Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant?
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Solution
Transverse palmar crease
Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness.
Which of the following is characteristic of a preschooler with mid-mental retardation?
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Solution
Slow to feed self
Mild mental retardation refers to development disability involving an IQ 50 to 70. Typically, the child is not noted as being retarded, but exhibits slowness in performing tasks, such as self-feeding, walking, and taking.
Options B, C, and D: Little or no speech, marked motor delays, and gait disabilities would be seen in more severe forms mental retardation.
Which of the following aspects of psychosocial development is necessary for the nurse to keep in mind when providing care for the preschool child?
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Solution
Fear of body mutilation is a common preschool fear
During the preschool period, the child has mastered a sense of autonomy and goes on to master a sense of initiative. During this period, the child commonly experiences more fears than at any other time. One common fear is fear of the body mutilation, especially associated with painful experiences.
Options A, C, and D: The preschool child uses simple, not complex, reasoning, engages in associative, not competitive, play (interactive and cooperative play with sharing), and is able to tolerate longer periods of delayed gratification.
When discussing normal infant growth and development with parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-old?
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Solution
Large blocks
Because the 8-month-old is refining his gross motor skills, being able to sit unsupported and also improving his fine motor skills, probably capable of making hand-to-hand transfers, large blocks would be the most appropriate toy selection.
Option A: Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment.
Options B and D: Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. Mobiles pose a danger to older infants because of possible strangulation.
At which of the following ages would the nurse expect to administer the varicella zoster vaccine to a child?
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Solution
12 months
The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DTaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years.
Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome?
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Solution
Notify the physician immediately
Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation.
Option A: Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia.
Option C: The cast, not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate.
Option D: In this situation, specific action not continued monitoring is indicated.
Which of the following would the nurse need to keep in mind as a predisposing factor when formulating a teaching plan for a child with a urinary tract infection?
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Solution
A shorter urethra in females
In females, the urethra is shorter than in males. This decreases the distance for organisms to travel, thereby increasing the chance of the child developing a urinary tract infection.
Option B: Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress.
Option C: Increased fluid intake enables the bladder to be cleared more frequently, thus helping to prevent urinary tract infections.
Option D: The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development.
Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is leaning forward and drooling?
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Solution
Notify the physician immediately and prepare for intubation.
The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy.
Option A: Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening emergency.
Option B: Having the child lie down would cause additional distress and may result in respiratory arrest.
Option C: Throat examination may result in laryngospasm that could be fatal.
Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease?
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Solution
Susceptibility to respiratory infection
Children with congenital heart disease are more prone to respiratory infections.
Options B, C, and D: Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.
Which of the following is being used when the mother of a hospitalized child calls the student nurse and states, “You idiot, you have no idea how to care for my sick child”?
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Solution
Projection
The mother is using projection, the defense mechanism used when a person attributes his or her own undesirable traits to another.
Option A: Displacement is the transfer of emotion onto an unrelated object, such as when the mother would kick a chair or bang the door shut.
Option C: Repression is the submerging of painful ideas into the unconscious.
Option D: Psychosis is a state of being out of touch with reality.