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A 2-year-old child with respiratory syncytial virus (RSV) is being treated in the hospital. What should the healthcare provider monitor for in this child?
- A. Increased urine output.
- B. Decreased respiratory rate.
- C. Labored breathing.
- D. Improved appetite.
Correct Answer: C
Rationale: Labored breathing is a critical sign of worsening respiratory distress in children with RSV. It indicates that the child's condition may be deteriorating, requiring prompt intervention to ensure adequate oxygenation and prevent respiratory failure. Monitoring for labored breathing allows healthcare providers to promptly assess and manage the child's respiratory status, potentially preventing further complications associated with RSV infection.
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The practical nurse is reinforcing information about Lyme disease prevention with a client who is preparing for a camping trip with family. Which statement by the client informs the nurse that the client understands the instruction?
- A. I'll make sure my son wears dark clothing on his hike.
- B. I'll get a prescription for amoxicillin to take with us.
- C. We should all get the Lyme disease vaccine before our trip.
- D. We will wear long pants and long-sleeved shirts in the woods.
Correct Answer: D
Rationale: The correct answer is D. Wearing long pants and long-sleeved shirts is an effective preventive measure against tick bites, which reduces the risk of contracting Lyme disease. This attire helps to minimize skin exposure to ticks, thereby decreasing the chances of a tick attaching and transmitting the disease-causing bacteria.
What suggestion should the nurse provide to prevent diaper rash in a 4-month-old infant as requested by the mother?
- A. Generously powder the baby's diaper area with talcum powder at each diaper change to promote dryness.
- B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
- C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
- D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.
Correct Answer: C
Rationale: Using a barrier cream like zinc oxide forms a protective layer on the skin, creating a barrier against irritants and moisture, thus helping to prevent diaper rash. Unlike other options, barrier creams do not need to be completely removed at each diaper change, allowing the skin to remain protected between changes.
A 12-year-old child is admitted to the hospital with a diagnosis of osteomyelitis. Which finding should the nurse expect during the assessment?
- A. Localized pain and swelling
- B. Generalized joint stiffness
- C. Pain in the muscles
- D. Limited range of motion in the limbs
Correct Answer: A
Rationale: In osteomyelitis, an infection of the bone, patients typically present with localized pain, swelling, and warmth over the affected bone. This is due to the inflammatory response in the bone tissue. Generalized joint stiffness, pain in the muscles, and limited range of motion in the limbs are not specific to osteomyelitis and are more commonly associated with other conditions.
During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while the infant is held
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: Auscultating the heart and lungs while the infant is held can provide important diagnostic information in assessing the cardiac and respiratory status of the infant who had surgical correction for tetralogy of Fallot. This intervention can help the nurse identify any abnormal heart or lung sounds, which may indicate complications or issues that need further evaluation or intervention.
When instilling ear drops in a 2-year-old child, how should the practical nurse (PN) position the earlobe to straighten the external auditory canal?
- A. Up and back.
- B. Down and back.
- C. Up and forward.
- D. Down and forward.
Correct Answer: B
Rationale: When administering ear drops to a child under three years old, it is essential to pull the earlobe down and back. This positioning helps straighten the external auditory canal, facilitating the proper administration of the ear drops. Pulling the earlobe down and back in young children aims to ensure that the medication reaches the intended area for optimal effectiveness.