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While the nurse is examining the infant for presence of testes, the father paces around the room shaking his head. Which of the following would be the most appropriate response by the nurse?
- A. I'm sure everything will work out for the best
- B. and he'll be fine.
- C. You seem upset; please tell me how you're feeling.
- D. Don't worry; his testes will probably descend on their own.
- E. Would you like to talk with a parent of a child who has the same problem?
Correct Answer: B
Rationale: This response shows empathy and opens communication.
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A nurse who witnesses an accident involving an adolescent riding a motorcycle, hitting a tree, and being thrown 30 feet into a field stops to help. The adolescent reports that he is now unable to move his legs. While waiting for the emergency medical service to arrive, what should the nurse do?
- A. Flex the adolescent's knees to relieve stress on his back.
- B. Leave the adolescent as he is, staying close by.
- C. Remove the adolescent's helmet as soon as possible.
- D. Assess the adolescent for abdominal trauma.
Correct Answer: B
Rationale: Immobilizing the adolescent by leaving him undisturbed prevents further spinal cord damage until EMS arrives.
The nurse is caring for a 10-year-old with sickle cell anemia who is experiencing a vaso-occlusive crisis. Which intervention should the nurse prioritize?
- A. Administering antibiotics as prescribed.
- B. Encouraging ambulation to improve circulation.
- C. Providing hydration and pain management.
- D. Applying cold packs to painful joints.
Correct Answer: C
Rationale: Hydration and pain management are critical in vaso-occlusive crises to reduce blood viscosity and alleviate pain, improving outcomes.
The nurse assesses the family's ability to cope with the child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease?
- A. Limiting interaction with extended family and friends.
- B. Learning measures to meet the child's physical needs.
- C. Requesting teaching about cerebral palsy in general.
- D. Not seeking financial help to pay for medical bills.
Correct Answer: A
Rationale: Limiting social interactions may indicate social isolation, a sign of poor coping, whereas the other options suggest proactive engagement with the child's needs.
During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which of the following findings should lead the nurse to formulate the nursing diagnosis Risk for infection?
- A. Dialysate leakage.
- B. Granulation tissue.
- C. Increased time for drainage.
- D. Tissue swelling.
Correct Answer: A
Rationale: Leakage increases infection risk.
The mother of a preschooler reports that her child creates a scene every night at bedtime. The nurse and the mother decide that the best course of action would be to do which of the following?
- A. Allow the child to stay up later one or two nights a week.
- B. Establish a set bedtime and follow a routine.
- C. Encourage active play before bedtime.
- D. Give the child a cookie if bedtime is pleasant.
Correct Answer: B
Rationale: A consistent bedtime routine promotes healthy sleep habits.