Nokea
Which of the following statements made by the mother of a school-age child who has had a craniotomy for a brain tumor would warrant further exploration by the nurse?
- A. After this, I'll never let her out of my sight again.'
- B. I hope that she'll be able to go back to school soon.'
- C. I wonder how long it will be before she can ride her bike.'
- D. Her best friend is eager to see her; I hope she won't be upset.'
Correct Answer: A
Rationale: Overprotectiveness may indicate anxiety or maladaptive coping, requiring further exploration to support the mother's emotional adjustment.
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A mother states that she thinks her 9-month-old 'is developing slowly.' When assessing the infant's development, the nurse is also concerned because the infant should be demonstrating which of the following characteristics?
- A. Vocalizing single syllables.
- B. Standing alone.
- C. Building a tower of two cubes.
- D. Drinking from a cup with little spilling.
Correct Answer: C
Rationale: Building a tower of two cubes is expected by 9 months; failure to do so suggests developmental delay.
The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?
- A. Standard precautions.
- B. Contact precautions.
- C. Airborne precautions.
- D. Droplet precautions.
Correct Answer: D
Rationale: Bacterial meningitis, such as meningococcal, requires droplet precautions due to transmission via respiratory secretions.
An adolescent male client scheduled for an emergency appendectomy is to be transferred directly from the emergency room to the operating room. Which of the following statements by the client should the nurse interpret as most significant?
- A. I'm scared about the surgery.
- B. I need to call my parents first.
- C. My pain is getting worse.
- D. I don't want to have a scar.
Correct Answer: C
Rationale: Worsening pain may indicate perforation, requiring urgent attention.
The mother of a 4-year-old expresses concern that her child may be hyperactive. She describes the child as always in motion, constantly dropping and spilling things. Which of the following actions would be appropriate at this time?
- A. Determine whether there have been any changes at home.
- B. Explain that this is not unusual behavior.
- C. Explore the possibility that the child is being abused.
- D. Assess that the child be seen by a pediatric neurologist.
Correct Answer: A
Rationale: Assessing home changes helps identify triggers for the behavior before assuming pathology.
An adolescent tells the nurse that the area below his knee has been hurting for several weeks. The nurse should obtain history information about participation in which of the following?
- A. Soccer.
- B. Golf.
- C. Diving.
- D. Swimming.
Correct Answer: A
Rationale: Pain below the knee in adolescents is often associated with Osgood-Schlatter disease, which is common in sports like soccer that involve repetitive knee stress.