Nokea
A mother has heard that several children have been diagnosed with mononucleosis. She asks the nurse what ascendancy what precautions should be taken to prevent this from occurring in her child. The nurse should instruct the mother to:
- A. Take no particular precautionary measures.
- B. Sterilize the child's eating utensils before they are reused.
- C. Wash the child's linens separately in hot, soapy water.
- D. Wear masks when providing direct personal care.
Correct Answer: A
Rationale: Mononucleosis spreads through saliva, but routine hygiene is sufficient; no special precautions are needed.
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A 13-year-old has been admitted with a diagnosis of rheumatic fever and is on bed rest. He complains of a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart below to determine what the nurse should do first.
- A. Report the heart rate to the physician.
- B. Apply lotion to the rash.
- C. Splint the joints to relieve the pain.
- D. Request an order for medication to treat the elevated temperature.
Correct Answer: A
Rationale: Rheumatic fever can cause carditis, and an elevated heart rate may indicate cardiac involvement, requiring immediate reporting. Other symptoms are managed after assessing cardiac status.
The nurse caring for a 7 -year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. The nurse should first:
- A. Assess the vital signs.
- B. Reinforce the dressing.
- C. Apply pressure just above the catheter insertion.
- D. Notify the physician.
Correct Answer: C
Rationale: Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the physician. The dressing can be reinforced after the bleeding has been contained.
An adolescent girl with a seizure disorder controlled with phenytoin (Dilantin) and carbamazepine (Tegretol) asks the nurse about getting married and having children. Which of the following responses by the nurse would be most appropriate?
- A. You probably shouldn't consider having children until your seizures are cured.'
- B. Your children won't necessarily have an increased risk of seizure disorder.'
- C. When you decide to have children, talk to the doctor about changing your medication.'
- D. Women with seizure disorders commonly have a difficult time conceiving.'
Correct Answer: C
Rationale: Consulting a doctor about medication adjustments before pregnancy ensures safety for mother and fetus, addressing teratogenic risks.
A 14-year-old has just had a plaster cast placed on his lower left leg. To provide safe cast care, the nurse should?
- A. Petal the cast as soon as it is put on.
- B. Keep the child in the same position for 24 hours until the cast is dry.
- C. Use only the palms of the hand when handling the cast.
- D. Notify the physician if the client complains of heat.
Correct Answer: C
Rationale: Using only the palms prevents indentations in the wet cast, which could cause pressure points or alter the cast's shape.
The nurse is assessing a child with sickle cell disease during a routine clinic visit. Which finding requires immediate follow-up by the nurse?
- A. Pallor of the nail beds and mucous membranes.
- B. A heart rate of 88 beats per minute.
- C. Intact and equal bilateral peripheral pulses.
- D. Normal vision and hearing reported by the parents.
Correct Answer: A
Rationale: Pallor of nail beds and mucous membranes indicates anemia or poor perfusion, a serious concern in sickle cell disease requiring immediate follow-up.