Nokea
The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inflamed conjunctiva. The child receives a prescription for an ophthalmic anti-infective ointment. Which instruction should the nurse provide the child's caregivers during discharge education?
- A. Discontinue the ointment once drainage resolves.
- B. Prepare the child for blurry vision after ointment application.
- C. Use a disposable moist wipe to remove eye crusts.
- D. Remove secretions by wiping toward the opposite eye.
Correct Answer: B
Rationale: Ophthalmic ointment can cause temporary blurry vision, and preparing the child for this effect is important.
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The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Speaks in simple sentences with four or more words.
- B. Recognizes most letters and numbers.
- C. Uses gestures with 1-to-2-word sentences.
- D. Uses 1-word sentences.
Correct Answer: A
Rationale: Speaking in simple sentences with four or more words is a normal milestone for a 3-year-old.
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Have the child blow a cotton ball and have the parent catch it.
- B. Place a toy in the child's hands while listening to the breath sounds.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Allow the child to use a stethoscope on a stuffed animal.
Correct Answer: D
Rationale: Allowing the child to use a stethoscope on a stuffed animal familiarizes them with the procedure, increasing cooperation.
The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
- A. Has doubled birth weight.
- B. Plays 'peek-a-boo.'
- C. Demonstrates startle reflex.
- D. Turns head to locate sound.
Correct Answer: C
Rationale: The startle reflex typically disappears by 3-4 months; its presence at 6 months may indicate a developmental or neurological issue.
The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for this child?
- A. Rye.
- B. Rice.
- C. Oats.
- D. Barley.
Correct Answer: B
Rationale: Rice is gluten-free and safe for celiac disease, unlike rye, oats, and barley, which contain gluten.
A 1-year-old child with respiratory syncytial virus (RSV) has been admitted to the pediatric unit. The nurse observes that the child has a fever, rhinorrhea, frequent coughing, and sneezing. Which additional finding should alert the nurse that the child is in acute respiratory distress?
- A. Flaring of the nares.
- B. Bilateral bronchial breath sounds.
- C. Diaphragmatic respirations.
- D. A resting respiratory rate of 35 breaths/min.
Correct Answer: A
Rationale: Nasal flaring indicates increased respiratory effort, a sign of acute respiratory distress.