Nokea
While assessing the penis of a child who has had surgery for repair of a hypospadias, the nurse observes the appearance of the penis. The nurse should report which aspect to the surgeon?
- A. Swollen.
- B. Dusky blue at the tip.
- C. Somewhat misshapen.
- D. Pink.
Correct Answer: B
Rationale: Dusky coloration may indicate compromised circulation.
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The nurse mentions that a group meeting for mothers of mentally retarded children is to be held soon. 'Not retarded!' the child's mother angrily blazes, 'Exceptional.' When responding to this outburst, which of the following replies by the nurse would be most appropriate?
- A. Retarded' is the commonly used and accepted term.'
- B. I'm sorry if I offended you by my thoughtless remark.'
- C. No matter what it's called, the condition is still the same, isn't it?'
- D. I'd like to hear more of your thoughts and feelings on that.'
Correct Answer: D
Rationale: Inviting the mother to share her feelings promotes therapeutic communication and addresses her emotional response sensitively.
Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?
- A. Abdomen appears slightly rounded.
- B. Bowel sounds are heard twice in 2 minutes.
- C. All four abdominal quadrants reveal tympany.
- D. The client demonstrates a cremasteric reflex.
Correct Answer: B
Rationale: Decreased bowel sounds suggest appendicitis due to peritoneal irritation.
After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the father states which of the following?
- A. There is no rectal opening for stool to pass.
- B. There is a tube between the trachea and esophagus.
- C. The nerves at the end of the large colon are missing.
- D. The muscle below the stomach is too tight.
Correct Answer: C
Rationale: Hirschsprung's disease is characterized by absent nerve cells in the distal colon.
After teaching the mother of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, the mother indicates that she understands her child's prognosis when she states which of the following?
- A. My child will need to wear protective pads until puberty.
- B. My child will need extra fluids to prevent constipation.
- C. My child will probably always need a high-fiber diet.
- D. My child has a good chance of being potty trained.
Correct Answer: D
Rationale: Low anorectal anomalies often have a good prognosis for continence with proper management.
A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child?
- A. Preventing siblings from being in close contact.
- B. Sending the child to day care as usual.
- C. Playing video games for several hours each evening.
- D. Playing with the child every day.
Correct Answer: D
Rationale: Playing with the child daily promotes emotional bonding and normal development, which is critical for a 9-month-old. Preventing sibling contact is unnecessary unless siblings are ill, day care may risk further infection, and video games are inappropriate for an infant.