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A 5-month-old infant is admitted to the ER with a temperature of 103.6° and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical sign in bacterial meningitis.
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Liquid iron preparation
Liquid iron preparation, which of the following directions would be appropriate for the nurse to teach?
- A. Administer at least one hour before meals.
- B. Inform the patient about the loose stools.
- C. Liquid iron must be taken with a straw.
- D. Avoid juices with iron.
Correct Answer: C
Rationale: Using a straw prevents tooth staining from liquid iron.
Mr. Smith is 67-year-old black male brought to the hospital by his wife, who stated that he fell down 20 minutes ago and has been unable to speak or move his right side since then, Mr. Smith has no significant past medical history. On exam, Mr. Smith is conscious, very anxious, his speech is garbed and unintelligible, he has a left facial droop, and he is completely right hemiphlegic.
The most likely etiology for his symptoms is:
- A. CVA
- B. Traumatic brain injury
- C. Brain tumor
- D. Alzheimer's disease
Correct Answer: A
Rationale: Symptoms of sudden speech loss, facial droop, and hemiplegia strongly suggest a cerebrovascular accident (stroke).
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
- A. Administration of cough suppressants
- B. Increasing oral fluid intake to 3000 cc per day
- C. Maintaining bed rest with bathroom privileges
- D. Performing chest physiotherapy twice a day
Correct Answer: B
Rationale: Increasing oral fluid intake to 3000 cc per day. Secretion removal is enhanced with adequate hydration, which thins and liquefies secretions.
The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
- A. Expected
- B. Rude
- C. Professional
- D. Enjoyable
Correct Answer: B
Rationale: Rude. Native Americans consider direct eye contact to be impolite or aggressive among strangers.
You're filling in as a substitute school nurse. When an 11-year-old child with an earache and sore throat reports to the nurse's office, you inspect the tympanic membrane using an otoscope.
Which color suggests a normal eardrum?
- A. Red
- B. White
- C. Gray
- D. Yellowish
Correct Answer: C
Rationale: A normal eardrum appears pearly gray.