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A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect?
- A. Maculopapular lesions between fingers and toes
- B. Inflamed area with white exudate
- C. Nonpruritic erythematous papule
- D. Rash with thick skin
Correct Answer: D
Rationale: Maculopapular lesions between fingers and toes: This finding is not typically associated with atopic dermatitis. Maculopapular lesions between the fingers and toes are more commonly seen in conditions like scabies or fungal infections. Inflamed area with white exudate: This finding is also not characteristic of atopic dermatitis. An inflamed area with white exudate may indicate a bacterial infection rather than atopic dermatitis. Nonpruritic erythematous papule: Atopic dermatitis often presents with erythematous (red) papules (small raised bumps) that are pruritic (itchy). However, the presence of nonpruritic lesions is less typical of atopic dermatitis. Rash with thick skin: This finding is consistent with atopic dermatitis. Chronic scratching and rubbing of the affected areas can lead to thickening of the skin (lichenification) in individuals with atopic dermatitis.
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You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)
- A. Bed in highest position
- B. Remove restrictive objects or clothing from patients' body
- C. Remove all pillows from the patient's head
- D. Oxygen and suction at bedside
- E. Padded bed rails
Correct Answer: B,D,E
Rationale: A. Bed in highest position: The height of the bed is not directly related to seizure precautions. B. Remove restrictive objects or clothing from patient's body: This is important to prevent injury during a seizure episode. C. Remove all pillows from the patient's head: While it's generally a good practice to remove pillows to prevent suffocation or obstruction, it's not specifically related to seizure precautions. D. Oxygen and suction at bedside: Oxygen and suction should be readily available to support the patient's respiratory status and clear any secretions or vomit during or after a seizure. E. Padded bed rails: Padded bed rails can help prevent injury if the patient thrashes or moves violently during a seizure.
A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?
- A. My belly doesn't hurt anymore.
- B. I am hungry and thirsty.
- C. I'm tired and want to take a nap.
- D. I am scared and I want to go home.
Correct Answer: A
Rationale: My belly doesn't hurt anymore.' - This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.
A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?
- A. Projectile vomiting
- B. Metabolic acidosis
- C. Effortless regurgitation
- D. Distended abdomen
Correct Answer: A
Rationale: Projectile vomiting is a classic symptom of pyloric stenosis in infants. It typically occurs within 30 minutes of feeding and is forceful, often projecting several feet away from the infant. This occurs due to the obstruction at the pyloric sphincter, leading to the stomach forcefully emptying its contents. Metabolic acidosis is not a typical finding associated with pyloric stenosis. Pyloric stenosis leads to vomiting, which can result in dehydration and electrolyte imbalances, but it typically does not cause metabolic acidosis directly. Effortless regurgitation is not a characteristic finding of pyloric stenosis. In pyloric stenosis, vomiting is forceful and projectile, rather than a passive regurgitation of stomach contents. A distended abdomen can be a finding in pyloric stenosis. The obstruction at the pyloric sphincter can lead to gastric retention, causing the stomach to become distended over time. However, it's important to note that not all infants with pyloric stenosis will present with a visibly distended abdomen.
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)
- A. Place a tongue depressor in the child's mouth.
- B. Restrain the child.
- C. Clear the area of hard objects.
- D. Loosen restrictive clothing.
- E. Place the child in a prone position
Correct Answer: C,
Rationale: A. Place a tongue depressor in the child's mouth: This is an incorrect action. Placing a tongue depressor or any other object in the child's mouth during a seizure can cause injury to the child's mouth, teeth, or airway. It may also increase the risk of choking. It's a common misconception that people can swallow their tongues during a seizure, but this is not true. It's important to keep the child's mouth clear of objects and allow the seizure to run its course. B. Restrain the child: This is also an incorrect action. Restraint can cause further injury to the child and increase agitation, which may worsen the seizure. It's important to allow the child to move freely during a seizure while taking steps to ensure their safety, such as clearing the area of objects and protecting the head from injury. C. Clear the area of hard objects: This is a correct action. Removing hard objects from the area helps prevent injury to the child during a seizure. Objects such as furniture corners or sharp items can pose a risk if the child thrashes or moves unpredictably during the seizure. D. Loosen restrictive clothing: This is also a correct action. During a seizure, it's important to ensure that the child's clothing is not too tight or restrictive. Loosening clothing, especially around the neck and chest area, helps ensure adequate airflow and prevents restriction of movement during the seizure. E. Place the child in a prone position: This is an incorrect action. Placing the child in a prone (face-down) position during a seizure can increase the risk of airway obstruction and make it more difficult for the child to breathe. Instead, the child should be placed on their side (recovery position) to help maintain an open airway and prevent aspiration if vomiting occurs.
A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?
- A. Place new linen on the client's bed every other day.
- B. Change gloves between sites when providing wound care to multiple wounds.
- C. Change the dressing on infected wounds first.
- D. Monitor vital signs every 4 hr.
Correct Answer: B
Rationale: Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.