Nokea
A nurse is contributing to the plan of care for a preschooler who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse recommend?
- A. Maintain clean technique during the child's dressing changes.
- B. Provide low-calorie snacks for the child three to four times each day between meals.
- C. Allow the child to set their own daily schedule for wound care.
- D. Ensure the child receives pain medication 30 to 45 min prior to therapy.
Correct Answer: D
Rationale: Pain medication 30-45 minutes before therapy manages pain during dressing changes or therapy. Clean technique is standard but not specific to pain, low-calorie snacks are irrelevant, and a child setting their own schedule is unsafe.
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A nurse in a clinic is caring for a group of infants. Which of the following findings should the nurse report as a possible indication of physical maltreatment?
- A. A hemangioma on the infant's torso
- B. A burn with splash marks on the lower right leg
- C. A large, irregular, brownish-blue area on the infant's buttock
- D. An abrasion on the back of the infant's arm
Correct Answer: B
Rationale: Splash-mark burns suggest possible abuse due to their pattern and should be reported. Hemangiomas are benign, bruises need context, and abrasions may be accidental.
A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
- A. Insomnia
- B. Irritability
- C. Diarrhea
- D. Hypothermia
Correct Answer: B
Rationale: Irritability may signal increased intracranial pressure post-head injury, requiring prompt reporting. Insomnia, diarrhea, and hypothermia are less directly related.
A nurse is preparing to percuss an adolescent's chest and abdomen. Which of the following areas should the nurse expect to hear a dull sound?
- A. This region of the chest is expected to be resonant on percussion because of the air in the lung.
- B. The right upper quadrant of the abdomen is usually dull on percussion because of the underlying liver.
- C. This site is tympanic because of the gas in the intestines.
Correct Answer: B
Rationale: The right upper quadrant is dull due to the liver. The chest is resonant, and intestines are tympanic.
A nurse is reinforcing teaching with the parent of a child who has a bacterial upper respiratory infection. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will force my child to drink fluids when they have a fever.
- B. I will use a dehumidifier in my child's room.
- C. I will keep my child's towels separate from those of the rest of the family.
- D. I will make sure my child eats three meals a day, even though their appetite is not good right now.
Correct Answer: C
Rationale: Separating towels prevents infection spread. Forcing fluids, using a dehumidifier, or insisting on three meals are not specific or recommended for bacterial infections.
A nurse is caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority?
- A. Monitor capillary refill of the casted extremity.
- B. Use the palms of the hands when supporting the cast.
- C. Examine the skin at the cast edges.
- D. Instruct the child not to put anything inside the cast.
Correct Answer: A
Rationale: Monitoring capillary refill is critical to assess circulation and detect complications like compartment syndrome post-cast application. Supporting the cast, checking skin, and instructing the child are important but secondary to ensuring circulation.