Nokea
A nurse is providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?
- A. The risk of transmission decreases once my child is on zidovudine for 2 weeks
- B. My child will need to double his medications for the next 6 months.
- C. My child will need to repeat his childhood immunizations once he's in remission.
- D. I will ensure that my child is tested for tuberculosis every year.
Correct Answer: D
Rationale: The correct answer is D because regular testing for tuberculosis is crucial for individuals with HIV due to their increased risk of developing tuberculosis. This indicates the parent understands the importance of monitoring for potential complications. Choice A is incorrect because zidovudine does not impact transmission risk. Choice B is incorrect as doubling medications without healthcare provider guidance can be harmful. Choice C is incorrect as childhood immunizations are typically not repeated in remission.
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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.
A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Nontender, protruding abdomen
- C. Natural loss of deciduous teeth
- D. Palpable fontanels
Correct Answer: B
Rationale: The correct answer is B: Nontender, protruding abdomen. In toddlers, it is normal to have a nontender, protruding abdomen due to the physiological characteristics of their developing digestive system and musculature. This is because toddlers have less developed abdominal muscles and a larger liver in proportion to their body size, causing their abdomen to appear slightly distended. This finding is considered normal and does not typically indicate any underlying health issues. The other options are incorrect because: A: Head circumference exceeding chest circumference is not a typical finding in a 2-year-old toddler. C: Natural loss of deciduous teeth typically occurs around age 6-7, not in toddlers. D: Fontanels should be closed by 18 months, so palpable fontanels in a 2-year-old would be abnormal.
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 is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?
- A. Pull the pinna of the infant's ear forward before inserting the probe.
- B. Place the tip of the thermometer under the center of the infant's axilla.
- C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.
- D. Insert the oral thermometer in front of the infant's tongue.
Correct Answer: B
Rationale: Correct Answer: B - Place the tip of the thermometer under the center of the infant's axilla.
Rationale: The axillary temperature is a common method for measuring an infant's temperature. Placing the thermometer under the center of the axilla ensures an accurate reading without causing discomfort or harm to the infant.
Incorrect Choices:
A: Pulling the pinna of the infant's ear forward before inserting the probe is not necessary for measuring temperature.
C: Inserting the probe 3.8 cm (1.5 in) into the infant's rectum is invasive and not appropriate for routine temperature measurement.
D: Inserting the oral thermometer in front of the infant's tongue is incorrect as oral thermometers are not suitable for infants due to the risk of choking.
A nurse is assessing a school-age child who is receiving morphine. For which of the following adverse effects should the nurse monitor?
- A. Hypertension
- B. Bradypnea
- C. Stevens-Johnson syndrome
- D. Prolonged wound healing
Correct Answer: B
Rationale: The correct answer is B: Bradypnea. Morphine is an opioid that can cause respiratory depression, leading to bradypnea (slow breathing). The nurse should monitor the child's respiratory rate regularly as a safety precaution. Hypertension (A), Stevens-Johnson syndrome (C), and prolonged wound healing (D) are not typically associated with morphine use in school-age children. Monitoring for these adverse effects would not be a priority in this situation.