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A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination?
- A. Bend forward from the waist with your head and arms downward.
- B. Touch your chin to your chest, and then look up at the ceiling.
- C. Lie prone on the examination table.
- D. Turn to the side and remain in a relaxed position.
Correct Answer: A
Rationale: Bending forward from the waist with the head and arms downward, also known as the Adams forward bend test, is the standard screening test for scoliosis. Touching the chin to the chest and then looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening. Lying prone on the examination table is not a standard position for scoliosis screening. Turning to the side and remaining in a relaxed position is not a standard position for scoliosis screening.
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A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperactive bowel sounds
- C. WBC 17,000/mm
- D. Left lower quadrant abdominal pain
Correct Answer: C
Rationale: Bradycardia, or a slower than normal heart rate, is not typically associated with acute appendicitis. In fact, tachycardia, or a faster than normal heart rate, may occur due to the body's response to inflammation and infection. Hyperactive bowel sounds are not a typical finding in acute appendicitis. In fact, bowel sounds may be normal or decreased due to the inflammatory process. A white blood cell (WBC) count of 17,000/mm is higher than the normal range, indicating the presence of an infection or inflammation in the body. This is a common finding in acute appendicitis. Pain from appendicitis is typically located in the right lower quadrant of the abdomen, not the left.
A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response?
- A. Follow the directions on the aspirin bottle for her age and weight.'
- B. She should be given acetaminophen, not aspirin.'
- C. Just be sure you administer the medication with food.'
- D. Give her no more than three baby aspirin every 4 hours.'
Correct Answer: B
Rationale: It's not advisable to follow the directions on the aspirin bottle for her age and weight. Aspirin is not recommended for use in children due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain. This is the correct response. Acetaminophen is a safer alternative to aspirin for managing fever in children. While it's generally a good idea to administer medication with food to prevent stomach upset, this advice does not address the specific risks associated with giving aspirin to a toddler. Giving a toddler three baby aspirin every 4 hours is not recommended due to the risk of Reye's syndrome.
A nurse is providing instructions about methylphenidate (Ritalin) to the parents of a school-age child who has ADHD. Which of the following instructions should the nurse include?
- A. You will need to give your child the medication after meals.
- B. You will need to have your child's blood glucose level checked monthly.
- C. You should not give your child the medication on weekends.
- D. You should give your child's last daily dose of the medication before 6 o'clock in the evening.
Correct Answer: D
Rationale: Methylphenidate (Ritalin) is a medication used to treat attention-deficit hyperactivity disorder (ADHD). It is not necessary to give the medication after meals. The medication can be taken with or without food. However, some people find that taking it with food can help prevent stomach upset. Regular blood glucose level checks are not typically required when a child is taking methylphenidate. This medication does not have a significant impact on blood sugar levels. It is not generally recommended to skip doses of methylphenidate on weekends. Consistent medication administration is important for managing ADHD symptoms. However, the prescribing doctor may sometimes recommend a 'drug holiday' or break from the medication. This should only be done under the guidance of a healthcare professional. This is the correct answer. Methylphenidate is a stimulant, and taking it later in the day can cause insomnia or trouble sleeping. Therefore, it is often recommended that the last dose of the medication be given before 6 o'clock in the evening to minimize sleep disturbances.
A nurse in an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler?
- A. Activated charcoal
- B. A chelating agent
- C. Acetylcysteine
- D. Digoxin immune FAB
Correct Answer: A
Rationale: Activated charcoal is often used in cases of drug overdose or poisoning, including aspirin ingestion. It works by binding to the drug or toxin in the stomach, preventing it from being absorbed into the body. This makes activated charcoal an effective treatment for aspirin overdose in a toddler. A chelating agent is a substance that can bind to heavy metals in the body, helping to remove them. While useful in cases of heavy metal poisoning, it would not be the first choice for an aspirin overdose. Acetylcysteine is an antidote for acetaminophen (Tylenol) overdose, not aspirin. It works by replenishing glutathione, a substance that helps to detoxify the liver. Digoxin immune FAB is used to treat digoxin toxicity. Digoxin is a medication used to treat heart conditions, and it is not related to aspirin.
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- A. Discourage the client from ambulating.
- B. Use a hair dryer on a hot setting to dry the cast.
- C. Keep the client's leg in a dependent position.
- D. Perform a neurovascular check of the lower extremities.
Correct Answer: D
Rationale: Discouraging the client from ambulating is not the best action. While it's important to limit weight-bearing activities initially, movement is encouraged to promote circulation and prevent complications such as deep vein thrombosis. Using a hair dryer on a hot setting to dry the cast is not recommended. Heat can cause the cast to dry out and crack, and it can also burn the skin. Keeping the client's leg in a dependent position is not advisable. This can lead to increased swelling and pain, and potentially delay healing. Performing a neurovascular check of the lower extremities is the correct action. This involves assessing for pain, pallor, pulselessness, paresthesia, and paralysis. These checks are crucial for monitoring for complications such as compartment syndrome and ensuring the cast is not too tight.