Nokea
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.
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Which of the following statements should the nurse use to describe to the parents why their child with leukemia is at risk for infections?
- A. Play activities are too strenuous.
- B. Vitamin C intake is reduced over a period of time.
- C. The number of red blood cells is inadequate for carrying oxygen.
- D. Immature white blood cells are incapable of handling an infectious process.
Correct Answer: D
Rationale: Immature white blood cells in leukemia cannot effectively fight infections, increasing risk. Other options are unrelated.
Which of the following would indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning?
- A. Brassy cough.
- B. Substernal retractions.
- C. Decreased activity level.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: Substernal retractions indicate respiratory distress, often due to mucus accumulation in TEF, necessitating suctioning.
A 2-year-old child returns to the clinic after completing a 10-day course of amoxicillin prescribed to relieve an infection in his right ear. After completing the medication, the child has become fussy and has a low-grade fever. On physical examination, his right tympanic membrane is bulging and he is tugging at his ear. The nurse should:
- A. Suggest to the mother that a decongestant be used.
- B. Tell the mother the health care provider will probably repeat the 10-day course of amoxicillin.
- C. Suggest that the child should see an ear, nose, and throat specialist for myringotomy tubes.
- D. Report the assessment to the health care provider with the probability that another antibiotic will be used for a 10-day course.
Correct Answer: D
Rationale: Persistent symptoms like fussiness, fever, a bulging tympanic membrane, and ear tugging after completing amoxicillin suggest treatment failure, possibly due to resistant bacteria. The nurse should report these findings to the health care provider, who may prescribe a different antibiotic for another 10-day course.
A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide the treatment and
- A. Administer an aspirin-containing compound.
- B. Institute Rest, Ice, Compression, and Elevation (RICE).
- C. Begin physical therapy with active range of motion.
- D. Initiate skin traction.
Correct Answer: B
Rationale: RICE reduces swelling and bleeding in hemophilic joint bleeds. Aspirin worsens bleeding, active motion is harmful, and traction is inappropriate.
When explaining to parents how to reduce the risk of Sudden Infant Death Syndrome (SIDS) the nurse should teach about which of the following measures? Select all that apply.
- A. Maintain a smoke-free environment.
- B. Use a wedge for side-lying positions.
- C. Breast-feed the baby.
- D. Place the baby on his back to sleep.
- E. Use bumper pads over
- F. Have the baby sleep in the parent's bed.
Correct Answer: A,C,D
Rationale: Maintaining a smoke-free environment, breastfeeding, and placing the baby on his back to sleep are evidence-based measures to reduce SIDS risk. Side-lying positions, bumper pads, and bed-sharing increase SIDS risk and should be avoided.