Nokea
What instructions should the nurse provide to the parents about the treatment of head lice in a 3-year-old boy who has been confirmed to have head lice?
- A. Wash the child's bed linens and clothing in hot soapy water.
- B. Dispose of the child's brushes, combs, and other hair accessories.
- C. Rewash the child's hair following a 24-hour isolation period.
- D. Take the child to a hair salon for a shampoo and shorter haircut.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide to the parents is to wash the child's bed linens and clothing in hot soapy water. This is essential to eliminate head lice as they can survive on bedding and clothing. It is also important to wash any other items that the child may have used or come into contact with, such as brushes and combs, to prevent reinfestation. Rewashing the child's hair following an isolation period is not necessary, and taking the child to a hair salon for a shampoo and shorter haircut is not a recommended treatment for head lice.
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An adolescent female who is leaning forward with her hands on her knees to breathe tells the practical nurse that she has been using triamcinolone (Azmacort) inhalation aerosol before coming to the clinic. Which action should the PN implement?
- A. Obtain vital signs and assess breath sounds for wheezing.
- B. Collect a blood sample for white blood cell count.
- C. Give the client a nebulizer breathing treatment.
- D. Administer another dose of Azmacort.
Correct Answer: A
Rationale: When a patient presents with breathing difficulties, the first action should be to assess vital signs and breath sounds to evaluate the severity of the condition. This assessment will provide crucial information to determine the appropriate course of action and treatment. Collecting a blood sample for a white blood cell count, giving a nebulizer treatment, or administering another dose of Azmacort would not be the initial priority in this situation.
An adolescent female who comes to the school clinic is reluctant to confide her concerns to the practical nurse (PN). The PN tells the teen that confidentiality and privacy are maintained unless a life-threatening situation arises. Which principle supports the PN's response?
- A. The adolescent should be encouraged to seek help outside of the school clinic.
- B. Disclosures from the adolescent should be kept confidential.
- C. Honest information ensures establishing a trusting relationship.
- D. Minor adolescents should not be encouraged to disclose private concerns.
Correct Answer: C
Rationale: The correct principle supporting the practical nurse's response is that honest information ensures establishing a trusting relationship. By assuring confidentiality and privacy to the adolescent unless there is a life-threatening situation, the practical nurse fosters an environment where the teen feels safe to share their concerns openly. This approach helps build trust, encouraging effective communication and support for the adolescent's well-being.
The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next?
- A. Measure the infant's head-to-toe length.
- B. Palpate the anterior fontanel for tension and bulging.
- C. Observe the infant for sunken eyes.
- D. Plot the measurement on the infant's growth chart.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The caregiver is caring for a 3-year-old child with a diagnosis of gastroenteritis. The child has had several episodes of vomiting and diarrhea over the past 24 hours. What is the caregiver's priority assessment?
- A. Monitor the child's weight
- B. Assess the child's hydration status
- C. Evaluate the child's nutritional intake
- D. Check the child's temperature
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 9-year-old child is brought to the clinic with complaints of fatigue, pallor, and shortness of breath. The nurse notes that the child has a history of iron-deficiency anemia. What is the nurse's priority action?
- A. Administer iron supplements as prescribed
- B. Monitor the child's hemoglobin levels
- C. Educate the parents about dietary sources of iron
- D. Notify the healthcare provider
Correct Answer: A
Rationale: In a child with a history of iron-deficiency anemia presenting with symptoms of fatigue, pallor, and shortness of breath, the priority action for the nurse is to administer iron supplements as prescribed. Iron supplementation is essential to treat iron-deficiency anemia and improve the child's symptoms promptly.