1 The parents of a 5-month-old infant state that their infant seems to eat very little.
Most of the food comes out of the infant's mouth and onto his
... [Show More] clothes. Which of
the following explanations should the nurse give to the parents?
Trying to introduce food after the intake of a bottle formula is usually not
recommended because the infant is satiated and has no inclination to try something
new. Solid foods should be offered at 4 to 6 months. The gastrointestinal tract hasmatured enough to handle more nutrients and is less sensitive to potentially
allergenic foods. This deprives the infant of the pleasure of learning new tastes and
developing a discriminating palate. It may cause problems with poor chewing
because of lack of experience. Due to the extrusion (protrusion) reflex, the infant’s
tongue pushes the food out of the mouth. It is most helpful to suggest using a
longhandled spoon and placing the food in the back of the infant's mouth to avoid
the reflex.
"Give the baby a bottle of formula before solid food to assure adequate caloric
intake."
"Stop the solid foods and try again when the baby is 12 months old."
"Put the cereal in a bottle and feed the baby through a nipple with a large hole."
"Place the food in the back of the baby's mouth using a long-handled spoon."
2 A nurse smells an odor identified as marijuana coming from a room. Which
of the following client findings would confirm inhalation of the substance?
All are findings of a client who has smoked/inhaled cannabis/marijuana. These
clients are typically euphoric or somewhat mildly intoxicated. They have poor
coordination with bloodshot (red) eyes and may laugh inappropriately. These
findings are more commonly due to of the effects of depressants. These findings
are more commonly due to the effects of opiates. These findings are more
commonly due to the effects of cocaine.
Poor coordination, red eyes, and euphoria
Slurred speech, confusion, and combativeness
Loss of consciousness, respiratory depression, and coma
Hypertension, tachycardia, and hyperflexia
3 A nurse is checking children at an orthopedic outpatient setting. Which of
the following should the nurse expect to see as manifestations of scoliosis?Lumbar curvature is a manifestation of lordosis. These are manifestations of
scoliosis. Often parents observe that a child's skirt doesn't hang straight or the pant
legs are uneven. Tenderness is a general symptom that may indicate something is
wrong in an underlying organ. A nurse could not see changes such as swelling of
the spine. These symptoms could be associated with other orthopedic problems but
are not characteristic of scoliosis.
Pain and an exaggerated lumbar curvature
Uneven shoulder heights and poorly fitting slacks
Tenderness and swelling of the spine
Limited range of motion of the back and a limp
4 A nurse is providing client/patient education to the mother of an 8-year-old
child diagnosed with B-hemolytic streptococci infection (strep throat). The nurse
emphasizes the importance of promptly starting and completing the entire course
of antibiotics. The mother asks why this is important. The nurse states that the
antibiotic will
Pain may interfere with oral intake, but this is not the priority concern with prompt
diagnosis and care of strep throat. Cool fluids or ice chips may be comforting.
Relief to the neck may be provided by the application of cold or warm compresses
to the area. Warm saline gargles may also relieve throat discomfort. Sinusitis and
abscess formation on the pharyngeal and peri tonsillar areas are complications that
can develop with a strep throat infection, but these complications are not of the
greatest concern with this infection. Anterior cervical lymphadenopathy is a
symptom of a streptococcal infection resulting in pharyngitis and tender lymph
nodes. This usually subsides in 3 to 5 days if uncomplicated. Antibiotics should be
initiated as soon as possible and taken as prescribed to quickly and completely
eliminate the streptococcal organism, which can lead to acute rheumatic fever,
glomerulonephritis, and acute renal failure.
alleviate painful swallowing to avoid complications of dehydration and
malnutrition. prevent sinusitis or abscess formation on the pharyngeal or peri
tonsillar areas.reduce the risk of anterior cervical lymphadenopathy. eliminate organisms
that might initiate acute renal failure or rheumatic fever.
5 A nurse is reinforcing teaching about accidental poisoning to a parent during
a routine well-child visit. The nurse asks the parent, "What would be your first
response if your child accidentally took an overdose of acetaminophen (Tylenol)?"
Which of the following statements by the parent would indicate a correct
understanding?
Syrup of ipecac is no longer recommended as a routine home treatment of
poisoning. Giving syrup of ipecac might possibly be appropriate, but certain
substances that are corrosive would make using this measure contraindicated
because it would increase the damage to the mucosa lining. Placing the child into a
side-lying position is an appropriate measure to prevent aspiration. Calling the
Poison Control Center is the best initial response to an accidental poisoning
because each case needs to be dealt with by getting prompt medical attention to
initiate the appropriate emergency treatment actions. Giving the child one sip of
water, not a full glass, is appropriate to dilute the ingested poison. However, this is
not the first action that should be taken. "I will give my child a dose of ipecac."
"I will place my child on her back."
"I will call the Poison Control Center."
"I will get my child to drink a full glass of water."
6 A nurse is caring for a 23-month-old child with iron-deficiency anemia. The
parents indicate they have been taught about the diagnosis, but are concerned that
they are not doing all that they need to do. Which of the following should the nurse
include when reinforcing teaching?
Cow's milk contains substances that bind with iron and interfere with its
absorption. Iron should not be given with milk or milk products. There are no food
limitations or suggestions when children are taking oral iron preparations. Foods
with vitamin C, such as citrus fruits, enhance the absorption of iron. Oral iron
supplements do not cause GI bleeding or ulcers. Liquid iron may stain the teeth, sothe nurse should instruct the parents to give it through a straw placed in the back of
the child's mouth to avoid staining the teeth.
Give the oral iron supplementation with a glass of cow's milk to prevent stomach
problems.
Provide diet instructions including limiting citrus fruits in favor of more
vegetables.
Provide information about complications of iron including gastrointestinal bleeding
and ulcers.
Give liquid iron through a straw placed in the back of the mouth.
7 A nurse is reviewing discharge teaching with the parents of a child who has
pediculosis. Which of the following should the nurse include in the teaching?
Children should not share combs, hair ornaments, hats, caps, scarves, coats, and
other items used on or near the hair. Pets are not carriers of lice. Clothes should be
dried in a hot dryer for at least 20 min to kill the lice. Lice need a blood source to
survive. Placing the nonwashable items in a sealed plastic bag for 14 days will kill
the lice.
"Children can share scarves and coats, but not hats or combs."
"Household pets can carry and transmit lice to people."
"After washing clothing, hang clothes outside to dry."
"Seal nonwashable items in plastic bags for 14 days."
8 A nurse is caring for a toddler who is in an oxygen tent. Which of the
following actions should the nurse take in order to promote comfort while
maintaining the child's safety?
Not all toys are safe to put inside an oxygen tent. Vinyl or plastic toys that do not
absorb moisture are suitable to put inside the tent. Stuffed animals absorb moisture
and are difficult to dry. High levels of oxygen are a source of sparks, somechanical or electrical toys are a potential fire hazard. The moisture inside an
oxygen tent will make the child cold and the child’s clothes moist. Therefore, the
nurse should try to keep the child warm and dry by changing bedding and clothes,
which will enhance the child's comfort without compromising safety. Oxygen is
heavier than air; therefore, oxygen loss will be greater at the bottom of the tent.
The tent should be tucked snugly without open edges to prevent oxygen loss. Some
tents are opened at the top. Oxygen is a heavy gas and most of it will stay at the
bottom of the tent. This measure does not promote the child's comfort while in the
oxygen tent.
Give the child a stuffed animal and car with rubber wheels to play with.
Change the bedding and the child's clothing frequently or as often as needed.
Tuck the bottom of the tent under the mattress on three sides, leaving one side open
so the child can look out.
Cover the opening on the roof of the tent with a blanket to prevent the child from
becoming chilled.
9 A nurse is reinforcing teaching with the parent of a child with a urinary tract
infection. Which of the following statements made by the parent indicates
understanding of how to prevent future infections?
Children should be encouraged to void frequently, especially before long trips or
other circumstances in which toilet facilities may not be available for an extended
period of time. Urine that is held can harbor bacteria that can result in a urinary
tract infection. Cotton underwear allows for more air flow to the perineal area and
reduces the risk of urinary tract infections. Wiping from back to front increases the
risk of feces entering the urethra and causing a urinary tract infection. Bubble baths
and perfumed perineal products can irritate the urethra and lead to a urinary tract
infection. These should be avoided, especially for girls.
"I will bring my child to the bathroom before we leave for extended trips."
"I need to switch my child from cotton underwear to nylon underwear."
"I should teach my child to wipe from back to front after urinating.""I will have my child soak in a bubble bath once or twice a week."
10 A nurse is reviewing discharge instructions with the parent of an infant who has
acute laryngotracheobronchitis (croup). Which of the following statements made
by the parent indicates a need for further teaching?
This is a correct intervention. Corticosteroids have an anti-inflammatory effect that
decreases subglottic edema. This will make breathing easier. This is a correct
intervention. Clearing the nasal passages decreases the amount of secretions in the
upper and lower airways. Dry air will exacerbate the child's croup. Cool
temperature therapies are advocated for this condition. Cool mist constricts
edematous blood vessels. A cool air vaporizer can be used at home to maintain
high humidity and provide relief. Warm mist from warm running water such as a
hot shower in a closed bathroom may be beneficial. It is essential that children with
laryngotracheobronchitis (croup) be allowed and encouraged to drink any fluids
they like to increase fluid intake.
"I will give my child the corticosteroids prescribed by the doctor."
"I will clear the child's nasal passages with a bulb syringe to aid in breathing."
"I will place a dehumidifier in my child's room."
"I will encourage my child to take plenty of fluids over the next several days." [Show Less]