Nokea
The nurse is caring for a 15-year-old boy who has sustained burn injuries. The nurse observes the burn developing a purplish color with discharge and a foul odor. The nurse suspects which infection?
- A. Burn wound cellulitis.
- B. Invasive burn cellulitis.
- C. Burn impetigo.
- D. Staphylococcal scalded skin syndrome.
Correct Answer: B
Rationale: The correct answer is B: Invasive burn cellulitis. Invasive burn cellulitis presents with the burn developing a dark brown, black, or purplish color with discharge and a foul odor. Burn wound cellulitis (choice A) typically involves redness, warmth, and swelling around the burn site. Burn impetigo (choice C) is a superficial infection characterized by honey-colored crusting. Staphylococcal scalded skin syndrome (choice D) is a condition caused by exotoxins from Staphylococcus aureus, leading to widespread skin peeling.
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A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?
- A. Quality of the cry
- B. Signs of dehydration
- C. Coughing up feedings
- D. Characteristics of the stool
Correct Answer: B
Rationale: The correct answer is B: Signs of dehydration. Infants with hypertrophic pyloric stenosis (HPS) are at high risk of dehydration due to frequent vomiting. Assessing for signs of dehydration, such as decreased urine output, dry mucous membranes, and sunken fontanelles, is crucial for early intervention and management. Choices A, C, and D are not the most critical assessments for HPS. The quality of the cry (choice A) may not provide as much relevant information in this case. Coughing up of feedings (choice C) may be a symptom but is not as crucial as assessing for dehydration. Characteristics of the stool (choice D) are important but assessing for signs of dehydration takes precedence due to the immediate risk it poses to the infant's health.
When caring for a child diagnosed with asthma, what is an important nursing intervention?
- A. Administering bronchodilators
- B. Encouraging physical activity
- C. Monitoring oxygen saturation
- D. Providing nutritional support
Correct Answer: A
Rationale: Administering bronchodilators is a crucial nursing intervention for a child with asthma as it helps to open the airways and improve breathing. Bronchodilators work by relaxing the muscles around the airways, making breathing easier for the child. Encouraging physical activity may exacerbate asthma symptoms in some cases, so it is not recommended as a primary intervention. Monitoring oxygen saturation is important in assessing respiratory status, but administering bronchodilators would take precedence in this situation. Providing nutritional support is a general nursing intervention and not specific to managing asthma symptoms.
The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults?
- A. Most childhood cancers affect tissues rather than organs.
- B. Childhood cancers are usually localized when found.
- C. Unlike adult cancers, childhood cancers are less responsive to treatment.
- D. The majority of childhood cancers can be prevented.
Correct Answer: A
Rationale: The correct answer is A. Most childhood cancers, such as leukemias and sarcomas, affect tissues rather than specific organs, unlike many adult cancers. Choice B is incorrect because childhood cancers can be localized or spread, similar to adult cancers. Choice C is incorrect because childhood cancers can be highly responsive to treatment, especially when diagnosed early. Choice D is incorrect because the majority of childhood cancers cannot be prevented as they are often due to genetic mutations or unknown causes.
A child is diagnosed with atopic dermatitis. Which laboratory test would the nurse expect the child to undergo to provide additional evidence for this condition?
- A. Erythrocyte sedimentation rate
- B. Potassium hydroxide prep
- C. Wound culture
- D. Serum immunoglobulin E (IgE) level
Correct Answer: D
Rationale: The correct answer is D: Serum immunoglobulin E (IgE) level. An elevated serum IgE level is commonly associated with atopic dermatitis, reflecting an allergic response. Choice A, erythrocyte sedimentation rate, is a nonspecific test for inflammation and not specific to atopic dermatitis. Choice B, potassium hydroxide prep, is used to diagnose fungal infections like tinea versicolor, not atopic dermatitis. Choice C, wound culture, is not typically indicated for the diagnosis of atopic dermatitis as it is a chronic inflammatory skin condition rather than an infectious process.
What finding would lead healthcare providers to suspect Turner syndrome in a child?
- A. Webbed neck
- B. Microcephaly
- C. Gynecomastia
- D. Cognitive delay
Correct Answer: A
Rationale: A webbed neck is a classic physical characteristic seen in individuals with Turner syndrome, a genetic condition that results from a missing or partially missing X chromosome in females. This distinctive feature occurs due to excess skin on the neck and is a key clinical clue for healthcare providers. Microcephaly (choice B) refers to a small head size and is not typically associated with Turner syndrome. Gynecomastia (choice C) is the enlargement of breast tissue in males and is not a common finding in Turner syndrome. Cognitive delay (choice D) involves intellectual or developmental delays and is not a specific feature of Turner syndrome.