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A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?
- A. Influenza.
- B. Chickenpox.
- C. Mumps.
- D. Sore throat.
Correct Answer: D
Rationale: A recent untreated Group A Streptococcus sore throat is the primary risk factor for acute rheumatic fever, triggering an autoimmune response.
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A client who is in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
- A. Notify the operating room team.
- B. Administer a fluid bolus of 500 mL.
- C. Administer oxygen via face mask.
- D. Place the client in Trendelenburg.
Correct Answer: D
Rationale: Trendelenburg positioning relieves umbilical cord compression, preventing fetal hypoxia in this emergency.
For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.
- A. 3.3 mL
- B. 1.9 mL
- C. 5.0 mL
- D. 0.8 mL
Correct Answer: A
Rationale: For a 7 kg infant, 15 mg/kg = 105 mg. At 160 mg/5 mL, 105 mg requires 3.3 mL, providing effective pain relief without toxicity.
The nurse is giving instructions to the mother of a 10-year-old boy who is newly diagnosed with type 1 diabetes mellitus (DM). When attempting to teach the mother how to administer subcutaneous insulin injections to the child, the mother tells the nurse that she is afraid of needles and cannot perform the procedure. Which intervention should the nurse implement?
- A. Determine if the child can administer the insulin.
- B. Ask if the father can help with the injections.
- C. Assess the mother's parenting skills.
- D. Encourage the mother to handle the needles.
Correct Answer: D
Rationale: Gradual exposure to needles through practice builds the mother's confidence, ensuring effective insulin administration for diabetes management.
The parent of an 11-year-old client who has juvenile idiopathic arthritis tells the nurse, 'I really don't want my child to become dependent on pain medication, so I only allow taking the medication when the pain is really bad.' Which information is most important for the nurse to provide this parent?
- A. Giving pain medication around the clock helps control the pain.
- B. The use of hot baths can be used as an alternative for pain medication.
- C. The child should be encouraged to rest when experiencing pain.
- D. Encourage quiet activities such as watching television as a pain distracter.
Correct Answer: A
Rationale: Scheduled pain medication maintains consistent pain control, reduces inflammation, and prevents severe pain episodes in juvenile idiopathic arthritis, improving mobility and preventing joint damage.
History and Physical
Nurses' Notes
Flow Sheet
Vital signs
The client is a 9-month-old male who was born by cesarean section at 32 weeks gestation. He has been hospitalized once with respiratory syncytial virus at 2 months of age. He is up to date on vaccines.
Exhibits
Review H and P, nurse's note, and flow sheet.
Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Remove some of the baby's clothing
- B. Clean the area with warm water
- C. Alert child protective services
- D. Swab the area and send for a culture
- E. Hold the vaccines
- F. Temperature
- G. Parent's understanding of education
Correct Answer: A,B
Rationale: Miliaria, caused by overdressing, is addressed by removing clothing and cleaning with warm water. Monitoring temperature and parental education prevents recurrence.