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While checking the vital signs of a 10-year-old child who underwent a tonsillectomy earlier in the day, the nurse notices the child swallowing every 2 to 3 minutes. What action should the nurse take next?
- A. Check for signs of teeth clenching or grinding
- B. Inspect the back of the throat
- C. Stimulate the gag reflex by touching the tonsillar pillars
- D. Ask the child to speak to assess for any changes in voice tone .
Correct Answer: B
Rationale: Frequent swallowing may indicate post-tonsillectomy bleeding, requiring throat inspection.
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Which snack choice by a school-aged child with gastroesophageal reflux indicates to the nurse that the child understands the dietary restrictions?
- A. Chocolate milkshake
- B. Sugar cookies
- C. Tacos
- D. Pizza
Correct Answer: B
Rationale: Sugar cookies are less likely to trigger GERD symptoms compared to high-fat or acidic foods.
The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?
- A. Obtain point-of-care glucose.
- B. Assess urine for ketones.
- C. Check blood pressure.
- D. Review prior insulin prescriptions.
Correct Answer: A
Rationale: Symptoms suggest hyperglycemia; point-of-care glucose testing confirms this and guides treatment.
The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving the client?
- A. Flex the knees.
- B. Raise the hips.
- C. Cross the arms and legs.
- D. Perform a log roll.
Correct Answer: D
Rationale: Log rolling maintains spinal alignment, protecting the surgical site during movement.
A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?
- A. Fecal-fat test.
- B. Sweat-chloride test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: B
Rationale: The sweat-chloride test is the standard screening for cystic fibrosis due to elevated salt levels in sweat.
An adolescent client reports to the nurse of walking with a limp due to pain localized in the right knee which worsens at night but denies any recent injury or trauma. The nurse observes swelling and tenderness in the right lower thigh and imaging results reveal radial ossification in the soft tissues. What condition should the nurse consider as the probable cause of the findings?
- A. Osteosarcoma
- B. Hemosiderosis
- C. Growing pains
- D. Rhabdomyolysis
Correct Answer: A
Rationale: Symptoms and radial ossification suggest osteosarcoma, a common bone tumor in adolescents.