Nokea
While assessing a preschooler brought by her parents to the emergency department after ingestion of kerosene, the nurse should be alert for which of the following?
- A. Uremia.
- B. Hepatitis.
- C. Carditis.
- D. Pneumonitis.
Correct Answer: D
Rationale: Kerosene ingestion often causes chemical pneumonitis due to aspiration risk. Uremia, hepatitis, and carditis are not common complications.
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When discussing the onset of adolescence with parents, the nurse explains that it occurs at which of the following times?
- A. Same age for both boys and girls.
- B. 1 to 2 years earlier in boys than in girls.
- C. 1 to 2 years earlier in girls than in boys.
- D. 3 to 4 years later in boys than in girls.
Correct Answer: C
Rationale: Girls typically enter puberty 1-2 years earlier than boys, around ages 10-12.
A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see figure). The nurse should do which of the following?
- A. Reposition the infant to the left side.
- B. Ask the parents to put the infant back in his crib.
- C. Remind the parents that the infant cannot use a pacifier now.
- D. Tell the parents they have positioned their infant correctly.
Correct Answer: D
Rationale: An infant seat is appropriate for a 6-month-old post-pyloromyotomy, supporting recovery and comfort.
When explaining to the parents of a child with a hydrocele about the possible cause of the condition, the nurse bases this explanation on the interpretation that a hydrocele is most likely the result of which condition?
- A. Blockage in the inguinal canal that allows fluid to accumulate in epididymis and ductus deferens.
- B. Failure of the upper part of the processus vaginalis to atrophy, allowing accumulation of fluid in the testicle and the peritoneal cavity.
- C. A patent processus vaginalis that results in the collection of fluid along the spermatic cord or tunica vaginalis of the testicle.
- D. An obliterated processus vaginalis that allows fluid to accumulate in the scrotal sac.
Correct Answer: C
Rationale: Patent processus vaginalis leads to fluid collection.
After placing an infant with myelomeningocele in an isolette shortly after birth, which indicator should the nurse use as the best way to determine the effectiveness of this intervention?
- A. The partial pressure of arterial oxygen remains between 94 and 100 mm Hg.
- B. The axillary temperature remains between 97° and 98°F (36.1° and 36.7°C).
- C. The respiratory rate remains within normal limits.
- D. The heart rate remains stable.
Correct Answer: B
Rationale: The isolette maintains a stable thermal environment. Monitoring axillary temperature ensures the infant is normothermic, indicating the isolette's effectiveness.
Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which of the following clinical finding?
- A. A urine output of 60 mL in 4 hours.
Correct Answer: A
Rationale: urine output of 60 mL in 4 hours is adequate (1 mL/kg/hr for a 15-kg child is 15 mL/hr, or 60 mL in 4 hours). No other findings are provided, so no notification is needed.