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A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?
- A. My belly doesn't hurt anymore.
- B. I am hungry and thirsty.
- C. I'm tired and want to take a nap.
- D. I am scared and I want to go home.
Correct Answer: A
Rationale: My belly doesn't hurt anymore.' - This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.
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A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?
- A. Place new linen on the client's bed every other day.
- B. Change gloves between sites when providing wound care to multiple wounds.
- C. Change the dressing on infected wounds first.
- D. Monitor vital signs every 4 hr.
Correct Answer: B
Rationale: Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect?
- A. Maculopapular lesions between fingers and toes
- B. Inflamed area with white exudate
- C. Nonpruritic erythematous papule
- D. Rash with thick skin
Correct Answer: D
Rationale: Maculopapular lesions between fingers and toes: This finding is not typically associated with atopic dermatitis. Maculopapular lesions between the fingers and toes are more commonly seen in conditions like scabies or fungal infections. Inflamed area with white exudate: This finding is also not characteristic of atopic dermatitis. An inflamed area with white exudate may indicate a bacterial infection rather than atopic dermatitis. Nonpruritic erythematous papule: Atopic dermatitis often presents with erythematous (red) papules (small raised bumps) that are pruritic (itchy). However, the presence of nonpruritic lesions is less typical of atopic dermatitis. Rash with thick skin: This finding is consistent with atopic dermatitis. Chronic scratching and rubbing of the affected areas can lead to thickening of the skin (lichenification) in individuals with atopic dermatitis.
A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions after feeding?
- A. Left side
- B. Upright
- C. Right side
- D. Prone
Correct Answer: B
Rationale: Left side: Placing the infant on the left side after feeding is not typically recommended for managing gastroesophageal reflux. This position may not provide optimal support for digestion and may not effectively reduce reflux symptoms. Upright: This is the correct answer. Placing the infant in an upright position after feeding can help reduce gastroesophageal reflux. Gravity helps keep stomach contents down, preventing them from flowing back up into the esophagus. Holding the infant upright on the caregiver's shoulder or in a baby carrier can be effective in minimizing reflux symptoms. Right side: Placing the infant on the right side after feeding is not typically recommended for managing gastroesophageal reflux. Similar to the left side, this position may not provide optimal support for digestion and may not effectively reduce reflux symptoms. Prone: Placing the infant in a prone (face-down) position after feeding is not recommended due to the risk of sudden infant death syndrome (SIDS). Prone positioning is associated with an increased risk of SIDS, and current guidelines advise against placing infants to sleep or rest on their stomachs. Additionally, a prone position may not effectively reduce gastroesophageal reflux and may pose other risks to the infant's health and safety.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Monitor the client's hemoglobin level
- B. Restrain the client's extremities
- C. Place the client in a prone position
- D. Record the time and length of the seizure
Correct Answer: D
Rationale: Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.
A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select the 3 that apply.)
- A. Wheezing
- B. Rigid abdomen
- C. Pallor
- D. Weight loss
- E. Vomiting
Correct Answer: A,D,E
Rationale: A. Wheezing: Wheezing is a common symptom associated with asthma, which can be exacerbated by gastroesophageal reflux (GER) in infants. GER occurs when stomach contents flow back into the esophagus, leading to irritation and inflammation of the airways. This inflammation can cause wheezing sounds during breathing, especially if the refluxed material reaches the lower respiratory tract. B. Rigid abdomen: While gastroesophageal reflux (GER) primarily affects the upper gastrointestinal tract, it typically does not cause a rigid abdomen. A rigid abdomen may indicate other underlying gastrointestinal issues such as bowel obstruction, intussusception, or peritonitis. These conditions are not typically associated with GER in infants. C. Pallor: Pallor, or paleness of the skin, is not a common symptom of gastroesophageal reflux (GER) in infants. GER primarily affects the upper gastrointestinal tract and is characterized by symptoms such as spitting up, regurgitation, and irritability. Pallor may be indicative of other health issues such as anemia or circulatory problems but is not directly related to GER. D. Weight loss: Weight loss can occur in infants with gastroesophageal reflux (GER) if frequent vomiting leads to inadequate intake of nutrients. However, it is not a direct symptom of GER itself. Infants with GER may experience feeding difficulties, irritability, and discomfort associated with feeding, which can contribute to poor weight gain over time if not managed effectively. E. Vomiting: Vomiting is a common symptom of gastroesophageal reflux (GER) in infants. It occurs when stomach contents flow back up into the esophagus and sometimes out of the mouth. Infants with GER may spit up or vomit frequently after feeding or during burping, which can lead to discomfort and irritability. Vomiting may also contribute to poor weight gain and nutritional deficiencies if not managed effectively.