Nokea
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
- A. Monitor peripheral pulses and sensation in the right leg
- B. Cleanse pin sites as prescribed
- C. Check skin for redness and signs of tissue breakdown
- D. Reposition the child every 2 hours
Correct Answer: A
Rationale: Monitoring pulses and sensation is critical to detect vascular or nerve complications from traction.
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The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inflamed conjunctiva. The child receives a prescription for an ophthalmic antinfective ointment. What instruction should the nurse provide the child's caregivers during discharge education?
- A. Use a disposable moist wipe to remove eye crusts.
- B. Prepare the child for blurry vision after ointment application.
- C. Remove secretions by wiping toward the opposite eye.
- D. Discontinue the ointment once drainage resolves.
Correct Answer: B
Rationale: Ointment can cause temporary blurry vision, and caregivers should be prepared.
A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?
- A. Compare the child's vital signs over the past three weeks.
- B. Counsel the parents to pay more attention to the child.
- C. Ask the boy to describe a typical day at school.
- D. Conduct a complete neurological assessment.
Correct Answer: C
Rationale: Asking the boy to describe a typical day at school helps identify potential stressors or psychosocial factors contributing to his non-specific symptoms.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?
- A. The thyroxine level is low because the TSH level is high.
- B. High thyroxine levels normally occur in breastfeeding infants.
- C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
- D. The TSH is high because of the low production of T4 by the thyroid.
Correct Answer: D
Rationale: High TSH results from low T4 production, indicating congenital hypothyroidism.
The nurse is educating the caregiver of a school-age child who has recently been diagnosed with attention-deficit hyperactivity disorder (ADHD). Which of the caregiver's statements indicate that they have understood the education? (Select all that apply.)
- A. Create an organization chart for tasks.
- B. Understand that nonstimulant medications show little benefit in treatment.
- C. Know that medication is the best approach to treatment.
- D. Designate an established area for study.
- E. Maintain a consistent home schedule.
- F. Anticipate being automatically entered into a specialized education plan.
Correct Answer: A,D,E
Rationale: Organizational charts, a designated study area, and consistent schedules provide structure, benefiting ADHD management.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Recognizes most letters and numbers
- B. Uses 1-word sentences
- C. Speaks in simple sentences with four or more words
- D. Uses gestures with 1 to 2-word sentences .
Correct Answer: C
Rationale: Simple sentences with four or more words are expected for a 3-year-old's language development.