Nokea
The school nurse is seeing a child who collected some poison ivy leaves during recess. He says only his hands touched it. What is the most appropriate nursing action?
- A. Soak his hands in warm water.
- B. Apply Burow's solution compresses.
- C. Rinse his hands in cold running water.
- D. Scrub his hands thoroughly with antibacterial soap.
Correct Answer: C
Rationale: Rinsing with cold running water within 15 minutes neutralizes urushiol, the oil causing poison ivy dermatitis, preventing it from bonding to the skin. Warm water is used after dermatitis develops, Burow's solution treats lesions, and antibacterial soap can spread urushiol by removing skin oils.
You may also like to solve these questions
During a well-child visit, the nurse plots the childs BMI on the health record. What is the purpose of the BMI?
- A. To determine medication dosages
- B. To predict adult height and weight
- C. To identify coping strategies used by the child
- D. To provide a consistent measure of obesity
Correct Answer: D
Rationale: BMI provides a standardized measure to assess obesity by comparing body weight to height, guiding interventions. It?s not used for medication dosages, height prediction, or coping strategies.
During the physical examination of an adolescent with significant weight loss, what finding may indicate an eating disorder?
- A. Diarrhea
- B. Amenorrhea
- C. Appetite suppression
- D. Erosion of tooth enamel
Correct Answer: D
Rationale: Erosion of tooth enamel is a sign of bulimia nervosa due to repeated vomiting. Amenorrhea may occur in anorexia nervosa but is less specific, diarrhea relates to other conditions, and appetite suppression is not a physical exam finding.
An adolescent girl is brought to the hospital emergency department by her parents after being raped. The girl is calm and controlled throughout the interview and examination. The nurse should recognize this behavior is what?
- A. A sign that a rape has not actually occurred
- B. One of a variety of behaviors normally seen in rape victims
- C. Indicative of a higher than usual level of maturity in the adolescent
- D. Suggestive that the adolescent had severe emotional problems before the rape occurred
Correct Answer: B
Rationale: Rape victims exhibit varied responses, including calm behavior, which may mask inner turmoil. This is a normal coping mechanism, not indicative of the event?s validity, maturity, or pre-existing emotional issues.
What behavior is the nurse most likely to assess in an adolescent with anorexia nervosa (AN)?
- A. Eats in secrecy
- B. Uses food as a coping mechanism
- C. Has a marked preoccupation with food
- D. Lacks awareness of how eating affects weight loss
Correct Answer: C
Rationale: Individuals with AN are preoccupied with food, often preparing it for others or hoarding it while eating minimally. Secret eating and using food as a coping mechanism are typical of bulimia nervosa, and those with AN are aware of calorie intake?s impact.
The nurse has determined that an adolescents body mass index (BMI) is in the 90th percentile. What information should the nurse convey to the adolescent?
- A. The adolescent is overweight.
- B. The adolescent has maintained weight within the normal range.
- C. The adolescent is at risk for becoming overweight.
- D. Nutritional supplementation should occur at least three times per week
Correct Answer: C
Rationale: A BMI in the 85th-94th percentile indicates a risk for becoming overweight, requiring monitoring and lifestyle changes. A BMI ?95th percentile denotes overweight, and supplementation is not indicated.