Nokea
A mother asks the nurse, 'How did my children get pinworms?' The nurse explains that pinworms are most commonly spread by which of the following when contaminated?
- A. Food.
- B. Hands.
- C. Animals.
- D. Toilet seats.
Correct Answer: B
Rationale: Pinworms are spread primarily through hand-to-mouth contact after touching contaminated surfaces.
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The nurse observes an 18 month old who has been admitted with a respiratory tract infection (see figure). The nurse should fi rst:
- A. Position the child supine
- B. Call the rapid response team
- C. Offer the child a carbonated drink
- D. Place the child in a croup tent
Correct Answer: D
Rationale: The child is in respiratory distress and is sitting in a position to relieve the airway obstruction; the nurse should provide a humidifi ed environment with a croup tent with cool mist to facilitate breathing and liquefy secretions. The child should remain sitting to facilitate breathing; the nurse should allow the child to determine the most comfortable position. After the child is breathing normally, the nurse can offer fl uids; the physician also may order intravenous fluids. The nurse can call the rapid response team if the respiratory distress is not relieved by using a croup tent or other vital signs changes indicate further distress.
The physician orders a urinalysis for a child who has undergone surgical repair of a hypospadias. Which of the following results should the nurse report to the physician?
- A. Urine specific gravity of 1.017.
- B. Ten red blood cells per high-powered field.
- C. Twenty-five white blood cells per high-powered field.
- D. Urine pH of 6.0.
Correct Answer: C
Rationale: High WBC count indicates infection.
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which of the following nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply.
- A. Offer an ice pack.
- B. Apply a heating pad.
- C. Encourage the child to assume a position of comfort.
- D. Limit the child's activity.
- E. Request an order for a cathartic.
Correct Answer: A,C,D
Rationale: Ice, comfortable positioning, and activity limitation reduce pain; heating pads and cathartics may worsen appendicitis.
The nurse talks to an adolescent about how she can tell her friends about her new diagnosis of diabetes. Which of the following behaviors by the adolescent indicates that the adolescent has responded positively to the discussion?
- A. She asks the nurse for material on diabetes for a school paper.
- B. She introduces the nurse to her friends as the nurse to the taught me all about my diabetes.
- C. She says, 'I'll try to tell my friends, but they'll probably quit hanging out with me.'
- D. She asks her friends what they think about someone who has a lifelong illness.
Correct Answer: A
Rationale: Requesting materials indicates proactive engagement and willingness to share knowledge, reflecting a positive response. Other options show hesitation or indirect approaches.
The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which of the following would be appropriate for the nurse to administer at this visit?
- A. Diphtheria, tetanus, and acellular pertussis (DTaP); Haemophilus influenzae type B (Hib); inactivated poliomyelitis vaccine (IPV); and purified protein derivative (PPD).
- B. DTaP; Hib; oral polio vaccine (OPV); and measles, mumps, and rubella (MMR).
- C. PPD, MMR, hepatitis B (hepB), and OPV.
- D. HepB, IPV, Hib, and varicella.
Correct Answer: A
Rationale: These vaccines align with catch-up schedules for a 9-month-old, except PPD, which is a test, not a vaccine.