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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.
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A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will have to feed my baby formula, rather than breast milk.
- B. I should move my baby into a side-lying position during sleep.
- C. My baby's formula can be thickened with oatmeal.
- D. I will keep my baby in an upright position after feedings.
Correct Answer: D
Rationale: I will have to feed my baby formula, rather than breast milk.' - This statement indicates a misunderstanding. Breast milk is generally preferred for infants with gastroesophageal reflux (GER) because it is more easily digested and less likely to exacerbate reflux symptoms compared to formula. Breastfeeding mothers may be encouraged to continue breastfeeding, and formula-fed infants may benefit from specialized formulas designed to reduce reflux symptoms. 'I should move my baby into a side-lying position during sleep.' - This statement indicates a misunderstanding. Placing an infant in a side-lying position during sleep is not recommended due to the risk of sudden infant death syndrome (SIDS). Instead, infants with GER should be placed on their back to sleep, as recommended by safe sleep guidelines. Elevating the head of the crib or bassinet slightly may also help reduce reflux symptoms during sleep. 'My baby's formula can be thickened with oatmeal.' - This statement indicates an understanding of the teaching. Thickening formula with oatmeal or rice cereal can help reduce gastroesophageal reflux (GER) symptoms in infants by making the formula heavier and less likely to reflux back into the esophagus. However, this should only be done under the guidance of a healthcare provider to ensure proper preparation and feeding technique. 'I will keep my baby in an upright position after feedings.' - This statement indicates an understanding of the teaching. Keeping the baby in an upright position after feedings can help reduce reflux symptoms by allowing gravity to keep the stomach contents down. Parents can hold the baby upright on their shoulder or in an infant seat for a period of time after feeding to minimize reflux episodes.
When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most important to avoid which of the following?
- A. Measuring the child's chest circumference
- B. Palpating the child's abdomen
- C. Measuring the child's occipitofrontal circumference
- D. Placing the child in an upright position
Correct Answer: B
Rationale: Measuring the child's chest circumference: Measuring the chest circumference may not directly aid in the assessment of Wilm's tumor. While it's important for assessing respiratory conditions or monitoring growth, it's not a primary assessment for Wilm's tumor, which primarily affects the abdomen. Palpating the child's abdomen: This is an essential action in assessing for Wilm's tumor. The nurse should carefully palpate the abdomen to check for any masses, swelling, or tenderness, as these could be indicative of the tumor. Measuring the child's occipitofrontal circumference: This measurement pertains to the head circumference and is not directly related to the assessment of Wilm's tumor. While it's important for monitoring head growth and development, it's not a priority when assessing for Wilm's tumor. Placing the child in an upright position: Placing the child in an upright position may be necessary for certain assessments or procedures, but it's not directly related to assessing for Wilm's tumor. The focus should primarily be on abdominal assessment and palpation to detect any signs of the tumor.
An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?
- A. No treatment is necessary, the fluid is reabsorbing normally
- B. Keeping the infant in a flat, supine position until the fluid is gone
- C. Referral to a surgeon for repair
- D. Massaging the groin area twice a day until the fluid is gone.
Correct Answer: A
Rationale: No treatment is necessary, the fluid is reabsorbing normally: - This option suggests that the hydrocele is resolving spontaneously, which is often the case in infants. The physician may choose to observe the hydrocele over time as it is likely to resolve without intervention. Keeping the infant in a flat, supine position until the fluid is gone: - This option does not address the underlying cause of the hydrocele and is not a standard treatment recommendation. Additionally, positioning changes are unlikely to affect the resolution of the hydrocele. Referral to a surgeon for repair: - Surgical repair may be considered if the hydrocele persists beyond a certain age or if it causes discomfort or complications. However, it is typically not recommended in infants unless the hydrocele persists beyond infancy or causes other issues. Massaging the groin area twice a day until the fluid is gone: - Massaging the groin area is not a recommended treatment for hydrocele and may not be effective in resolving the condition. Additionally, manipulating the scrotum may cause discomfort or injury to the infant.
A nurse is reinforcing teaching about lice with the parents of a school-age child at a well-child visit. Which of the following information should the nurse include?
- A. Lice do not survive away from the host.
- B. Washing your child's hair daily will prevent lice.
- C. Encourage your child to avoid sharing hats with other children.
- D. Lice can jump from one child to another.
Correct Answer: C
Rationale: Lice do not survive away from the host.' - This statement is incorrect. Lice can survive away from the host (human scalp) for a limited period, usually up to 1-2 days. They may be found on items such as bedding, clothing, hats, or hair accessories. Therefore, proper cleaning and disinfection of these items are essential to prevent the spread of lice. 'Washing your child's hair daily will prevent lice.' - This statement is incorrect. While maintaining good hygiene is important, washing hair daily does not necessarily prevent lice infestation. Lice infestations occur through direct head-to-head contact with an infested person, not due to uncleanliness. Additionally, lice are more commonly found in clean hair rather than dirty hair. 'Encourage your child to avoid sharing hats with other children.' - This statement is correct. Sharing personal items such as hats, scarves, brushes, or hair accessories can facilitate the spread of lice from one person to another. Therefore, it's important to advise children not to share these items to reduce the risk of lice transmission. 'Lice can jump from one child to another.' - This statement is incorrect. Lice do not have the ability to jump or fly. They spread through direct contact with the hair or scalp of an infested person. However, they can crawl quickly from one person to another, especially when there is close contact, such as during play or when sharing personal items.
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.