Nokea
The nurse is assessing a 9-year-old child who has third-degree burns as shown below. Using the 'Rule of Nines' adapted for children, the nurse estimates that the extent of burns for this child is:
- A. 9%.
- B. 14%.
- C. 18%.
- D. 24%.
Correct Answer: C
Rationale: In children, the Rule of Nines assigns 18% to each arm (including forearm and hand). A third-degree burn on one forearm approximates 18%, assuming the burn covers the entire forearm as implied.
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An adolescent complains of chest pain and goes to the school nurse. The nurse determines that the teenager has a history of asthma but has had no problems for years. Which of the following should the nurse do next?
- A. Call the adolescent's parent.
- B. Have the adolescent lie down for 30 minutes.
- C. Obtain a peak flow reading.
- D. Give two puffs of a short-acting bronchodilator.
Correct Answer: C
Rationale: Obtaining a peak flow reading is the next step to objectively assess the adolescent's respiratory status, given the history of asthma and new chest pain, which could indicate an asthma exacerbation.
A nurse is teaching the parents of a preschooler about the possibility of post-operative hemorrhage after a tonsillectomy and adenoidectomy. The nurse should explain that the risk is greatest at which of the following times?
- A. 1 to 3 days after surgery.
- B. 4 to 6 days after surgery.
- C. 7 to 10 days after surgery.
- D. 11 to 14 days after surgery.
Correct Answer: C
Rationale: The risk of post-operative hemorrhage after a tonsillectomy is greatest 7 to 10 days after surgery, as this is when the eschar (scab) typically sloughs off, potentially exposing blood vessels and leading to bleeding.
The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which of the following activities should the nurse and family decide the child should avoid?
- A. Rock climbing.
- B. Hiking.
- C. Swimming.
- D. Tennis.
Correct Answer: C
Rationale: Swimming poses a drowning risk during a seizure; it should be avoided unless closely supervised.
The parents of a 3-year-old suspect that the child has recently ingested a large amount of acetaminophen. The child does not appear in immediate distress. The nurse should anticipate doing which of these interventions in order of priority, from first to last?
- A. Draw acetaminophen serum levels.
- B. Attempt to determine the exact time and amount of drug ingested.
- C. Administer acetylcysteine (Acetadote IV).
- D. Administer activated charcoal.
Correct Answer: B,D,A,C
Rationale: First, determine ingestion details (B) to assess risk. Administer charcoal (D) within 1-2 hours to reduce absorption. Draw serum levels (A) at 4 hours to confirm toxicity. Administer acetylcysteine (C) if levels are toxic.
After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child:
- A. Fears another procedure.
- B. Does not understand body integrity.
- C. Is expressing pain.
- D. Is attempting to regain control.
Correct Answer: B
Rationale: Preschoolers may fear loss of body integrity, believing blood will leak out without a bandage.