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A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room
- B. Administer aspirin to the child for fever
- C. Use droplet precautions when caring for the child
- D. Assess the child for health spots
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella (chickenpox) is highly contagious and spreads through airborne particles. Placing the child in a negative air pressure room helps prevent the spread of the virus to other patients and staff. Administering aspirin to a child with varicella can lead to Reye's syndrome, making choice B incorrect. Droplet precautions are used for illnesses like influenza or pertussis, not varicella, so choice C is incorrect. Choice D is incorrect because the characteristic rash in varicella is not described as health spots.
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A nurse is caring for a 9-year-old child at a clinic. The nurse should determine that the assessment findings are consistent with which of the following conditions?
- A. Edema
- B. Ecchymosis
- C. Pain Level
- D. Sensation
Correct Answer: B
Rationale: The correct answer is B: Ecchymosis. Ecchymosis is the presence of bruising, which is commonly seen in cases of trauma such as sprains, fractures, and dislocations. In a 9-year-old child, ecchymosis may indicate underlying injury or trauma. Edema can also be present in sprains, fractures, and dislocations, but it is not specific to these conditions. Pain level is subjective and can vary depending on the individual, so it is not as definitive as ecchymosis in identifying a specific condition. Sensation is important to assess in cases of injury, but it is not as indicative of a specific condition as ecchymosis. Therefore, the presence of ecchymosis is the most specific assessment finding to determine the underlying condition in this case. (0, 1, 0)
A nurse is assessing a school-age child who is receiving prednisone. For which of the following adverse effects should the nurse monitor?
- A. Renal failure
- B. Stevens-Johnson syndrome
- C. Prolonged wound healing
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Prolonged wound healing. Prednisone is a corticosteroid that can suppress the immune system and delay wound healing due to its anti-inflammatory effects. The nurse should monitor for this adverse effect by assessing the child's wounds regularly for signs of slow or impaired healing. Renal failure (A) is not a common adverse effect of prednisone. Stevens-Johnson syndrome (B) is a severe skin reaction usually caused by medications but is not typically associated with prednisone. Hypotension (D) is not a common adverse effect of prednisone and is more commonly associated with other medications or conditions.
A nurse is assessing the fontanels of an infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open.
- C. Both fontanels are the same size.
- D. Both fontanels show molars.
Correct Answer: B
Rationale: The correct answer is B: The anterior fontanel is open. The anterior fontanel is typically open in infants to allow for brain growth and development. It is a normal finding during infancy and should close by around 18 months of age. Choice A is incorrect because the posterior fontanel closes shortly after birth. Choice C is incorrect because the fontanels are not expected to be the same size; the anterior fontanel is larger than the posterior fontanel. Choice D is incorrect because the presence of molars in the fontanels would not be expected and could indicate a medical issue.
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 assessing a child who has measles. Which of the following areas should the nurse inspect for Koplik spots?
Correct Answer: C
Rationale: The correct answer is C. Koplik spots are small, white, grain-like spots with a red halo that appear on the buccal mucosa opposite the molars. They are specific to measles and typically appear 2-4 days before the rash. Inspecting other areas like the skin (choice A), scalp (choice B), nails (choice D), ears (choice E), throat (choice F), or feet (choice G) would not reveal Koplik spots as they are only found in the mouth. Therefore, choice C is the correct option for assessing Koplik spots in a child with measles.