Nokea
Which assessment finding is most indicative of a child with a protein deficiency?
- A. Brittle hair and dry skin
- B. Frequent nosebleeds
- C. High fever and chills
- D. Rapid weight gain
Correct Answer: A
Rationale: Protein deficiency can lead to brittle hair and dry skin due to inadequate protein for tissue repair and maintenance, a hallmark of conditions like kwashiorkor.
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If the parents report all the following history findings to the nurse, which one is most closely correlated with an increased risk of rheumatic fever?
- A. The child was exposed to measles within the past 4 weeks.
- B. The child had a severe sore throat within the past 2 weeks.
- C. The child is lethargic and no longer interested in schoolwork.
- D. The child received a bump on the head while playing.
Correct Answer: B
Rationale: Rheumatic fever is strongly associated with a recent streptococcal infection, such as a sore throat caused by group A Streptococcus. A severe sore throat within the past 2 weeks is a key risk factor, as it may indicate an untreated or inadequately treated streptococcal infection.
The nurse correctly advises the parents to avoid administering medications containing which ingredient to their child who has hemophilia?
- A. Acetaminophen
- B. Aspirin
- C. Ibuprofen
- D. Penicillin
Correct Answer: B
Rationale: Aspirin inhibits platelet function and increases bleeding risk, which is dangerous for a child with hemophilia, a condition characterized by impaired clotting.
Which response by the nurse best explains why aspirin is preferred to acetaminophen (Tylenol) in the treatment of rheumatic fever?
- A. Aspirin controls fever better.
- B. Aspirin prevents infections.
- C. Aspirin relieves joint inflammation.
- D. Aspirin prevents cardiac enlargement.
Correct Answer: C
Rationale: Aspirin is preferred in rheumatic fever due to its anti-inflammatory properties, which relieve joint inflammation and pain associated with polyarthritis. Acetaminophen lacks significant anti-inflammatory effects, making aspirin more effective.
The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn’s HR is 80 bpm. What should the nurse do next?
- A. Assign a 2 for the Apgar score that pertains to the heart rate.
- B. Suction the excess secretions from the newborn’s oral cavity.
- C. Wrap in warm blankets and place on the mother’s abdomen.
- D. Begin immediate positive pressure ventilation on the newborn.
Correct Answer: D
Rationale: A newborn HR of less than 100 bpm scores as a 1 on the HR criterion and indicates a need to begin positive pressure ventilation by bag mask or Neopuff® ventilation. A score of 2 requires HR above 100 bpm. Suctioning is not indicated and wrapping is done after assessment.
Which finding documented by the nurse is most indicative of the presence of a Curling's ulcer in the burned child?
- A. Absence of bowel sounds
- B. A positive hemoccult test
- C. An elevated hematocrit
- D. A distended abdomen
Correct Answer: B
Rationale: A positive hemoccult test indicates gastrointestinal bleeding, characteristic of a Curling's ulcer, a stress ulcer common in burn patients due to physiological stress and reduced mucosal protection.