109 - Nursing Exams Questions & Answers - Svastham Exemplar

Question 5471) 

The nurse notes that a child who has had a serious heart condition since birth does not do the expected activities for that age. The child’s mother says, “I worry constantly about my child. I don’t let the older children or the neighborhood kids play with my child very much. I try to make things as easy for my child as I can.” What is the best interpretation of these data? 

A. The child is physically incapable due to his cardiac defect 

B. The child’s mother is overprotective and allows the child few challenges to develop skills.

C. The child is probably mentally retarded from the effects of continual hypoxia. 

D. The child has regressed due to the effects of hospitalization. 

Answer: B 

Explanation: The child’s mother does not let the child play with others and appears to do everything for the child. She seems to be overprotective. Most children with heart defects are capable of doing most age-appropriate activities. There is no evidence to support that the child is mentally retarded. There are no data to support that the child has regressed. 

Question 5472) 

Ten days after cardiac surgery, an 18-month-old child is recovering well. The child is alert and fairly active and is playing well with the parents. Discharge is planned soon. The nurse notes that the parents are still very reluctant to allow the child to do anything without help. What is the best initial action for the nurse to take? 

A. Reemphasize the need for autonomy in toddlers 

B. Provide opportunities for autonomy when the parents are not present 

C. Reassess the parent’s needs and concerns 

D. Discuss the success of the surgery and how well the child is doing 

Answer: C 

Explanation: Before the nurse can teach the parents, it will be necessary to reassess their needs and concerns. The question asks for the best initial action. Initially, the nurse should assess. Later, the nurse may emphasize the toddler’s need for autonomy. The nurse may provide the child with opportunities to develop autonomy, although it would be better to teach the parents. The nurse may also discuss the success of the surgery and how well the child is doing, but this is not the initial action. 

Question 5473) 

Sodium salicylate is prescribed for a child with rheumatic fever. What should the nurse assess the child for because the child is on this medication? 

A. Tinnitus and nausea 

B. Dermatitis and blurred vision 

C. Unconsciousness and acetone odor of breath 

D. Chills and elevation of temperature 

Answer: A 

Explanation: Tinnitus and nausea are signs of toxicity to salicylate drugs 

Question 5474) 

The nurse makes an initial assessment of a 4-year old child admitted with possible epiglottitis. Which observation is most suggestive of epiglottitis? 

A. Low-grade fever 

B. Retching 

C. Excessive drooling 

D. Substernal retractions 

Answer: C 

Explanation: Excessive drooling is a sign of epiglottitis. A child with epiglottitis is apt to have a high fever. Retching is not typical. Retractions could occur if respiratory distress was great enough, but drooling is the hallmark of epiglottitis. 

Question 5475) 

Which Nursing Action could be life threatening for a child with epiglottitis? 

A. Examining the child’s throat with a tongue blade 

B. Placing the child in a semi-sitting position 

C. Maintaining high humidity 

D. Obtaining a nasopharyngeal culture 

Answer: A 

Explanation: Examining the child’s throat with a tongue blade may cause the epiglottis to become so irritated that it will close off completely and obstruct the airway. The child should be placed in a semi-sitting to upright position. Humidity is not a problem. A nasopharyngeal culture would not cause problems. The nurse should get a throat culture, however.