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A healthcare provider is assessing a child with suspected bacterial meningitis. What is a common clinical manifestation that the provider is likely to observe?
- A. Rash
- B. Photophobia
- C. Jaundice
- D. Kernig sign
Correct Answer: D
Rationale: A common clinical manifestation of bacterial meningitis is a positive Kernig sign, which indicates meningeal irritation. Kernig sign is elicited when the leg is bent at the hip and knee at 90-degree angles, and pain and resistance are felt with extension at the knee due to inflamed meninges. Options A, B, and C are not typically associated with bacterial meningitis. A rash is more commonly seen in viral illnesses, photophobia can be present but is not specific to bacterial meningitis, and jaundice is not a typical clinical manifestation of this condition.
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A nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia (ALL). What is the priority nursing intervention?
- A. Administering chemotherapy
- B. Preventing infection
- C. Monitoring for signs of bleeding
- D. Providing nutritional support
Correct Answer: B
Rationale: The correct answer is preventing infection. In caring for a child with acute lymphoblastic leukemia (ALL), preventing infection is the priority nursing intervention. Children with ALL are immunocompromised due to the disease and its treatment, making them more susceptible to infections. Administering chemotherapy, while important, is not the priority as preventing infection takes precedence to avoid complications. Monitoring for signs of bleeding and providing nutritional support are also essential components of care for a child with ALL, but preventing infection is the priority to ensure the child's safety and well-being.
A 3-year-old child with a diagnosis of acute otitis media is being discharged. What should the nurse include in the discharge teaching?
- A. Encourage the child to drink plenty of fluids
- B. Encourage the child to eat a balanced diet
- C. Administer pain medication as needed
- D. Apply warm compresses to the affected ear
Correct Answer: A
Rationale: The correct answer is to encourage the child to drink plenty of fluids. Encouraging adequate fluid intake helps to relieve symptoms and prevent dehydration in children with acute otitis media. A balanced diet (choice B) is important for overall health but is not specifically related to managing otitis media. While pain medication (choice C) may be prescribed, it should not be administered without medical advice. Applying warm compresses (choice D) is not typically recommended for acute otitis media as it can potentially worsen the condition by promoting bacterial growth.
A healthcare provider is assessing a child with suspected pneumonia. What clinical manifestation is the provider likely to observe?
- A. Cough
- B. Diarrhea
- C. Rash
- D. Vomiting
Correct Answer: A
Rationale: A cough is a common clinical manifestation of pneumonia. Pneumonia often presents with symptoms such as cough, fever, chest pain, and difficulty breathing. The inflammation and infection in the lungs lead to the characteristic cough observed in patients with pneumonia. Diarrhea, rash, and vomiting are not typically associated with pneumonia and are less likely to be observed in a child with this condition.
When a parent tells a nurse at the clinic, 'Each morning I offer my 24-month-old child juice, and all I hear is 'No.' What should I do because I know my child needs fluid?' What strategy should the nurse suggest?
- A. Offer the child a choice of two juices.
- B. Distract the child with a favorite food.
- C. Offer the child the glass in a firm manner.
- D. Allow the child to see the parent getting angry.
Correct Answer: A
Rationale: The nurse should suggest offering the child a choice of two juices. Giving the child a choice between two options empowers them to make a decision, fostering a sense of control, and increasing the likelihood of cooperation. This approach respects the child's autonomy while addressing the parent's concern about the child's fluid intake. Choices B, C, and D are incorrect because distracting the child, offering the glass in a firm manner, or displaying anger are not effective strategies for encouraging a 24-month-old child to drink juice.
Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. Management should include
- A. Oxygen, uterine massage, and transport
- B. Oxygen, placement on the left side, and transport
- C. Oxygen, treatment for shock, and uterine massage during transport
- D. Oxygen, internal vaginal pads, and treatment for shock during transport
Correct Answer: C
Rationale: In this scenario, the 21-year-old mother is showing signs of hemorrhagic shock with increased heart rate, diaphoresis, and vaginal bleeding. The appropriate management includes providing oxygen to support tissue perfusion, treating for shock to restore adequate circulation, and performing uterine massage to help control bleeding during transport. Options A, B, and D do not address the comprehensive management needed for postpartum hemorrhage in this situation.