Nokea
When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis?
- A. Where did the pain start?
- B. What did you do for the pain?
- C. How often do you have a bowel movement?
- D. Is the pain continuous, or does it let up?
Correct Answer: A
Rationale: Pain starting near the umbilicus and migrating to the right lower quadrant is characteristic of appendicitis.
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During physical assessment of a 4-month-old infant with Hirschsprung's disease, the nurse should most likely note which of the following?
- A. Scaphoid-shaped abdomen.
- B. Weight less than expected for height and age.
- C. Cyanosis of the fingers and toes.
- D. Hyperactive deep tendon reflexes.
Correct Answer: B
Rationale: Hirschsprung's disease can lead to poor weight gain due to bowel obstruction.
The nurse judges that the mother understands the term cerebral palsy when she describes it as a term applied to impaired movement resulting from which of the following?
- A. Injury to the cerebrum caused by viral infection.
- B. Malformed blood vessels in the ventricles caused by inheritance.
- C. Nonprogressive brain damage caused by injury.
- D. Inflammatory brain disease caused by metabolic imbalances.
Correct Answer: C
Rationale: Cerebral palsy is characterized by nonprogressive brain damage from injury, often occurring before, during, or shortly after birth, leading to impaired movement.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:
- A. Keep their home warmer than usual.
- B. Encourage twenty or outdoor activities.
- C. Promote interactions with one friend instead of groups.
- D. Limit bathing to prevent skin irritation.
Correct Answer: C
Rationale: Hyperthyroidism causes irritability and hyperactivity, so limiting social interactions to one friend reduces overstimulation. Warmer homes, excessive activity, and limited bathing are inappropriate.
Nonsteroidal anti-inflammatory drugs are the first choice in treating a child with juvenile idiopathic arthritis. Which adverse effects should the nurse include in the teaching plan for the parents? Select all that apply.
- A. Weight gain.
- B. Abdominal pain.
- C. Blood in the stool.
- D. Folic acid deficiency.
- E. Reduced blood clotting ability.
Correct Answer: B,C,E
Rationale: NSAIDs can cause gastrointestinal issues like abdominal pain and blood in the stool, and they may reduce blood clotting ability due to their effect on platelet function.
When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: Bending forward at the waist with arms hanging freely allows the nurse to observe for spinal asymmetry, a key sign of scoliosis.