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A nurse is reinforcing teaching about lice with the parents of a school-age child at a well-child visit. Which of the following information should the nurse include?
- A. Lice do not survive away from the host.
- B. Washing your child's hair daily will prevent lice.
- C. Encourage your child to avoid sharing hats with other children.
- D. Lice can jump from one child to another.
Correct Answer: C
Rationale: Lice do not survive away from the host.' - This statement is incorrect. Lice can survive away from the host (human scalp) for a limited period, usually up to 1-2 days. They may be found on items such as bedding, clothing, hats, or hair accessories. Therefore, proper cleaning and disinfection of these items are essential to prevent the spread of lice. 'Washing your child's hair daily will prevent lice.' - This statement is incorrect. While maintaining good hygiene is important, washing hair daily does not necessarily prevent lice infestation. Lice infestations occur through direct head-to-head contact with an infested person, not due to uncleanliness. Additionally, lice are more commonly found in clean hair rather than dirty hair. 'Encourage your child to avoid sharing hats with other children.' - This statement is correct. Sharing personal items such as hats, scarves, brushes, or hair accessories can facilitate the spread of lice from one person to another. Therefore, it's important to advise children not to share these items to reduce the risk of lice transmission. 'Lice can jump from one child to another.' - This statement is incorrect. Lice do not have the ability to jump or fly. They spread through direct contact with the hair or scalp of an infested person. However, they can crawl quickly from one person to another, especially when there is close contact, such as during play or when sharing personal items.
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The nurse is caring for a 7-year-old child who fell off an ATV sustaining a flesh wound. The child is awaiting wound debridement. What nursing action best demonstrates the concept of atraumatic care?
- A. Allowing siblings to visit the client in the hospital
- B. Using a doll to demonstrate an invasive procedure
- C. Encouraging communication between the parents and nurse
- D. Arranging the room to accommodate religious practices
Correct Answer: B
Rationale: Allowing siblings to visit the client in the hospital - Allowing siblings to visit the client in the hospital is a compassionate gesture and promotes family-centered care. However, it may not directly address the concept of atraumatic care, which focuses on minimizing physical and psychological stress related to healthcare procedures. Using a doll to demonstrate an invasive procedure - Using a doll to demonstrate an invasive procedure is an example of atraumatic care. It allows the nurse to provide preparatory information to the child in a non-threatening and understandable manner. By visually demonstrating the procedure on a doll, the child can better understand what will happen, reducing anxiety and fear. Encouraging communication between the parents and nurse - Encouraging communication between the parents and nurse is important for providing holistic care and addressing the child's needs. While effective communication is essential, it may not directly demonstrate the concept of atraumatic care unless it involves discussing how to minimize stress and anxiety during procedures. Arranging the room to accommodate religious practices - Arranging the room to accommodate religious practices is a form of patient-centered care and respects the cultural and religious beliefs of the patient and family. While important for overall comfort and respect for the patient's values, it may not directly relate to the concept of atraumatic care, which specifically focuses on reducing stress and anxiety during healthcare procedures.
A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child?
- A. Broth
- B. Apple juice
- C. Cherry gelatin
- D. Pedialyte
Correct Answer: D
Rationale: Broth: Broth is not typically recommended for children with acute diarrhea because it lacks the necessary electrolytes to adequately replace those lost through diarrhea. While it can help provide some fluids, it may not be sufficient for rehydration and could potentially worsen dehydration if electrolytes are not adequately replaced. Apple juice: While apple juice may seem like a hydrating option, it is not the best choice for children with acute diarrhea. Apple juice contains a high amount of sugar, which can draw water into the intestines and worsen diarrhea. Additionally, it lacks the necessary electrolytes needed for rehydration. Cherry gelatin: Cherry gelatin is not recommended for rehydrating a child with acute diarrhea. Like apple juice, it contains sugar, which can exacerbate diarrhea by drawing water into the intestines. Gelatin also lacks the electrolytes needed to replace those lost through diarrhea. Pedialyte: Pedialyte is the preferred choice for rehydrating a child with acute diarrhea. It is specifically formulated to replace lost fluids and electrolytes and is less likely to worsen diarrhea compared to sugary beverages like juice or gelatin. Pedialyte helps prevent dehydration by providing a balanced mixture of water, sugar, and electrolytes, making it an effective choice for managing diarrhea in children.
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)
- A. Place a tongue depressor in the child's mouth.
- B. Restrain the child.
- C. Clear the area of hard objects.
- D. Loosen restrictive clothing.
- E. Place the child in a prone position
Correct Answer: C,
Rationale: A. Place a tongue depressor in the child's mouth: This is an incorrect action. Placing a tongue depressor or any other object in the child's mouth during a seizure can cause injury to the child's mouth, teeth, or airway. It may also increase the risk of choking. It's a common misconception that people can swallow their tongues during a seizure, but this is not true. It's important to keep the child's mouth clear of objects and allow the seizure to run its course. B. Restrain the child: This is also an incorrect action. Restraint can cause further injury to the child and increase agitation, which may worsen the seizure. It's important to allow the child to move freely during a seizure while taking steps to ensure their safety, such as clearing the area of objects and protecting the head from injury. C. Clear the area of hard objects: This is a correct action. Removing hard objects from the area helps prevent injury to the child during a seizure. Objects such as furniture corners or sharp items can pose a risk if the child thrashes or moves unpredictably during the seizure. D. Loosen restrictive clothing: This is also a correct action. During a seizure, it's important to ensure that the child's clothing is not too tight or restrictive. Loosening clothing, especially around the neck and chest area, helps ensure adequate airflow and prevents restriction of movement during the seizure. E. Place the child in a prone position: This is an incorrect action. Placing the child in a prone (face-down) position during a seizure can increase the risk of airway obstruction and make it more difficult for the child to breathe. Instead, the child should be placed on their side (recovery position) to help maintain an open airway and prevent aspiration if vomiting occurs.
A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect?
- A. Orange-tinged urine
- B. Hypertension
- C. Periorbital edema
- D. Polyuria
Correct Answer: C
Rationale: Orange-tinged urine - This manifestation is not typically associated with nephrotic syndrome. Orange-tinged urine may indicate other conditions such as dehydration, liver disease, or the presence of certain medications or foods. Hypertension - Hypertension is not a common manifestation of nephrotic syndrome. However, it can occur in some cases due to the retention of sodium and water, which can lead to fluid overload and increased blood pressure. Periorbital edema - This is a classic manifestation of nephrotic syndrome. Periorbital edema, or swelling around the eyes, is often one of the initial signs observed in children with nephrotic syndrome due to the loss of protein in the urine, leading to fluid accumulation in the tissues. Polyuria - Polyuria, or increased urine output, is not typically associated with nephrotic syndrome. Instead, children with nephrotic syndrome may experience oliguria or normal urine output, depending on the severity of renal involvement and fluid balance.
12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be?
- A. 24 lb 6 oz
- B. 20 lb 5oz
- C. 32 lb 8 0z
- D. 16 lb 4 oz
Correct Answer: A
Rationale: The nurse should expect the 12-month-old boy to weigh approximately 24 lb 6 oz (since 0.375 lb ≈ 6 oz).
So, around 24 lbs 6 oz is a normal expected weight at 12 months for a baby born at 8 lb 2 oz.