Nokea
When teaching an adolescent male client about testicular self-examination, which instruction should the nurse include?
- A. Have examination after a warm bath or shower.
- B. Report any difference in the size of your testicles to the physician.
- C. Malignant lumps are usually located on the front side of the testicles.
- D. Both testicles should be examined simultaneously to detect differences.
Correct Answer: A
Rationale: Performing testicular self-examination after a warm bath or shower relaxes the scrotum, making it easier to detect abnormalities, a key instruction for effective screening.
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Which nursing action is most appropriate at this time?
- A. Recognize that the fluid is cerebrospinal fluid (CSF) and remove the dressing, observing for the source of the leakage.
- B. Recognize that the fluid is CSF and call the chaplain because death of the child is imminent.
- C. Recognize that the fluid is CSF and notify the operating room because additional surgery will be necessary.
- D. Recognize that the fluid is CSF and reinforce the dressing until the physician can change it.
Correct Answer: D
Rationale: Clear drainage on a head dressing post-craniotomy is likely CSF, indicating a leak. Reinforcing the dressing prevents infection and maintains a sterile barrier until the physician assesses the leak.
Which statement by the parents indicates they understand the home care instructions given by the nurse?
- A. We've made arrangements for a homebound teacher.
- B. We'll use ice packs on our child's joints during episodes of inflammation.
- C. We'll serve meals that prevent excess weight gain.
- D. We'll keep our child in bed most of the time.
Correct Answer: C
Rationale: Maintaining a healthy weight reduces stress on inflamed joints in JRA. Serving meals that prevent excess weight gain shows understanding of home care instructions to support joint health.
Which assessment finding may indicate a serious neurovascular problem that should be reported immediately to the charge nurse or physician?
- A. The toes of the left foot are warmer than the toes of the right foot.
- B. The toes of both feet are cool to the touch.
- C. The child is unable to wiggle the toes of the right foot.
- D. The capillary refill in the toes of the right foot is 2 seconds.
Correct Answer: C
Rationale: Inability to wiggle toes suggests neurovascular compromise, such as nerve or vascular injury, requiring immediate reporting to prevent permanent damage.
Which statement by the child indicates a need for further teaching about bicycle safety?
- A. I'll wear my helmet whenever I ride my bicycle.
- B. I'll ride my bicycle in the opposite direction of traffic flow.
- C. I'll stop at all intersections and look both ways before proceeding.
- D. I won't ride my bicycle after dark on the street.
Correct Answer: B
Rationale: Riding in the opposite direction of traffic flow is unsafe, increasing collision risk. Bicycles should be ridden with traffic flow, indicating a need for further teaching.
A child is prescribed 10 mg/kg of a medication, and the child weighs 15 kg. The medication is available as 50 mg/mL. How many milliliters should the nurse administer?
Correct Answer: 3 mL
Rationale: Calculation: 15 kg × 10 mg/kg = 150 mg. Volume = 150 mg ÷ 50 mg/mL = 3 mL. Since no options are provided, the calculated volume is noted for accuracy.