Nokea
When teaching an adolescent with a seizure disorder who is receiving valproic acid (Depakene), which sign or symptom should the nurse instruct the client to report to the health care provider?
- A. Three episodes of diarrhea.
- B. Loss of appetite.
- C. Jaundice.
- D. Sore throat.
Correct Answer: C
Rationale: Jaundice indicates potential liver toxicity, a serious side effect of valproic acid, requiring immediate reporting.
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When assessing a 3-month-old with Hirschsprung's disease, which finding should the nurse report immediately?
- A. Soft, formed stools.
- B. Abdominal distension.
- C. Regular feeding patterns.
- D. Mild fussiness.
Correct Answer: B
Rationale: Abdominal distension may indicate obstruction, requiring urgent intervention.
The stool culture of a child with profuse diarrhea reveals Salmonella bacilli. After teaching the mother about Salmonella, which of the following statements by the mother indicates effective teaching?
- A. Some people become carriers and stay infectious for a long time.
- B. After the acute stage passes, the organism is usually not present in the stool.
- C. Although the organism may be alive indefinitely, in time it will be of no danger to anyone.
- D. If my child continues to have the organism in the stool, an antitoxin can help destroy the organism.
Correct Answer: A
Rationale: Salmonella can lead to a carrier state with prolonged infectiousness.
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which of the following nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply.
- A. Offer an ice pack.
- B. Apply a heating pad.
- C. Encourage the child to assume a position of comfort.
- D. Limit the child's activity.
- E. Request an order for a cathartic.
Correct Answer: A,C,D
Rationale: Ice, comfortable positioning, and activity limitation reduce pain; heating pads and cathartics may worsen appendicitis.
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.
A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. Which of the following play activities would be most appropriate at this time?
- A. Reading the child a story.
- B. Painting with watercolors.
- C. Pounding on a pegboard.
- D. Stacking a tower of blocks.
Correct Answer: C
Rationale: Pounding on a pegboard allows the child to express frustration physically, which is developmentally appropriate for a preschooler.