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Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?
- A. Abdomen appears slightly rounded.
- B. Bowel sounds are heard twice in 2 minutes.
- C. All four abdominal quadrants reveal tympany.
- D. The client demonstrates a cremasteric reflex.
Correct Answer: B
Rationale: Decreased bowel sounds suggest appendicitis due to peritoneal irritation.
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During hospitalization, a 10-year-old child with acute poststreptococcal glomerulonephritis and oliguria asks for food from home. After teaching the mother and child about diet, the nurse determines that the teaching had been effective when the mother brings in which food?
- A. Pizza and cola.
- B. Hamburger and fries.
- C. Ice cream sundae.
- D. Strawberries and kiwi.
Correct Answer: D
Rationale: Low-sodium, low-protein options are best.
Which of the following statements should the nurse use to describe to the parents why their child with leukemia is at risk for infections?
- A. Play activities are too strenuous.
- B. Vitamin C intake is reduced over a period of time.
- C. The number of red blood cells is inadequate for carrying oxygen.
- D. Immature white blood cells are incapable of handling an infectious process.
Correct Answer: D
Rationale: Immature white blood cells in leukemia cannot effectively fight infections, increasing risk. Other options are unrelated.
Which of the following should the nurse expect to observe in an infant with intussusception before surgical intervention?
- A. Fever and lethargy.
- B. Currant jelly stools.
- C. Frequent loose stools.
- D. Increased appetite.
Correct Answer: B
Rationale: Currant jelly stools are a classic sign of intussusception due to mucosal bleeding.
When teaching the parents of an infant how to perform back slaps to dislodge a foreign body, which of the following should the nurse tell the parents to use to deliver the blows?
- A. Palm of the hand.
- B. Heel of the hand.
- C. Fingertips.
- D. Entire hand.
Correct Answer: B
Rationale: The heel of the hand is used to deliver back slaps in infants to effectively dislodge a foreign body without causing injury.
A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child?
- A. Preventing siblings from being in close contact.
- B. Sending the child to day care as usual.
- C. Playing video games for several hours each evening.
- D. Playing with the child every day.
Correct Answer: D
Rationale: Playing with the child daily promotes emotional bonding and normal development, which is critical for a 9-month-old. Preventing sibling contact is unnecessary unless siblings are ill, day care may risk further infection, and video games are inappropriate for an infant.