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When observing the parent instilling prescribed ear drops ordered twice a day for a toddler, the nurse decides that the teaching about positioning of the pinna for instillation of the drops is effective when the parent pulls the toddler's pinna in which of the following directions?
- A. Up and forward.
- B. Up and backward.
- C. Down and forward.
- D. Down and backward.
Correct Answer: D
Rationale: In children under 3, the pinna is pulled down and back to straighten the ear canal.
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A child is started on a soft diet after having been on clear liquids following an episode of severe gastroenteritis. When helping the mother choose foods for her child, which of the following foods would be most appropriate?
- A. Muffins and eggs.
- B. Bananas and rice.
- C. Bran cereal and a bagel.
- D. Pancakes and sausage.
Correct Answer: B
Rationale: Bananas and rice are gentle on the gut, suitable for a soft diet.
A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The parents ask if this behavior is normal. The nurse should explain to the parents that toddlers use ritualistic patterns to:
- A. Establish a sense of identity.
- B. Establish control over adults in their environment.
- C. Establish sequenced patterns of learning behavior.
- D. Establish a sense of security.
Correct Answer: D
Rationale: Ritualistic behaviors in toddlers provide comfort and security.
An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?
- A. Cover the adolescent's legs with blankets.
- B. Report this finding to the physician immediately.
- C. Reposition the adolescent's legs.
- D. Lay the adolescent flat to aid circulation.
Correct Answer: A
Rationale: Cool extremities indicate poor circulation, common in spinal cord injury; covering with blankets promotes warmth and comfort.
When developing a recreational therapy plan of care for a 3-year-old child hospitalized with pneumonia and cystic fibrosis, which of the following toys would be appropriate?
- A. 100-piece jigsaw puzzle.
- B. Child's favorite doll.
- C. Fuzzy stuffed animal.
- D. Scissors, paper, and paste.
Correct Answer: B
Rationale: A child's favorite doll is appropriate for a 3-year-old, providing comfort and familiarity without posing a risk of irritation or infection, unlike fuzzy stuffed animals which can harbor dust or bacteria.
A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention?
- A. Fatigue and anorexia.
- B. Fever and petechiae.
- C. Swollen neck lymph glands and lethargy.
- D. Enlarged liver and spleen.
Correct Answer: B
Rationale: Fever and petechiae indicate infection and bleeding risk, requiring urgent intervention in leukemia due to immunosuppression and low platelets.