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A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Place a pillow under the child's head.
- B. Remove the child's eyeglasses.
- C. Time the seizure.
- D. Move the child into a side-lying position.
Correct Answer: D
Rationale: While placing a pillow under the child's head might seem like a good idea, it's actually not recommended during a seizure. The child's movements could be unpredictable, and a pillow could potentially cause suffocation. Removing the child's eyeglasses is a good idea, but it's not the first thing you should do. The child's safety is the top priority, and eyeglasses can be removed once the child is safe. Timing the seizure is important for medical professionals to know, but it's not the first action to take. The child's immediate safety is the priority. Moving the child into a side-lying position is the priority. This position helps keep the airway clear and allows any vomit to exit the mouth, reducing the risk of choking.
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A nurse is collecting data from an infant who has otitis media. Which of the following findings should the nurse expect?
- A. Bluish-green discharge from the ear canal
- B. Erythema and edema of the affected auricle
- C. Increase in appetite
- D. Tugging on the affected ear lobe
Correct Answer: D
Rationale: Bluish-green discharge from the ear canal is not a typical finding in otitis media. This could suggest a different condition, such as an external ear infection or a ruptured eardrum. Erythema and edema of the affected auricle (outer part of the ear) are not typical findings in otitis media. These symptoms are more commonly associated with conditions affecting the external ear, such as otitis externa. An increase in appetite is not typically associated with otitis media. In fact, children with otitis media may have a decreased appetite due to discomfort or pain while swallowing. Tugging on the affected ear lobe is a common sign of otitis media in infants and young children. This is often due to the pain and discomfort caused by the infection.
A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)
- A. Smooth the rough edges of the cast to maintain skin integrity
- B. Wear sterile gloves when touching or removing the cast
- C. Monitor capillary refill and color of nail beds of the left-hand
- D. Monitor for signs of pain
- E. Assess for numbness, tingling, or decreased sensation of the left hand.
Correct Answer: A,C,D,E
Rationale: Choice A rationale: Smoothing the rough edges of the cast can help maintain skin integrity and prevent skin irritation or injury. Choice C rationale: Monitoring capillary refill and color of nail beds of the left hand is important to assess the circulation to the hand and ensure that the cast is not too tight. Choice D rationale: Monitoring for signs of pain can help detect complications such as compartment syndrome, which is a serious condition that can occur if pressure within the muscles builds to dangerous levels. Choice E rationale: Assessing for numbness, tingling, or decreased sensation of the left hand is important as these can be signs of nerve damage or compression. Choice B rationale: Wearing sterile gloves when touching or removing the cast is not typically necessary. The outside of a cast is not a sterile environment, and healthcare providers do not usually wear sterile gloves when handling it.
A nurse is providing instructions about methylphenidate (Ritalin) to the parents of a school-age child who has ADHD. Which of the following instructions should the nurse include?
- A. You will need to give your child the medication after meals.
- B. You will need to have your child's blood glucose level checked monthly.
- C. You should not give your child the medication on weekends.
- D. You should give your child's last daily dose of the medication before 6 o'clock in the evening.
Correct Answer: D
Rationale: Methylphenidate (Ritalin) is a medication used to treat attention-deficit hyperactivity disorder (ADHD). It is not necessary to give the medication after meals. The medication can be taken with or without food. However, some people find that taking it with food can help prevent stomach upset. Regular blood glucose level checks are not typically required when a child is taking methylphenidate. This medication does not have a significant impact on blood sugar levels. It is not generally recommended to skip doses of methylphenidate on weekends. Consistent medication administration is important for managing ADHD symptoms. However, the prescribing doctor may sometimes recommend a 'drug holiday' or break from the medication. This should only be done under the guidance of a healthcare professional. This is the correct answer. Methylphenidate is a stimulant, and taking it later in the day can cause insomnia or trouble sleeping. Therefore, it is often recommended that the last dose of the medication be given before 6 o'clock in the evening to minimize sleep disturbances.
What symptoms should a nurse expect in a 6-week-old infant admitted for evaluation of suspected pyloric stenosis?
- A. Projectile vomiting.
- B. Effortless regurgitation.
- C. Metabolic acidosis.
- D. Distended abdomen.
Correct Answer: A
Rationale: Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine. Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
Which client on an acute care pediatric unit requires the nurse's immediate attention?
- A. An 18-month-old client who had a cleft palate repair and is crying in pain.
- B. A 12-year-old client who had an appendectomy and refuses to ambulate.
- C. An 8-year-old client who had a tonsillectomy and is swallowing frequently.
- D. A 15-year-old client who has an IV infusion and reports pain at the insertion site.
Correct Answer: C
Rationale: While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient's health. A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient's health. Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention. While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient's health.