Nokea
A school-age child has been bitten on the leg by a large snake that may be poisonous. During transport to an emergency facility, what should the care include?
- A. Apply ice to the snakebite.
- B. Immobilize the leg with a splint.
- C. Place a loose tourniquet distal to the bite.
- D. Apply warm compresses to the snakebite.
Correct Answer: B
Rationale: Immobilizing the leg with a splint minimizes venom spread by reducing movement. Ice reduces blood flow, potentially trapping venom, a tourniquet should be proximal if used, and warm compresses increase circulation, spreading the venom.
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The middle school nurse is planning a behavior modification program for overweight children. What is the most important goal for participants of the program?
- A. Learn how to cook low-fat meals.
- B. Improve relationships with peers.
- C. Identify and eliminate inappropriate eating habits.
- D. Achieve normal weight during the program.
Correct Answer: C
Rationale: Identifying and eliminating inappropriate eating habits is the core of behavior modification, addressing root causes of obesity. Cooking skills are secondary, peer relationships are not the focus, and normal weight is a long-term goal.
The nurse should know what about Lyme disease?
- A. Very difficult to prevent
- B. Easily treated with oral antibiotics in stages 1, 2, and 3
- C. Caused by a spirochete that enters the skin through a tick bite
- D. Common in geographic areas where the soil contains the mycotic spores that cause the disease
Correct Answer: C
Rationale: Lyme disease is caused by Borrelia burgdorferi, a spirochete transmitted through a tick bite, leading to symptoms like erythema migrans. Prevention involves avoiding tick-infested areas and wearing protective clothing. It is not caused by mycotic spores, and while treatable with antibiotics, later stages may require more complex treatment.
The school nurse is seeing a child who collected some poison ivy leaves during recess. He says only his hands touched it. What is the most appropriate nursing action?
- A. Soak his hands in warm water.
- B. Apply Burow's solution compresses.
- C. Rinse his hands in cold running water.
- D. Scrub his hands thoroughly with antibacterial soap.
Correct Answer: C
Rationale: Rinsing with cold running water within 15 minutes neutralizes urushiol, the oil causing poison ivy dermatitis, preventing it from bonding to the skin. Warm water is used after dermatitis develops, Burow's solution treats lesions, and antibacterial soap can spread urushiol by removing skin oils.
An adolescent girl calls the nurse at the clinic because she had unprotected sex the night before and does not want to be pregnant. What should the nurse explain?
- A. It is too late to prevent an unwanted pregnancy.
- B. An abortion may be the best option if she is pregnant.
- C. The risk of pregnancy is minimal, so no action is necessary.
- D. Postcoital contraception is available to prevent implantation and therefore pregnancy.
Correct Answer: D
Rationale: Emergency contraception like Plan B, if taken within 72 hours, can prevent pregnancy by inhibiting implantation. It?s not too late, abortion isn?t immediately necessary, and pregnancy risk varies but warrants action.
A 6-year-old boy with very fair skin will be joining his family during a beach vacation. What should the nurse recommend?
- A. Keep him off the beach during the daytime hours.
- B. Use sunscreen with an SPF of at least 15 and reapply it every 2 to 3 hours.
- C. Apply a topical sunscreen product with an SPF of 30 in the morning.
- D. Dress him in long pants and long-sleeved shirt and keep him under a beach umbrella.
Correct Answer: B
Rationale: Sunscreen with SPF 15 or higher, reapplied every 2-3 hours and after water exposure, protects fair skin from UV damage. Avoiding the beach is impractical, a single SPF 30 application is insufficient, and long clothing with an umbrella is less practical than sunscreen.