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The parent of an infant asks when the baby's first immunization for measles, mumps, and rubella (MMR) should be given. Which age should the nurse provide the parent?
- A. 6 months.
- B. 12 months.
- C. 24 months.
- D. 2 months.
Correct Answer: B
Rationale: The CDC recommends the first MMR dose at 12-15 months of age.
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A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?
- A. Mumps.
- B. Chickenpox.
- C. Sore throat.
- D. Influenza.
Correct Answer: C
Rationale: Acute rheumatic fever is often preceded by a streptococcal infection, commonly presenting as a sore throat.
While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
- A. Inspect the posterior oropharynx.
- B. Touch the tonsillar pillars to stimulate the gag reflex.
- C. Ask the child to speak to evaluate change in voice tone.
- D. Assess for teeth clenching or grinding.
Correct Answer: A
Rationale: Frequent swallowing may indicate postoperative bleeding, so inspecting the oropharynx is critical.
The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?
- A. Administer topical antibiotic therapy daily.
- B. Provide passive range of motion exercises.
- C. Ensure no weight bearing on the affected extremity.
- D. Schedule ice pack applications to the infected area.
Correct Answer: C
Rationale: No weight bearing on the affected extremity prevents further damage during the initial treatment phase of osteomyelitis.
A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?
- A. Report the findings immediately to the healthcare provider.
- B. Obtain a swab of secretions from the penis and urethra.
- C. Collect a sterile urine sample for culture and sensitivity.
- D. Provide the adolescent with a urinal for urinary hesitancy.
Correct Answer: A
Rationale: Significant erythema and swelling suggest testicular torsion, a medical emergency requiring immediate reporting.
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
- A. Apply lotion to hands and feet.
- B. Encourage the child to rest when possible.
- C. Place the child in a quiet environment.
- D. Make a list of foods that the child likes.
Correct Answer: C
Rationale: A quiet environment reduces sensory stimulation, alleviating irritability, which is a primary concern in Kawasaki disease.