Nokea
A nurse is assessing a school-age child who is receiving morphine. For which of the following adverse effects should the nurse monitor?
- A. Hypertension
- B. Bradypnea
- C. Stevens-Johnson syndrome
- D. Prolonged wound healing
Correct Answer: B
Rationale: The correct answer is B: Bradypnea. Morphine is an opioid that can cause respiratory depression, leading to bradypnea (slow breathing). The nurse should monitor the child's respiratory rate regularly as a safety precaution. Hypertension (A), Stevens-Johnson syndrome (C), and prolonged wound healing (D) are not typically associated with morphine use in school-age children. Monitoring for these adverse effects would not be a priority in this situation.
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A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following activities should the nurse expect the child to participate?
- A. Using scissors to cut out paper shapes
- B. Playing with a large plastic truck
- C. Looking at alphabet flash cards
- D. Watching a cartoon in the activity room
Correct Answer: D
Rationale: The correct answer is D: Watching a cartoon in the activity room. Toddlers with acute lymphocytic leukemia are often immunocompromised, making them susceptible to infections. Therefore, activities that involve potential injury or exposure to germs, such as using scissors (choice A) or playing with toys that cannot be easily cleaned (choice B) should be avoided. Looking at alphabet flash cards (choice C) may be mentally stimulating but does not address the safety concerns. Watching a cartoon in the activity room (choice D) is a safe and enjoyable activity that can help keep the child entertained without posing a risk of injury or infection.
The nurse is continuing to care for the child. The nurse should anticipate a prescription for pain medication.
- A. Skin traction
- B. Surgical consultation
- C. Antibiotics
- D. Pain medication
- E. Limb immobilization
- F. Bed rest
Correct Answer: B,D
Rationale: The correct answers are B and D. A surgical consultation (B) may be needed to address the underlying cause of the child's pain. Pain medication (D) is essential to provide comfort and manage the child's pain. Skin traction (A) and limb immobilization (E) are interventions for orthopedic issues, not for immediate pain relief. Antibiotics (C) are not indicated unless there is an infection. Bed rest (F) is not a proactive measure for pain management.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Fever
- B. Steatorrhea
- C. Tinnitus
- D. Dysphagia
Correct Answer: A
Rationale: The correct answer is A: Fever. Bacterial pneumonia commonly presents with fever due to the body's immune response to the infection. This is a classic sign of inflammation caused by the bacterial infection in the lungs. Steatorrhea (B), tinnitus (C), and dysphagia (D) are not typical manifestations of bacterial pneumonia. Steatorrhea is associated with malabsorption disorders, tinnitus is often related to ear issues, and dysphagia is difficulty swallowing, which is not a common symptom of pneumonia. Therefore, the nurse should expect fever as a key manifestation of bacterial pneumonia in the child.
A nurse on the pediatric unit is admitting the child from the emergency department. Complete the following sentence by using the lists of options. The nurse suspects the child is experiencing rheumatic fever. The nurse should recognize the child is at greatest risk of developing--- due to---
- A. Glomerulonephritis
- B. Pericarditis
- C. Rheumatic heart disease
- D. Streptococcal pharyngitis
- E. Recent immunizations
- F. Viral infection
Correct Answer: C,D
Rationale: The correct answers are C: Rheumatic heart disease and D: Streptococcal pharyngitis. Rheumatic fever is caused by untreated streptococcal infection. If not treated promptly, it can lead to rheumatic heart disease, a serious complication. Streptococcal pharyngitis is a common precursor to rheumatic fever. Glomerulonephritis (A) is a potential complication of streptococcal infection but not directly related to rheumatic fever. Pericarditis (B) is an inflammation of the pericardium and not directly associated with rheumatic fever. Recent immunizations (E) and viral infections (F) are not linked to the development of rheumatic fever.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Administer aspirin to the child for fever.
- C. Use droplet precautions when caring for the child.
- D. Assess the child for Koplik spots.
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella, commonly known as chickenpox, is highly contagious and spreads through respiratory droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to others by containing the infectious particles within the room. This isolation measure is crucial in protecting both the child and other patients.
Choice B is incorrect because aspirin should not be administered to children with varicella due to the risk of Reye's syndrome. Choice C is incorrect as droplet precautions are not necessary for varicella, which primarily spreads through airborne respiratory droplets. Choice D is incorrect as Koplik spots are associated with measles, not varicella.