The nurse admitting and assessing a teenage boy with suspected testicular torsion (twisted testicle) will most likely find which of the following manifestations in addition to possible nausea and vomiting and acute testicular pain?

Correct Answer: B

Rationale: The correct answer is B: Cremasteric reflex depressed or absent. Testicular torsion causes twisting of the spermatic cord, cutting off blood supply to the testicle, leading to severe pain, nausea, and vomiting. The cremasteric reflex, which causes the testicle to elevate when the inner thigh is stroked, is typically absent in cases of testicular torsion due to the severe pain and ischemia. Choices A, C, and D are incorrect as relief of pain with elevation of the testicle, pain or discomfort upon urination, and presence of white blood cells and bacteria in the urine are not typical manifestations of testicular torsion.

Correct Answer: D

Rationale: The correct answer is D: "Breast milk should be the only food for the first 6 months." This is based on the WHO recommendation that exclusive breastfeeding for the first 6 months of life provides optimal nutrition and protection for infants. Breast milk contains essential nutrients and antibodies crucial for the premature infant's growth and immune system development. Other choices are incorrect because: A: Introducing solid foods too early can be harmful to a premature infant's digestive system. B: While some mothers breastfeed for 2 years, it is not a specific guideline for premature infants. C: Breastfeeding for at least a month is not sufficient; exclusive breastfeeding for 6 months is recommended for all infants, including premature ones.

Correct Answer: D

Rationale: The correct answer is D: Use a nightlight in the child’s room. This answer is correct because a nightlight can provide a sense of security for the child and help alleviate any fear of the dark, which is a common issue for young children. It can also help the child feel more comfortable and relaxed, promoting better sleep. Choice A is incorrect as always sleeping in a quiet, darkened room may not address the child's fear of the dark. Choice B is incorrect as high-carbohydrate snacks before bedtime can actually disrupt sleep. Choice C is incorrect as eliminating the afternoon nap may lead to overtiredness, making it harder for the child to fall asleep at night.

Correct Answer: C

Rationale: The correct answer is C: Appropriate weight gain for age. In congestive heart failure, decreasing the demands on the heart is crucial. Appropriate weight gain indicates good cardiac output and effective management of fluid retention. Irritability (choice A) can be a sign of distress, capillary refill of more than 5 seconds (choice B) indicates poor perfusion, and positioning in high Fowler position (choice D) is more related to respiratory support rather than decreasing demands on the heart.

Correct Answer: A

Rationale: The correct answer is A: Immediately bring the child to clinic for evaluation. Given the child's medical history of a repaired ventricular septal defect (VSD) and presenting symptoms of decreased appetite, fever, and muscle/joint aches, there is concern for a possible infection or cardiac-related issue. It is crucial to promptly assess the child's condition due to the potential risks associated with cardiac conditions and infections in this population. Delaying evaluation could lead to serious complications. Choices B and C are incorrect because waiting until next week or simply treating symptoms with acetaminophen may result in a missed opportunity to address a potentially serious issue. Choice D is incorrect as it dismisses the child's symptoms as manipulation, which is not a responsible or evidence-based approach to healthcare.