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Which of the following is a normal response from an adolescent who has just returned to her room after an appendectomy?
- A. I'll need plastic surgery for this scar.
- B. I'm worried about the size of my scar.
- C. I don't want to have any pain.
- D. What will my boyfriend say about the scar?
Correct Answer: B
Rationale: Concern about scar size is a typical adolescent response, reflecting body image concerns.
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A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to:
- A. Observe the child closely.
- B. Allow the child to participate in activities that will not tire him.
- C. Provide for adequate periods of rest between activities.
- D. Encourage someone in the family to be with the child 24 hours a day.
Correct Answer: C
Rationale: Rest is critical in rheumatic fever to reduce cardiac strain and prevent complications like carditis. Observation and limited activities are important, but rest is the priority.
After insertion of bilateral tympanostomy tubes in a toddler, which of the following instructions should the nurse include in the child's discharge plan for the parents?
- A. Insert ear plugs into the canals when the child bathes.
- B. Blow the nose forcibly during a cold.
- C. Administer the prescribed antibiotic while the tubes are in place.
- D. Disregard any drainage from the ear after 1 week.
Correct Answer: C
Rationale: Administering prescribed antibiotics as directed is crucial to prevent infection after tympanostomy tube insertion. Ear plugs are not typically recommended, as they can introduce bacteria. Forcibly blowing the nose can disrupt the tubes, and any drainage after 1 week should be reported, not disregarded.
The nurse is caring for a child with osteomyelitis who will be receiving high-dose intravenous antibiotic therapy for 3 to 4 weeks. What should the nurse plan to monitor?
- A. Blood glucose level.
- B. Thrombin times.
- C. Urine glucose level.
- D. Urine specific gravity.
Correct Answer: D
Rationale: Urine specific gravity should be monitored to assess hydration status, as prolonged antibiotic therapy can affect renal function.
Which assessment finding in an infant with colic should the nurse prioritize?
- A. Frequent spitting up.
- B. Crying for 3 hours daily.
- C. Weight gain below average.
- D. Fever of 100.4°F.
Correct Answer: D
Rationale: Fever suggests an underlying illness, requiring urgent evaluation. Prolonged crying is typical of colic, but spitting up and slow weight gain are less acute concerns.
As part of a health education program, the nurse teaches a group of parents CPR. The nurse determines the teaching has been effective when a parent states:
- A. If I am by myself, I should call for help before starting CPR.
- B. I should compress the chest using 2-3 fingers.
- C. I should deliver chest compression at a rate of 100 per minute.
- D. If I can't get the breaths to make the chest rise, I should administer abdominal thrusts.
Correct Answer: A
Rationale: Calling for help before starting CPR when alone ensures timely emergency response, which is critical for improving outcomes.