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 :

🛏️Clients in a halo vest require strict spinal precautions; using a turning sheet allows movement while maintaining cervical spine alignment.

⚠️The screws should only be adjusted by a provider, as improper tightening can cause neurologic injury.

📋Neck movement is restricted to prevent spinal cord damage, so flexion/extension is contraindicated.

🔬Pin sites should be assessed at least once per shift to detect early signs of infection, not just every other day.

📌core message

Use a turning sheet to reposition a client with a halo vest while maintaining spinal stability.

Answer 2

Correct Answers:

Implement a 3-hr feeding schedule.

Rationale :

🍼Infants with heart failure fatigue easily, so frequent, scheduled feedings help meet nutritional needs without overexertion.

⏲️A 3-hour schedule balances nutrition with energy conservation and reduces the risk of fatigue during feeding.

🚫Feeding sessions should be limited to 20–30 minutes, as prolonged attempts increase caloric expenditure.

📋Crying increases oxygen demand and should be minimized with a calm, structured routine.

📌core message

A 3-hour feeding schedule supports nutrition while minimizing fatigue in infants with heart failure.

Answer 3

Correct Answers:

FLACC

Rationale :

😐The FLACC scale is appropriate for non-verbal or cognitively impaired children, evaluating pain based on facial expression, leg movement, activity, cry, and consolability.

📊It offers an objective method of assessing pain when self-reporting is not reliable.

👶The FACES and visual analog scales require cognitive ability to self-identify pain level, which may not be possible for this toddler.

🩺The CRIES scale is used for neonates, not toddlers.

📌core message

Use the FLACC scale for pain assessment in nonverbal or cognitively impaired toddlers.

Answer 4

Correct Answers:

"Your child should walk the bicycle through intersections."

Rationale :

🚸Walking the bike across intersections reduces the risk of vehicular accidents and promotes safer navigation of crossways.

🚲The bicycle should be ridden with the flow of traffic, not against it.

📏Children should be able to reach the ground with their feet when seated for balance and control—not hover inches above.

📍Staying too far from the curb increases exposure to passing vehicles.

📌core message

Children should walk bicycles through intersections for maximum safety.

Answer 5

Correct Answers:

Establish a reward system.

Rationale :

🌟Children with autism spectrum disorder benefit from structured, predictable routines and positive reinforcement strategies.

📈Reward systems encourage desired behaviors while minimizing stress and resistance.

🚫Avoid forced touch or prolonged eye contact, which may be distressing for these children.

🎭Cooperative play may be challenging; parallel or individual play is often more appropriate.

📌core message

Use a structured reward system to support behavior and communication in children with autism.

Answer 6

Correct Answers:

Apply pressure just above the insertion site.

Rationale :

🩸The priority in post-cardiac catheterization bleeding is to control hemorrhage by applying pressure just above the puncture site (usually in the groin).

📉Bleeding here can lead to rapid blood loss, so immediate intervention is life-saving.

🖐️Checking pulses or vital signs can follow, but hemorrhage control must come first.

📋Reinforcing the dressing without pressure is insufficient for arterial bleeds.

📌core message

For bleeding post-cardiac catheterization, apply pressure above the site immediately to control arterial bleeding.

Answer 7

Correct Answers:

Weigh the child once per day

Rationale :

⚖️Daily weights help monitor fluid retention, a hallmark of the acute phase of nephrotic syndrome.

🧂These children often experience massive edema due to protein loss and fluid shifts.

🚫Increasing fluids is contraindicated; fluid and sodium restriction is typically prescribed.

🛏️Positioning and calorie limitation are not primary concerns—fluid balance is the priority.

📌core message

In nephrotic syndrome, monitor for fluid retention with daily weights.

Answer 8

Correct Answers:

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

Rationale :

🧪CRP and ESR are nonspecific markers of inflammation and are typically elevated in rheumatic fever.

🧬The ASO titer identifies recent infection with group A streptococcus, which is the causative agent of rheumatic fever.

📉BUN and PTT are not related to this condition and provide no diagnostic value in this context.

📋These labs help confirm diagnosis alongside clinical criteria (e.g., Jones criteria).

📌core message

ASO titer, CRP, and ESR help confirm rheumatic fever by showing recent infection and inflammation.

Answer 9

Correct Answers:

Dietitian

Rationale :

🥣Children with cystic fibrosis require high-calorie, high-protein diets with pancreatic enzyme supplementation to maintain growth.

👩‍⚕️A dietitian helps ensure nutritional adequacy and tailors plans for malabsorption.

🏃Physical therapy is also useful, but nutrition is foundational and should be addressed first.

📋Speech and occupational therapy are not priority referrals upon initial admission.

📌core message

A dietitian is essential for children with cystic fibrosis to manage malnutrition and growth.

Answer 10

Correct Answers:

Doll's eye reflex intact

Rationale :

👁️The doll’s eye reflex (oculocephalic reflex) disappears by 2 to 3 months, and its persistence at 4 months suggests neurologic immaturity or dysfunction.

🧠This abnormal finding requires prompt neurologic evaluation to rule out CNS problems.

👶Absence of head lag and presence of tears are expected at this age, as is a Babinski reflex.

📋Monitoring developmental reflexes is critical in early detection of neurodevelopmental delays.

📌core message

The doll’s eye reflex should disappear by 2–3 months; its presence at 4 months is abnormal.

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 thetoddler'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?

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 thetoddler'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?

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 thetoddler'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?