Nokea
Which statement by the parents best indicates that the nurse's teaching has been effective?
- A. We'll give our child the penicillin for the full 10 days.
- B. We will keep our child at home until fully recovered.
- C. We will make sure that our child stays out of the sun with being treated.
- D. We'll notify the physician if our child has a sore throat.
Correct Answer: D
Rationale: Effective teaching about rheumatic fever emphasizes preventing recurrent streptococcal infections, which can trigger relapse. Notifying the physician about a sore throat ensures prompt treatment of potential streptococcal infections, reducing recurrence risk.
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Which explanation by the nurse is most accurate?
- A. Your child's condition, which involves a 35-degree curvature, may improve without treatment.
- B. Your child may develop problems with bladder control without treatment.
- C. Your child may develop problems with bowel control without treatment.
- D. Your child may develop breathing problems without treatment.
Correct Answer: D
Rationale: A 35-degree scoliosis curvature is significant and, without treatment, may progress, potentially compressing the lungs and causing breathing difficulties.
The agitated father of the 12-hour-old newborn reports to the nurse that his baby’s hands and feet are blue. The nurse confirms acrocyanosis and intervenes by taking which action?
- A. Immediately stimulates the infant to cry
- B. Explain that this is normal in a newborn
- C. Assess the newborn’s temperature
- D. Assess the newborn’s cardiac status
Correct Answer: B
Rationale: Acrocyanosis blueness of hands and feet is a normal newborn phenomenon in the first 24 to 48 hours after birth. The nurse should explain this to relieve anxiety. Stimulation temperature or cardiac assessments are unnecessary.
If the following snacks are available, which one is best to meet the child's need for protein?
- A. Strawberry milkshake
- B. A popsicle stick with cinnamon
- C. Cubes of flavored gelatin
- D. Warmed beef broth
Correct Answer: D
Rationale: Warmed beef broth is a high-protein snack suitable for a burn patient, providing protein needed for tissue repair and wound healing, unlike the other options, which are lower in protein.
The parents are visiting their newborn,who is in the neonatal intensive care unit (NICU) after being diagnosed with a terminal cardiac condition. Which statement best reflects the nurse’s judgment about interventions to promote parental attachment?
- A. Interventions should be delayed until it is certain that the newborn will live.
- B. The parents should be encouraged to provide as much care as possible.
- C. The parents should only be encouraged to touch and name their newborn.
- D. The parents should be assured that they did not do anything to cause this condition.
Correct Answer: B
Rationale: Encouraging parents to provide care promotes attachment aiding coping if the infant dies. Delaying interventions limiting to touch/naming or assuming guilt are less supportive.
Which assessment finding should the nurse report immediately to the charge nurse or physician?
- A. Clear, watery nasal drainage
- B. Glasgow Coma Scale score of 15
- C. Child does not know the time of day
- D. Apical pulse of 80 beats/minute
Correct Answer: A
Rationale: Clear, watery nasal drainage may indicate cerebrospinal fluid (CSF) leakage, a serious complication of head injury requiring immediate reporting to prevent infection or neurological damage.