The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement
... [Show More] by the client best demonstrates that learning has taken place?
A. "I will read all the literature you gave me before surgery."
B. "I have had surgery before when I broke my wrist in a bike accident, so I know what to expect."
C. "All the things people have told me will help me take care of my back."
D. "I understand that I will be in a body cast and I will show you how you taught me to turn." - D. "I understand that I will be in a body cast and I will show you how you taught me to turn."
To take the vital signs of a 4-month-old child, which order will give the most accurate results?
A. Respiratory rate, heart rate, then rectal temperature.
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate.
D. Rectal temperature, respiratory rate, then heart rate. - A. Respiratory rate, heart rate, then rectal temperature.
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly Gray, slightly bulging, and not movable. What action should the nurse take next?
A. No action required, as this is an expected finding for a school-aged child.
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible.
D. Call the parents and have them take the child home from school for the rest of the day. - B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
Which restraint should be used for a toddler after a cleft palate repair?
A. Clove hitch.
B. Mummy.
C. Elbow.
D. Jacket. - C. Elbow.
What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?
A. Monitor for signs of metabolic acidosis.
B. Estimate the quantity of diarrhea stools.
C. Place in a supine position after feeding.
D. Observe for projectile vomiting. - D. Observe for projectile vomiting.
A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child?
A. Keep restraints on at all times.
B. Remove restraints one at a time and provide range of motion exercises.
C. Remove all restraints simultaneously and provide play activities.
D. Renew the healthcare provider's prescription for restraints every 72 hours. - B. Remove restraints one at a time and provide range of motion exercises.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?
A. Congenital heart disease.
B. Fragile X chromosome.
C. Trisomy 13.
D. Pyloric stenosis. - A. Congenital heart disease.
When assessing a child with asthma, the nurse should expect intercostal retractions during
A. Inspiration.
B. Coughing.
C. Apneic episodes.
D. Expiration. - A. Inspiration.
When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it
A. Increases salivation.
B. Increases the respiratory rate.
C. Leads to vomiting.
D. Stresses the suture line. - D. Stresses the suture line.
A full-term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited?
A. Choking, coughing, and cyanosis.
B. Projectile vomiting and cyanosis.
C. Apneic spells and grunting.
D. Scaphoid abdomen and anorexia. - A. Choking, coughing, and cyanosis. [Show Less]