Nokea
A nurse is reviewing discharge teaching with the parents of a child who has pediculosis.Which of the following should the nurse include in the teaching?
- A. "Children can share scarves and coats ,but not hats or combs."'
- B. "Household pets can carry and transmit lice to people."'
- C. "After washing clothing,hang clothes outside to dry."'
- D. "Seal nonwashable items in plastic bags for 14 days."'
Correct Answer: D
Rationale: The correct answer is D. The nurse should include sealing nonwashable items in plastic bags for 14 days in the teaching for pediculosis. This is important to prevent reinfestation as lice can survive for up to 48 hours without a host. By sealing items in plastic bags for 14 days, any remaining lice or eggs will die off.
Choice A is incorrect because lice can be transmitted through shared hats and combs, not just scarves and coats. Choice B is incorrect as lice do not live on household pets. Choice C is incorrect as hanging clothes outside will not effectively eliminate lice.
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A nurse is caring for a child with acute glomerulonephritis. The child has edema, hypertension, and gross hematuria. Which of the following is the most appropriate nursing intervention?
- A. Monitor the oxygen saturation every 4 hr.
- B. Teach the parents dietary restrictions regarding protein.
- C. Weigh the child daily and record intake and output.
- D. Counsel the parents about the need for follow-up.
Correct Answer: C
Rationale: The correct answer is C: Weigh the child daily and record intake and output. This intervention is crucial in monitoring fluid balance and kidney function in a child with acute glomerulonephritis. Daily weights help assess for fluid retention, while intake and output measurements help evaluate kidney function. Edema, hypertension, and gross hematuria are key symptoms of this condition, indicating the need for close monitoring.
Choice A is incorrect because monitoring oxygen saturation is not directly related to the management of acute glomerulonephritis. Choice B is also incorrect as dietary restrictions regarding protein are not the priority in this situation. Choice D is incorrect as counseling about follow-up is important but not the most immediate intervention needed.
Which condition must occur in order for identical (monozygotic) twins to develop?
- A. One sperm fertilizes two ova
- B. Two sperm fertilize two ova
- C. One sperm fertilizes one ovum
- D. Two sperm fertilize one ovum
Correct Answer: C
Rationale: The correct answer is C: One sperm fertilizes one ovum. Identical twins result from the fertilization of a single egg by a single sperm, leading to the formation of a zygote that later splits into two embryos. This process results in genetically identical individuals. Choices A, B, and D involve multiple fertilization events, which would lead to fraternal (dizygotic) twins with different genetic compositions. Therefore, the only condition that can lead to the development of identical twins is when one sperm fertilizes one ovum.
A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond?
- A. Enlarged breasts are common for both boys and girls. It will go away.
- B. Let me look at the baby for you.
- C. Everything is going to be just fine. Your baby is healthy.
- D. You should ask your doctor about that.
Correct Answer: A
Rationale: The correct answer is A. Enlarged breasts in newborn boys and girls are a common physiological phenomenon called breast engorgement due to maternal hormones. The nurse should reassure the mother that it is normal and will resolve on its own. Choice B is unnecessary as the nurse already knows the cause. Choice C is vague and does not address the mother's concern directly. Choice D is not ideal as the nurse can provide basic information on the issue.
A nurse is reinforcing teaching given to the parent of a 1-year-old child who has had a high temperature, vomiting, and diarrhea for 48 hr. The child has sunken eyes and cracked lips. Which of the following should the nurse tell the parent?
- A. Give the infant applesauce and rice cereal because these have been found to have high nutritional value.
- B. Encourage the child to take sips of chicken or beef broth because they will replace the fluid losses your child is experiencing.
- C. Give the infant oral rehydration solutions that are available commercially. They replace some of the electrolytes lost through vomiting.
- D. Give the child nothing by mouth for 4 hr. Once the vomiting has decreased you can introduce sips of clear water.
Correct Answer: C
Rationale: Oral rehydration solutions effectively replace fluids and electrolytes lost due to vomiting and diarrhea.
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.