Nokea
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.
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A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. What should the nurse suspect?
- A. Unintentional injury
- B. Shaken baby syndrome
- C. Congenital neurologic problem
- D. Sudden infant death syndrome (SIDS)
Correct Answer: B
Rationale: Shaken baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. With unintentional injuries, external signs are usually present. Congenital neurologic problems would usually have signs of abnormal neurologic anatomy. SIDS does not usually have identifiable injuries.
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.
An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which manner?
- A. Giving half of the solution and then repeating the other half in 1 hour
- B. Mixing with a flavorful beverage in an opaque container with a straw
- C. Serving it in a clear plastic cup so the child can see how much has been drunk
- D. Administering it through a nasogastric tube because the child will not drink it because of the taste
Correct Answer: B
Rationale: Although activated charcoal can be mixed with a flavorful sugar-free beverage, it will be black and resemble mud. When it is served in an opaque container, the child will not have any preconceived ideas about its being distasteful. The ability to see the charcoal solution may affect the childs desire to drink the solution. The child should be encouraged to drink the solution all at once. The nasogastric tube would be traumatic. It should be used only in children who cannot be cooperative or those without a gag reflex.
What is a clinical manifestation of acetaminophen poisoning?
- A. Hyperpyrexia
- B. Hepatic involvement
- C. Severe burning pain in stomach
- D. Drooling and inability to clear secretions
Correct Answer: B
Rationale: Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach and does not pose an airway threat.
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.