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When preparing the teaching plan for the mother of a child with asthma, which of the following should the nurse include as signs to alert the mother that her child is having an asthma attack?
- A. Secretion of thin, copious mucus.
- B. Tight, productive cough.
- C. Wheezing on expiration.
- D. Temperature of 99.4°F (37.4°C).
Correct Answer: C
Rationale: Wheezing on expiration is a hallmark sign of an asthma attack, indicating airway narrowing. The mother should be taught to recognize this to initiate prompt treatment.
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While the nurse is examining the infant for presence of testes, the father paces around the room shaking his head. Which of the following would be the most appropriate response by the nurse?
- A. I'm sure everything will work out for the best
- B. and he'll be fine.
- C. You seem upset; please tell me how you're feeling.
- D. Don't worry; his testes will probably descend on their own.
- E. Would you like to talk with a parent of a child who has the same problem?
Correct Answer: B
Rationale: This response shows empathy and opens communication.
The nurse identifies a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure for a school-age child scheduled for a tonsillectomy. Which of the following is an expected outcome for this nursing diagnosis?
- A. The child is able to tell about the surgery and recovery.
- B. The child remains on nothing-by-mouth (NPO) status for the designated preoperative period.
- C. The child and family demonstrate an understanding of the procedure.
- D. The child knows the parents will not leave.
Correct Answer: B
Rationale: The most appropriate outcome for a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure should be that the child remains NPO for the designated period of time before surgery, thereby minimizing the risk of aspiration during the surgery. Ability to tell about the surgery and demonstrating an understanding of the procedure are appropriate outcomes for a nursing diagnosis of Deficient knowledge. Knowing that the parents will not leave is associated with a nursing diagnosis of Anxiety or Fear related to separation from support systems or an unfamiliar environment.
The nurse assesses the family's ability to cope with the child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease?
- A. Limiting interaction with extended family and friends.
- B. Learning measures to meet the child's physical needs.
- C. Requesting teaching about cerebral palsy in general.
- D. Not seeking financial help to pay for medical bills.
Correct Answer: A
Rationale: Limiting social interactions may indicate social isolation, a sign of poor coping, whereas the other options suggest proactive engagement with the child's needs.
The nurse should refer the parents of an 8-month-old child to a health care provider if the child is unable to:
- A. Stand momentarily without holding onto furniture.
- B. Stand alone well for long periods of time.
- C. Stoop to recover an object.
- D. Sit without support for long periods of time.
Correct Answer: D
Rationale: An 8-month-old should be able to sit without support; inability to do so warrants further evaluation.
A father asks the nurse how he would know if his child had developed mononucleosis. The nurse explains that in addition to fatigue, which of the following would be most common?
- A. Liver tenderness.
- B. Enlarged lymph glands.
- C. Persistent nonproductive cough.
- D. A blush-like generalized skin rash.
Correct Answer: B
Rationale: Enlarged lymph glands, especially in the neck, are a hallmark symptom of mononucleosis.