Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. A 3-year-old child with a newly applied cast for a fractured arm who stutters
A 3-year-old child with a newly applied cast for a fractured arm who stutters: Stuttering in a 3-year-old is not an immediate indicator for an auditory evaluation unless accompanied by other signs of hearing issues.
B. A 3-month-old infant discharged two days ago after hospitalization for bacterial meningitis
A 3-month-old infant discharged two days ago after hospitalization for bacterial meningitis: Bacterial meningitis can lead to hearing loss, so an auditory evaluation is appropriate for this infant to assess for any hearing impairment resulting from the infection.
C. A 24-month-old toddler who recently completed a course of erythromycin for treatment of pertussis
A 24-month-old toddler who recently completed a course of erythromycin for treatment of pertussis: Erythromycin use is not typically associated with hearing loss. The focus should be on monitoring recovery from pertussis.
D. A 6-month-old infant who is experiencing loose stools and is babbling loudly
A 6-month-old infant who is experiencing loose stools and is babbling loudly: Loose stools and babbling are not related to hearing issues and do not indicate the need for an auditory evaluation.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Paediatrics 2023 Proctored Exam. Take the full exam now
Full Explanation
A. A 3-year-old child with a newly applied cast for a fractured arm who stutters: Stuttering in a 3-year-old is not an immediate indicator for an auditory evaluation unless accompanied by other signs of hearing issues.
B. A 3-month-old infant discharged two days ago after hospitalization for bacterial meningitis: Bacterial meningitis can lead to hearing loss, so an auditory evaluation is appropriate for this infant to assess for any hearing impairment resulting from the infection.
C. A 24-month-old toddler who recently completed a course of erythromycin for treatment of pertussis: Erythromycin use is not typically associated with hearing loss. The focus should be on monitoring recovery from pertussis.
D. A 6-month-old infant who is experiencing loose stools and is babbling loudly: Loose stools and babbling are not related to hearing issues and do not indicate the need for an auditory evaluation.
Similar Questions
A nurse in a pediatric clinic is assessing a 6-month-old infant. Which of the following findings should the nurse identify as an indication of a visual Impairment?
A. The infant reacts to bright light.
The infant reacts to bright light. Reacting to bright light is a normal response and indicates that the infant can see. This does not indicate a visual impairment.
B. The infant's corneal light reflex is symmetrical.
The infant's corneal light reflex is symmetrical. A symmetrical corneal light reflex indicates proper eye alignment and does not suggest a visual impairment.
C. The infant does not fixate and follow an object.
The infant does not fixate and follow an object. By 6 months, an infant should be able to fixate on and follow an object. Failure to do so can be an indication of a visual impairment.
D. The infant's red reflex is present bilaterally.
The infant's red reflex is present bilaterally. A normal red reflex in both eyes indicates that the eyes are clear and healthy. Absence of the red reflex could suggest a problem, but its presence does not indicate impairment.
Full Explanation
A. The infant reacts to bright light. Reacting to bright light is a normal response and indicates that the infant can see. This does not indicate a visual impairment.
B. The infant's corneal light reflex is symmetrical. A symmetrical corneal light reflex indicates proper eye alignment and does not suggest a visual impairment.
C. The infant does not fixate and follow an object. By 6 months, an infant should be able to fixate on and follow an object. Failure to do so can be an indication of a visual impairment.
D. The infant's red reflex is present bilaterally. A normal red reflex in both eyes indicates that the eyes are clear and healthy. Absence of the red reflex could suggest a problem, but its presence does not indicate impairment.
A nurse in a pediatric intensive care unit is assessing a 6-month-old infant. Which of the following findings should the nurse identify as an indication of neurological impairment?
A. The child's oxygen saturation is 96% on room air.
The child's oxygen saturation is 96% on room air. This is a normal oxygen saturation level for an infant on room air and does not indicate neurological impairment. Normal oxygen saturation levels are typically between 95% and 100%.
B. The child reports pain as 8 on a scale of 0 to 10.
The child reports pain as 8 on a scale of 0 to 10. A 6-month-old infant cannot verbally report pain on a numeric scale. Pain assessment in infants is typically done using behavioral and physiological indicators, not a numeric scale. This choice is not relevant for this age group.
C. The child is drowsy but responds immediately to verbal stimuli.
The child is drowsy but responds immediately to verbal stimuli. This could be an indication of neurological impairment. While infants can sleep a lot, being excessively drowsy and requiring verbal stimuli to respond could suggest an altered level of consciousness, which warrants further assessment for potential neurological issues.
D. The child's blood pressure is 100/60 mm Hg.
The child's blood pressure is 100/60 mm Hg. This is within normal limits for a 6-month-old infant and does not indicate neurological impairment. Normal blood pressure for infants ranges from about 70-100/50-65 mm Hg.
Full Explanation
A. The child's oxygen saturation is 96% on room air. This is a normal oxygen saturation level for an infant on room air and does not indicate neurological impairment. Normal oxygen saturation levels are typically between 95% and 100%.
B. The child reports pain as 8 on a scale of 0 to 10. A 6-month-old infant cannot verbally report pain on a numeric scale. Pain assessment in infants is typically done using behavioral and physiological indicators, not a numeric scale. This choice is not relevant for this age group.
C. The child is drowsy but responds immediately to verbal stimuli. This could be an indication of neurological impairment. While infants can sleep a lot, being excessively drowsy and requiring verbal stimuli to respond could suggest an altered level of consciousness, which warrants further assessment for potential neurological issues.
D. The child's blood pressure is 100/60 mm Hg. This is within normal limits for a 6-month-old infant and does not indicate neurological impairment. Normal blood pressure for infants ranges from about 70-100/50-65 mm Hg.
A nurse is planning care for a school-age child following the application of a plaster cast for a right forearm fracture. Which of the following interventions should the nurse plan to implement?
A. Apply plastic covering to the cast until dry.
Apply plastic covering to the cast until dry. Covering the cast with plastic can cause moisture accumulation, which can delay drying and increase the risk of infection and skin irritation. The cast should be allowed to dry naturally and in a well-ventilated area.
B. Apply pieces of moleskin around the edges of the cast.
Apply pieces of moleskin around the edges of the cast. Applying moleskin around the edges of the cast helps to protect the skin from irritation and potential injury from the rough edges of the cast. This is an appropriate intervention.
C. Use tips of fingers to reposition the cast until dry.
Use tips of fingers to reposition the cast until dry. Using the tips of fingers to handle the cast while it is drying can create indentations, leading to pressure points and potential skin breakdown. The cast should be handled with the palms of the hands to avoid indentations.
D. Maintain casted extremity below heart level.
Maintain casted extremity below heart level. The casted extremity should be elevated above heart level, especially in the first 24-48 hours, to reduce swelling and promote venous return. Keeping it below heart level can increase swelling.
Full Explanation
A. Apply plastic covering to the cast until dry. Covering the cast with plastic can cause moisture accumulation, which can delay drying and increase the risk of infection and skin irritation. The cast should be allowed to dry naturally and in a well-ventilated area.
B. Apply pieces of moleskin around the edges of the cast. Applying moleskin around the edges of the cast helps to protect the skin from irritation and potential injury from the rough edges of the cast. This is an appropriate intervention.
C. Use tips of fingers to reposition the cast until dry. Using the tips of fingers to handle the cast while it is drying can create indentations, leading to pressure points and potential skin breakdown. The cast should be handled with the palms of the hands to avoid indentations.
D. Maintain casted extremity below heart level. The casted extremity should be elevated above heart level, especially in the first 24-48 hours, to reduce swelling and promote venous return. Keeping it below heart level can increase swelling.