Question

A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?

Answer 1

Correct Answers:

Irritability

Rationale :

🔹 Increased intracranial pressure (ICP) in infants can manifest as behavioral changes, with irritability being one of the earliest signs.

🔹 The infant may be inconsolable or exhibit a high-pitched cry due to the pressure effect on the brain tissue.

🔹 Other signs may include bulging fontanels, vomiting, and a decreased level of consciousness.

🔹 Prompt recognition of these early indicators is crucial to prevent brain damage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Maintain night splints to the affected joint.

Rationale :

✅ Night splints help maintain joint alignment and prevent contractures in children with juvenile rheumatoid arthritis (JRA).

✅ This intervention also reduces morning stiffness by promoting passive joint positioning during rest.

✅ Consistent use of splints supports joint mobility and comfort without relying on high-dose medication.

✅ Splinting is part of a broader therapy plan including physical activity and anti-inflammatory meds.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Defining a sense of self

Rationale :

🟢 According to Erikson’s psychosocial development theory, adolescents are in the stage of identity vs. role confusion.

🟢 They work on forming a sense of identity and often explore different roles, beliefs, and values.

🟢 Successful resolution leads to a strong sense of self, while failure may result in confusion and insecurity.

🟢 Peer relationships and independence are vital at this stage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Heart rate 110/min

Rationale :

🔵 A heart rate of 110/min is within the expected range for a 4-year-old child (typically 80–120 bpm).

🔵 Capillary refill >3 seconds and RR of 32/min are outside normal limits, indicating possible distress.

🔵 A weight gain of only 0.9 kg/year is less than expected for a child this age (average 2–3 kg/year).

🔵 Heart rate is a reliable, early indicator of physiologic stability in pediatrics.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Avoid a diet consisting of primarily milk.

Rationale :

🟠 Toddlers who consume large volumes of milk are at risk for iron deficiency anemia, as milk is low in iron and may reduce the intake of iron-rich foods.

🟠 Excess milk can also interfere with iron absorption and irritate the gut lining, increasing blood loss risk.

🟠 A balanced diet including iron-fortified cereals, meats, and green vegetables is essential to meet developmental needs.

🟠 The American Academy of Pediatrics recommends limiting cow’s milk to 16–24 oz/day in toddlers.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Apply clean gloves and clean the outer ear prior to instilling drops.

Rationale :

🟢 Before instilling ear drops, the nurse should always apply clean gloves and clean the outer ear to prevent introducing pathogens into the ear canal.

🟢 Purulent drainage may indicate an ear infection with perforation, so cleanliness is critical.

🟢 The outer ear should be gently wiped without inserting anything into the canal to avoid further trauma or contamination.

🟢 This ensures that the medication is effective and reduces risk of worsening infection.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

"You should bring the infant's favorite blanket to the hospital."

Rationale :

🟡 Bringing familiar objects, like a favorite blanket or toy, helps reduce separation anxiety in infants and provides comfort during hospitalization.

🟡 At 8 months, infants begin experiencing stranger anxiety and benefit from transitional objects.

🟡 Maintaining familiar routines and items can help the child adjust to the unfamiliar environment.

🟡 This is a developmentally appropriate strategy for minimizing stress and promoting emotional well-being.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

"I will continue to check his blood sugar two times every day."

Rationale :

🔴 During illness, blood glucose levels can become unstable; thus, monitoring should occur every 3 to 4 hours, not just twice a day.

🔴 Illness increases the risk of diabetic ketoacidosis, even if the child is not eating well.

🔴 Frequent monitoring helps detect hyperglycemia or hypoglycemia early and allows prompt intervention.

🔴 Parents should be instructed on sick day management for children with type 1 diabetes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Tingling in the right foot

Rationale :

🟠 Tingling indicates possible neurovascular compromise, which could signal compartment syndrome, a medical emergency.

🟠 Early signs include paresthesia (tingling), pain, pallor, pulselessness, and paralysis.

🟠 Even with normal pulses and cap refill, the subjective report of tingling requires immediate action.

🟠 Failure to act may result in permanent nerve or tissue damage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

"My son might have nausea and vomiting with hypoglycemia."

Rationale :

🟢 Nausea and vomiting are more associated with hyperglycemia, not hypoglycemia.

🟢 Hypoglycemia usually presents with sweating, shakiness, confusion, and irritability due to low blood glucose.

🟢 Recognizing the difference between high and low glucose symptoms helps prevent inappropriate interventions.

🟢 The statement reflects a misunderstanding and requires clarification to ensure safe home management.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?

2 :
A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take?

3 :
A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks?

4 :
A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?

5 :
A nurse is providing teaching about Iron deficiency anemia to the parents of a 14-month-old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?

6 :
A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?

7 :
A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?

8 :
A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?

9 :
A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?

10 :
A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

QLexNursing

1 : A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?

2 : A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take?

3 : A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks?

4 : A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?

5 : A nurse is providing teaching about Iron deficiency anemia to the parents of a 14-month-old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?

6 : A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?

7 : A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?

8 : A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?

9 : A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?

10 : A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

1 :
A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?

2 :
A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take?

3 :
A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks?

4 :
A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?

5 :
A nurse is providing teaching about Iron deficiency anemia to the parents of a 14-month-old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?

6 :
A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?

7 :
A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?

8 :
A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?

9 :
A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?

10 :
A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?