Nokea
A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin shampoo and calls his parents. Which instruction should the nurse provide to the parents about treatment for head lice?
- A. Take the child to a hair salon for a shampoo and a shorter haircut.
- B. Dispose of the child's brushes, combs, and other hair accessories.
- C. Rewash the child's hair following a 24-hour isolation period.
- D. Wash the child's bed linens and clothing in hot soapy water.
Correct Answer: D
Rationale: Washing bed linens and clothing in hot soapy water kills lice and prevents reinfestation.
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The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?
- A. Rebound tenderness in the left lower abdominal quadrant.
- B. Stool that consists of mucus and blood.
- C. Olive-size mass in the epigastric area.
- D. Frequent burping accompanied by poor feeding.
Correct Answer: C
Rationale: An olive-size mass in the epigastric area is characteristic of pyloric stenosis, associated with projectile vomiting.
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Have the child blow a cotton ball and have the parent catch it.
- B. Place a toy in the child's hands while listening to the breath sounds.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Allow the child to use a stethoscope on a stuffed animal.
Correct Answer: D
Rationale: Allowing the child to use a stethoscope on a stuffed animal familiarizes them with the procedure, increasing cooperation.
The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Audible heart murmur.
- B. Heart rate of 162 beats/minute.
- C. Poor oral intake and suckling effort.
- D. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours.
Correct Answer: C
Rationale: Poor oral intake and suckling effort indicate feeding difficulties, which can lead to dehydration and poor weight gain, requiring immediate reporting.
The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Avoid smoke exposure.
- B. Inspect the infant's ears daily.
- C. Position prone after feeding.
- D. Breastfeed frequently.
Correct Answer: A
Rationale: Avoiding smoke exposure reduces the risk of otitis media recurrence, a known risk factor.
A 9-week-old infant is scheduled for a cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. White blood cell count of 10,000/mm (10x 10/L).
- B. Weight gain of 2 pounds (0.91 kg) since birth.
- C. Red blood cell count of 2.3 cell/mcl or (2.3 x 10/L).
- D. Urine specific gravity is 1.011.
Correct Answer: C
Rationale: A low red blood cell count indicates anemia, increasing surgical risks, making it critical to report to the surgeon.