Nokea
Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply.
- A. Coughing.
- B. Respiratory rate of 35 breaths/minute.
- C. Heart rate of 95 beats/minute.
- D. Restlessness.
- E. Malaise.
- F. Diaphoresis.
Correct Answer: B,D,F
Rationale: A respiratory rate of 35 breaths/minute (elevated for a toddler), restlessness, and diaphoresis indicate respiratory distress, reflecting increased work of breathing and stress. Coughing may be present but is less specific, while a heart rate of 95 bpm and malaise are not directly indicative of acute respiratory distress.
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After teaching the mother of a young child with a peritoneal catheter about the signs and symptoms of peritonitis, the nurse determines that the mother has understood the teaching when she identifies which of the following as an important sign?
- A. Cloudy dialysate drainage return.
- B. Distended abdomen.
- C. Shortness of breath.
- D. Weight gain of 3 lb in 2 days.
Correct Answer: A
Rationale: Cloudy drainage indicates infection.
The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant's condition has been controlled. The nurse should determine that the father understands when he explains that which of the following will occur with his infant?
- A. The infant will receive clear liquids for a period of time.
- B. Formula and juice will be offered.
- C. Blood will be drawn daily to test for anemia.
- D. The infant will be allowed to go to the playroom.
Correct Answer: A
Rationale: Clear liquids are introduced gradually after stabilization.
When teaching a mother about measures to prevent lead poisoning in her children, which of the following preventive measures should the nurse include as the most effective?
- A. Condemning of old housing developments.
- B. Educating the public on common sources of lead.
- C. Educating the public on the importance of good nutrition.
- D. Keeping pregnant women out of old homes that are being remodeled.
Correct Answer: B
Rationale: Education on lead sources (e.g., paint, dust) empowers families to avoid exposure. Condemning housing is impractical, nutrition is secondary, and protecting pregnant women is less broad-reaching.
The nurse is inserting a nasogastric (NG) tube in a child admitted with head trauma. The nurse should explain to the parents that the NG tube will be used to:
- A. Administer medications.
- B. Decompress the stomach.
- C. Obtain gastric specimens for analysis.
- D. Provide adequate nutrition.
Correct Answer: B
Rationale: An NG tube in head trauma decompresses the stomach to prevent aspiration and manage gastric distension.
The parents of a preschooler ask the nurse how to handle their child's temper tantrums. Which of the following should the nurse include in the teaching plan? Select all that apply.
- A. Putting the child in 'time-out.'
- B. Telling the child to go to his bedroom.
- C. Ignoring the child.
- D. Putting the child to bed.
- E. Spanking the child.
- F. Trying to reason with the child.
Correct Answer: A,C
Rationale: Time-out and ignoring the tantrum are effective strategies to reduce attention-seeking behavior.