Nokea
The nurse urges the mother of a 6-month-old child to get her child inoculated with Haemophilus influenzae type B. What does this immunization protect against?
- A. Encephalitis
- B. Influenza
- C. Bacterial meningitis
- D. Otitis media
Correct Answer: C
Rationale: H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.
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What might the nurse explain as a common treatment for amblyopia?
- A. Patching the good eye to force the brain to use the affected eye
- B. Patching the affected eye to allow the refractory muscles to rest
- C. Using glasses that will slightly blur the image for the good eye
- D. Using corticosteroids to treat inflammation of the optic nerve
Correct Answer: A
Rationale: Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors.
Which situation would cause the nurse to suspect a hearing impairment?
- A. 3-month-old infant with a positive Moro (startle reaction) reflex
- B. 15-month-old toddler who is babbling
- C. 18-month-old toddler who is speaking one-syllable words
- D. 24-month-old toddler who communicates by pointing
Correct Answer: D
Rationale: The child who is not making verbal attempts by 24 months should undergo a complete physical examination.
A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion?
- A. Sleepy but easily arousable
- B. Complaining of a stiff neck
- C. Cannot remember what happened to him
- D. Pupils react sluggishly to light
Correct Answer: C
Rationale: A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness, often accompanied by a loss of memory of the events.
The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?
- A. Athetoid
- B. Ataxic
- C. Spastic
- D. Mixed
Correct Answer: C
Rationale: Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.
What will the nurse include when documenting a grand mal seizure? (Select all that apply.)
- A. Presence of incontinence
- B. Current dose of antispasmodic medication
- C. Activity level prior to and following seizure
- D. Level of consciousness following seizure
- E. Length of seizure
Correct Answer: A,C,D,E
Rationale: Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure.