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Which intervention is most appropriate initially for an 8-year-old child who selects the fourth face on the Wong-Baker FACES Pain Rating Scale?
- A. Take no action; the child is pain-free.
- B. Provide diversional activities to relieve the child's pain.
- C. Document findings, and recheck the child later.
- D. Give the prescribed analgesic to relieve the pain.
Correct Answer: D
Rationale: The fourth face on the Wong-Baker FACES Pain Rating Scale indicates moderate to severe pain, requiring administration of a prescribed analgesic for effective pain relief.
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Which instruction is essential to give the parents before the child's discharge?
- A. Return the child for a follow-up visit in 3 to 5 days.
- B. Give the child nothing by mouth for the next 12 hours.
- C. Check the child's pupillary response every 4 hours.
- D. Awaken the child every 4 hours during the first night.
Correct Answer: D
Rationale: Awakening the child every 4 hours during the first night allows monitoring for neurological deterioration, such as altered consciousness, critical after a head injury.
The nurse would expect to withhold penicillin V (Pen-Vee-K) and notify the physician if the child had a previous allergic reaction to a medication from which drug group?
- A. Aminoglycosides
- B. Cephalosporins
- C. Macrolides
- D. Sulfonamides
Correct Answer: B
Rationale: Penicillin V is a penicillin antibiotic, and cephalosporins have a similar beta-lactam structure, which can lead to cross-reactivity in patients with penicillin allergies. Withholding penicillin and notifying the physician is necessary if the child has a cephalosporin allergy.
If the parents of a child with Duchenne's muscular dystrophy are having a difficult time accepting the diagnosis, which nursing action is most beneficial to the family?
- A. Recommend that the parents place the child in an institution.
- B. Recommend that the parents contact the local social welfare agency.
- C. Recommend that the parents talk with other parents who have children with muscular dystrophy.
- D. Recommend that the parents read as much literature as possible about treatment of muscular dystrophy.
Correct Answer: C
Rationale: Connecting with other parents who have children with Duchenne's muscular dystrophy provides emotional support and practical insights, helping the family cope with the diagnosis.
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.
A 24 years old G2P1A0 had last menstrual period 9 weeks ago. She presents with bleeding and passage of tissues pervaginum. Bleeding is associated with lower abdominal pain. The most likely diagnosis is:
- A. Threatened abortion.
- B. Inevitable abortion.
- C. Incomplete abortion.
- D. Twin pregnancy.
- E. Ectopic pregnancy.
Correct Answer: C
Rationale: Incomplete abortion occurs when products of conception are partially expelled leading to vaginal bleeding passage of tissue and lower abdominal pain as seen in this case. Threatened abortion involves bleeding without tissue passage or cervical dilation. Inevitable abortion implies an open cervix but not necessarily tissue passage. Ectopic pregnancy typically presents with unilateral pain and no tissue passage. Twin pregnancy is unrelated to these symptoms.