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Questions 158

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Question 1 of 5

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

Correct Answer: C

Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.

Question 2 of 5

A client with a history of hypothyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:

Correct Answer: A

Rationale: Hypothyroidism slows metabolism, leading to weight gain, fatigue, and other symptoms like cold intolerance and constipation.

Question 3 of 5

In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:

Correct Answer: B

Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.

Question 4 of 5

A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?

Correct Answer: B

Rationale: If awakened first, the child will know that nothing painful will be done without the child being alerted. The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. The parent will be able to offer support and comfort during and after the injection.

Question 5 of 5

The client is prescribed digoxin (Lanoxin) for heart failure. Which instruction should the nurse include in the teaching plan?

Correct Answer: B

Rationale: Digoxin toxicity is increased with bradycardia, so a pulse below 60 beats per minute should be reported. It can be taken with or without food, potassium monitoring is important but not increasing, and extra doses are dangerous.

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