Nokea
While making rounds, the nurse observes the following client behaviors. Which child should the nurse further evaluate for postoperative pain?
- A. The 6-month-old in deep sleep
- B. The 2-year-old who is cooperative when the nurse takes vital signs
- C. The 4-year-old who is actively watching cartoons
- D. The 14-month-old who is screaming and thrashing his arms and legs
Correct Answer: D
Rationale: The correct answer is D because screaming and thrashing his arms and legs are indicative behaviors of discomfort or pain in young children. The child's actions suggest a higher likelihood of experiencing postoperative pain and necessitate further evaluation. Choices A, B, and C do not exhibit overt signs of distress or discomfort associated with pain, making them less likely candidates for postoperative pain assessment.
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The nurse is preparing to feed a 10-month-old child diagnosed with failure to thrive (FTT). Which actions should the nurse plan to implement?
- A. Be persistent.
- B. Introduce new foods slowly.
- C. All are correct
- D. Maintain a calm, even temperament.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.)
- A. Oliguric renal failure
- B. Increased intracranial pressure
- C. Mechanical ventilation
- D. All above
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
By what age does birth weight usually triple?
- A. 1 year
- B. 1 month
- C. 2 years
- D. 6 months
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Several types of long-term central venous access devices are used. What is a benefit of using an implanted port (e.g., Port-a-Cath)?
- A. You do not need to pierce the skin for access.
- B. It is easy to use for self-administered infusions.
- C. The patient does not need to limit regular physical activity, including swimming.
- D. The catheter cannot dislodge from the port even if the child plays with the port site.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How is masturbation in the pre-school child viewed?
- A. Abnormal behavior that needs to be dealt with immediately
- B. Disruptive to the family
- C. Normal behavior that can best be dealt with by ignoring and providing distraction
- D. Embarrassing to the parents
Correct Answer: C
Rationale: Masturbation in preschool children is a normal behavior as they explore their bodies. It is best viewed as a natural part of development. Parents are often advised to ignore it and provide distractions rather than making the child feel ashamed or embarrassed. Choice A is incorrect because it is a natural behavior and not considered abnormal in this context. Choice B is incorrect as it does not necessarily disrupt the family. Choice D is incorrect as the focus should be on the child's development and well-being, not on the parents' feelings of embarrassment.