RN

1. Which physiological acid-base balance complication would be most important for the nurse to assess in a patient with diarrhea?

• A. High serum pH
• B. Normal serum pH
• C. Metabolic alkalosis
• D. Metabolic acidosis

Correct Answer: D

Rationale: The correct answer is metabolic acidosis. Diarrhea can lead to the loss of bicarbonate, causing an imbalance in the acid-base status of the body, specifically resulting in metabolic acidosis. High serum pH (choice A) is incorrect as diarrhea-induced bicarbonate loss would lower pH, not increase it. Normal serum pH (choice B) is not the best answer as diarrhea can disrupt the acid-base balance. Metabolic alkalosis (choice C) is an alkaline state, which is less likely to be caused by diarrhea.

2. The predominant characteristic of the intellectual development of a child aged 2 to 7 years is egocentricity. Which of the following best describes this concept?

• A. Selfishness
• B. Unable to see another’s point of view
• C. Able to put self in another’s place
• D. Prefers to play alone

Correct Answer: B

Rationale: Egocentricity in children aged 2 to 7 years means they are unable to see things from another person's perspective. This characteristic is a normal part of their cognitive development during this stage. Choice A, 'Selfishness,' is not an accurate description as egocentricity is more about a limited ability to understand others' viewpoints rather than intentional selfishness. Choice C, 'Able to put self in another’s place,' is incorrect as egocentric children struggle to do this. Choice D, 'Prefers to play alone,' is not directly related to egocentricity but may be a behavior exhibited by some children for various reasons.

3. A 5-year-old is hospitalized with a fractured femur. Which pain assessment tool is appropriate for this child?

• A. CRIES Scale
• B. Faces Pain Rating Scale
• C. SUN Scale
• D. NIPS Scale

Correct Answer: B

Rationale: The Faces Pain Rating Scale is appropriate for assessing pain in children who can express their feelings visually. For a 5-year-old child who can communicate effectively, using a tool like the Faces Pain Rating Scale, which uses facial expressions to indicate pain levels, is more suitable than the CRIES Scale (used for neonates), the SUN Scale (used for infants), or the NIPS Scale (used for preterm and term newborns).

4. A child has a planned hospitalization in a few weeks, and the client and family appear very stressed. Which nursing action will minimize their stress?

• A. Telling the client and family that everything will be fine
• B. Explaining how the child will benefit from the surgery
• C. Telling the client and family that the surgeon is very good
• D. Giving a tour of the hospital unit or surgical area

Correct Answer: D

Rationale: The correct nursing action to minimize the stress of the child and family is giving a tour of the hospital unit or surgical area. Familiarizing them with the hospital environment can help reduce their anxiety by allowing them to see where the child will be staying and the surroundings. Choices A, B, and C do not directly address the need to reduce stress by providing a tangible way to alleviate anxiety through exposure to the hospital setting.

5. A two-month-old infant who has gastroesophageal reflux is thriving without other complications. Which instruction should the nurse include in the teaching plan?

• A. Place the infant in the Trendelenburg position after feeding
• B. Thicken formula with rice cereal
• C. Give continuous nasogastric feedings
• D. Give larger, less frequent feeds

Correct Answer: B

Rationale: The correct instruction for a two-month-old infant with gastroesophageal reflux who is thriving without complications is to thicken the formula with rice cereal. This can help reduce reflux by increasing the weight of the formula, making it less likely to be regurgitated. Placing the infant in the Trendelenburg position after feeding (Choice A) is not recommended as it can increase the risk of aspiration. Continuous nasogastric feedings (Choice C) are not typically indicated for uncomplicated reflux in infants. Giving larger, less frequent feeds (Choice D) can worsen reflux symptoms by overloading the stomach.