Nokea
Which of the following should the nurse expect to include in the plan of care for a child who is diagnosed with rheumatic fever and carditis and admitted to the hospital?
- A. Ensuring continuous parental presence at the child's bedside.
- B. Providing the child with periods of rest.
- C. Encouraging participation in age-appropriate activities.
- D. Advising the child to eat as much as possible.
Correct Answer: B
Rationale: Rest is essential in rheumatic fever with carditis to minimize cardiac workload and prevent further damage. Other options are supportive but not the priority.
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An 18-year-old high school senior wishes to obtain birth control through her parents' insurance but doesn't want this information disclosed. The nurse tells the client that under the Health Information Portability and Accountability Act (HIPAA) parents:
- A. Have the right to review a minor's medical records until high school graduation.
- B. Have the right to review a minor's medical record if they are responsible for the payment.
- C. May not view the medical record, but may learn of the visit through the insurance bill.
- D. May not view the minor's medical record or the insurance bill.
Correct Answer: C
Rationale: HIPAA protects the minor's privacy, but insurance billing may disclose the visit.
Which of the following foods should the nurse encourage the mother to offer to her child with iron deficiency anemia?
- A. Rice cereal, whole milk, and yellow vegetables.
- B. Potato, peas, and chicken.
- C. Macaroni, cheese, and ham.
- D. Pudding, green vegetables, and rice.
Correct Answer: B
Rationale: Chicken and peas are iron-rich, supporting anemia treatment. Other options lack sufficient iron sources.
Initiation of which of the following immunizations is recommended prior to the adolescent entering college?
- A. Diphtheria, tetanus, and acellular pertussis (DTaP).
- B. Varicella.
- C. Meningococcal.
- D. Pneumococcal conjugate vaccine (PCV).
Correct Answer: C
Rationale: Meningococcal vaccine is recommended before college due to increased risk in dormitories.
A child with spastic cerebral palsy is to begin botulinum toxin type A (Botox) injections. Which treatment goals should the health care team set for the child related to Botox? Select all that apply.
- A. Improved nutritional status.
- B. Improved motor function.
- C. Enhanced self-esteem.
- D. Reduced caregiver strain and improved selfcare.
- E. Decreased speech impediments.
Correct Answer: B,D
Rationale: Botox injections in spastic cerebral palsy aim to reduce muscle spasticity, improving motor function and easing caregiving tasks, thus reducing caregiver strain.
The nurse is assisting with conscious sedation for a 6-year-old undergoing a bone marrow biopsy. The nurse's most important responsibility during the procedure is to:
- A. Administer the topical anesthetic.
- B. Keep the parents informed.
- C. Monitor the client.
- D. Record the procedure.
Correct Answer: C
Rationale: Monitoring the child during conscious sedation ensures safety, detecting respiratory or cardiovascular changes promptly.