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Which suggestion by the nurse would be most helpful in relieving the teenager's menstrual pain and discomfort?
- A. Stay in bed until cramping is relieved, increase your fluid intake, and eat a low-fat diet.
- B. Drink plenty of cold liquids, add extra salt to your diet, and take a nap in the afternoon.
- C. Apply ice packs to the abdomen, eat a high-calorie diet, and have your largest meal at noon.
- D. Get at least 8 hours of sleep, eat a well-balanced diet, and apply heat to your abdomen.
Correct Answer: D
Rationale: Applying heat to the abdomen relaxes uterine muscles, reducing cramping, while adequate sleep and a balanced diet support overall health, alleviating dysmenorrhea symptoms.
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Which of the following assessment findings would alert the nurse that the child may be exhibiting early signs of sepsis?
- A. Increased level of pain
- B. Disorientation
- C. Decreased urine output
- D. Jitteriness
Correct Answer: B
Rationale: Disorientation can indicate early sepsis in burn patients, reflecting systemic infection affecting the central nervous system. Other signs like fever or tachycardia may also occur, but disorientation is a critical early warning.
The parents of the child with juvenile rheumatoid arthritis (JRA) ask the nurse why the child cannot have aspirin. The parents further explain that they have heard that aspirin is used in the elderly for arthritis and the use of the patients. The nurse correctly explains that children with JRA are given different medications than adults with arthritis and explains that the toxic effects of aspirin include which manifestations?
- A. Constipation, weight gain, and fluid retention
- B. Ringing in the ears, nausea, and vomiting
- C. Anorexia, weight loss, and double vision
- D. Headache, dry mouth, and dental cavities
Correct Answer: B
Rationale: Aspirin in children can cause toxicity, including ringing in the ears (tinnitus), nausea, and vomiting, and is avoided due to the risk of Reye's syndrome, especially in children with viral infections.
The nurse is concerned that a newborn may have congenital hydrocephalus. Which finding did the nurse likely observe on assessment?
- A. Bulging anterior fontanel
- B. Head and chest circumference equal
- C. A narrowed posterior fontanel
- D. Low-set ears
Correct Answer: A
Rationale: A bulging anterior fontanel suggests hydrocephalus due to increased intracranial pressure. Equal head/chest circumferences narrow posterior fontanel and low-set ears are normal or unrelated.
The nurse reviews the labor and delivery record of the 2-hour-old male newborn and sees this notation: “40 weeks’ gestation,large for gestational (LGA) age.” In response to this information it is most important for the nurse to plan to assess the infant carefully for which condition?
- A. Acrocyanosis
- B. Undescended testicles
- C. Intact clavicles
- D. Hypothermia
Correct Answer: C
Rationale: LGA infants risk birth trauma like fractured clavicles due to macrosomia. Acrocyanosis is normal testicles are typically descended at term and LGA infants are less prone to hypothermia.
Maximum normal time for second stage of labour in primigravida without anaesthesia is about:
- A. 20 minutes.
- B. 60 minutes.
- C. 120 minutes.
- D. 240 minutes.
- E. There is no normal maximum.
Correct Answer: C
Rationale: The second stage in primigravida without anesthesia is typically up to 2 hours (120 minutes). Beyond this intervention is considered due to risks of maternal or fetal distress.