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During a clinical conference with a group of nursing students, the instructor is describing burn classification. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?
- A. Skin that is reddened, dry, and slightly swollen
- B. Skin appearing wet with significant pain
- C. Skin with blistering and swelling
- D. Skin that is leathery and dry with some numbness
Correct Answer: D
Rationale: Full-thickness burns are characterized by a leathery, dry appearance with numbness due to nerve damage. Choice A describes characteristics of superficial burns, which are not full-thickness. Choice B describes characteristics of partial-thickness burns with intact blisters, not full-thickness burns. Choice C describes characteristics of partial-thickness burns with blistering and swelling, not full-thickness burns.
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A 4-year-old child is admitted with a diagnosis of bacterial pneumonia. What is the priority nursing intervention?
- A. Administering antipyretics
- B. Administering antibiotics
- C. Monitoring fluid intake
- D. Providing nutritional support
Correct Answer: B
Rationale: The priority nursing intervention in a 4-year-old child admitted with bacterial pneumonia is administering antibiotics. Antibiotics are crucial for treating the infection and preventing potential complications. Administering antipyretics (Choice A) may help reduce fever, but addressing the underlying infection with antibiotics is the priority. Monitoring fluid intake (Choice C) is important for hydration but does not take precedence over administering antibiotics. Providing nutritional support (Choice D) is essential for overall care but is not the immediate priority when managing bacterial pneumonia.
A child has been admitted to the pediatric unit with a severe asthma attack. What type of acid-base imbalance should the nurse expect the child to develop?
- A. metabolic alkalosis due to insufficient production of acid metabolites
- B. respiratory alkalosis due to depressed respirations and retention of carbon dioxide
- C. respiratory acidosis due to impaired respirations and increased formation of carbonic acid
- D. metabolic acidosis due to the kidneys' inability to compensate for decreased carbonic acid formation
Correct Answer: C
Rationale: In a severe asthma attack, the child is likely to develop respiratory acidosis. This occurs due to impaired respirations, leading to the retention of carbon dioxide and the formation of carbonic acid. Choice A is incorrect as metabolic alkalosis is not expected in this situation. Choice B is incorrect as respiratory alkalosis does not align with the scenario of impaired respirations in severe asthma attacks. Choice D is also incorrect as it describes metabolic acidosis, which is not typically associated with severe asthma attacks.
During an assessment, a nurse is examining the skin of a child with cellulitis. What would the nurse expect to find?
- A. Red, raised hair follicles
- B. Warmth at skin disruption site
- C. Papules progressing to vesicles
- D. Honey-colored exudate
Correct Answer: B
Rationale: The correct answer is B: 'Warmth at skin disruption site.' Cellulitis is characterized by localized warmth at the site of skin disruption, which indicates an infection. Choice A, 'Red, raised hair follicles,' is more typical of folliculitis. Choice C, 'Papules progressing to vesicles,' is suggestive of conditions like herpes simplex virus infections. Choice D, 'Honey-colored exudate,' is associated with impetigo, not cellulitis. When assessing cellulitis, nurses should primarily look for warmth, erythema, edema, and tenderness at the affected site.
A parent asks a nurse how to tell the difference between measles (rubeola) and German measles (rubella). What should the nurse tell the parent about rubeola that is different from rubella?
- A. High fever and Koplik spots
- B. Rash on the trunk with pruritus
- C. Nausea, vomiting, and abdominal cramps
- D. Characteristics of a cold, followed by a rash
Correct Answer: A
Rationale: Rubeola (measles) is characterized by a high fever and the presence of Koplik spots, which are not seen in rubella (German measles). Therefore, the correct answer is A. Choice B, rash on the trunk with pruritus, is more indicative of rubella rather than rubeola. Choice C, nausea, vomiting, and abdominal cramps, are not specific differentiating symptoms between rubeola and rubella. Choice D, characteristics of a cold followed by a rash, does not specifically distinguish between rubeola and rubella.
What is the priority nursing intervention for a child with juvenile idiopathic arthritis (JIA)?
- A. Encouraging a diet high in protein
- B. Administering nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Applying heat to affected joints
- D. Providing range-of-motion exercises
Correct Answer: B
Rationale: The priority nursing intervention for a child with juvenile idiopathic arthritis (JIA) is to administer nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs help manage pain and inflammation associated with JIA, making them crucial in providing relief to the child. Encouraging a diet high in protein (Choice A) may be beneficial for overall health but is not the priority in managing JIA symptoms. Applying heat to affected joints (Choice C) can provide comfort but does not address the underlying inflammation. Providing range-of-motion exercises (Choice D) is important for maintaining joint mobility but is not the priority intervention when managing acute symptoms of JIA.