Nokea
While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which of the following would be most important for the nurse to do?
- A. Check the diaper for recent urination.
- B. Give the infant a pacifier.
- C. Ensure that the room is kept warm.
- D. Tap lightly on the left inguinal ring.
Correct Answer: C
Rationale: Ensuring the room is warm helps relax the cremaster muscle, facilitating examination.
You may also like to solve these questions
Which of the following is appropriate language development for an 8-month-old? The child should be:
- A. Saying 'dada' and 'mama' specifically ('dada' to father and 'mama' to mother).
- B. Saying three other words besides 'mama' and 'dada.'
- C. Saying 'dada' and 'mama' nonspecifically.
- D. Saying 'ball' when parents point to a ball.
Correct Answer: C
Rationale: At 8 months, infants typically say 'dada' and 'mama' nonspecifically, as specific use develops closer to 12 months.
A nurse evaluates discharge teaching as successful when the parents of a school-age child with a ventriculoperitoneal shunt insertion identify which sign as signaling a blocked shunt?
- A. Decreased urine output with stable intake.
- B. Tense fontanel and increased head circumference.
- C. Elevated temperature and reddened incisional site.
- D. Irritability and increasing difficulty with eating.
Correct Answer: D
Rationale: Irritability and difficulty eating are early signs of shunt blockage due to increased intracranial pressure, which parents should recognize for timely intervention.
The nurse has identified a priority nursing diagnosis of Anxiety related to surgery for a 4-yearold preparing for a tonsillectomy. The nurse should tell the child:
- A. You won't have so many sore throats after your tonsils are removed.
- B. The doctor will put you to sleep so you don't feel anything.
- C. Show me how to give the doll an I.V.
- D. When it is done you will get to see your mommy and get a Popsicle.
Correct Answer: D
Rationale: When preparing a child for a procedure the nurse should use neutral words, focus on sensory experiences, and emphasize the positive aspects at the end. Being reunited with parents and having an ice pop would be considered pleasurable events. Children this age fear bodily harm. To reduce anxiety, avoid the word 'removed' to describe what is being done to the tonsils. Using the terms 'put to sleep' and 'I.V.' may be threatening. Additionally, directing a play experience to focus on I.V. insertion may be counterproductive as the child may have little recollection of this aspect of the procedure.
An adolescent male client scheduled for an emergency appendectomy is to be transferred directly from the emergency room to the operating room. Which of the following statements by the client should the nurse interpret as most significant?
- A. I'm scared about the surgery.
- B. I need to call my parents first.
- C. My pain is getting worse.
- D. I don't want to have a scar.
Correct Answer: C
Rationale: Worsening pain may indicate perforation, requiring urgent attention.
The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?
- A. Standard precautions.
- B. Contact precautions.
- C. Airborne precautions.
- D. Droplet precautions.
Correct Answer: D
Rationale: Bacterial meningitis, such as meningococcal, requires droplet precautions due to transmission via respiratory secretions.