Nokea
A parent arrives in the emergency clinic with a 3-month-old baby who has difficulty breathing and prolonged periods of apnea. Which assessment data should alert the nurse to suspect shaken baby syndrome (SBS)?
- A. Birth occurred before 32 weeks' gestation
- B. Lack of stridor and adventitious breath sounds
- C. Previous episodes of apnea lasting 10 to 15 seconds
- D. Retractions and use of accessory respiratory muscles
Correct Answer: D
Rationale: Retractions and the use of accessory respiratory muscles are signs of respiratory distress in infants. These clinical manifestations can be associated with trauma, such as shaken baby syndrome (SBS), which can lead to severe head injuries and respiratory compromise. Birth before 32 weeks' gestation (Choice A) is more related to prematurity complications rather than SBS. The absence of stridor and adventitious breath sounds (Choice B) may not be specific indicators of SBS. Previous episodes of apnea lasting 10 to 15 seconds (Choice C) alone may not be as concerning as the presence of retractions and use of accessory muscles in the context of a distressed infant.
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A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?
- A. Immobilize the affected limb
- B. Apply ice to the affected area
- C. Elevate the affected limb
- D. Check the child's neurovascular status
Correct Answer: A
Rationale: The priority nursing action when a child with a suspected fracture is brought to the emergency department is to immobilize the affected limb. Immobilization helps prevent further injury until a fracture is confirmed or ruled out. Applying ice or elevating the limb may be necessary interventions but should come after immobilizing the limb. Checking the child's neurovascular status is important but should follow immobilization to ensure no further harm is done during the assessment.
A nurse is inspecting the skin of a child with atopic dermatitis. What would the nurse expect to observe?
- A. Erythematous papulovesicular rash
- B. Dry, red, scaly rash with lichenification
- C. Pustular vesicles with honey-colored exudates
- D. Hypopigmented oval scaly lesions
Correct Answer: B
Rationale: In atopic dermatitis, the nurse would expect to observe a dry, red, scaly rash with lichenification. Lichenification is thickened skin due to chronic scratching. Choices A, C, and D are incorrect. Erythematous papulovesicular rash is more characteristic of contact dermatitis, pustular vesicles with honey-colored exudates are seen in impetigo, and hypopigmented oval scaly lesions are typical of pityriasis alba.
The nurse is assessing a 4-year-old client. Which finding suggests to the nurse this child may have a genetic disorder?
- A. The inquiry determines the child had feeding problems.
- B. The child weighs 40 lb (18.2 kg) and is 40 in (101.6 cm) in height.
- C. The child has low-set ears with lobe creases.
- D. The child can hop on one foot but cannot skip.
Correct Answer: C
Rationale: Low-set ears with lobe creases are often associated with genetic disorders, such as Down syndrome, and can indicate underlying chromosomal abnormalities. This physical characteristic is a common feature seen in various genetic syndromes. The other choices, including feeding problems, weight and height measurements, and motor skills, are not typically specific indicators of genetic disorders in the absence of other associated features.
What should the nurse recommend to reduce the risk of sudden infant death syndrome (SIDS) in a 6-month-old infant?
- A. Place the infant on their back to sleep
- B. Use a pacifier during sleep
- C. Have the infant sleep on their side
- D. Keep the infant's room cool
Correct Answer: A
Rationale: Placing the infant on their back to sleep is the correct recommendation to reduce the risk of sudden infant death syndrome (SIDS). This sleep position has been shown to significantly decrease the incidence of SIDS. Using a pacifier during sleep (Choice B) can also help reduce the risk, but it is secondary to the back sleeping position. Having the infant sleep on their side (Choice C) is not recommended, as it increases the risk of SIDS. Keeping the infant's room cool (Choice D) may provide a comfortable sleeping environment but does not directly reduce the risk of SIDS.
A 3-year-old child is being discharged after being treated for dehydration. What should be included in the discharge teaching?
- A. Monitor for signs of infection
- B. Monitor for signs of dehydration
- C. Monitor for signs of hypovolemia
- D. Monitor for signs of malnutrition
Correct Answer: B
Rationale: The correct answer is to monitor for signs of dehydration. After treatment for dehydration, it is crucial to educate caregivers about recognizing early signs of dehydration to prevent its recurrence. Monitoring for dehydration ensures that appropriate measures can be taken promptly if signs reappear. Choices A, C, and D are incorrect because infection, hypovolemia, and malnutrition, while important considerations in healthcare, are not the primary focus after treating dehydration in a 3-year-old child.