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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.
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When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?
- A. Skeletal traction
- B. Physical therapy
- C. Orthotics
- D. Occupational therapy
Correct Answer: A
Rationale: In caring for a child with cerebral palsy, skeletal traction is least likely to be a part of the treatment plan. Cerebral palsy is a neurological disorder affecting movement and muscle coordination, and skeletal traction, which involves applying a pulling force on a bone to correct alignment, is not a common intervention for this condition. Physical therapy, orthotics, and occupational therapy are more commonly used in the management of cerebral palsy. Physical therapy helps improve mobility and strength, orthotics assist in supporting and aligning the body, and occupational therapy focuses on enhancing daily living skills and independence. Therefore, skeletal traction is the least likely treatment option among the choices provided.
The nurse is teaching a parent group about the reasons for adhering to the immunization schedule. What complication of mumps is important for adolescents to avoid?
- A. Sterility
- B. Hypopituitarism
- C. Decrease in libido
- D. Decrease in androgens
Correct Answer: A
Rationale: The correct answer is A: Sterility. Mumps can lead to serious complications such as sterility, especially in adolescent males. Vaccination is essential to prevent this potential outcome. Hypopituitarism (Choice B) is not a typical complication of mumps. Choices C and D, decrease in libido and decrease in androgens, are not directly associated with mumps complications, particularly in the context of adolescents.
A child with a diagnosis of diabetes mellitus is being discharged from the hospital. What is important for the nurse to include in the discharge teaching?
- A. Monitor blood glucose levels daily
- B. Administer insulin based on blood glucose levels
- C. Recognize signs of hypoglycemia
- D. Follow a specific meal plan
Correct Answer: D
Rationale: For a child with diabetes mellitus, following a specific meal plan is crucial for managing blood glucose levels effectively. This helps in maintaining stable blood sugar levels and preventing complications associated with the condition. Monitoring blood glucose levels daily and recognizing signs of hypoglycemia are also important aspects of managing diabetes; however, adherence to a specific meal plan plays a fundamental role in overall diabetes care. Administering insulin based on blood glucose levels alone is not recommended without a specific plan provided by healthcare providers.
After eating, a child with a diagnosis of gastroesophageal reflux disease (GERD) should be placed in what position as recommended by the nurse?
- A. Supine
- B. Prone
- C. Semi-Fowler's
- D. Trendelenburg
Correct Answer: C
Rationale: Placing the child in a semi-Fowler's position after eating is beneficial for reducing symptoms of gastroesophageal reflux. This position helps prevent gastric contents from flowing back into the esophagus. The supine position (choice A) may worsen reflux symptoms by allowing gravity to assist in reflux, leading to discomfort and regurgitation. Prone position (choice B) is not recommended after eating as it may cause discomfort and increase the risk of aspiration due to pressure on the stomach. Trendelenburg position (choice D), with the head lower than the rest of the body, is not indicated for managing GERD after eating and may not provide the desired benefits in this context.
A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?
- A. Monitoring for signs of infection
- B. Providing nutritional support
- C. Monitoring for signs of bleeding
- D. Monitoring for signs of pain
Correct Answer: A
Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, putting the child at a higher risk of developing infections. Early detection of signs of infection is crucial to prevent serious complications and initiate timely treatment. Providing nutritional support is important for overall health but is not the priority when the child is at risk of infection. Monitoring for signs of bleeding is essential, but infection surveillance takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of pain is important for comfort but is not the priority over infection prevention and management.