Question

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Position the child laterally

Rationale :

🛌 Positioning the child on their side (lateral position) is the safest and most essential action during a seizure.

🛌 This helps maintain an open airway, prevents aspiration of saliva or vomit, and allows secretions to drain from the mouth.

🛌 Lateral positioning also reduces the risk of tongue obstruction or suffocation while preserving airway patency.

🛌 It is a standard seizure protocol and is often the first step after ensuring the area is safe.

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Answer 2

Correct Answers:

"l will apply heat."

Rationale :

🔷 Hemophilia is a genetic bleeding disorder caused by a deficiency in clotting factors (usually Factor VIII or IX), which leads to prolonged bleeding even from minor injuries.

🔷 The application of heat to a bleeding area is contraindicated because it causes vasodilation, which increases blood flow and can worsen bleeding.

🔷 The parent should instead apply cold compresses, which promote vasoconstriction and help reduce bleeding.

🔷 Other appropriate interventions include compression, elevation, and rest, which are part of the standard RICE protocol used to control bleeding and swelling.

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Answer 3

Correct Answers:

Insert the needle just below the acromion process_

Rationale :

⚪ The deltoid muscle is used for intramuscular (IM) vaccine administration in children aged 3 years and older.

⚪ The correct anatomical site is 2.5 to 5 cm (1 to 2 inches) below the acromion process, ensuring the injection reaches the thickest part of the muscle.

⚪ A 0.5-inch, 22–25 gauge needle is typically appropriate for preschoolers, not a 20-gauge, which is too large.

⚪ A 15° angle is incorrect; IM injections require a 90° angle for proper depth and absorption into muscle tissue.

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Answer 4

Correct Answers:

Projectile vomiting

Rationale :

⚫ Pyloric stenosis is a condition in which the pyloric sphincter hypertrophies, blocking gastric emptying and leading to forceful, projectile vomiting after feeding.

⚫ This condition typically occurs in infants aged 2 to 8 weeks and presents with non-bilious vomiting, which can be severe enough to cause dehydration and weight loss.

⚫ Red currant jelly stools are characteristic of intussusception, not pyloric stenosis.

⚫ Distended neck veins and rigid abdomen are signs associated with cardiac or peritonitis conditions, respectively.

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Answer 5

Correct Answers:

"We will give our child pancreatic enzymes with snacks and meals."

Rationale :

🖊️ Cystic fibrosis (CF) is a genetic disorder that affects the exocrine glands, leading to thick mucus that blocks pancreatic enzyme secretion into the intestine.

🖊️ Children with CF require pancreatic enzyme replacement therapy (PERT) with all meals and snacks to aid in the digestion and absorption of fats and proteins.

🖊️ Salt should not be restricted; in fact, sodium intake should be increased due to excessive loss through sweat.

🖊️ Low-fat, low-protein diets are not appropriate—children with CF often need high-calorie, high-protein diets to support growth.

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Answer 6

Correct Answers:

"l will add Polycose to each of my baby's bottles."

Rationale :

👉 In pediatric heart failure, feeding can be exhausting due to increased metabolic demands and decreased energy.

👉 Polycose (a glucose polymer) is used to increase caloric density of formula or breast milk without increasing fluid volume, helping meet nutritional needs efficiently.

👉 Infants with HF should be fed frequently and in small volumes to minimize energy expenditure.

👉 Allowing prolonged feeding times can lead to fatigue and poor intake, and feeding every 3 hours (not every 4) is preferred. Crying should be minimized but not forcibly timed.

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Answer 7

Correct Answers:

rice

Rationale :

🏵️ Celiac disease is an autoimmune disorder triggered by the ingestion of gluten, which is found in wheat, barley, and rye.

🏵️ The appropriate diet must be strictly gluten-free to avoid intestinal damage, especially villous atrophy in the small intestine.

🏵️ Rice is a naturally gluten-free grain and is safe for consumption.

🏵️ Foods like barley and wheat are harmful and must be excluded from the diet entirely.

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Answer 8

Correct Answers:

Facial edema

Rationale :

🌼 Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, and edema, especially facial and periorbital swelling.

🌼 The loss of plasma proteins causes a decrease in oncotic pressure, leading to fluid shifting into tissues.

🌼 Hypertension is more typical in acute glomerulonephritis, and smoky brown urine (hematuria) is also more consistent with that diagnosis.

🌼 Polyuria is not common in nephrotic syndrome; instead, oliguria may occur due to fluid retention.

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Answer 9

Correct Answers:

"Avoid triggers that cause an attack?'

Rationale :

🔺 Asthma is a chronic inflammatory airway disorder marked by bronchoconstriction, increased mucus production, and hyperresponsiveness to various triggers.

🔺 Teaching should focus on trigger identification and avoidance (e.g., dust, pet dander, pollen, cold air, exercise-induced triggers).

🔺 Peak flow meters should be used daily, not weekly, to monitor control and detect exacerbations early.

🔺 Cromolyn sodium is a mast cell stabilizer used prophylactically, not at the first sign of symptoms. Exercise is not contraindicated if well-controlled.

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Answer 10

Correct Answers:

A child who has nephrotic syndrome

Rationale :

🔴 Children with leukemia are often immunocompromised due to both disease and chemotherapy, so infection prevention is paramount.

🔴 Nephrotic syndrome is not infectious, making this child the safest roommate option.

🔴 Cystic fibrosis carries a risk of chronic respiratory infections, posing a danger to the immunocompromised child.

🔴 Ruptured appendix and rheumatic fever pose risks of active infection or sepsis, which are unacceptable for a child with compromised immunity.

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QLexNursing

1 :
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

2 :
A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

3 :
A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

4 :
A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

5 :
A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

6 :
A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching?

7 :
A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child?

8 :
A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect?

9 :
A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?

10 :
A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

QLexNursing

1 : A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

2 : A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

3 : A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

4 : A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

5 : A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

6 : A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching?

7 : A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child?

8 : A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect?

9 : A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?

10 : A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

1 :
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

2 :
A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

3 :
A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

4 :
A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

5 :
A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

6 :
A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching?

7 :
A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child?

8 :
A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect?

9 :
A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?

10 :
A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?