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During a well-child visit, the nurse plots the childs BMI on the health record. What is the purpose of the BMI?
- A. To determine medication dosages
- B. To predict adult height and weight
- C. To identify coping strategies used by the child
- D. To provide a consistent measure of obesity
Correct Answer: D
Rationale: BMI provides a standardized measure to assess obesity by comparing body weight to height, guiding interventions. It?s not used for medication dosages, height prediction, or coping strategies.
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The school nurse is seeing a child who collected some poison ivy leaves during recess. He says only his hands touched it. What is the most appropriate nursing action?
- A. Soak his hands in warm water.
- B. Apply Burow's solution compresses.
- C. Rinse his hands in cold running water.
- D. Scrub his hands thoroughly with antibacterial soap.
Correct Answer: C
Rationale: Rinsing with cold running water within 15 minutes neutralizes urushiol, the oil causing poison ivy dermatitis, preventing it from bonding to the skin. Warm water is used after dermatitis develops, Burow's solution treats lesions, and antibacterial soap can spread urushiol by removing skin oils.
An adolescent girl is brought to the hospital emergency department by her parents after being raped. The girl is calm and controlled throughout the interview and examination. The nurse should recognize this behavior is what?
- A. A sign that a rape has not actually occurred
- B. One of a variety of behaviors normally seen in rape victims
- C. Indicative of a higher than usual level of maturity in the adolescent
- D. Suggestive that the adolescent had severe emotional problems before the rape occurred
Correct Answer: B
Rationale: Rape victims exhibit varied responses, including calm behavior, which may mask inner turmoil. This is a normal coping mechanism, not indicative of the event?s validity, maturity, or pre-existing emotional issues.
Descriptions of young people with anorexia nervosa (AN) often include which criteria?
- A. Impulsive
- B. Extroverted
- C. Perfectionist
- D. Low achieving
Correct Answer: C
Rationale: Individuals with AN are often perfectionists, striving for control and high academic achievement. Impulsivity and extroversion are more characteristic of bulimia nervosa, not AN.
A parent calls the clinic nurse because his 7-year-old child was bitten by a black widow spider. What action should the nurse advise the parent to take?
- A. Apply warm compresses.
- B. Carefully scrape off the stinger.
- C. Take the child to the emergency department.
- D. Apply a thin layer of corticosteroid cream.
Correct Answer: C
Rationale: Black widow spider venom is neurotoxic, requiring emergency treatment with antivenin and possibly muscle relaxants. Warm compresses spread the venom, black widows lack stingers, and corticosteroid cream is ineffective against the venom.
During the physical examination of an adolescent with significant weight loss, what finding may indicate an eating disorder?
- A. Diarrhea
- B. Amenorrhea
- C. Appetite suppression
- D. Erosion of tooth enamel
Correct Answer: D
Rationale: Erosion of tooth enamel is a sign of bulimia nervosa due to repeated vomiting. Amenorrhea may occur in anorexia nervosa but is less specific, diarrhea relates to other conditions, and appetite suppression is not a physical exam finding.