Nokea
A mother brings her 17-month-old son to the well-baby clinic for a routine check-up. She confides to the nurse that she is concerned because her son sucks his thumb, especially at night when he is put to bed.
Which of the suggestions by the nurse would be BEST?
- A. If you want the behavior to stop put a negative reinforcer, such as red pepper, on this thumb.'
- B. Don't intervene at this time. This behavior usually subsides after 24 months of age.'
- C. What you are seeing is a common form of self-stimulation. You should discourage this behavior.'
- D. This behavior will cause malformation of his teeth. You should wrap his thumb at bedtime.'
Correct Answer: B
Rationale: Strategy: 'BEST' indicates there may be more than one correct response. Remember growth and development concepts. (1) controversial treatment for an older child (2) correct-normal behavior, peaks at 18-20 months, most prevalent when child is hungry or tired (3) normal behavior in child this age, should not be discouraged (4) malocclusion occurs if thumb sucking persists past 4 years old or when permanent teeth erupt
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The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?
- A. Fish sticks, french fries, banana, cookies, milk
- B. Ground beef patty, lima beans, wheat roll, raisins, milk
- C. Chicken nuggets, macaroni, peas, cantaloupe, milk
- D. Peanut butter and jelly sandwich, apple slices, milk
Correct Answer: B
Rationale: Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice. It is high in iron and is appropriate for a toddler.
The nurse is caring for a client who is receiving a continuous IV infusion of nitroglycerin for chest pain. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 100/60 mmHg
- B. Heart rate of 80 bpm
- C. Respiratory rate of 18 breaths/min
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: Hypotension (100/60 mmHg) is a serious nitroglycerin side effect, risking inadequate perfusion. Options B, C, and D are normal findings.
Which contraindication should the nurse assess for prior to giving a child immunizations?
- A. Mild cold symptoms
- B. Chronic asthma
- C. Depressed immune system
- D. Allergy to eggs
Correct Answer: C
Rationale: Depressed immune system. Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.
The nurse is caring for a client with a history of glaucoma.
- A. Which instruction should the nurse include for a client with glaucoma using timolol eye drops?
- B. Apply pressure to the inner canthus after instillation.
- C. Administer the drops at bedtime only.
- D. Use the drops only when symptoms occur.
- E. Cleanse the eye with saline before instillation.
Correct Answer: A
Rationale: Applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of timolol, reducing side effects like bradycardia. Drops are used regularly, not symptom-based, and cleansing is unnecessary unless debris is present.
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- A. Which dietary instruction is most appropriate for a client with peptic ulcer disease?
- B. Avoid spicy foods and caffeine.
- C. Eat large meals three times daily.
- D. Consume high-fat foods to coat the stomach.
- E. Drink alcohol in moderation.
Correct Answer: A
Rationale: Avoiding spicy foods and caffeine reduces gastric irritation in peptic ulcer disease. Small, frequent meals are preferred, high-fat foods delay healing, and alcohol exacerbates ulcers.