Nokea
Which of the following behaviors exhibited by the parents of an infant with pyloric stenosis should the nurse correctly interpret as a positive indication of parental coping?
- A. Telling the nurse that they have to get away for a while.
- B. Discussing the infant's care realistically.
- C. Repeatedly asking if their child is normal.
- D. Exhibiting fear that they will disturb the infant.
Correct Answer: B
Rationale: Realistic discussion of care indicates acceptance and engagement with the situation.
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When developing the plan of care for a school-age child with a suspected diagnosis of appendicitis who is complaining of severe abdominal pain, which of the following measures should the nurse expect to include in the child's plan of care?
- A. Application of a heating pad.
- B. Insertion of a rectal tube.
- C. Application of an ice bag.
- D. Administration of an intravenous narcotic.
Correct Answer: C,D
Rationale: Ice and narcotics relieve pain without risking perforation, unlike heat or rectal tubes.
The charge nurse on the pediatric floor has assigned a 6-year-old girl of Arab-American ethnicity with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-immune treatment. The 6-year-old's mother is upset because the parent staying with the other child is the father. The nurse should:
- A. Explain to the parents that this room arrangement facilitates teaching.
- B. Reassign the children to different rooms.
- C. Offer the Arab-American parent another place to sleep.
- D. Refer the parent to the customer service representative.
Correct Answer: B
Rationale: Cultural sensitivity requires addressing the mother's discomfort, likely due to gender norms. Reassigning rooms respects her concerns while maintaining care. Teaching convenience, alternative sleeping, or customer service do not address cultural needs.
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.
The family of a 5-year-old, only child has just moved to a rural setting where the father has started a dental practice. At the well-child visit, the father expresses concern that his child seems prone to minor accidents such as skinning his elbow and knees or falling off his scooter. The nurse tells the father:
- A. Only children use accidents as a way to seek parents' attention.
- B. Children who live in the suburbs typically have more accidents.
- C. Children frequently have more accidents when families experience change.
- D. We see a relationship between accidents and parental education.
Correct Answer: C
Rationale: Changes like moving can increase accidents due to stress or unfamiliar environments.
A diagnosis of hemophilia A is confirmed in an infant. Which of the following instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
- A. Administer one-half of a children's aspirin for a temperature higher than 101°F (38.3°C).
- B. Sew thick padding into the elbows and knees of the child's clothing.
- C. Check the color of the child's urine every day.
- D. Expect the eruption of the primary teeth to produce moderate to severe bleeding.
Correct Answer: B
Rationale: Padding protects joints from trauma, reducing bleeding risk in hemophilia. Aspirin increases bleeding, urine checks are unnecessary, and teething bleeding is minimal.