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The nurse should teach the parents to take which of the following actions during a seizure?
- A. Minimize movement of the limbs.
- B. Clear the area of hard objects.
- C. Place the child in a prone position.
- D. Insert a tongue blade between the teeth.
Correct Answer: B
Rationale: The correct answer is B: Clear the area of hard objects. This action is crucial during a seizure to prevent injury. Hard objects can cause harm if the child hits them during convulsions. Minimizing limb movement is not recommended as it may lead to further injury. Placing the child in a prone position can obstruct breathing and should be avoided. Inserting a tongue blade can also cause harm and is not recommended. Clearing the area of hard objects is the most effective way to ensure safety during a seizure.
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Which of the following instructions should the nurse include in the teaching?
- A. Apply bactericidal ointment to lesions.
- B. Administer acyclovir PO two times per day.
- C. Soak hairbrushes in boiling water for 10 min.
- D. Seal soft toys in a plastic bag for 14 days.
Correct Answer: A
Rationale: The correct answer is A: Apply bactericidal ointment to lesions. This instruction is essential to prevent secondary bacterial infection in lesions caused by herpes zoster. The ointment will help to keep the lesions clean and prevent bacterial growth. Administering acyclovir helps treat the viral infection but does not prevent bacterial infection. Soaking hairbrushes and sealing soft toys are not directly related to preventing infection in the lesions. Overall, the focus should be on proper wound care to prevent complications.
Which of the following actions by the staff nurse indicates an understanding of infection control practices?
- A. Maintains droplet precautions while the child is coughing and sneezing.
- B. Applies a face mask after entering the child's room.
- C. Wears gloves when assisting the child to the bathroom.
- D. Follows airborne precautions by wearing an N95 respirator while caring for the child.
Correct Answer: A
Rationale: The correct answer is A because maintaining droplet precautions while the child is coughing and sneezing is essential for preventing the spread of infection through respiratory droplets. This action shows understanding of infection control practices by implementing specific measures to reduce transmission of pathogens. Choice B is incorrect as wearing a face mask after entering the room does not provide adequate protection during exposure to respiratory secretions. Choice C is incorrect as gloves are not sufficient for preventing transmission of respiratory infections. Choice D is incorrect as airborne precautions are not necessary for droplet precautions.
Which of the following recommendations should the nurse make?
- A. Store opened vials of insulin for up to 60 days.
- B. Follow up with physical therapy.
- C. Consult with a nutritionist.
- D. Monitor capillary blood glucose daily.
Correct Answer: C
Rationale: The correct recommendation is to consult with a nutritionist (Choice C). This is crucial in diabetes management as a nutritionist can provide personalized dietary guidance to help control blood sugar levels. By consulting with a nutritionist, the patient can learn about healthy eating habits, portion control, and meal planning tailored to their specific needs. This can lead to better blood glucose control and overall improved health outcomes. Storing opened vials of insulin for 60 days (Choice A) is incorrect as insulin should be discarded after a certain period to ensure its effectiveness. Following up with physical therapy (Choice B) may be beneficial for other health conditions but is not specifically related to managing diabetes. Monitoring capillary blood glucose daily (Choice D) is important but does not address the need for dietary adjustments which a nutritionist can provide.
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
- A. Instruct the parent to ensure the pneumococcal vaccine is current.
- B. Administer folic acid as prescribed.
- C. Monitor oxygen saturation continuously.
- D. Place the client on strict bed rest.
- E. Apply cold compresses to the affected joints.
- F. Administer meperidine IV for pain.
Correct Answer: B,C,E,F,H
Rationale: The correct interventions for the adolescent are B, C, E, F, and H. Administering folic acid (B) is important for growth and development. Monitoring oxygen saturation (C) ensures respiratory function. Applying cold compresses (E) helps reduce inflammation in affected joints. Administering meperidine IV (F) addresses pain management. The rationale for excluding other choices: A is irrelevant for adolescent care, D may worsen joint symptoms, and G is incomplete.
For which of the following adverse effects should the nurse monitor?
- A. Prolonged wound healing
- B. Nausea
- C. Stevens-Johnson syndrome
- D. Renal failure
Correct Answer: B
Rationale: The correct answer is B: Nausea. The nurse should monitor for nausea as it is a common adverse effect of many medications and can impact the patient's overall well-being. Nausea can lead to decreased appetite, dehydration, and noncompliance with medications. Prolonged wound healing (A) is a potential adverse effect but is not as common or immediate as nausea. Stevens-Johnson syndrome (C) is a severe and life-threatening skin reaction that is rare and not typically monitored by nurses. Renal failure (D) is a serious adverse effect but may not be directly related to all medications.