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A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Nontender, protruding abdomen
- C. Natural loss of deciduous teeth
- D. Palpable fontanels
Correct Answer: B
Rationale: The correct answer is B: Nontender, protruding abdomen. In toddlers, it is normal to have a nontender, protruding abdomen due to the physiological characteristics of their developing digestive system and musculature. This is because toddlers have less developed abdominal muscles and a larger liver in proportion to their body size, causing their abdomen to appear slightly distended. This finding is considered normal and does not typically indicate any underlying health issues. The other options are incorrect because: A: Head circumference exceeding chest circumference is not a typical finding in a 2-year-old toddler. C: Natural loss of deciduous teeth typically occurs around age 6-7, not in toddlers. D: Fontanels should be closed by 18 months, so palpable fontanels in a 2-year-old would be abnormal.
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The nurse is continuing to care for the child. Complete the following sentence by using the list of options. The child is at highest risk of developing------ as evidenced bt the child's------
- A. Deep vein thrombosis
- B. Osteomyelitis
- C. Compartment syndrome
- D. Swelling
- E. Warmth and redness
- F. Paresthesia
- G. Weak pulses
Correct Answer: C,F
Rationale: The correct answer is C, Compartment syndrome, and F, Paresthesia. Compartment syndrome results from increased pressure within a closed anatomical space, leading to compromised blood flow and nerve function. Paresthesia, abnormal sensations like tingling or numbness, is an early sign of nerve compression in compartment syndrome. The combination of these symptoms indicates a critical condition requiring immediate intervention to prevent tissue damage. Choices A, B, D, and E do not align with the clinical presentation of compartment syndrome, whereas choice G, weak pulses, may be seen in severe cases but are not specific enough to be the highest risk factor in this scenario.
A nurse on the pediatric unit is admitting the child from the emergency department. Complete the following sentence by using the lists of options. The nurse suspects the child is experiencing rheumatic fever. The nurse should recognize the child is at greatest risk of developing--- due to---
- A. Glomerulonephritis
- B. Pericarditis
- C. Rheumatic heart disease
- D. Streptococcal pharyngitis
- E. Recent immunizations
- F. Viral infection
Correct Answer: C,D
Rationale: The correct answers are C: Rheumatic heart disease and D: Streptococcal pharyngitis. Rheumatic fever is caused by untreated streptococcal infection. If not treated promptly, it can lead to rheumatic heart disease, a serious complication. Streptococcal pharyngitis is a common precursor to rheumatic fever. Glomerulonephritis (A) is a potential complication of streptococcal infection but not directly related to rheumatic fever. Pericarditis (B) is an inflammation of the pericardium and not directly associated with rheumatic fever. Recent immunizations (E) and viral infections (F) are not linked to the development of rheumatic fever.
A nurse is assessing a school-age child who is receiving morphine. For which of the following adverse effects should the nurse monitor?
- A. Hypertension
- B. Bradypnea
- C. Stevens-Johnson syndrome
- D. Prolonged wound healing
Correct Answer: B
Rationale: The correct answer is B: Bradypnea. Morphine is an opioid that can cause respiratory depression, leading to bradypnea (slow breathing). The nurse should monitor the child's respiratory rate regularly as a safety precaution. Hypertension (A), Stevens-Johnson syndrome (C), and prolonged wound healing (D) are not typically associated with morphine use in school-age children. Monitoring for these adverse effects would not be a priority in this situation.
A nurse is caring for a 1-year-old child who has been hospitalized. Which of the following items in the child's room is a common source of health care-associated infections?
- A. Disposable diapers
- B. Bedside commode
- C. Protective plastic gowns
- D. Unopened bottles of formula
Correct Answer: B
Rationale: The correct answer is B: Bedside commode. This item can harbor bacteria and pathogens if not properly cleaned and sanitized, leading to healthcare-associated infections. Disposable diapers (A) are single-use and unlikely to cause infections. Protective plastic gowns (C) are meant to prevent infections. Unopened bottles of formula (D) are sterile and not a common source of infections.
A nurse in the emergency department is caring for a 10-year-old child. The nurse is assessing the child. Which of the following findings require follow-up? Select the 5 findings that require follow-up.
- A. Temperature
- B. Heart rate
- C. Report of pain
- D. Respiratory rate
- E. Tonsillar findings
- F. Oxygen saturation
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes all options (A, B, C, D, E, F) because they are essential vital signs and key indicators of the child's health status. Temperature (A), heart rate (B), respiratory rate (D), and oxygen saturation (F) are crucial physiological parameters that can indicate underlying health issues if abnormal. Report of pain (C) is important to assess the child's comfort and potential underlying conditions. Tonsillar findings (E) could indicate infections or other throat issues. Follow-up on all these findings is necessary for a comprehensive assessment of the child's health.