Nokea
After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which of the following, if stated by the father, indicates successful teaching?
- A. It results from overexposure to the sun.
- B. It's caused by infestation with a mite.
- C. It's a fungal infection of the scalp.
- D. It's an allergic reaction.
Correct Answer: C
Rationale: Tinea capitis is caused by a fungal infection, not mites, sun exposure, or allergies.
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After teaching the parents of a child with febrile seizures about methods to lower temperature other than using medication, which of the following statements indicates that further teaching is necessary?
- A. We'll add extra blankets when he complains of being cold.'
- B. We'll wrap him in a blanket if he starts shivering.'
- C. We'll make the bath water cold enough to make him shiver.'
- D. We'll use a solution of half alcohol and half water when sponging him.'
Correct Answer: A,B,C,D
Rationale: All options are incorrect: blankets increase temperature, cold baths cause discomfort, and alcohol sponging is unsafe. Further teaching is needed.
When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for which of the following purposes?
- A. To decrease back muscle spasms.
- B. To improve the brace's traction effect.
- C. To prevent spinal contractures.
- D. To strengthen the back and abdominal muscles.
Correct Answer: D
Rationale: Exercises for scoliosis in a Boston brace focus on strengthening back and abdominal muscles to support spinal alignment and improve posture.
A 10-year old child is admitted to the hospital with complications related to chickenpox. The nurse should do which of the following to prevent the transmission of the infection to other children on the unit? Select all that apply.
- A. Place the child on contact isolation.
- B. Wear a gown, mask, and gloves before entering the room.
- C. Place the child in a room with a 10-year-old who has had chickenpox.
- D. Place the child in a negative air-flow room.
- E. Maintain isolation until lesions have disappeared.
Correct Answer: A,B,C,E
Rationale: Chickenpox requires contact and airborne precautions (gown, mask, gloves) and isolation until lesions crust. Rooming with an immune child reduces risk. Negative airflow is for diseases like tuberculosis.
After placing an infant with myelomeningocele in an isolette shortly after birth, which indicator should the nurse use as the best way to determine the effectiveness of this intervention?
- A. The partial pressure of arterial oxygen remains between 94 and 100 mm Hg.
- B. The axillary temperature remains between 97° and 98°F (36.1° and 36.7°C).
- C. The respiratory rate remains within normal limits.
- D. The heart rate remains stable.
Correct Answer: B
Rationale: The isolette maintains a stable thermal environment. Monitoring axillary temperature ensures the infant is normothermic, indicating the isolette's effectiveness.
Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.