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The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.)
- A. Encourage books with large type.
- B. Words in books should be closely spaced.
- C. Provide adequate lighting without glare.
- D. Be sure desks and chairs are adequate height.
- E. Instruct child to squint when reading.
Correct Answer: A,C,D
Rationale: Children who are beginning to read need books with large type in which the letters are spaced far apart.
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An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented? (Select all that apply.)
- A. Parental education regarding prevention
- B. Respiratory support
- C. Cardiovascular support
- D. Controlled rewarming
- E. Adequate cerebral oxygenation
Correct Answer: B,C,D,E
Rationale: Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care.
Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which statement by the parents alerts the nurse they need further instruction?
- A. We dress our son every morning for school.'
- B. Our son participates in the Special Olympics every year.'
- C. Our son attends play therapy at a center close to home.'
- D. We attend a support group once a week.'
Correct Answer: A
Rationale: The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should not 'take over' projects.
The nurse observes a child's position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture?
- A. Correct anatomical position
- B. Decorticate
- C. Decerebrate
- D. Opisthotonos
Correct Answer: C
Rationale: In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.
What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?
- A. The medication should be given on an empty stomach.
- B. Insomnia can be a significant side effect.
- C. Gums should be massaged regularly to prevent hyperplasia.
- D. Blood pressure should be closely monitored.
Correct Answer: C
Rationale: Dilantin can cause gum overgrowth, which can be minimized by regular massaging.
A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect?
- A. Meningitis
- B. Reye's syndrome
- C. Brain tumor
- D. Encephalitis
Correct Answer: C
Rationale: The signs and symptoms of a brain tumor are related to its size and location, creating increased intracranial pressure with hallmark symptoms of headache, vomiting, drowsiness, and seizures.