Nokea
Which situation would cause the nurse to suspect a hearing impairment?
- A. 3-month-old infant with a positive Moro (startle reaction) reflex
- B. 15-month-old toddler who is babbling
- C. 18-month-old toddler who is speaking one-syllable words
- D. 24-month-old toddler who communicates by pointing
Correct Answer: D
Rationale: The child who is not making verbal attempts by 24 months should undergo a complete physical examination.
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Which aspect(s) of a child's development does the nurse caution parents that hearing impairment can affect? (Select all that apply.)
- A. Speech clarity
- B. Language development
- C. Immunity to disease
- D. Personality development
- E. Academic achievement
Correct Answer: A,B,D,E
Rationale: All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.
An adolescent has just had a generalized seizure and collapsed in the school nurse's office. When should the nurse should call 911?
- A. The seizure lasts more than 5 minutes.
- B. The child is sleepy and lethargic after the seizure.
- C. The child vomited at the onset of the seizure.
- D. The child is confused and has slurred speech after the seizure.
Correct Answer: A
Rationale: If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.
A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect?
- A. Meningitis
- B. Reye's syndrome
- C. Brain tumor
- D. Encephalitis
Correct Answer: C
Rationale: The signs and symptoms of a brain tumor are related to its size and location, creating increased intracranial pressure with hallmark symptoms of headache, vomiting, drowsiness, and seizures.
Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which statement by the parents alerts the nurse they need further instruction?
- A. We dress our son every morning for school.'
- B. Our son participates in the Special Olympics every year.'
- C. Our son attends play therapy at a center close to home.'
- D. We attend a support group once a week.'
Correct Answer: A
Rationale: The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should not 'take over' projects.
What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?
- A. The medication should be given on an empty stomach.
- B. Insomnia can be a significant side effect.
- C. Gums should be massaged regularly to prevent hyperplasia.
- D. Blood pressure should be closely monitored.
Correct Answer: C
Rationale: Dilantin can cause gum overgrowth, which can be minimized by regular massaging.