Nokea
Which of the following toys is the most appropriate for a 2-year old with Tetralogy of Fallot?
- A. A toy horn
- B. A stethoscope
- C. A push-pull toy
- D. A shape sorter
Correct Answer: C
Rationale: A push-pull toy encourages gentle physical activity suitable for a 2-year-old with Tetralogy of Fallot, who may tire easily. A toy horn requires exertion, a stethoscope is not age-appropriate, and a shape sorter is sedentary.
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The nurse is caring for a client with hyperosmolar hyperglycemic state (HHS). The nurse should recognize which characteristic is most consistent with HHS?
- A. Abdominal pain
- B. Altered level of consciousness
- C. History of type 1 diabetes
- D. Kussmaul respirations
Correct Answer: B
Rationale: Altered consciousness (B) is a hallmark of HHS due to severe hyperglycemia and dehydration. Abdominal pain (A) and Kussmaul respirations (D) are more typical of DKA, and HHS is associated with type 2 diabetes (C).
The nurse is providing teaching to the parents of a 1-year-old who was just prescribed a 10-day course of amoxicillin for acute otitis media. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.
- A. Give your child over-the-counter decongestants to help speed up recovery'
- B. If your child develops loose stools, please discontinue the antibiotic'
- C. Return to the clinic if your child does not improve within 48-72 hours.'
- D. Stop administering the amoxicillin if your child is feeling better in 5-7 days.'
- E. Your child may need a hearing screening after the ear infection has resolved.'
Correct Answer: C, E
Rationale: Returning if no improvement (C) and hearing screening (E) are appropriate. Decongestants (A) are not recommended, loose stools (B) do not warrant stopping, and stopping early (D) risks resistance.
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- A. Strange bed and surroundings
- B. Separation from parents
- C. Presence of other toddlers
- D. Unfamiliar toys and games
Correct Answer: B
Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.
The nurse is caring for a client with tuberculosis who is on airborne isolation precautions. The nurse can delegate which tasks to experienced unlicensed assistive personnel? Select all that apply.
- A. Alert the x-ray department about maintaining airborne isolation precautions
- B. Explain to the client why the client must wear a mask during transport to another department
- C. Post signs for airborne isolation precautions on the client's door and stock necessary equipment
- D. Remind visitors to wear a respirator mask and keep the door closed while in the client's room
- E. Talk with the family about the reasons for airborne isolation precautions in the client
Correct Answer: C, D
Rationale: Posting signs and stocking equipment (C) and reminding visitors about precautions (D) are within UAP scope. Alerting departments (A), explaining to the client (B), and educating family (E) require nursing judgment.
A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
- A. Touching the abdomen could cause cancer cells to spread.'
- B. Examining the area would cause difficulty to the child.'
- C. Pushing on the stomach might lead to the spread of infection.'
- D. Placing any pressure on the abdomen may cause an abnormal experience.'
Correct Answer: A
Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.