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A nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names?
- A. Shingles
- B. Athlete's foot
- C. Fever blister
- D. Pinworms
Correct Answer: B
Rationale: Shingles: This is a viral infection caused by the varicella-zoster virus, which also causes chickenpox. It typically manifests as a painful rash that develops into fluid-filled blisters. Athlete's foot: This is a fungal infection of the skin on the feet, particularly between the toes. It causes itching, burning, and cracked, flaking skin. Fever blister: Also known as a cold sore, this is a viral infection caused by the herpes simplex virus. It typically appears as a cluster of small, fluid-filled blisters on or around the lips. Pinworms: This is a parasitic infection caused by tiny, white worms that infect the intestines. It commonly causes anal itching, particularly at night, due to the female worms laying eggs around the anal area.
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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.
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.
12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be?
- A. 24 lb 6 oz
- B. 20 lb 5oz
- C. 32 lb 8 0z
- D. 16 lb 4 oz
Correct Answer: A
Rationale: The nurse should expect the 12-month-old boy to weigh approximately 24 lb 6 oz (since 0.375 lb ≈ 6 oz).
So, around 24 lbs 6 oz is a normal expected weight at 12 months for a baby born at 8 lb 2 oz.
A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?
- A. Reports of exposure to a skin irritant
- B. Elevated temperature
- C. Denial of pruritus
- D. Reports of joint discomfort
Correct Answer: A
Rationale: Reports of exposure to a skin irritant: This finding is consistent with contact dermatitis, as it typically occurs due to exposure to irritants or allergens. Therefore, it is an expected finding. Elevated temperature: Elevated temperature is not typically associated with contact dermatitis unless there is a secondary infection. It is not a typical finding in uncomplicated contact dermatitis. Denial of pruritus: Pruritus, or itching, is a common symptom of contact dermatitis. Clients with contact dermatitis often experience itching or discomfort in the affected area. Therefore, denial of pruritus would be an unexpected finding. Reports of joint discomfort: Joint discomfort is not typically associated with contact dermatitis. Contact dermatitis primarily affects the skin and does not usually involve the joints. Therefore, reports of joint discomfort would be an unexpected finding.
A nurse is checking a school-age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?
- A. Firmly attached white particles on the hair
- B. Itching and scratching of the head
- C. Thick, yellow-crusted lesions on a red base
- D. Patchy areas of hair loss
Correct Answer: A
Rationale: Firmly attached white particles on the hair: Firmly attached white particles on the hair are characteristic of nits, which are the eggs of lice. While this finding supports the diagnosis of pediculosis capitis, it is not a definitive indication on its own. Itching and scratching of the head: Itching and scratching of the head are common symptoms of pediculosis capitis. However, they are also common symptoms of various other scalp conditions, so they are not definitive indications. Thick, yellow-crusted lesions on a red base: This description is more characteristic of impetigo, a bacterial skin infection, rather than pediculosis capitis. Impetigo typically presents with yellow-crusted lesions on a red base, but it does not involve lice infestation. Patchy areas of hair loss: Patchy areas of hair loss are not typically associated with pediculosis capitis. This finding is more suggestive of conditions like alopecia areata or fungal infections.