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When obtaining the nursing history from the mother of an infant with suspected intussusception, which of the following questions would be most helpful?
- A. What do the stools look like?
- B. When was the last time your child urinated?
- C. Is your child eating normally?
- D. Has your child had any episodes of vomiting?
Correct Answer: A
Rationale: Stool appearance (e.g., currant jelly stools) is a hallmark of intussusception, aiding diagnosis.
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A 2-year-old child brought to the clinic by her parents is uncooperative when the nurse tries to look in her ears. Which of the following should the nurse try first?
- A. Ask another nurse to assist.
- B. Allow a parent to assist.
- C. Wait until the child calms down.
- D. Restrain the child's arms.
Correct Answer: B
Rationale: Parental involvement can comfort the child and improve cooperation.
Shortly after an infant is returned to his room following hydrocele repair, the infant's mother tells the nurse that the child's scrotum looks swollen and bruised. Which of the following responses by the nurse would be most appropriate?
- A. Let me see if the doctor has ordered aspirin for him. If he did
- B. I'll get it right away.
- C. Why don't you wait in his room? Then you can ask me any questions when I get there.
- D. What you are describing is unusual after this type of surgery. I'll let the doctor know.
- E. This is normal after this type of surgery. Let's look at it together just to be sure.
Correct Answer: D
Rationale: Swelling and bruising post-surgery are common.
During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which of the following findings should lead the nurse to formulate the nursing diagnosis Risk for infection?
- A. Dialysate leakage.
- B. Granulation tissue.
- C. Increased time for drainage.
- D. Tissue swelling.
Correct Answer: A
Rationale: Leakage increases infection risk.
Which assessment finding in an infant with colic should the nurse prioritize?
- A. Frequent spitting up.
- B. Crying for 3 hours daily.
- C. Weight gain below average.
- D. Fever of 100.4°F.
Correct Answer: D
Rationale: Fever suggests an underlying illness, requiring urgent evaluation. Prolonged crying is typical of colic, but spitting up and slow weight gain are less acute concerns.
A mother asks the nurse, 'How did my children get pinworms?' The nurse explains that pinworms are most commonly spread by which of the following when contaminated?
- A. Food.
- B. Hands.
- C. Animals.
- D. Toilet seats.
Correct Answer: B
Rationale: Pinworms are spread primarily through hand-to-mouth contact after touching contaminated surfaces.