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The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?
- A. Abdominal rigidity and pain on palpation.
- B. Rounded abdomen and hypoactive bowel sounds.
- C. Visible peristalsis and weight loss.
- D. Distention of the lower abdomen and constipation.
Correct Answer: B
Rationale: Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped mass in the upper abdomen, and signs of dehydration. A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting. The infant may appear hungry after vomiting and will continue to feed, leading to weight loss. Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible peristalsis occurs as the infant tries to force the stomach contents through the narrowed pyloric sphincter. Weight loss is a result of poor feeding and vomiting. Distention of the lower abdomen and constipation are not typical findings in pyloric stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis primarily affects the upper gastrointestinal tract.
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A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations?
- A. Haemophilus influenza type b (Hib)
- B. Inactivated poliovirus (IPv)
- C. Hepatitis B (HepB)
- D. Influenza
Correct Answer: D
Rationale: The Haemophilus influenza type b (Hib) vaccine is not contraindicated for people with egg allergies. The Hib vaccine is used to prevent Haemophilus influenza type b, a bacteria responsible for severe pneumonia, meningitis and other invasive diseases almost exclusively in children aged less than 5 years. The Inactivated poliovirus (IPv) vaccine is not contraindicated for people with egg allergies. The IPV vaccine is used to prevent polio, a crippling and potentially deadly infectious disease. The Hepatitis B (HepB) vaccine is not contraindicated for people with egg allergies. The HepB vaccine is used to prevent hepatitis B, a viral infection that attacks the liver. The Influenza vaccine is contraindicated for people with severe egg allergies. Most flu vaccines today are produced using an egg-based manufacturing process and thus contain a small amount of egg protein called ovalbumin.
A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination?
- A. Bend forward from the waist with your head and arms downward.
- B. Touch your chin to your chest, and then look up at the ceiling.
- C. Lie prone on the examination table.
- D. Turn to the side and remain in a relaxed position.
Correct Answer: A
Rationale: Bending forward from the waist with the head and arms downward, also known as the Adams forward bend test, is the standard screening test for scoliosis. Touching the chin to the chest and then looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening. Lying prone on the examination table is not a standard position for scoliosis screening. Turning to the side and remaining in a relaxed position is not a standard position for scoliosis screening.
A nurse is attending a continuing education course about communicable diseases. The nurse should identify that varicella has which of the following incubation periods?
- A. 2 to 5 days
- B. 3 to 4 weeks
- C. 7 to 10 days
- D. 2 to 3 weeks
Correct Answer: D
Rationale: The incubation period for varicella, or chickenpox, is typically longer than 2 to 5 days. It usually ranges from 10 to 21 days. An incubation period of 3 to 4 weeks is within the typical range for varicella. However, the average incubation period is usually around 14 to 16 days. An incubation period of 7 to 10 days is shorter than the typical incubation period for varicella, which is usually around 14 to 16 days. An incubation period of 2 to 3 weeks is within the typical range for varicella. The average incubation period is usually around 14 to 16 days.
A nurse is contributing to the plan of care of an unconscious adolescent who ingested a non-corrosive substance that has no recommended antidote. The nurse should recommend performing gastric lavage with which of the following substances?
- A. Activated charcoal
- B. Osmotic diarrheal agents
- C. Syrup of ipecac
- D. 0.9% sodium chloride
Correct Answer: A
Rationale: Activated charcoal is often used in the management of poisoning. It works by binding to the poison in the stomach and preventing it from being absorbed into the body. Osmotic diarrheal agents are not typically used in gastric lavage. These agents work by increasing the amount of water in the intestinal tract, which can stimulate bowel movements. Syrup of ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended for use in poisoning cases. 0.9% sodium chloride, or normal saline, is a type of fluid that's often used in medical treatments, but it's not typically used in gastric lavage for poisoning.
Your child will need to increase his calcium intake to 3,000 milligrams daily. A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching?
- A. Bone marrow can be lost through the fracture.
- B. Fractures in a child take longer to heal than fractures in an adult.
- C. Normal bone growth can be affected by the fracture.
- D. The child will need to increase his calcium intake to 3,000 milligrams daily.
Correct Answer: C
Rationale: While it's true that bone marrow can be lost through a fracture, this is not specific to fractures of the epiphyseal plate. The healing time for fractures in children and adults can vary depending on many factors, but it's not accurate to say that fractures in children take longer to heal than fractures in adults. Normal bone growth can indeed be affected by a fracture of the epiphyseal plate. The epiphyseal plate, or growth plate, is the area of growing tissue near the ends of the long bones in children and adolescents. When a fracture occurs at the epiphyseal plate, it can disrupt the normal growth of the bone and lead to deformities. While calcium is important for bone health, increasing a child's calcium intake to 3,000 milligrams daily is not typically recommended as part of the treatment or management of a fracture.