Nokea
Which nursing action would best promote the adolescent's compliance with wearing the brace?
- A. Advising the parents to keep a constant watch on their daughter to make sure she wears her brace
- B. Suggesting that the parents help their daughter find stylish clothing that will hide the brace
- C. Telling the parents that it might be best to arrange for a homebound teacher
- D. Advising the parents to limit their daughter's participation in school activities
Correct Answer: B
Rationale: Helping the adolescent find stylish clothing to conceal the brace addresses body image concerns, promoting compliance by making the brace less noticeable.
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The nurse is discharging the 3-day-old term newborn with a right-sided cephalohematoma. The nurse should instruct the parents to observe their infant closely over the next week for the development of which problem associated with the cephalohematoma?
- A. Jaundice
- B. Difficulty feeding
- C. Pale extremities
- D. Bulging on the right side of the head with crying
Correct Answer: A
Rationale: Cephalohematoma resolution causes RBC hemolysis leading to jaundice. It doesn’t affect feeding cause paleness or bulge with crying.
The nurse is caring for a 30-year-old,single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client’s lifestyle?
- A. Observe how the client interacts with her hospital visitors.
- B. Review the prenatal record for clues about the client’s lifestyle.
- C. Ask the client what plans she has made for newborn care at home.
- D. Observe the relationship between the client and her newborn’s father.
Correct Answer: C
Rationale: Open-ended questions about newborn care plans encourage sharing of lifestyle adjustments especially for single parents. Visitors prenatal records or father involvement are less direct.
Which finding best indicates that a school-age child has acute glomerular nephritis?
- A. Periorbital edema
- B. Excessive urination
- C. Increased appetite
- D. Low blood pressure
Correct Answer: A
Rationale: Periorbital edema is a classic sign of acute glomerular nephritis due to fluid retention from impaired glomerular filtration, reflecting reduced sodium and water excretion.
The nurse is caring for a preterm infant who must be fed via bolus gavage feeding. The infant has a 5 French feeding tube already secured in the left naris. The nurse has aspirated the infant’s stomach contents, noting color, amount, and consistency, and has reinserted the residual amount because it was less than one-fourth the previous feeding. Prioritize the remaining steps that the nurse should take to complete this feeding.
- A. Elevate the syringe 6 to 8 inches over the infant’s head.
- B. Position the infant on the right side.
- C. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate.
- D. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel.
- E. Cap the lavage feeding tube.
Correct Answer: D, A, F, C, E, B, G
Rationale: Sequence: Position infant on right side (D) to reduce aspiration risk connect syringe barrel (A) crimp tube and pour formula (F) elevate syringe (C) uncrimp for gravity flow (E) clear tubing with air (B) cap tube (G).
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.