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A school nurse is completing routine health evaluations for school-age children. Which of the following manifestation should alert the nurse to the possibility of pediculosis capitis?
- A. Patches of baldness
- B. Blisters on the scalp
- C. Dry patches on the scalp
- D. Reports of scalp itchiness
Correct Answer: D
Rationale: Patches of baldness: Patches of baldness on the scalp could be indicative of conditions like alopecia areata, a disorder characterized by hair loss in patches. However, it is not a typical manifestation of pediculosis capitis, which primarily presents with scalp itchiness due to lice bites rather than hair loss. Blisters on the scalp: Blisters on the scalp may suggest other conditions such as herpes simplex infection or contact dermatitis. While scratching from head lice infestation could lead to skin irritation, blisters are not a common presentation of pediculosis capitis. Dry patches on the scalp: Dry patches on the scalp might be caused by conditions like seborrheic dermatitis or eczema. While scalp dryness can occur with pediculosis capitis due to irritation from scratching, it is not a specific symptom associated with head lice infestation. Reports of scalp itchiness: Scalp itchiness is a hallmark symptom of pediculosis capitis. It occurs as a result of lice bites and the body's inflammatory response to their saliva. It is the most characteristic and common manifestation of head lice infestation and often prompts further examination for the presence of lice or their eggs (nits).
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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.
A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Increased appetite
- C. Mucus in stools
- D. Jaundice
Correct Answer: C
Rationale: Drooling - Drooling is not typically associated with intussusception. Intussusception is a condition where one portion of the intestine telescopes into another, leading to bowel obstruction and subsequent symptoms such as abdominal pain, vomiting, and 'currant jelly' stools. Increased appetite - Increased appetite is unlikely in a toddler with intussusception. Instead, affected toddlers may experience symptoms such as abdominal pain, vomiting, and lethargy, which can lead to decreased appetite. Mucus in stools - Mucus in stools is a characteristic finding in intussusception. As the telescoping of the intestine causes irritation and inflammation, mucus may be passed in the stool along with blood and, in some cases, a characteristic 'currant jelly' appearance. Jaundice - Jaundice is not a typical manifestation of intussusception. It may be present in conditions affecting the liver or bile ducts, such as biliary atresia or obstructive jaundice, but it is not a direct symptom of intussusception.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Change to cloth diapers until the skin is healed.
- B. Use a moisturizer to wipe urine from the skin.
- C. Apply a light layer of talcum powder with each diaper change.
- D. Expose the excoriated area to hot air frequently.
Correct Answer: B
Rationale: While some parents may prefer cloth diapers, they can retain moisture and irritants. Disposable diapers with good absorbency are often preferred in managing diaper dermatitis. Using a gentle moisturizer to clean the skin can help protect the infant's skin and maintain its barrier function, especially in cases of diaper dermatitis. Moisturizers help soothe and heal the affected area by providing hydration and protection. Talcum powder is not recommended due to the risk of inhalation, which can cause respiratory issues. Additionally, powders can clump and worsen skin irritation. Exposing the skin to hot air can dry out the skin and worsen irritation. It's better to allow the area to air-dry naturally or use a cool blow dryer on a low setting.
A nurse is checking a school-age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?
- A. Firmly attached white particles on the hair
- B. Itching and scratching of the head
- C. Thick, yellow-crusted lesions on a red base
- D. Patchy areas of hair loss
Correct Answer: A
Rationale: Firmly attached white particles on the hair: Firmly attached white particles on the hair are characteristic of nits, which are the eggs of lice. While this finding supports the diagnosis of pediculosis capitis, it is not a definitive indication on its own. Itching and scratching of the head: Itching and scratching of the head are common symptoms of pediculosis capitis. However, they are also common symptoms of various other scalp conditions, so they are not definitive indications. Thick, yellow-crusted lesions on a red base: This description is more characteristic of impetigo, a bacterial skin infection, rather than pediculosis capitis. Impetigo typically presents with yellow-crusted lesions on a red base, but it does not involve lice infestation. Patchy areas of hair loss: Patchy areas of hair loss are not typically associated with pediculosis capitis. This finding is more suggestive of conditions like alopecia areata or fungal infections.