Nokea
When teaching the parents of an older infant with cystic fibrosis (CF) about the type of diet the child should consume, which of the following would be appropriate?
- A. Low-protein diet.
- B. High-fat diet.
- C. Low-carbohydrate diet.
- D. High-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet is appropriate for an infant with cystic fibrosis to meet increased energy needs due to malabsorption and chronic respiratory issues.
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A child with a known seizure disorder is hospitalized for an appendectomy. While assisting the child back from the restroom, the child begins tonic-clonic movements. The nurse should take which actions in order of priority from first to last?
- A. Note the time.
- B. Clear the area of potentially harmful objects and pad the head.
- C. Ease the child to the floor.
- D. Roll the child to the side.
Correct Answer: C,B,D,A
Rationale: Easing the child to the floor prevents injury, clearing objects and padding the head ensures safety, rolling to the side maintains airway, and noting the time tracks seizure duration.
An adolescent tells the nurse that the area below his knee has been hurting for several weeks. The nurse should obtain history information about participation in which of the following?
- A. Soccer.
- B. Golf.
- C. Diving.
- D. Swimming.
Correct Answer: A
Rationale: Pain below the knee in adolescents is often associated with Osgood-Schlatter disease, which is common in sports like soccer that involve repetitive knee stress.
The nurse is assessing a child with sickle cell disease during a routine clinic visit. Which finding requires immediate follow-up by the nurse?
- A. Pallor of the nail beds and mucous membranes.
- B. A heart rate of 88 beats per minute.
- C. Intact and equal bilateral peripheral pulses.
- D. Normal vision and hearing reported by the parents.
Correct Answer: A
Rationale: Pallor of nail beds and mucous membranes indicates anemia or poor perfusion, a serious concern in sickle cell disease requiring immediate follow-up.
The nurse begins CPR on a 5-year-old unresponsive client. When the emergency response team arrives, the child continues to have no respiratory effort but has a heart rate of 50 with cyanotic legs. The team should next:
- A. Discontinue compressions but continue administering breaths with a bag-mask device.
- B. Establish an intravenous line with a large bore needle while preparing the defibrillator.
- C. Begin 2-person CPR at a ratio of 2 breaths to 15 compressions.
- D. Begin 2-person CPR at a ratio of 2 breaths to 30 compressions.
Correct Answer: C
Rationale: For a 5-year-old with a heart rate of 50 (bradycardia) and no respiratory effort, 2-person CPR with a ratio of 2 breaths to 15 compressions is appropriate to optimize oxygenation and circulation.
Which of the following beverages should the nurse plan to give a child with leukemia to relieve nausea?
- A. Orange juice.
- B. Weak tea.
- C. Plain water.
- D. A carbonated beverage.
Correct Answer: B
Rationale: Weak tea is gentle and soothing, helping relieve nausea without irritation. Other options may worsen nausea.