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While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child's left thigh is swollen. What should the nurse do next?
- A. Assess the neurologic status of the toes.
- B. Determine the circulatory status of the upper thigh.
- C. Obtain the child's vital signs.
- D. Notify the physician immediately.
Correct Answer: D
Rationale: Swelling, pain, and refusal to walk suggest a serious injury, possibly a fracture, requiring immediate physician notification.
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A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is an order to administer Tylenol with Codeine every 3 to 4 hours as needed. The nurse is beginning the shift and reviews the chart below for pain history. Based on the information in the chart, what should the nurse do next?
- A. Administer the Tylenol with Codeine.
- B. Distract the child by giving him breakfast.
- C. Instruct the child to take deep breaths and blow his pain away.
- D. Assess the child again in 1 hour.
Correct Answer: A
Rationale: The FACES score of 4 at 7:00 am indicates pain, and it's been 6 hours since the last dose, warranting medication.
When explaining the plan of care to the parents of an infant with an undescended testis, the nurse should tell the parents about which of the following as a nonsurgical treatment method?
- A. A trial of human chorionic gonadotrophic hormone.
- B. A trial of adrenocorticotropic hormone.
- C. Frequent stimulation of the cremasteric reflex.
- D. Use of several warm baths each day.
Correct Answer: A
Rationale: hCG can stimulate testicular descent in some cases.
Which of the following should the nurse include in the plan of care for an infant with severe diarrhea to prevent skin breakdown?
- A. Changing diapers every 4 hours.
- B. Applying a petroleum-based ointment.
- C. Using harsh soaps for cleaning.
- D. Keeping the skin exposed to air.
Correct Answer: B
Rationale: Petroleum-based ointment protects the skin from irritation due to frequent stools.
Which of the following should the nurse include in the teaching plan for a child with iron deficiency anemia to increase iron absorption?
- A. Administer iron supplements with milk.
- B. Take iron supplements between meals.
- C. Avoid eating green leafy vegetables.
- D. Limit intake of citrus fruits.
Correct Answer: B
Rationale: Taking iron supplements between meals enhances absorption, as food, especially milk, can interfere. Citrus fruits and leafy greens support absorption.
Which of the following foods should the nurse encourage the mother to offer to her child with iron deficiency anemia?
- A. Rice cereal, whole milk, and yellow vegetables.
- B. Potato, peas, and chicken.
- C. Macaroni, cheese, and ham.
- D. Pudding, green vegetables, and rice.
Correct Answer: B
Rationale: Chicken and peas are iron-rich, supporting anemia treatment. Other options lack sufficient iron sources.