Nokea
Which of the following assessments would be most important for the nurse to make initially in a school-age child being seen in the clinic who has a sore throat, muscle tenderness, arms feeling weak, and generally is not feeling well?
- A. Difficulty swallowing.
- B. Recent history of viral infection.
- C. Presence of fever.
- D. History of recent trauma.
Correct Answer: A
Rationale: Difficulty swallowing indicates potential cranial nerve involvement, a critical early sign in Guillain-Barré syndrome, requiring immediate attention.
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When assessing the development of a 15-month-old child with cerebral palsy, which of the following milestones should the nurse expect a toddler of this age to have achieved?
- A. Walking up steps.
- B. Using a spoon.
- C. Copying a circle.
- D. Putting a block in cup.
Correct Answer: D
Rationale: A 15-month-old typically can put a block in a cup, a milestone achievable even with motor challenges from cerebral palsy, unlike the other options which require more advanced skills.
A child with cystic fibrosis is receiving gentamicin. Which of the following nursing actions is most important?
- A. Monitoring intake and output.
- B. Obtaining daily weights.
- C. Monitoring the client for indications of constipation.
- D. Obtaining stool samples for hemoccult testing.
Correct Answer: A
Rationale: Monitoring intake and output is critical when administering gentamicin, an aminoglycoside, to detect early signs of nephrotoxicity, a common adverse effect.
A school-age child with cystic fibrosis asks the nurse what sports she can become involved in as she becomes older. Which of the following activities would be appropriate for the nurse to suggest?
- A. Swimming.
- B. Track.
- C. Baseball.
- D. Javelin throwing.
Correct Answer: A
Rationale: Swimming is appropriate for a child with cystic fibrosis, as the humid environment minimizes airway irritation, and the activity promotes respiratory muscle strength without excessive strain.
On finding a child who is not breathing, which of the following should the nurse do first?
- A. Clear the airway.
- B. Begin mouth-to-mouth resuscitation.
- C. Initiate oxygen therapy.
- D. Start chest compressions.
Correct Answer: A
Rationale: Clearing the airway is the first step in CPR to ensure no obstructions prevent effective ventilation.
The nurse judges that the mother understands the diet restrictions for her child with chronic renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which of the following?
- A. Sodium and water restrictions.
- B. High protein and carbohydrates.
- C. High potassium and iron.
- D. Protein and phosphorus restrictions.
Correct Answer: A
Rationale: Dietary restrictions help manage symptoms.