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A nurse is preparing to administer immunizations to a 5-year-old child who is up to date with the current immunization schedule. Which of the following immunizations should the nurse plan to administer?
- A. Haemophilus influenzae type B
- B. Varicella
- C. Hepatitis B
- D. Diphtheria
Correct Answer: B
Rationale: The correct answer is B: Varicella. At the age of 5, children are due for their second dose of the Varicella vaccine according to the current immunization schedule. Varicella vaccine is given to protect against chickenpox. Haemophilus influenzae type B and Hepatitis B vaccines are typically administered at earlier ages. Diphtheria vaccine is usually given in combination with other vaccines and not as a standalone. In summary, Varicella is the correct choice as it aligns with the child's age and the recommended immunization schedule, while the other options are not due at this time.
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A nurse in the emergency department is caring for a 10-year-old child. The nurse is assessing the child. Which of the following findings require follow-up? Select the 5 findings that require follow-up.
- A. Temperature
- B. Heart rate
- C. Report of pain
- D. Respiratory rate
- E. Tonsillar findings
- F. Oxygen saturation
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes all options (A, B, C, D, E, F) because they are essential vital signs and key indicators of the child's health status. Temperature (A), heart rate (B), respiratory rate (D), and oxygen saturation (F) are crucial physiological parameters that can indicate underlying health issues if abnormal. Report of pain (C) is important to assess the child's comfort and potential underlying conditions. Tonsillar findings (E) could indicate infections or other throat issues. Follow-up on all these findings is necessary for a comprehensive assessment of the child's health.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Apply talcum powder to the irritated area.
- B. Wipe stool from the skin using store-bought baby wipes.
- C. Apply zinc oxide ointment to the irritated area.
- D. Wipe urine from the skin using a cool cloth.
Correct Answer: C
Rationale: The correct answer is C: Apply zinc oxide ointment to the irritated area. Zinc oxide ointment provides a protective barrier on the skin, helping to soothe and heal diaper dermatitis. It also helps to keep moisture away from the irritated skin, promoting healing.
Incorrect options:
A: Applying talcum powder can further irritate the skin as it can be abrasive.
B: Store-bought baby wipes may contain chemicals or fragrances that can worsen the condition.
D: Wiping urine with a cool cloth is a good practice, but it does not address the issue of diaper dermatitis.
Overall, option C is the best choice as it directly addresses the diaper dermatitis by providing a protective barrier and promoting healing.
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine, used for ADHD, can potentially cause liver toxicity. Monitoring liver function tests helps detect any signs of liver damage early on. Choice B, kidney function tests, is not as relevant as atomoxetine primarily affects the liver. Choice C, hemoglobin and hematocrit, is not directly impacted by atomoxetine. Choice D, serum sodium and potassium, is not typically affected by atomoxetine use.
A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid picking up my baby too often to keep from spoiling him.
- B. I will hang a pastel-colored mobile 24 inches above my baby's crib.
- C. I can use a firm pillow to prop up the bottle when feeding my baby.
- D. I will place a ticking clock nearby to soothe my baby throughout the day.
Correct Answer: B
Rationale: The correct answer is B: "I will hang a pastel-colored mobile 24 inches above my baby's crib." This statement indicates an understanding of the teaching because hanging a mobile can provide visual stimulation for the infant, promoting cognitive development. It also helps in soothing and calming the baby.
Incorrect choices:
A: Incorrect because picking up the baby frequently is not spoiling and is important for bonding and meeting the baby's needs.
C: Incorrect because using a firm pillow to prop up the bottle can be a choking hazard and is not recommended for feeding infants.
D: Incorrect because placing a ticking clock nearby can actually be a suffocation risk and is not recommended for soothing babies.
A nurse on the pediatric unit is admitting the child from the emergency department. Complete the following sentence by using the lists of options. The nurse suspects the child is experiencing rheumatic fever. The nurse should recognize the child is at greatest risk of developing--- due to---
- A. Glomerulonephritis
- B. Pericarditis
- C. Rheumatic heart disease
- D. Streptococcal pharyngitis
- E. Recent immunizations
- F. Viral infection
Correct Answer: C,D
Rationale: The correct answers are C: Rheumatic heart disease and D: Streptococcal pharyngitis. Rheumatic fever is caused by untreated streptococcal infection. If not treated promptly, it can lead to rheumatic heart disease, a serious complication. Streptococcal pharyngitis is a common precursor to rheumatic fever. Glomerulonephritis (A) is a potential complication of streptococcal infection but not directly related to rheumatic fever. Pericarditis (B) is an inflammation of the pericardium and not directly associated with rheumatic fever. Recent immunizations (E) and viral infections (F) are not linked to the development of rheumatic fever.