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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 safety measures should the nurse include in the teaching?
- A. Check clothing for loose buttons.
- B. Adjust the water heater temperature to 54° C (129.2° F).
- C. Place screens on all windows.
- D. Provide balloons for play.
Correct Answer: A
Rationale: The correct answer is A: Check clothing for loose buttons. This safety measure is important to prevent choking hazards in children. Loose buttons can easily come off and be swallowed. B is incorrect as the recommended water heater temperature is 49°C (120°F) to prevent scalding. C is irrelevant to the safety of a child's clothing. D is incorrect as balloons pose a choking hazard.
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 statements should the nurse include?
- A. Your child will have chest x-rays periodically to monitor for disease reactivation.
- B. Your child might need to have their tonsils and adenoids removed.
- C. Your child should take pancreatic enzymes with meals and snacks.
- D. Your child will take isoniazid for 9 months.
Correct Answer: C
Rationale: The correct answer is C: Your child should take pancreatic enzymes with meals and snacks. This is the correct statement to include because it pertains to the management of cystic fibrosis, a condition that affects the pancreas' ability to produce digestive enzymes. Pancreatic enzymes help in digesting food properly, ensuring proper nutrient absorption.
Choice A is incorrect as chest x-rays are not typically used for monitoring cystic fibrosis. Choice B is incorrect as tonsil and adenoid removal is not a standard treatment for cystic fibrosis. Choice D is incorrect as isoniazid is a medication used to treat tuberculosis, not cystic fibrosis.
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 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.