What statement by a patient's mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media?
- A. I will continue using the medication until symptoms are relieved.'
- B. I will share the medicine with siblings if their symptoms are the same.'
- C. I will give the medication with a glass of milk.'
- D. I will administer prescribed doses until all the medication is used.'
Correct Answer: D
Rationale: Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.
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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.
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.
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.
Which aspect(s) of a child's development does the nurse caution parents that hearing impairment can affect? (Select all that apply.)
- A. Speech clarity
- B. Language development
- C. Immunity to disease
- D. Personality development
- E. Academic achievement
Correct Answer: A,B,D,E
Rationale: All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.
Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.)
- A. Hypersensitivity to noise
- B. Irritability
- C. Ecchymotic ear canal
- D. Rolls head from side to side
- E. Temperature of 39.4?°C (103?°F)
Correct Answer: B,D,E
Rationale: Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.
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