Nokea
When discussing the onset of adolescence with parents, the nurse explains that it occurs at which of the following times?
- A. Same age for both boys and girls.
- B. 1 to 2 years earlier in boys than in girls.
- C. 1 to 2 years earlier in girls than in boys.
- D. 3 to 4 years later in boys than in girls.
Correct Answer: C
Rationale: Girls typically enter puberty 1-2 years earlier than boys, around ages 10-12.
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At the 2 week well-child visit a parent states, 'My baby seems to keep his head tilted to the right.' The nurse should further assess the:
- A. Fontanel.
- B. Cervical vertebrae.
- C. Trapezius muscle.
- D. Sternocleidomastoid muscle.
Correct Answer: D
Rationale: Torticollis is commonly caused by tightness or shortening of the sternocleidomastoid muscle, which should be assessed for asymmetry or tightness.
When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for which of the following purposes?
- A. To decrease back muscle spasms.
- B. To improve the brace's traction effect.
- C. To prevent spinal contractures.
- D. To strengthen the back and abdominal muscles.
Correct Answer: D
Rationale: Exercises for scoliosis in a Boston brace focus on strengthening back and abdominal muscles to support spinal alignment and improve posture.
Which of the following would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate (Sulfamylon)?
- A. Ensure parental support during the dressing.
- B. Allow the child to assist in removing the dressings and applying the cream.
- C. Give the child permission to cry during the procedure.
- D. Allow the child to schedule the time for dressing changes.
Correct Answer: B
Rationale: Allowing the child to participate fosters a sense of control, reducing fear and combative behavior. Parental support and crying are helpful but less empowering, and scheduling may disrupt care.
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.
A 10-year-old with leukemia is taking immunosuppressive drugs. To maintain health the nurse should instruct the child and parents to:
- A. Continue with immunizations.
- B. Not receive any live attenuated vaccines.
- C. Receive vitamin and mineral supplements.
- D. Stay away from peers.
Correct Answer: B
Rationale: Live attenuated vaccines are contraindicated in immunosuppression due to infection risk. Other options are unnecessary or overly restrictive.