A mother brings her 8 mo. old baby boy to clinic because he has been vomiting and had diarrhea for last
3
days. Which assessment is most important for nurse to make?
A.Assess infant abdomen for tenderness
b.Determine if the infant was exposed to a virus
C. Measure the infant's pulse
d. Evaluate the infant's cry - correct answer C. Measure the infant's pulse
While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse
observes
the child swallowing every 2-3 minutes. Which assessment should the nurse implement? - correct
answer Inspect the posterior oropharynx
parents of a 3-year old boy who has Duchenne muscular dystrophy ask, "How can our son have this
disease? We are wondering if we should have any more children." What information should the nurse
provide to parents? - correct answer This is an inherited X-linked recessive disorder, which primarily
affects male children in the
,family
2-weck-old female infant is hospitalized for the surgical repair of an umbilical hernia. After retuming to
the postoperative neonatal unit, her R and HR have increased during the last hour. Which intervention
should the nurse implement? - correct answer Administer a PRN analgesic prescription
2-year-old girl is brought to the clinic by her 17-year-old mother. When the nurse observes that the child
is drinking sweetened soda from her bottle, what information should the nurse discuss with this
mother? - correct answer -Dental caries is associated with drinking soda
-Toddlers should be drinking from a cup by age 2
mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night.
Which finding is most significant in planning care for this family?
a.The mother is a single parent and lives with her parents
b.The mother states the baby is irritable during feedings
C the infant's formula has been changed twice
D.The diaper area shows severe skin breakdown - correct answer D.The diaper area shows severe skin
breakdown
The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary
stream from the ventral surface of the penis. What action should the nurse take? - correct answer
Document the finding
16-year-old with acute myelocytic leukemia is receiving chemotherapy (CT) via an implanted
medication port at the out-patient oncology clinic. What action should the nurse implement when the
infusion is complete? - correct answer Flush mediport w/ saline and heparin solution
mother brings her 3-week old infant to the clinic because the baby vomits after eating and always seems
hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless.
Which additional assessment finding indicates the possibility of a life-threatening complication? - correct
answer Irregular palpable pulse
, nurse is performing a routine assessment of a &-year old at a sommunity health center. Which behavior
by the child should alert she nurse to request a
follow up for a posaible autism spectrum disorder? - correct answer Perform odd repetitive behaviors
Following admission for cardiac catheterization, the nurse is providing discharge teaching to the parents
of a 2-year-old toddler with tetralogy of Fallot. What instruction should the nurse give the parents if
their
mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for
the past 12 hours. The child's oral temperature is 101.2 F. Which intervention should the nurse
implement? - correct answer Ask the mother if the child has had a runny nose
13. During a follow up olinical visit a mother tells tia nurse that her 5-monih-old son who had surgical
correction for tetralogy of fallot has rapid breathing, often takes a long time to eat, and requires
frequent
rest periods. The infant is not crying while being held and his growth is in the expected range. Which
intervention should the nurse implement? - correct answer Auscultate heart and lungs while infant is
held
The mother of an 11-year old boy who has juvenile arthritis tells the nurse, "I really don't want my son
to
become dependent on pain medication, so I only allow him to take it when he is really hurting." Which
information is most important for the nurse to provide this mother? - correct answer Giving pain
medication around the clock helps control the pain
mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant.
The mother states, "My mother says I should put rice cereal in the baby's bottle now." The nurse should
instruct the mother
to introduce solid foods when her child exhibits which behavior? - correct answer Opens mouth when
food comes her way
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