Nokea
Which of the following instructions should the nurse include in the teaching?
- A. Apply bactericidal ointment to lesions.
- B. Administer acyclovir PO two times per day.
- C. Soak hairbrushes in boiling water for 10 min.
- D. Seal soft toys in a plastic bag for 14 days.
Correct Answer: A
Rationale: The correct answer is A: Apply bactericidal ointment to lesions. This instruction is essential to prevent secondary bacterial infection in lesions caused by herpes zoster. The ointment will help to keep the lesions clean and prevent bacterial growth. Administering acyclovir helps treat the viral infection but does not prevent bacterial infection. Soaking hairbrushes and sealing soft toys are not directly related to preventing infection in the lesions. Overall, the focus should be on proper wound care to prevent complications.
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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.
Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.
Which of the following statements should the nurse make?
- A. You need to come back in a week for retesting.
- B. I have to notify the public health department.
- C. I have to contact your parents.
- D. Let's review the side effects of metronidazole.
Correct Answer: B
Rationale: The correct answer is B: I have to notify the public health department. This statement is crucial in cases of reportable diseases to prevent the spread of infection. Notifying the public health department is a legal and ethical responsibility to ensure appropriate measures are taken. Choice A is incorrect because it lacks urgency in notifying the proper authorities. Choice C is incorrect as contacting the patient's parents may not be necessary in this situation. Choice D is incorrect as reviewing side effects of metronidazole is not the priority when dealing with a reportable disease.
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
- A. The child maintains balance when standing with eyes closed.
- B. The child exhibits a gag reflex when stimulated with a tongue blade.
- C. The child correctly identifies specific scents.
- D. The child has symmetrical jaw strength when biting down.
Correct Answer: D
Rationale: The correct answer is D because symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, which controls the muscles of mastication. Choice A relates to the vestibular system, not the trigeminal nerve. Choice B involves the glossopharyngeal and vagus nerves. Choice C is related to the olfactory nerve.
Specify 2 parameters the nurse should monitor to assess the client's progress.
- A. Number of steatorrhea stools
- B. Intake and output
- C. Respiratory Status (Monitor respiratory)
- D. Presence of periorbital edema
Correct Answer: B,C
Rationale: The correct parameters for the nurse to monitor to assess the client's progress are intake and output (B) and respiratory status (C). Monitoring intake and output is crucial to assess fluid balance and kidney function. Changes in these values can indicate dehydration or fluid overload. Respiratory status should be monitored to assess oxygenation and ventilation, which are essential for tissue perfusion and overall health.
The incorrect choices are A, D, E, F, and G. A (Number of steatorrhea stools) is not directly related to assessing overall client progress. D (Presence of periorbital edema) may be indicative of fluid retention but is not as direct as intake and output monitoring. Choices E, F, and G are not provided, thus not applicable to the question.