Nokea
A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be corrected?
- A. Patching the unaffected eye
- B. Corrective lenses
- C. Laser treatment
- D. Surgery
Correct Answer: B
Rationale: In nonparalytic strabismus, the refractory error is usually corrected with eyeglasses.
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What will the nurse include when documenting a grand mal seizure? (Select all that apply.)
- A. Presence of incontinence
- B. Current dose of antispasmodic medication
- C. Activity level prior to and following seizure
- D. Level of consciousness following seizure
- E. Length of seizure
Correct Answer: A,C,D,E
Rationale: Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure.
What statement by a patient's mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media?
- A. I will continue using the medication until symptoms are relieved.'
- B. I will share the medicine with siblings if their symptoms are the same.'
- C. I will give the medication with a glass of milk.'
- D. I will administer prescribed doses until all the medication is used.'
Correct Answer: D
Rationale: Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.
What assessment does the school nurse recognize as the cardinal sign of a hyphema?
- A. Opacity of the lens
- B. A yellow-white reflex on the pupil
- C. A dark-red spot in front of the iris
- D. Inflamed mucous membranes of the eyelids
Correct Answer: C
Rationale: A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.
A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?
- A. Restlessness
- B. Sleepiness
- C. Nausea
- D. Anxiety
Correct Answer: B
Rationale: Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.
The nurse is caring for a 3-year-old child with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)?
- A. Temperature increase from 37.2?°C (99?°F) to 37.7?°C (100?°F)
- B. Increase in blood pressure with an attendant decrease in pulse
- C. Increase in respirations
- D. Equilateral pupils
Correct Answer: B
Rationale: Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.