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Which of the following findings should the nurse report to the provider?
- A. An 18-month-old toddler who has a heart rate of 68/min
- B. A school-age child who has a rectal body temperature of 37.3° C (99.1° F)
- C. An adolescent who has a BP of 132/82 mm Hg
- D. A 3-month-old infant who has a respiratory rate of 30/min
Correct Answer: A
Rationale: The correct answer is A: An 18-month-old toddler who has a heart rate of 68/min. This finding should be reported to the provider because a heart rate of 68/min in an 18-month-old toddler is below the normal range for that age group, which is typically around 100-130/min. This could indicate bradycardia, which may be a sign of an underlying health issue that requires further evaluation and intervention. Reporting this abnormal finding promptly can help the provider assess the toddler's cardiovascular health and determine appropriate management.
The other choices are within normal ranges for their respective age groups:
B: A school-age child with a rectal temperature of 37.3°C (99.1°F) is within the normal range.
C: An adolescent with a blood pressure of 132/82 mm Hg is within the normal range for that age group.
D: A 3-month-old infant with a respiratory rate of 30/min is within the normal
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Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child might experience mood swings.
- B. I should take my child to the clinic for a weekly blood test.
- C. I should withhold my child's medication before physical activity.
- D. My child might have a decreased appetite.
Correct Answer: A
Rationale: The correct answer is A: "My child might experience mood swings." This statement shows understanding as mood swings can be a side effect of the medication being discussed. It demonstrates awareness of potential effects and indicates readiness to handle them. Choice B is incorrect as weekly blood tests are not typically necessary. Choice C is incorrect as withholding medication before physical activity can be dangerous. Choice D is incorrect as a decreased appetite is not a common side effect.
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.
Which of the following findings should the nurse expect?
- A. Cyanosis
- B. Weight loss
- C. Bounding peripheral pulses
- D. Dyspnea
- E. Tachycardia
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Cyanosis indicates poor oxygenation, dyspnea signifies difficulty in breathing, and tachycardia suggests an increased heart rate to compensate for decreased oxygen levels. Weight loss and bounding peripheral pulses are not typical findings in a patient with impaired oxygenation. In summary, the nurse should expect cyanosis, dyspnea, and tachycardia as key findings in a patient with compromised oxygenation.
Which of the following actions is appropriate for the nurse to take?
- A. Obtain written consent from the client.
- B. Request verbal consent from the social worker.
- C. Contact the client's parents to obtain phone consent.
- D. Postpone the testing until the client's parents are present.
Correct Answer: A
Rationale: Correct Answer: A. Obtain written consent from the client.
Rationale: Written consent from the client is essential to ensure autonomy and informed decision-making. It shows respect for the client's rights and allows them to fully understand the procedure or treatment. Verbal consent may not provide a legal record of agreement. Contacting the client's parents without the client's consent may violate confidentiality and autonomy. Postponing testing can delay necessary healthcare. Written consent is the most appropriate choice to uphold ethical and legal standards in healthcare practice.
The child's parents ask for information on hemodialysis. Which of the following statements should the nurse make?
- A. Hemodialysis uses your child's abdominal cavity as a membrane to clean their blood.
- B. Hemodialysis uses an electrolyte solution to clean your child's blood.
- C. Hemodialysis uses an artificial membrane outside the body to clean your child's blood.
- D. Hemodialysis slowly filtrates your child's blood continuously.
Correct Answer: C
Rationale: The correct answer is C. Hemodialysis uses an artificial membrane outside the body to clean the child's blood. This is because hemodialysis involves the process of blood being filtered through a machine that uses a synthetic membrane to remove wastes and excess fluids. This process mimics the function of the kidneys in filtering the blood.
Choice A is incorrect because hemodialysis does not use the abdominal cavity as a membrane, it uses an external artificial membrane. Choice B is incorrect as hemodialysis does not involve the use of an electrolyte solution to clean the blood. Choice D is incorrect because hemodialysis is not a continuous filtration process, it is done intermittently during treatment sessions.