Nokea
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
- A. The child maintains balance when standing with eyes closed.
- B. The child exhibits a gag reflex when stimulated with a tongue blade.
- C. The child correctly identifies specific scents.
- D. The child has symmetrical jaw strength when biting down.
Correct Answer: D
Rationale: The correct answer is D because symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, which controls the muscles of mastication. Choice A relates to the vestibular system, not the trigeminal nerve. Choice B involves the glossopharyngeal and vagus nerves. Choice C is related to the olfactory nerve.
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Which of the following actions should the nurse take first?
- A. Obtain an x-ray of the child's neck.
- B. Administer intravenous antibiotics.
- C. Initiate droplet precautions.
- D. Place intubation equipment at the bedside.
Correct Answer: D
Rationale: The correct action for the nurse to take first is to place intubation equipment at the bedside (Choice D). This is crucial in case the child's condition deteriorates rapidly and respiratory support is needed. Placing the intubation equipment ensures immediate access to airway management, which takes precedence over other actions. Obtaining an x-ray may provide diagnostic information but is not as urgent as ensuring airway patency. Administering antibiotics and initiating droplet precautions (Choice C) are important but not the immediate priority in this scenario. Therefore, Choice D is the correct first action to ensure the child's safety and optimal care.
What is a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux s tachycardia at risk for?
- A. Nephrotic syndrome
- B. Renal Scarring
- C. Polycystic kidney
- D. Acute glomerulonephritis
- E. Pyclonephritis
Correct Answer: B,E
Rationale: The correct answers for a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux at risk for are B: Renal Scarring and E: Pyelonephritis. Vesicoureteral reflux increases the risk of recurrent UTIs, leading to pyelonephritis. Renal scarring can result from repeated pyelonephritis episodes. Nephrotic syndrome (A) is not typically associated with UTIs or reflux. Polycystic kidney (C) is a congenital condition, not related to the scenario. Acute glomerulonephritis (D) is usually caused by post-streptococcal infection, not UTIs.
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
- A. Instruct the parent to ensure the pneumococcal vaccine is current.
- B. Administer folic acid as prescribed.
- C. Monitor oxygen saturation continuously.
- D. Place the client on strict bed rest.
- E. Apply cold compresses to the affected joints.
- F. Administer meperidine IV for pain.
Correct Answer: B,C,E,F,H
Rationale: The correct interventions for the adolescent are B, C, E, F, and H. Administering folic acid (B) is important for growth and development. Monitoring oxygen saturation (C) ensures respiratory function. Applying cold compresses (E) helps reduce inflammation in affected joints. Administering meperidine IV (F) addresses pain management. The rationale for excluding other choices: A is irrelevant for adolescent care, D may worsen joint symptoms, and G is incomplete.
Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.
Which of the following information should the nurse include in the teaching?
- A. Provide for periods of rest.
- B. Increase the child's oxygen flow rate until the child no longer has cyanosis.
- C. Withhold digoxin if the child's pulse is greater than 100/min.
- D. Weigh the child once each month.
Correct Answer: A
Rationale: Correct Answer: A - Provide for periods of rest.
Rationale: It is important for the nurse to include information about providing periods of rest in the teaching because rest is essential for recovery and healing. Rest allows the body to conserve energy, reduce stress, and promote overall well-being. By including this information, the nurse is promoting the child's health and supporting the healing process.
Summary of other choices:
B: Increasing oxygen flow rate until cyanosis resolves can lead to oxygen toxicity and is not a safe or appropriate intervention.
C: Withholding digoxin based solely on pulse rate without considering other factors or consulting the healthcare provider can be dangerous and potentially harmful.
D: Weighing the child once a month is important for monitoring growth and nutrition, but it is not directly related to the immediate care and teaching needed in this scenario.