Nokea
Which development is necessary for toilet training readiness for a 2-year-old? Select all that apply.
- A. Adequate neuromuscular development for sphincter control.
- B. Appropriate chronological age.
- C. Ability to communicate the need to use the toilet.
- D. Desire to please the parents.
- E. Ability to play with other 2-year-olds.
Correct Answer: A,C,D
Rationale: Neuromuscular control, communication, and motivation are key for toilet training readiness.
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After teaching a group of parents of preschoolers attending a well-child clinic about oral hygiene and tooth brushing, the nurse determines that the teaching has been successful when the parents state that children can begin to brush their teeth without help at which of the following ages?
- A. 3 years.
- B. 5 years.
- C. 7 years.
- D. 9 years.
Correct Answer: C
Rationale: Children can brush their teeth independently around 7 years, when fine motor skills are developed.
After teaching the parents of a preschooler who has undergone a tonsillectomy and adenoidectomy about appropriate foods to give the child after discharge, which of the following, if stated by the parents as appropriate foods, indicates successful teaching?
- A. Meat loaf and uncooked carrots.
- B. Pork and noodle casserole.
- C. Cream of chicken soup and orange sherbet.
- D. Hot dog and potato chips.
Correct Answer: C
Rationale: Cream of chicken soup and orange sherbet are soft, non-irritating foods suitable for a child post-tonsillectomy, as they are easy to swallow and unlikely to irritate the surgical site. Meat loaf, uncooked carrots, pork, noodles, hot dogs, and potato chips are harder or crunchier foods that could irritate or cause discomfort.
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arch the back (see figure). The nurse should:
- A. Notify the physician
- B. Stroke the back to release the arching
- C. Pad the side rails of the crib
- D. Place the child prone
Correct Answer: A
Rationale: The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the physician immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the fi rst action is to notify the physician. Placing the child in a prone position will not relieve the herniation or release the arching.
After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant's parents are Catholic and do not want the surgery to take place unless the infant has first been baptized. The nurse asks the parents:
- A. Are you worried your baby might die?
- B. Do you want me to help arrange the baptism?
- C. Do you want to speak with the social worker?
- D. Would you prefer to wait for the surgery?
Correct Answer: B
Rationale: Offering to arrange the baptism respects the parents' religious beliefs and facilitates timely surgery.
A child with a lead level of 20 mcg/dL is prescribed oral chelation therapy. The nurse should monitor for which side effect?
- A. Hypertension.
- B. Renal toxicity.
- C. Hypoglycemia.
- D. Seizures.
Correct Answer: B
Rationale: Oral chelators like succimer can cause renal toxicity, requiring monitoring of kidney function. Hypertension, hypoglycemia, and seizures are not common side effects.