows the nurse to address fears while explaining the need for school awareness (e.g., for hypoglycemia management). Other responses dismiss or mandate without dialogue.
The nurse in the emergency department is caring for a 3-year-old child with a fractured humerus. The child is crying and screaming, 'I hate you.' Which of the following would be most appropriate:
- A. Tell the parents they will need to wait out in the lobby.
- B. Ask the charge nurse to assign this client to another nurse.
- C. Reassure the parents that this is a normal behavior under the circumstances.
- D. Ask the parents to discipline the child so that the physician can treat her.
Correct Answer: C
Rationale: Such behavior is a normal stress response in a young child experiencing pain and fear in an emergency setting.
When the infant returns to the unit after imperforate anus repair, the nurse should place the infant in which of the following positions?
- A. On the abdomen, with legs pulled up under the body.
- B. On the back, with legs extended straight out.
- C. Lying on the side with the hips elevated.
- D. Lying on the back in a position of comfort.
Correct Answer: C
Rationale: Lying on the side with hips elevated minimizes pressure on the surgical site and promotes healing.
Which intervention should the nurse prioritize for an infant with failure to thrive?
- A. Administer IV fluids.
- B. Establish a feeding schedule.
- C. Order a developmental evaluation.
- D. Increase room temperature.
Correct Answer: B
Rationale: A consistent feeding schedule addresses poor intake, promoting weight gain. IV fluids are for acute dehydration, developmental evaluation is secondary, and room temperature is less relevant.
After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's disease?
- A. I try to keep him happy at all costs; otherwise, he has an asthma attack.
- B. We keep our child away from other children to help cut down on infections.
- C. Although our child's disease is serious, we try not to let it be the focus of our family.
- D. I'm afraid that when my child gets older, he won't be able to care for himself like I do.
Correct Answer: C
Rationale: The statement 'Although our child's disease is serious, we try not to let it be the focus of our family' reflects a positive adjustment, indicating the family is managing the chronic condition without letting it dominate their lives.