Nokea
A nurse in a clinic is caring for a group of infants. Which of the following findings should the nurse report as a possible indication of physical maltreatment?
- A. A hemangioma on the infant's torso
- B. A burn with splash marks on the lower right leg
- C. A large, irregular, brownish-blue area on the infant's buttock
- D. An abrasion on the back of the infant's arm
Correct Answer: B
Rationale: Splash-mark burns suggest possible abuse due to their pattern and should be reported. Hemangiomas are benign, bruises need context, and abrasions may be accidental.
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A nurse is reinforcing teaching with the parent of a child who has diabetes mellitus. The parent asks the nurse how to minimize the child's pain when monitoring blood glucose levels. Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child should use their index finger to obtain blood samples.
- B. My child should hold their finger under warm water before obtaining a sample.
- C. My child should puncture the center of their finger pad when obtaining a sample.
- D. My child should hold their finger against a table when obtaining a sample.
Correct Answer: B
Rationale: Warm water increases blood flow, reducing pain during glucose monitoring. Index finger use, central punctures, or table pressure do not specifically minimize discomfort.
A nurse is caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority?
- A. Monitor capillary refill of the casted extremity.
- B. Use the palms of the hands when supporting the cast.
- C. Examine the skin at the cast edges.
- D. Instruct the child not to put anything inside the cast.
Correct Answer: A
Rationale: Monitoring capillary refill is critical to assess circulation and detect complications like compartment syndrome post-cast application. Supporting the cast, checking skin, and instructing the child are important but secondary to ensuring circulation.
A nurse is reviewing the medical records of several children in an outpatient clinic. The nurse should identify that which of the following infections is included on the list of nationally notifiable conditions?
- A. Scarlet fever
- B. Rotavirus
- C. Erythema infectiosum (Fifth disease)
- D. Pertussis
Correct Answer: D
Rationale: Pertussis is nationally notifiable for public health surveillance. Scarlet fever, rotavirus, and fifth disease are not typically required to be reported.
A nurse is reinforcing teaching with an adolescent client who has oral candidiasis and a new prescription for clotrimazole troche. Which of the following instructions should the nurse include in the teaching?
- A. Place the medication in the refrigerator after each use.
- B. Be sure to let the troche dissolve in your mouth for 15 minutes.
- C. Crush the troche before mixing it with applesauce.
- D. Stop the medication if white patches appear in your mouth.
Correct Answer: B
Rationale: Dissolving the troche slowly maximizes effectiveness. Refrigeration isn't needed, crushing alters delivery, and white patches indicate ongoing infection, not a reason to stop.
A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take?
- A. Record the diastolic value as the first Korotkoff sound (K1).
- B. Release the cuff pressure at a rate of about 5 mm Hg/second.
- C. Position the child's arm at the level of the heart.
- D. Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference.
Correct Answer: C
Rationale: Positioning the arm at heart level ensures accuracy. Diastolic is K5, cuff release should be 2-3 mm Hg/second, and cuff size is ~40% of arm circumference.