Nokea
Which of the following client actions should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy?
- A. Insisting on wearing a T-shirt and gym shorts rather than pajamas.
- B. Avoiding interactions with other adolescents on the nursing unit.
- C. Refusing to fill out the menu, and allowing the nurse to do so.
- D. Not taking telephone calls from friends so he can rest.
Correct Answer: A
Rationale: Choosing preferred clothing reflects autonomy and positive coping.
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A 16-month-old child is seen in the clinic for a checkup for the first time. The nurse notices that the toddler limps when walking. Which of the following would be appropriate to use when assessing this toddler for developmental dysplasia of the hip?
- A. I couldn'ts maneuver.
- B. Barlow's maneuver.
- C. Adam's position.
- D. Trendelenburg's sign.
Correct Answer: B
Rationale: Barlow's maneuver is used to assess for hip instability in infants and toddlers, appropriate for detecting developmental dysplasia of the hip.
A child with Kawasaki disease is receiving low dose aspirin. The mother calls the clinic and states that the child has been exposed to influenza. Which recommendations should the nurse make?
- A. Increase fluid intake.
- B. Stop the aspirin.
- C. Keep the child home from school.
- D. Watch for fever.
- E. Weigh the child daily.
Correct Answer: B,C,D
Rationale: Aspirin should be stopped due to the risk of Reye's syndrome with influenza. Keeping the child home and monitoring for fever help manage infection risk.
The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents:
- A. It is only necessary to have the vaccine if your daughter will be living in a dormitory.'
- B. We recommend the vaccine, but it needs to be given as a series of three injections.'
- C. Let's review your records. The vaccine may have already been given a few years ago.'
- D. We highly recommend this vaccine, but we will need to do a pregnancy screening first.'
Correct Answer: C
Rationale: Checking vaccination records confirms whether the MCV4 vaccine, recommended for adolescents, was previously administered.
After teaching the parents of a toddler about commonly aspirated foods, which of the following foods, if identified by the parents as easily aspirated, would indicate the need for additional teaching?
- A. Popcorn.
- B. Raw vegetables.
- C. Round candy.
- D. Crackers.
Correct Answer: D
Rationale: Popcorn, raw vegetables, and round candy are commonly aspirated due to their size, shape, or texture, posing a choking risk. Crackers, while a potential choking hazard, are less commonly associated with aspiration compared to the others, indicating the parents may need further clarification on specific risks.
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, which of the following descriptions about the stoma's appearance should the nurse include in the teaching?
- A. Becoming dark brown in 2 months.
- B. Appearing moist and pink to red.
- C. Drying out within a few weeks.
- D. Shrinking significantly in size.
Correct Answer: B
Rationale: A healthy stoma is moist and pink to red, indicating good blood supply.