Nokea
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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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 is caring for a 3-year-old child with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)?
- A. Temperature increase from 37.2?°C (99?°F) to 37.7?°C (100?°F)
- B. Increase in blood pressure with an attendant decrease in pulse
- C. Increase in respirations
- D. Equilateral pupils
Correct Answer: B
Rationale: Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.
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.
Which assessment finding in a child with meningitis should be reported immediately?
- A. Irregular respirations
- B. Tachycardia
- C. Slight drop in blood pressure
- D. Elevated temperature
Correct Answer: A
Rationale: Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately, because they could indicate increased intracranial pressure.
The nurse urges the mother of a 6-month-old child to get her child inoculated with Haemophilus influenzae type B. What does this immunization protect against?
- A. Encephalitis
- B. Influenza
- C. Bacterial meningitis
- D. Otitis media
Correct Answer: C
Rationale: H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.