Nokea
Which of the following outcomes indicates that the activity restriction necessary for a 7 -year-old child with rheumatic fever during the acute phase has been effective?
- A. Joints demonstrate absence of permanent injury.
- B. The resting heart rate is between 60 and 100 bpm.
- C. The child exhibits a decrease in chorea movements.
- D. The subcutaneous nodules over the joints are no longer palpable.
Correct Answer: B
Rationale: A normal resting heart rate (60-100 bpm) indicates reduced cardiac strain, showing effective activity restriction. Other outcomes are relevant but less directly tied to activity restriction.
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The school nurse develops a plan with an adolescent to provide relief of dysmenorrhea to aid in her development of which of the following?
- A. Positive peer relations.
- B. Positive self-identity.
- C. A sense of autonomy.
- D. A sense of independence.
Correct Answer: C
Rationale: Managing dysmenorrhea supports autonomy by empowering the adolescent to control her health.
The nurse is transferring a child who has had open heart surgery from the pediatric intensive care unit to the pediatric unit. The child's blood pressure has been fluctuating but has been stable during the last 2 hours. The nurse from the pediatric intensive care unit should include which of the following information in the report to the nurse on the pediatric unit?
- A. Medications being used.
- B. Current vital signs.
- C. Potential for blood pressure to drop.
- D. Drip rate for the intravenous infusion.
- E. Time of the most recent dose of pain medication.
Correct Answer: A,B,C,D,E
Rationale: All listed information is critical for continuity of care, ensuring the receiving nurse can monitor and manage the child's condition effectively.
The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which of the following activities should the nurse and family decide the child should avoid?
- A. Rock climbing.
- B. Hiking.
- C. Swimming.
- D. Tennis.
Correct Answer: C
Rationale: Swimming poses a drowning risk during a seizure; it should be avoided unless closely supervised.
The mother of a child with chronic renal failure who is receiving peritoneal dialysis at home asks the nurse what she can do if both inflow and drain times are increased. Which of the following instructions would be most appropriate for the nurse to include when responding to the mother?
- A. Assess the child for constipation.
- B. Decrease the amount of dialysate infused for each dwell.
- C. Incorporate the increased inflow and drain times into the dialysis schedule.
- D. Monitor the child for shoulder pain during inflow and drain times.
Correct Answer: A
Rationale: Constipation can affect dialysis flow.
The nurse is caring for a 5-year-old boy who is taking prednisolone for nephrotic syndrome. The child is at the 75th percentile for height and has a blood pressure of 114/73. The nurse compares the reading to the below blood pressure levels for boys age and height percentiles. The nurse determines that the blood pressure represents a change and notifies the primary care provider of the assessment of:
- A. Hypotension.
- B. Prehypertension.
- C. Hypertension.
- D. Hypertension stage II.
Correct Answer: C
Rationale: BP indicates hypertension.