Nokea
Which nursing action should be avoided when giving care to a child diagnosed with Wilms' tumor?
- A. Palpating the child's abdomen
- B. Collecting a catheterized urine sample
- C. Assessing pupillary reflex with a penlight
- D. Eliciting a patellar reflex with a reflex hammer
Correct Answer: A
Rationale: Palpating the abdomen in a child with Wilms' tumor risks dislodging tumor cells, potentially causing metastasis, and should be avoided to ensure safety.
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When teaching an adolescent male client about testicular self-examination, which instruction should the nurse include?
- A. Have examination after a warm bath or shower.
- B. Report any difference in the size of your testicles to the physician.
- C. Malignant lumps are usually located on the front side of the testicles.
- D. Both testicles should be examined simultaneously to detect differences.
Correct Answer: A
Rationale: Performing testicular self-examination after a warm bath or shower relaxes the scrotum, making it easier to detect abnormalities, a key instruction for effective screening.
Which information about methamphetamine use is most accurate and important for the parents to know?
- A. Methamphetamines are tried by most adolescents and cause no harm.
- B. Methamphetamines are known to lead to addiction.
- C. Methamphetamines are a central nervous system depressant.
- D. Methamphetamines are harmful only if taken intravenously.
Correct Answer: B
Rationale: Methamphetamines are highly addictive stimulants, and informing parents about the risk of addiction is critical to understanding the severity of the adolescent's behavior.
The nurse is measuring both the chest and head circumference during the full-term newborn’s initial assessment. The newborn’s father observes this and asks the nurse why both measurements are necessary. Which explanation is most accurate?
- A. “Comparing the measurements helps determine if there are head or chest size abnormalities.”
- B. “Measuring the head circumference provides information about future intellectual ability.”
- C. “Measuring the newborn’s chest provides needed information when assessing cardiac health.”
- D. “Comparing the head and chest measurements helps to determine future adult body size.”
Correct Answer: A
Rationale: The circumference of the normal newborn’s head is approximately 2 centimeters greater than the chest at birth. Extreme differences may indicate abnormalities like microcephalus or hydrocephalus. Head size doesn’t predict intelligence chest size doesn’t assess cardiac health and measurements don’t predict adult size.
A G2P1 with previous cesarean section due to obstructed labour comes for first antenatal visit at 34 weeks of gestation. She is seeking advice for home delivery this time. What will be the most dangerous complication in her case if we allow her to deliver at home by untrained birth attendent:
- A. Prolonged latent phase.
- B. Arrest in second stage of labour.
- C. Delayed progress in active phase of labour.
- D. Rupture uterus.
- E. Placental retention.
Correct Answer: D
Rationale: Uterine rupture is a life-threatening complication in women with a previous cesarean section especially during labor managed by untrained attendants due to the risk of scar dehiscence. Other complications are less immediately dangerous.
For the teenager recovering from an appendectomy, which nursing measure is most appropriate to prevent respiratory complications during the postoperative period?
- A. Administer a bronchodilator by inhalation.
- B. Administer oxygen by nasal cannula.
- C. Give the child a corticosteroid.
- D. Have the child use an incentive spirometer.
Correct Answer: D
Rationale: Using an incentive spirometer encourages deep breathing, preventing atelectasis and pneumonia, common respiratory complications post-surgery due to immobility and anesthesia.