Nokea
Which of the following instructions should the nurse include in the teaching?
- A. Wash the child's hair with shampoo containing ketoconazole.
- B. Treat everyone who came into close contact with the child.
- C. Apply petroleum jelly to the affected areas.
- D. Soak combs and brushes in boiling water for 10 min.
Correct Answer: B
Rationale: The correct answer is B: Treat everyone who came into close contact with the child. This is important in preventing the spread of contagious conditions such as lice or scabies. Treating close contacts helps eliminate the source of reinfestation.
A: Washing the child's hair with ketoconazole shampoo may be helpful for treating specific conditions but does not address preventing spread to others.
C: Applying petroleum jelly to affected areas may soothe symptoms but does not prevent transmission to others.
D: Soaking combs and brushes in boiling water is a good practice for cleaning but does not address treating close contacts.
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Which of the following findings should the nurse expect?
- A. Pinpoint pupils
- B. Ataxia
- C. Hyperactive reflexes
- D. Hypothermia
Correct Answer: B
Rationale: The correct answer is B: Ataxia. Ataxia is a neurological finding characterized by lack of coordination and unsteady gait, commonly seen in conditions like cerebellar dysfunction. Pinpoint pupils (A) suggest opioid toxicity, hyperactive reflexes (C) indicate possible hyperthyroidism or CNS injury, and hypothermia (D) is associated with hypothyroidism or hypothermia. Ataxia is the most relevant finding in this context, indicating a potential neurological issue.
For which of the following adverse effects should the nurse monitor?
- A. Prolonged wound healing
- B. Nausea
- C. Stevens-Johnson syndrome
- D. Renal failure
Correct Answer: B
Rationale: The correct answer is B: Nausea. The nurse should monitor for nausea as it is a common adverse effect of many medications and can impact the patient's overall well-being. Nausea can lead to decreased appetite, dehydration, and noncompliance with medications. Prolonged wound healing (A) is a potential adverse effect but is not as common or immediate as nausea. Stevens-Johnson syndrome (C) is a severe and life-threatening skin reaction that is rare and not typically monitored by nurses. Renal failure (D) is a serious adverse effect but may not be directly related to all medications.
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
Which of the following actions should the nurse take first?
- A. Obtain an x-ray of the child's neck.
- B. Administer intravenous antibiotics.
- C. Initiate droplet precautions.
- D. Place intubation equipment at the bedside.
Correct Answer: D
Rationale: The correct action for the nurse to take first is to place intubation equipment at the bedside (Choice D). This is crucial in case the child's condition deteriorates rapidly and respiratory support is needed. Placing the intubation equipment ensures immediate access to airway management, which takes precedence over other actions. Obtaining an x-ray may provide diagnostic information but is not as urgent as ensuring airway patency. Administering antibiotics and initiating droplet precautions (Choice C) are important but not the immediate priority in this scenario. Therefore, Choice D is the correct first action to ensure the child's safety and optimal care.
Which of the following statements should the nurse make?
- A. An alarm will sound if your child has an abnormal heart rhythm.
- B. Leads will be placed on your child's back prior to the procedure.
- C. This procedure will take at least 30 minutes to complete.
Correct Answer: B
Rationale: The correct answer is B because leads are typically placed on the back before a procedure like an electrocardiogram (ECG) to monitor the heart's electrical activity. This step is crucial for obtaining accurate results. Choice A is incorrect as alarms are not typically used during ECGs. Choice C is incorrect because the duration of the procedure can vary and is not necessarily 30 minutes. Choices D, E, F, and G are blank, so they do not provide any relevant information.