Nokea
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 is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Apply a warm compress to the operative site once daily.
- B. Administer analgesics on a scheduled basis for the first 24 hr.
- C. Give cromolyn nebulized solution every 8 hr.
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr.
Rationale: Postoperative pain management is crucial for the comfort and recovery of the child. Administering analgesics on a scheduled basis helps control pain effectively and prevents breakthrough pain. The first 24 hours following surgery are critical for pain control as the child may experience increased discomfort during this time. By providing analgesics on a schedule, the nurse ensures that the child receives timely pain relief.
Summary of incorrect choices:
A: Applying a warm compress to the operative site is not a standard practice post-appendectomy and may not effectively manage pain.
C: Cromolyn nebulized solution is not typically used for pain management post-appendectomy.
D: Offering clear liquids 6 hours following surgery may not be appropriate as the child may not be ready to tolerate oral intake so soon after surgery.
A nurse is teaching a group of parents about childhood immunization. The nurse should identify that infants should receive the first dose of which of the following immunizations at 12 months of age?
- A. Inactivated poliovirus
- B. Human papillomavirus
- C. Hepatitis B
- D. Varicella
Correct Answer: D
Rationale: The correct answer is D: Varicella. Infants should receive the first dose of varicella vaccine at 12 months of age to prevent chickenpox. Varicella is highly contagious and can lead to serious complications in children. The other choices are incorrect because:
A: Inactivated poliovirus - The first dose of polio vaccine is typically given at 2 months of age.
B: Human papillomavirus - HPV vaccine is usually recommended for adolescents, not infants.
C: Hepatitis B - Hepatitis B vaccine is usually given shortly after birth, not at 12 months of age.
In summary, varicella is the appropriate immunization for infants at 12 months to protect them from chickenpox, while the other options are administered at different ages or for different diseases.
A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive crisis. Which of the following actions should the nurse take?
- A. Apply cold compresses to the affected areas.
- B. Prepare for a transfusion of platelets.
- C. Promote active range of motion exercises.
- D. Increase oral fluid intake.
Correct Answer: D
Rationale: The correct answer is D: Increase oral fluid intake. During a vaso-occlusive crisis in sickle cell anemia, there is a blockage of blood flow leading to tissue ischemia and pain. Increasing oral fluid intake helps to hydrate the child and improve blood flow, potentially reducing the severity of the crisis. Cold compresses (A) can worsen vasoconstriction, platelet transfusion (B) is not indicated for vaso-occlusive crisis, and active range of motion exercises (C) can exacerbate pain and further compromise blood flow. Increasing fluid intake is the most appropriate intervention to help manage the crisis.
A nurse is caring for a recently admitted 18-year-old client:
Nurses' Notes
1000:
Client admitted to behavioral health unit for prolonged weight loss and refusal to eat. Client collapsed at school. The client's parents were called. They contacted the primary care provider, who arranged for a direct admission.
Weight 37.2 kg (82 lb)
Height 157.5 cm (62 inches)
BMI 15
1200:
Client observed during noon meal. Client pushed food around the plate. Intake 10% of meal. Offered nutritional supplement. Client declined. Reports feeling anxious due to admission and mealtime. Client states, "I cannot eat this with you watching me."
1500:
Snack provided. Client observed throwing snack into the trash can. When realized they had been observed, they admitted to their action and asked for a second snack. Client ate 10% of their snack.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Provide the client, with foods that have a variety of textures, Accept the client’s belief about "forbidden" foods, Focus on the client’s underlying feelings of lack of control, Encourage the client to limit fasting, Provide a structured meal environment.
- B. Bulimia Nervosa, Binge eating disorder, Anorexia nervosa, Avoidant/restrictive food intake disorder.
- C. Cardiac function with ECG, Weight on a daily basis, Calcium level, Vital signs every 8 hr, Behavior 15min after meals.
Correct Answer: A[2,4],B[2],C[0,4]
Rationale: Action to Take: Provide the client with foods that have a variety of textures, Encourage the client to limit fasting; Potential Condition: Anorexia nervosa; Parameter to Monitor: Weight on a daily basis, Behavior 15 minutes after meals.
Rationale: In anorexia nervosa, the client typically has a fear of gaining weight, leading to restrictive eating habits. Providing foods with different textures can help normalize eating habits and improve nutrition. Encouraging the client to limit fasting can help address the underlying issue of restricted food intake. Weight monitoring is crucial in assessing nutritional status, while monitoring behavior post-meals can provide insights into the client's relationship with food. Bulimia nervosa and binge eating disorder are not the most likely conditions based on the client's symptoms. Monitoring cardiac function with ECG and calcium level are not the primary parameters for assessing progress in anorexia nervosa.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.