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A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Fever
- B. Steatorrhea
- C. Tinnitus
- D. Dysphagia
Correct Answer: A
Rationale: The correct answer is A: Fever. Bacterial pneumonia commonly presents with fever due to the body's immune response to the infection. This is a classic sign of inflammation caused by the bacterial infection in the lungs. Steatorrhea (B), tinnitus (C), and dysphagia (D) are not typical manifestations of bacterial pneumonia. Steatorrhea is associated with malabsorption disorders, tinnitus is often related to ear issues, and dysphagia is difficulty swallowing, which is not a common symptom of pneumonia. Therefore, the nurse should expect fever as a key manifestation of bacterial pneumonia in the child.
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A nurse is assessing the fontanels of an infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open.
- C. Both fontanels are the same size.
- D. Both fontanels show molars.
Correct Answer: B
Rationale: The correct answer is B: The anterior fontanel is open. The anterior fontanel is typically open in infants to allow for brain growth and development. It is a normal finding during infancy and should close by around 18 months of age. Choice A is incorrect because the posterior fontanel closes shortly after birth. Choice C is incorrect because the fontanels are not expected to be the same size; the anterior fontanel is larger than the posterior fontanel. Choice D is incorrect because the presence of molars in the fontanels would not be expected and could indicate a medical issue.
A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?
- A. Pull the pinna of the infant's ear forward before inserting the probe.
- B. Place the tip of the thermometer under the center of the infant's axilla.
- C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.
- D. Insert the oral thermometer in front of the infant's tongue.
Correct Answer: B
Rationale: Correct Answer: B - Place the tip of the thermometer under the center of the infant's axilla.
Rationale: The axillary temperature is a common method for measuring an infant's temperature. Placing the thermometer under the center of the axilla ensures an accurate reading without causing discomfort or harm to the infant.
Incorrect Choices:
A: Pulling the pinna of the infant's ear forward before inserting the probe is not necessary for measuring temperature.
C: Inserting the probe 3.8 cm (1.5 in) into the infant's rectum is invasive and not appropriate for routine temperature measurement.
D: Inserting the oral thermometer in front of the infant's tongue is incorrect as oral thermometers are not suitable for infants due to the risk of choking.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?
- A. Offer a high-calorie, high-protein diet.
- B. Administer pancreatic enzymes with meals.
- C. Initiate droplet precautions.
- D. Carefully suction the child's oropharynx to remove secretions.
Correct Answer: C
Rationale: The correct answer is C: Initiate droplet precautions. Epiglottitis is a serious condition that involves inflammation of the epiglottis, which can lead to airway obstruction. Droplet precautions are necessary to prevent the spread of infection, as epiglottitis is usually caused by a bacterial infection. Offering a high-calorie, high-protein diet (choice A) is not the priority in the acute phase of epiglottitis. Administering pancreatic enzymes with meals (choice B) is unrelated to the care of a toddler with epiglottitis. Carefully suctioning the child's oropharynx to remove secretions (choice D) can potentially worsen the condition by triggering a gag reflex and causing further airway obstruction.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Steatorrhea
- B. Fever
- C. Drooling
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Fever. In bacterial pneumonia, the body's immune response leads to fever as a common manifestation due to the infection. This is because the body is trying to fight off the bacterial invasion. Steatorrhea (A) is not typically associated with bacterial pneumonia. Drooling (C) is more commonly seen in conditions affecting the mouth or throat. Tinnitus (D) is a symptom related to the ears and is not typically associated with pneumonia. Therefore, the presence of fever is the most relevant sign in a child with bacterial pneumonia.