Nokea
What assessment does the school nurse recognize as the cardinal sign of a hyphema?
- A. Opacity of the lens
- B. A yellow-white reflex on the pupil
- C. A dark-red spot in front of the iris
- D. Inflamed mucous membranes of the eyelids
Correct Answer: C
Rationale: A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.
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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.
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.
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.
What will the nurse teach parents when giving instructions for acute conjunctivitis?
- A. Apply cool compresses to the affected eye several times a day.
- B. Instill topical steroid eyedrops for 1 week.
- C. Clear drainage from the inner to the outer aspect of the eye.
- D. Keep the eye patched until the inflammation resolves.
Correct Answer: C
Rationale: Eye secretions are always cleared from the inner canthus downward and away from the opposite eye.
A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. Of which type of seizure is this behavior a characteristic?
- A. Absence
- B. Akinetic
- C. Myoclonic
- D. Complex partial
Correct Answer: A
Rationale: Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and may last only a few seconds.