Which of the following would the nurse use to document a finding that the patient's ear is draining?
- A. Otorrhea
- B. Otalgia
- C. Ototoxic
- D. Tinnitus
Correct Answer: A
Rationale: Otorrhea is the medical term used to describe drainage from the ear. It is a finding that indicates the ear is draining fluid, which can be a sign of infection or other underlying issues. Otalgia refers to ear pain, ototoxic refers to substances that can damage the ear, and tinnitus refers to ringing in the ears. Therefore, otorrhea is the most appropriate term to document the finding of a draining ear.
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The Andrews family has been taking good care of their youngest, Archie, who was diagnosed with asthma. Which of the following statements indicate a need for further home care teaching?
- A. "He should increase his fluid intake regularly to thin secretions."
- B. "We'll make sure that he avoids exercise to prevent attacks."
- C. "He is to use his bronchodilator inhaler before the steroid inhaler."
- D. "We need to identify what things trigger his attacks." 50
Correct Answer: B
Rationale: It is important to note that exercise should not be completely avoided for a child with asthma. Regular physical activity is beneficial for overall health and can help improve lung function in asthmatic individuals. Supervised and controlled exercise under the guidance of healthcare providers can be safe for children with asthma. Avoiding exercise altogether can lead to deconditioning and other health issues. It is important to educate the family on the proper management of asthma during exercise, such as using a rescue inhaler before engaging in physical activity. Therefore, this statement indicates a need for further home care teaching.
for pain management. When applying a new system, the nurse should:
- A. Press the system in place for 30 to 60 seconds.
- B. Choose a site on the lower torso.
- C. Shave the application site before use.
- D. Apply the system immediately after removal from a package.
Correct Answer: B
Rationale: When applying a new system for pain management, it is recommended to choose a site on the lower torso. This area is often a suitable location for applying transdermal pain medication patches because it tends to have fewer hair follicles, making it easier for the patch to adhere properly and be absorbed effectively. The lower torso also typically provides a discreet location for patch placement, helping to maintain patient privacy and comfort.
Older school-age children who begin to participate in competitive sports should have a careful evaluation of the
- A. vision
- B. hearing
- C. sexual maturity
- D. cardiovascular system
Correct Answer: D
Rationale: Cardiovascular evaluation is important for children participating in competitive sports.
An infant with gastroschisis is MORE likely than one with an omphalocele to have which of the following conditions?
- A. Congenital heart disease
- B. History of prematurity
- C. Imperforate anus
- D. N/A
Correct Answer: B
Rationale: Infants with gastroschisis are more likely to have a history of prematurity compared to those with omphalocele, though neither condition is strongly associated with congenital heart disease or imperforate anus.
Latasha, age 8 years, is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which will help her most in her adjustment to the hospital?
- A. Explain hospital schedules to her, such as mealtimes.
- B. Use terms such as "honey" and "dear" to show a caring attitude.
- C. Explain when parents can visit and why siblings cannot come to see her.
- D. Orient her parents, because she is young, to her room and hospital facility.
Correct Answer: A
Rationale: Explaining hospital schedules to Latasha, such as mealtimes, will help her most in adjusting to the hospital environment. Providing her with a sense of routine and structure can help reduce her anxiety and uncertainty during her stay. By knowing when things like meals will happen, Latasha can feel more in control of her surroundings and what to expect, which can be comforting for a child in a new and potentially scary situation like being in the hospital.