Nokea
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. Mumps.
- B. Chickenpox.
- C. Sore throat.
- D. Influenza.
Correct Answer: C
Rationale: Acute rheumatic fever is often preceded by a streptococcal infection, commonly presenting as a sore throat.
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When providing care for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
- A. Change position every 2 hours.
- B. Monitor peripheral pulses and sensation in the right leg.
- C. Cleanse pin sites as prescribed.
- D. Assess skin for redness and signs of tissue breakdown.
Correct Answer: B
Rationale: Monitoring pulses and sensation detects vascular or nerve compromise, critical in traction care.
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 caring for a child with hypoparathyroidism who demonstrates a carpal spasm when pressure is applied to the upper arm. Which laboratory value should the nurse review?
- A. Potassium.
- B. Chloride.
- C. Sodium.
- D. Calcium.
Correct Answer: D
Rationale: Hypoparathyroidism causes low calcium levels, leading to carpal spasms, so reviewing calcium levels is critical.
A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?
- A. Report the findings immediately to the healthcare provider.
- B. Obtain a swab of secretions from the penis and urethra.
- C. Collect a sterile urine sample for culture and sensitivity.
- D. Provide the adolescent with a urinal for urinary hesitancy.
Correct Answer: A
Rationale: Significant erythema and swelling suggest testicular torsion, a medical emergency requiring immediate reporting.
The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?
- A. Administer topical antibiotic therapy daily.
- B. Provide passive range of motion exercises.
- C. Ensure no weight bearing on the affected extremity.
- D. Schedule ice pack applications to the infected area.
Correct Answer: C
Rationale: No weight bearing on the affected extremity prevents further damage during the initial treatment phase of osteomyelitis.