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Questions 163

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Question 1 of 5

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply.

Correct Answer: A,B,D

Rationale:
To manage separation anxiety: a stuffed animal provides comfort, a familiar schedule offers stability, and play distracts and engages. Isolating the child may worsen anxiety, and removing parental reminders could increase distress.

Question 2 of 5

The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?

Correct Answer: C

Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.

Question 3 of 5

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply.

Correct Answer: A,C,E

Rationale: SIADH causes water retention, leading to decreased serum osmolality , high urine specific gravity , and low serum sodium due to dilution. High osmolality and increased urine output are opposite findings.

Question 4 of 5

The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?

Correct Answer: D

Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.

Question 5 of 5

The nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply.

Correct Answer: A,C,E

Rationale: Signs of hearing deficit in a toddler include withdrawn behavior , monotone speech , and loud speech due to inability to modulate voice. Inintelligible speech at 12 months is normal, and attentiveness suggests intact hearing.

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