Nokea
A child is admitted to the hospital with lesions on his abdomen that appear like cigarette burns. What should accurate documentation by the nurse include?
- A. Two unhealed lesions are on the childs abdomen.
- B. Two round 4-mm lesions are on the childs lower abdomen.
- C. Two round symmetrical lesions are on the childs lower abdomen.
- D. Two round lesions on the childs abdomen that appear to be cigarette burns.
Correct Answer: B
Rationale: Burn documentation should include the location, pattern, demarcation lines, and presence of eschar or blisters. The option that includes the size of the lesions is the most accurate.
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A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?
- A. Reassure the father that Visine is harmless.
- B. Direct him to seek immediate medical treatment.
- C. Recommend inducing vomiting with ipecac.
- D. Advise him to dilute Visine by giving his daughter several glasses of water to drink.
Correct Answer: B
Rationale: Visine is a sympathomimetic and if ingested may cause serious consequences. Medical treatment is necessary. Inducing vomiting is no longer recommended for ingestions. Dilution will not decrease risk.
A child is admitted with a suspected diagnosis of Munchausen syndrome by proxy (MSBP). What is an important consideration in the care of this child?
- A. Monitoring the parents whenever they are with the child
- B. Reassuring the parents that the cause of the disorder will be found
- C. Teaching the parents how to obtain necessary specimens
- D. Supporting the parents as they cope with diagnosis of a chronic illness
Correct Answer: A
Rationale: MSBP refers to an illness that one person fabricates or induces in another. The child must be continuously observed for development of symptoms to determine the cause. MSBP is caused by an individual harming the child for the purpose of gaining attention. Nursing staff should obtain all specimens for analyzing. This minimizes the possibility of the abuser contaminating the sample. The child must be supported through the diagnosis of MSBP. The abuser must be identified and the child protected from that individual.
What is a significant secondary prevention nursing activity for lead poisoning?
- A. Chelation therapy
- B. Screening children for blood lead levels
- C. Removing lead-based paint from older homes
- D. Questioning parents about ethnic remedies containing lead
Correct Answer: B
Rationale: Screening children for lead poisoning is an important secondary prevention activity. Screening does not prevent the initial exposure of the child to lead. It can lead to identification and treatment of children who are exposed. Chelation therapy is treatment, not prevention. Removing lead-based paints from older homes before children are affected is primary prevention. Questioning parents about ethnic remedies containing lead is part of the assessment to determine the potential source of lead.
A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is what?
- A. Hepatic dysfunction
- B. Dehydration secondary to vomiting
- C. Esophageal stricture and shock
- D. Bronchitis and chemical pneumonia
Correct Answer: D
Rationale: Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic consequence of hydrocarbon ingestion.
When only one child is abused in a family, the abuse is usually a result of what?
- A. The child is the firstborn.
- B. The child is the same gender as the abusing parent.
- C. The parent abuses the child to avoid showing favoritism.
- D. The parent is unable to deal with the childs behavioral style.
Correct Answer: D
Rationale: The child unintentionally contributes to the abuse. The fit or compatibility between the childs temperament and the parents ability to deal with that behavior style is an important predictor. Birth order and gender can contribute to abuse, but there is not a specific birth order or gender relationship that is indicative of abuse. Being the firstborn or the same gender as the abuser is not linked to child abuse. Avoidance of favoritism is not usually a cause of abuse.