Question

A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Reposition the client using a turning sheet.

Rationale :

🟦 Halo vests stabilize cervical fractures, and improper handling can displace spinal alignment.

🟦 A turning sheet allows the entire body to be repositioned as a unit, preventing torque on the cervical spine.

🟦 Avoid pulling on extremities or torso independently, which could cause spinal misalignment or injury.

🟦 This method ensures spinal precautions are maintained, which is critical in post-op care.

🟦 The nurse must always assess pain, neurovascular status, and integrity of the halo after movement.

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Answer 2

Correct Answers:

Implement a 3-hr feeding schedule.

Rationale :

🟩 Infants with heart failure tire easily; a regular feeding schedule conserves energy and ensures adequate nutrition.

🟩 3-hour intervals balance rest and nutritional intake without overexerting the infant.

🟩 Feeding should last no longer than 20–30 minutes to avoid fatigue and maintain growth.

🟩 Upright or semi-upright positioning during feeding reduces the risk of aspiration.

🟩 Fortified formula or high-calorie nutrition may be used to meet metabolic demands.

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Answer 3

Correct Answers:

FLACC

Rationale :

🔶 The FLACC scale is used to assess pain in infants and cognitively impaired children, aged 2 months to 7 years.

🔶 It evaluates five behavioral criteria: Face, Legs, Activity, Cry, and Consolability, scored 0–2 each.

🔶 Ideal for children unable to verbalize pain or self-report.

🔶 Helps nurses objectively quantify pain levels and evaluate treatment effectiveness.

🔶 It is reliable for nonverbal or developmentally delayed children.

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Answer 4

Correct Answers:

"Your child should walk the bicycle through intersections. "

Rationale :

🟨 Teaching street safety reduces the risk of injury for school-age children.

🟨 Intersections are high-risk areas, and walking the bike enhances visibility and control.

🟨 This rule aligns with pedestrian safety education taught in school health programs.

🟨 Children may not have full cognitive development to judge traffic speed and distance.

🟨 Walking ensures the child follows traffic signals and remains alert.

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Answer 5

Correct Answers:

Establish a reward system.

Rationale :

🟪 Positive reinforcement promotes desired behaviors in children with autism spectrum disorder (ASD).

🟪 A reward system reduces frustration and supports structured routine, essential for children with ASD.

🟪 Helps in teaching communication and social skills through repetition and motivation.

🟪 Rewards should be immediate and consistent to associate behavior with positive outcomes.

🟪 This strategy aligns with behavioral therapy principles used in ASD care.

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Answer 6

Correct Answers:

Apply pressure just above the insertion site-

Rationale :

🟥 Active bleeding post-cardiac catheterization requires immediate direct pressure to prevent hemorrhage.

🟥 Pressure is applied just above the insertion site to occlude the femoral artery and control bleeding.

🟥 This is a priority intervention before assessing vitals or dressing.

🟥 Bleeding risk is high due to arterial puncture and use of anticoagulants during the procedure.

🟥 Delay in controlling bleeding can lead to hypovolemia or hematoma formation.

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Answer 7

Correct Answers:

Weigh the child once per day

Rationale :

🟫 Daily weights are the most accurate method for tracking fluid retention or loss in nephrotic syndrome.

🟫 Children with nephrotic syndrome can accumulate significant edema, making visual assessments unreliable.

🟫 Weights should be measured at the same time each day with the same scale and clothing.

🟫 Tracking weight aids in evaluating effectiveness of diuretics or corticosteroids.

🟫 Monitoring is critical during the acute phase, where fluid shifts are rapid.

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Answer 8

Correct Answers:

C-reactive protein (CRP)
Antistreptolysin O (ASO) titer
Erythrocyte sedimentation rate (ESR)

Rationale :

C-reactive protein (CRP)

🟢 CRP is an acute-phase reactant produced by the liver in response to inflammation. In rheumatic fever, CRP levels become elevated as part of the body's systemic inflammatory response.

🟢 A high CRP level supports the diagnosis by indicating ongoing active inflammation. This is especially important in children who present with vague symptoms like fever and joint pain.

🟢 CRP is used not only in diagnosis but also in monitoring treatment effectiveness, as levels typically decline with successful therapy.

🟢 The test is non-specific but highly sensitive, making it valuable when interpreted alongside other rheumatic markers.

🟢 CRP is one of the supportive minor criteria in the modified Jones criteria for rheumatic fever diagnosis.

Antistreptolysin O (ASO) titer

🟢 The ASO titer detects antibodies produced in response to group A Streptococcus (GAS), the bacteria responsible for triggering rheumatic fever.

🟢 A positive or elevated ASO titer indicates a recent streptococcal infection, even if the throat culture is negative at the time of diagnosis.

🟢 This test is essential because the rheumatic process often begins 2–3 weeks after the infection, when bacterial cultures may no longer be positive.

🟢 A rising ASO titer is considered strong evidence of prior streptococcal exposure, fulfilling a major diagnostic criterion.

🟢 Used in combination with clinical findings to support a definitive diagnosis under the Jones criteria.

Erythrocyte sedimentation rate (ESR)

🟢 ESR measures the rate at which erythrocytes settle in a tube over a set period and reflects nonspecific inflammation in the body.

🟢 Like CRP, an elevated ESR supports the presence of systemic inflammation commonly seen in rheumatic fever, particularly in cases involving arthritis or carditis.

🟢 Although nonspecific, it is useful when combined with clinical symptoms and other lab tests.

🟢 ESR can remain elevated for a longer duration than CRP, making it useful in tracking subacute inflammation.

🟢 It is included in the minor criteria for diagnosing rheumatic fever and aids in establishing the overall inflammatory picture.

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Answer 9

Correct Answers:

Dietitian

Rationale :

🟦 Children with cystic fibrosis require high-calorie, high-protein, high-fat diets to meet nutritional needs.

🟦 A dietitian ensures appropriate calorie density and helps manage pancreatic enzyme replacement therapy (PERT) timing.

🟦 Malabsorption is a key concern; nutrient deficiencies are common.

🟦 A tailored nutrition plan supports growth and lung health.

🟦 Dietitians also provide guidance for fat-soluble vitamin supplementation.

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Answer 10

Correct Answers:

Doll's eye reflex intact

Rationale :

🔵 The doll’s eye reflex (oculocephalic reflex) should disappear by 2 to 3 months of age.

🔵 Persistence of this reflex at 4 months suggests a neurological delay or dysfunction.

🔵 It is a red flag for delayed brainstem development or injury.

🔵 This finding requires immediate provider notification and further evaluation.

🔵 Routine well-baby assessments should screen for primitive reflex integration.

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QLexNursing

1 :
A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?

2 :
A nurse is teaching the parent of an infant who has a new diagnosis of heart failure about nutrition. Which of the following instructions should the nurse include in the teaching?

3 : A nurse is evaluating the pain level of a toddler who is cognitively impaired to a non- pharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?

4 :
A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

6 :
A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

7 :
A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?

8 : A nurse is reviewing the laboratory results of a child who was recently admitted for suspected rheumatic fever. The nurse should identify that which of the following laboratory tests can contribute to confirming this diagnosis? Select all that apply.

9 :
A nurse is caring for a newly admitted child who has cystic fibrosis. For which of the following members of the interprofessional team should the nurse initiate a referral?

10 :
A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?

QLexNursing

1 : A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?

2 : A nurse is teaching the parent of an infant who has a new diagnosis of heart failure about nutrition. Which of the following instructions should the nurse include in the teaching?

3 : A nurse is evaluating the pain level of a toddler who is cognitively impaired to a non- pharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?

4 : A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?

5 : A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

6 : A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

7 : A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?

8 : A nurse is reviewing the laboratory results of a child who was recently admitted for suspected rheumatic fever. The nurse should identify that which of the following laboratory tests can contribute to confirming this diagnosis? Select all that apply.

9 : A nurse is caring for a newly admitted child who has cystic fibrosis. For which of the following members of the interprofessional team should the nurse initiate a referral?

10 : A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?

1 :
A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?

2 :
A nurse is teaching the parent of an infant who has a new diagnosis of heart failure about nutrition. Which of the following instructions should the nurse include in the teaching?

4 :
A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

6 :
A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

7 :
A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?

9 :
A nurse is caring for a newly admitted child who has cystic fibrosis. For which of the following members of the interprofessional team should the nurse initiate a referral?

10 :
A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?