Nokea
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.
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A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?
- A. Restlessness
- B. Sleepiness
- C. Nausea
- D. Anxiety
Correct Answer: B
Rationale: Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.
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.
An adolescent has just had a generalized seizure and collapsed in the school nurse's office. When should the nurse should call 911?
- A. The seizure lasts more than 5 minutes.
- B. The child is sleepy and lethargic after the seizure.
- C. The child vomited at the onset of the seizure.
- D. The child is confused and has slurred speech after the seizure.
Correct Answer: A
Rationale: If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.
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.
The nurse observes a child's position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture?
- A. Correct anatomical position
- B. Decorticate
- C. Decerebrate
- D. Opisthotonos
Correct Answer: C
Rationale: In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.