Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a 6-month-old infant who has a subdural hematoma. Which of the following findings should the nurse expect?
A. Pinpoint pupils
"Pinpoint pupils." A subdural hematoma typically causes unequal or dilated pupils due to increased intracranial pressure (ICP), rather than pinpoint pupils, which are more commonly associated with opioid toxicity or pontine damage.
B. Sunken anterior fontanel
"Sunken anterior fontanel." A sunken fontanel is a sign of dehydration. In cases of increased ICP, as seen with a subdural hematoma, the anterior fontanel is more likely to be bulging.
C. Hypertonia
"Hypertonia." Neurological changes can occur, but hypotonia (decreased muscle tone) is more common in infants with increased ICP rather than hypertonia (increased muscle tone).
D. Vomiting
"Vomiting." Vomiting is a classic sign of increased ICP in infants, which occurs due to the pressure on the brainstem. Other symptoms may include irritability, a bulging fontanel, seizures, and lethargy.
This question is an excerpt from Nurse Dive's nursing test bank - Ati rn paediatrics nursing proctored exam 2023. Take the full exam now
Full Explanation
A. "Pinpoint pupils." A subdural hematoma typically causes unequal or dilated pupils due to increased intracranial pressure (ICP), rather than pinpoint pupils, which are more commonly associated with opioid toxicity or pontine damage.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration. In cases of increased ICP, as seen with a subdural hematoma, the anterior fontanel is more likely to be bulging.
C. "Hypertonia." Neurological changes can occur, but hypotonia (decreased muscle tone) is more common in infants with increased ICP rather than hypertonia (increased muscle tone).
D. "Vomiting." Vomiting is a classic sign of increased ICP in infants, which occurs due to the pressure on the brainstem. Other symptoms may include irritability, a bulging fontanel, seizures, and lethargy.
Similar Questions
A nurse is providing teaching to an adolescent who has vulvovaginitis. Which of the following statements should the nurse include in the teaching?
A. "Apply scented baby powder to absorb residual moisture."
"Apply scented baby powder to absorb residual moisture." Scented products can irritate the vaginal area and worsen symptoms of vulvovaginitis. Instead, keeping the area dry and clean is recommended.
B. "Apply a warm, moist compress three times per day."
"Apply a warm, moist compress three times per day." Warm compresses help soothe irritation and reduce inflammation associated with vulvovaginitis.
C. "Wear a feminine deodorant pad for vaginal drainage."
"Wear a feminine deodorant pad for vaginal drainage." Deodorant pads contain chemicals that can further irritate the area. Instead, using unscented pads or breathable cotton underwear is recommended.
D. "Wear nylon underwear at night."
"Wear nylon underwear at night." Nylon traps moisture and heat, which creates an environment for bacterial and fungal growth. Instead, wearing loose-fitting cotton underwear or sleeping without underwear is recommended to promote airflow and prevent irritation.
Full Explanation
A. "Apply scented baby powder to absorb residual moisture." Scented products can irritate the vaginal area and worsen symptoms of vulvovaginitis. Instead, keeping the area dry and clean is recommended.
B. "Apply a warm, moist compress three times per day." Warm compresses help soothe irritation and reduce inflammation associated with vulvovaginitis.
C. "Wear a feminine deodorant pad for vaginal drainage." Deodorant pads contain chemicals that can further irritate the area. Instead, using unscented pads or breathable cotton underwear is recommended.
D. "Wear nylon underwear at night." Nylon traps moisture and heat, which creates an environment for bacterial and fungal growth. Instead, wearing loose-fitting cotton underwear or sleeping without underwear is recommended to promote airflow and prevent irritation.
A nurse is caring for an infant who has otitis media and is to receive amoxicillin 30 mg/kg/day in divided doses every 12 hr. The child weighs 13 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
Determine the infant's weight in kg:13 lb ÷ 2.2 = 5.91 kg
Calculate the total daily dose:30 mg/kg/day × 5.91 kg = 177.3 mg/day
Divide the total daily dose by 2 (since the medication is given every 12 hours):177.3 mg ÷ 2 = 88.65 mg per dose
Round to the nearest whole number:89 mg per dose
A nurse is teaching a parent of a toddler how to prepare for the arrival of their newborn sibling. Which of the following statements by the parent indicates to the nurse an understanding of the teaching?
A. "I will start sending my toddler to daycare once the baby is born."
"I will start sending my toddler to daycare once the baby is born." Introducing major changes, like starting daycare, immediately after a new sibling's arrival may cause stress and feelings of rejection. If a change is necessary, it should be introduced well before the baby arrives to allow the toddler time to adjust.
B. "I will anticipate that my toddler might demand to have their pacifier again once their sibling is born."
"I will anticipate that my toddler might demand to have their pacifier again once their sibling is born." Regression is a common response in toddlers when a new sibling arrives. They may return to earlier behaviors such as wanting a pacifier, asking to be bottle-fed, or having potty-training setbacks. Parents should offer reassurance and patience rather than discouraging these behaviors.
C. "I will tell my toddler now about the date their sibling will arrive."
"I will tell my toddler now about the date their sibling will arrive." Toddlers have a limited understanding of time, so telling them too early can lead to confusion and anxiety. Instead, parents should introduce the idea gradually and use tangible events (e.g., "When the leaves start falling, the baby will be here").
D. "I will tell my toddler the baby will be their new playmate."
"I will tell my toddler the baby will be their new playmate." A newborn will not be an immediate playmate, and telling a toddler this may lead to disappointment or frustration. Instead, parents should explain that newborns need a lot of care but will grow and play later.
Full Explanation
A. "I will start sending my toddler to daycare once the baby is born." Introducing major changes, like starting daycare, immediately after a new sibling's arrival may cause stress and feelings of rejection. If a change is necessary, it should be introduced well before the baby arrives to allow the toddler time to adjust.
B. "I will anticipate that my toddler might demand to have their pacifier again once their sibling is born." Regression is a common response in toddlers when a new sibling arrives. They may return to earlier behaviors such as wanting a pacifier, asking to be bottle-fed, or having potty-training setbacks. Parents should offer reassurance and patience rather than discouraging these behaviors.
C. "I will tell my toddler now about the date their sibling will arrive." Toddlers have a limited understanding of time, so telling them too early can lead to confusion and anxiety. Instead, parents should introduce the idea gradually and use tangible events (e.g., "When the leaves start falling, the baby will be here").
D. "I will tell my toddler the baby will be their new playmate." A newborn will not be an immediate playmate, and telling a toddler this may lead to disappointment or frustration. Instead, parents should explain that newborns need a lot of care but will grow and play later.