Nokea
Which statement by a school-aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease?
- A. I'll cover my mouth with a wet cloth if there's too much dust blowing.
- B. Cuts and scrapes need to be washed out and covered right away.
- C. I'm not going to swim where the water is standing still or feels too hot.
- D. I have to wear long sleeves and pants when we're hiking around the pond.
Correct Answer: D
Rationale: The correct answer is D. Wearing long sleeves and pants helps prevent tick bites, which can transmit Lyme disease. Ticks carrying Lyme disease are often found in wooded or grassy areas, so covering exposed skin can reduce the risk of being bitten by an infected tick. Choices A, B, and C do not address the specific mode of transmission of Lyme disease through tick bites, making them incorrect.
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The healthcare provider is developing the plan of care for a hospitalized child with von Willebrand disease. What priority nursing intervention should be included in this child's plan of care?
- A. Reduce exposure to infection.
- B. Eliminate contact with cold objects.
- C. Guard against bleeding injuries.
- D. Reduce contact with other children.
Correct Answer: C
Rationale: Children with von Willebrand disease have a deficiency in a clotting protein, putting them at risk of bleeding episodes. The priority nursing intervention for a child with von Willebrand disease is to guard against bleeding injuries to prevent excessive bleeding or hemorrhage. Choices A, B, and D are not the priority interventions for von Willebrand disease. While reducing exposure to infection is important for any hospitalized child, it is not the priority for von Willebrand disease. Eliminating contact with cold objects is more relevant for conditions like Raynaud's disease. Reducing contact with other children is not a specific priority related to managing von Willebrand disease.
The nurse is caring for a 3-year-old child who has been recently diagnosed with cystic fibrosis. Which discharge instruction by the nurse is most important to promote pulmonary function?
- A. Chest physiotherapy should be performed before meals and at bedtime
- B. Cough suppressants can be used up to four times a day for relief
- C. Oxygen should be given through a nasal cannula between 4-6 L/min
- D. Exercise is discouraged in order to preserve pulmonary vital capacity
Correct Answer: B
Rationale: In cystic fibrosis, thick mucus obstructs the airways, making it difficult to clear from the lungs. Cough suppressants can help reduce the discomfort associated with persistent coughing, allowing the child to cough more effectively to clear the mucus, thus promoting pulmonary function. Chest physiotherapy, not exercise, helps mobilize the mucus. Oxygen therapy may be needed but is not the most important for promoting pulmonary function in this case.
The practical nurse is caring for a child who has just returned from surgery for an appendectomy. Which intervention should the nurse implement?
- A. Encourage early ambulation.
- B. Apply warm compresses to the incision site.
- C. Monitor for signs of infection at the surgical site.
- D. Provide a high-fiber diet immediately post-op.
Correct Answer: C
Rationale: Monitoring for signs of infection at the surgical site is crucial after an appendectomy as it helps in early detection and treatment of any potential complications. This intervention is essential for ensuring the child's proper healing and recovery post-surgery. Encouraging early ambulation is generally beneficial post-operatively but may not be the priority immediately after an appendectomy. Applying warm compresses to the incision site may not be indicated as it can increase the risk of infection. Providing a high-fiber diet immediately post-op is not recommended as the digestive system needs time to recover from surgery.
A child with cystic fibrosis is admitted to the hospital with respiratory distress. Which intervention should the practical nurse (PN) implement?
- A. Administer bronchodilators as prescribed.
- B. Limit fluid intake.
- C. Provide a high-fat diet.
- D. Encourage bed rest only.
Correct Answer: A
Rationale: Administering bronchodilators as prescribed is crucial for managing respiratory distress in children with cystic fibrosis. Bronchodilators help to open the airways, facilitating easier breathing for the child. Limiting fluid intake, providing a high-fat diet, or encouraging bed rest only are not appropriate interventions for respiratory distress associated with cystic fibrosis. Limiting fluid intake could worsen dehydration, a high-fat diet is not recommended due to pancreatic insufficiency in cystic fibrosis, and bed rest alone does not address the respiratory distress.
A 16-year-old adolescent is admitted to the hospital with a diagnosis of meningitis. The nurse notes that the client has a severe headache and photophobia. What is the nurse's priority action?
- A. Administer prescribed pain medication
- B. Place the client in a dark, quiet room
- C. Notify the healthcare provider
- D. Encourage the client to rest
Correct Answer: B
Rationale: The priority action for the nurse when a client with meningitis presents with a severe headache and photophobia is to place the client in a dark, quiet room. This intervention helps reduce stimuli that can exacerbate symptoms such as headache and photophobia. Creating a calm environment can provide relief and promote comfort for the client while also supporting their recovery. Administering pain medication may be necessary but ensuring a suitable environment takes precedence. Notifying the healthcare provider is important but is not the immediate priority. Encouraging rest is beneficial, but creating an appropriate environment to alleviate symptoms is the initial essential step.