Families Exam 4

When assessing a child for impetigo, the nurse expects which assessment findings? 1. Small, brown, benign lesions 2. Honey-colored, crusted lesions 3. Linear, threadlike burrows 4. Circular lesions that clear centrally

2. Honey-colored, crusted lesions

An 8-year-old child is suspected of having meningitis. Signs of meningitis include: 1. Cullen's sign. 2. Koplik's spots. 3. Kernig's sign. 4. Chvostek's sign

3. Kernig's sign.

What are some patient priorities during the emergent phase of burn management? (select all that apply) A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition

A and B

A patient has superficial partial thickness burns 63% of her body. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringerss that will be given over the next 24 hours? A. 22,932 mL B. 26,208 mL C. 16,380 mL D. 12,238 mL

A. 22,932 mL

A mother asks the nurse why her 12-month-old baby gets otitis media more frequently than her 10-year-old son. What should the nurse tell her? 1. "The baby's eustachian tubes are shorter and lie more horizontally." 2. "The baby is too young to blow his nose when he has a cold." 3. "The baby spends more time lying down than his older brother; therefore, more dirt gets in the baby's ear." 4. "The baby puts dirty toys in his mouth."

1. "The baby's eustachian tubes are shorter and lie more horizontally." RATIONALE: Infants and young children are more prone to otitis media because their eustachian tubes are shorter and lie more horizontally. Pathogens from the nasopharynx can more readily enter the eustachian tube of the middle ear. The inability to clear nasal passages by blowing the nose, lying down on the floor, and putting dirty toys in the mouth don't increase the tendency toward otitis media.

A nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to: 1. teach children to cover mouths and noses when they sneeze. 2. have their children immunized against impetigo. 3. teach children the importance of proper hand washing. 4. isolate the child with impetigo from other members of the family.

3. teach children the importance of proper hand washing.

A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include: 1. a depressed fontanel. 2. slurred speech. 3. tachycardia. 4. an altered level of consciousness.

4. an altered level of consciousness. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge — not depress — if he had increased ICP. Slurred speech isn't a sign of increased ICP in an infant because the child isn't able to speak at this age. However, a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.

What is the priority intervention for a child with a severe burn? A. Cool the burn with ice B. Offer oral rehydration C. Oxygen by NRB D. Remove jewelry

C. Oxygen by NRB

Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is: A. prone for two hours to prevent aspiration, should she vomit. B. semi-fowler's so she can watch TV for five hours and be entertained. C. supine for several hours, to prevent headache. D. on her right sides to encourage return of CSF

C. supine for several hours, to prevent headache. Rationale: Lying flat keeps the patient from having a "spinal headache." Increasing the fluid intake will assist in replenishing the lost fluid during this time.

The nurse is closely monitoring a child with increased intracranial pressure who has been exhibiting decorticate (flexor) posturing. The nurse notes that the child suddenly exhibits decerebrate (extensor) posturing and interprets that this change in the child's condition indicates which finding? A. An insignificant finding B. An improvement in condition C. Decreasing intracranial pressure D. Deteriorating neurological function

D. Deteriorating neurological function Rationale: The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants health care provider notification. Options 1, 2, and 3 are inaccurate interpretations.

The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first? A. Applies silver sulfadiazine (Silvadene) ointment B. Covers the area with an elastic wrap C. Places a synthetic dressing over the area D. Removes loose nonviable tissue

D. Removes loose nonviable tissue All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process is removing exudates and necrotic tissue.

The parent of a 12-month-old child who has received the MMR, Varivax, and hepatitis A vaccines calls the clinic to report redness and swelling at the vaccine injection sites and a temperature of 100.3° F. The nurse will perform which action? a. Recommend aspirin or an NSAID for pain and fever. b. Recommend acetaminophen and cold compresses. c. Report these adverse effects to the Vaccine Adverse Event Reporting System (VAERS). d. Schedule an appointment in clinic so the provider can evaluate the child.

b. Recommend acetaminophen and cold compresses These are common, minor side effects of vaccines and can be treated with acetaminophen and cold compresses. Aspirin is contraindicated in children because of its association with Reye's syndrome. Since these are not serious adverse effects, they do not need to be reported to VAERS. It is not necessary to schedule a clinic visit.

A child, age 4, fell and broke his arm and had a cast applied. Which of these statements by the child indicates an immediate risk for compartment syndrome? 1. "My arm hurts." 2. "I can't wiggle my fingers." 3. "I need to go home." 4. "Don't touch me."

2. "I can't wiggle my fingers." RATIONALE: Signs and symptoms of compartment syndrome, such as motor weakness, reflect a deficit or deterioration of neuromuscular status in the involved area. Inability to wiggle fingers indicates an immediate risk for compartment syndrome because it could suggest neurovascular pressure or damage caused by edema following the injury. The other statements don't indicate risk for compartment syndrome.

A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first? 1. An infant with a myelomeningocele who is scheduled for surgical placement of a ventriculoperitoneal shunt at 10 a.m. 2. A restless infant with a high-pitched cry who was transferred from intensive care unit (ICU) the previous evening 3. An infant with an axillary temperature of 100.4 ° F (38° C) on the third postoperative day 4. An infant whose ventriculoperitoneal shunt must be pumped every 2 hours following shunt revision the previous day. The shunt was last pumped at 6 a.m.

2. A restless infant with a high-pitched cry who was transferred from intensive care unit (ICU) the previous evening RATIONALE: An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transferred from ICU the previous night, assessing him for increased ICP should be a nursing priority. The infant with a myelomeningocele who is scheduled for surgical placement of a ventriculoperitoneal shunt is stable, so assessing him isn't the most urgent nursing priority. Although the nurse must assess a low-grade fever on the third postoperative day, this stable infant isn't the priority at this time. Pumping a ventriculoperitoneal shunt is less urgent than evaluating increased ICP.

Parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment? 1. Stuttering 2. Using gestures to express desires 3. Babbling continuously 4. Playing alongside rather than interacting with peers

2. Using gestures to express desires RATIONALE: Using gestures instead of verbal communication to express desires — especially in a child older than age 15 months — may indicate a hearing or communication impairment. Stuttering is normal in children ages 2 to 4, especially boys. Continuous babbling is a normal phase of speech development in young children. In fact, its absence, not presence, would be cause for concern. Parallel play — playing alongside peers without interacting — is typical of toddlers. However, in an older child, difficulty interacting with peers or avoiding social situations may indicate a hearing deficit.

A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: 1. "Does your child's ear hurt?" 2. "Does your child have any hearing problems?" 3. "Does your child tug at either ear?" 4. "Does anyone in your family have hearing problems?"

3. "Does your child tug at either ear?" RATIONALE: Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful because a young child usually can't describe symptoms accurately.

A 15-month-old child is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the parents indicates effective discharge teaching? 1. "We should have gone to the physician sooner. Next time, we will." 2. "We'll take our child to the physician's office every week until everything is okay." 3. "We'll go to the physician if our child pulls on the ears or won't lie down." 4. "We're just so glad this is all behind us."

3. "We'll go to the physician if our child pulls on the ears or won't lie down." RATIONALE: The parents indicate full understanding of discharge teaching by repeating the specific, common signs of otitis media in toddlers, such as pulling on the ears and refusing to lie down, and by verbalizing the need for immediate follow-up care if these signs arise. Expressing that they should have gone to the physician sooner doesn't indicate effective teaching because it implies a sense of guilt — a feeling not promoted through teaching. Stating that they'll take the child to the physician's office every week addresses only weekly follow-up care and expressing that they're happy the problem is behind them is unrealistic because the child's condition may recur.

A child with osteomyelitis is to receive nafcillin I.V. every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable? 1. 50 mg every 6 hours 2. 100 mg every 6 hours 3. 250 mg every 6 hours 4. 500 mg every 6 hours

3. 250 mg every 6 hours RATIONALE: First, the nurse determines the minimum dose: 50 mg × 10 kg = 500 mg/day 500 mg/4 doses (for administration every 6 hours) = 125 mg/dose. Next, the nurse determines the maximum dose: 100 mg × 10 kg = 1,000 mg/day 1,000 mg/4 doses = 250 mg/dose. Thus, the acceptable dosage range for this client is 125 to 250 mg every 6 hours.

For the last 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate (Amoxil) to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician orders topical nystatin (Mycostatin) to be applied to the perineum four times daily. The nurse should focus her assessment on: 1. the infant's heart and respiratory rate. 2. the infant's fontanels. 3. the inside of the infant's mouth. 4. the infant's height and weight.

3. the inside of the infant's mouth. RATIONALE: The nurse should pay close attention to the inside of the infant's mouth for white patches. Signs of thrush, these patches are common in children with C. albicans infections and should be reported to the physician. Although the other assessments should be performed as a part of an infant evaluation, they aren't the nurse's primary focus in this situation

A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. The school should be informed that: 1. these students are too young to screen; instead, older students should be screened. 2. these students are too old to screen and will no longer benefit from screening for scoliosis. 3. scoliosis screening requires sophisticated equipment and can't be done in school. 4. this is an appropriate request and arrangements will be made as soon as possible.

4. this is an appropriate request and arrangements will be made as soon as possible. RATIONALE: The school's request is appropriate because screening for scoliosis should begin at age 8 and be performed yearly thereafter. Also, because screening for scoliosis involves inspection of the spine and use of a scoliometer, both can be done in a school setting.

The nurse is caring for a child with erythema infectiosum (fifth disease). Which clinical manifestation should the nurse expect to note in the child? A. An intense fiery red edematous rash on the cheeks B. Pinkish-rose maculopapular rash on the face, neck, and scalp C. Reddish and pinpoint petechiae spots found on the soft palate D. Small bluish-white spots with a red base found on the buccal mucosa

A. An intense fiery red edematous rash on the cheeks Rationale: Fifth disease is characterized by the presence of an intense fiery red edematous rash on the cheeks, which gives an appearance that the child has been slapped. Options 2 and 3 are clinical manifestations related to rubella (German measles). Option 4 describes Koplik spots, which are found in rubeola (measles)

The nurse is monitoring a nursing student who is caring for a child who sustained a head injury from a fall. Which action by the nursing student indicates a need for further teaching? A. Forcing fluids B. Performing neurological assessments C. Keeping the child in a sitting-up position D. Keeping the child awake as much as possible

A. Forcing fluids Rationale: A child with a head injury is at risk for increased intracranial pressure (ICP). Forcing fluids may cause fluid overload and increased ICP. Additionally, the nurse should not "force" the client to do something. Neurological assessments must be performed to monitor for increased ICP. Sitting up will decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist in accurate evaluation of any cerebral edema that is present and will detect early coma

The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a "small amount of pain." How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Superficial

A. Full-thickness The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white in color with pain, and superficial burn color is pink to red, with pain.

Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant? A. Transverse palmar crease B. Small tongue C. Large nose D. Restricted joint movement

A. Transverse palmar crease Option A: Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness. Option B: The child with Down syndrome has a protruding tongue that is thick and fissured. Option C: A small nose is manifested by children with Down syndrome. Option D: There is no restricted joint movement, rather the child has joint hyperextensibility or hyper-flexibility.

The nurse provides instructions about cast care to the parents of a child with a short arm cast. Which statement by a parent indicates that further teaching is necessary regarding cast care? A. "I should check the skin around the cast edges for irritation." B. "I can use a ruler padded with gauze to scratch under the cast." C. "I will call the doctor if any unusual odor from the cast occurs." D. "I should keep the extremity elevated as much as possible to reduce swelling."

B. "I can use a ruler padded with gauze to scratch under the cast." Rationale: No item should be placed inside a cast because of the risk for alteration in skin integrity. A cotton-tipped applicator with rubbing alcohol may be used near the cast edges to relieve itching. The skin around the cast edges should be checked for redness, irritation, or blistering. The health care provider should be notified for any unusual odor and/or sudden unexplained fever indicating infection, or if numbness, tingling, pallor, cyanosis, and/or pain unrelieved by medication occurs because these signs indicate neurovascular compromise. The extremity should be elevated as much as possible to minimize swelling.

The school nurse is visiting a kindergarten classroom to teach the students the importance of hand washing. During the teaching session, she notices that one girl is scratching her head. On inspection, she determines that the child has pediculosis capitis. When teaching the mother about care of this condition, which statement by the mother indicates that she needs further teaching regarding this condition? A. "I will put all of the stuffed animals in a sealed plastic bag for 14 days." B. "I will call a carpet cleaning service to clean all my carpets in the house." C. "My two daughters should not share their hair brushes or any hair ribbons." D. "I will machine wash all of the washable clothing, towels, and bed linens in hot water."

B. "I will call a carpet cleaning service to clean all my carpets in the house." Rationale: Teaching the prevention of spread and recurrence of pediculosis capitis includes washing items in hot water, vacuuming carpets, discouraging sharing of personal items, and sealing items in plastic bags that cannot be vacuumed. Option 2 is not community-focused because it is too costly for many families and is unnecessary. The comments in option 2 indicate that the mother does not understand how to prevent the spread of the parasite. Options 1, 3, and 4 are interventions that are cost-effective and have a community focus in the prevention of recurrence of pediculosis capitis.

Nurse Imee is implementing a teaching plan to a group of adolescents regarding the causes of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder? A. "Acne is caused by oily skin" B. "The actual cause is not known" C. "Acne is caused by eating chocolate" D. "Acne is caused as a result of exposure to heat and humidity"

B. "The actual cause is not known" The actual cause of acne is unknown. Oily skin or the consumption of foods such as chocolate, nuts, or fatty foods are not causes of acne. Exacerbations that coincide with the menstrual cycle result from hormonal activity. Heat, humidity, and excessive perspiration may play a role in exacerbating acne but does not cause it.

At what age does a child starting receiving a yearly flu vaccine? A. 12 months B. 6 months C. 2 months D. 24 months

B. 6 months

During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? A. High fiber, low calories, and low protein B. High calorie, high protein and carbohydrate C. High potassium, high carbohydrate, and low protein D. Low sodium, high protein, and restrict fluids to 1 liter per day

B. High calorie, high protein and carbohydrate

A patient has an accidental fall while going to the bathroom without assistance. It appears the patient has sustained a bone fracture to the left leg. The leg's shape is deformed and the patient is unable to move it. The patient is alert and oriented but in pain. What will you do FIRST after confirming the patient is safe and stable? A. Apply an ice pack covered with a towel to the site. B. Immobilize the fracture with a splint. C. Administer pain medication. D. Elevate the extremity above heart level.

B. Immobilize the fracture with a splint. After confirming the patient is safe and stable, the nurse would immobilize the fracture with a splinting device. This will prevent the accidental movement of the extremity by the patient. Immobilization is important because it prevents further pain or bleeding along with more damage that can occur to the surrounding tissues. In addition, if a bone is not immobilized but moved after it has been fractured this can affect the healing process.

A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include? A. Normal social play that ceases by age 5 B. Lack of social interaction and awareness C. The consistent imitation of others' actions D. Normal verbal but abnormal nonverbal communication

B. Lack of social interaction and awareness Rationale: Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary characteristic is a lack of social interaction and awareness. Social behaviors in children with autism include a lack of or abnormal imitations of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and marked abnormal nonverbal communication.

The nurse prepares a teaching plan regarding the administration of eardrops for the parents of a 6-year-old child. The nurse tells the parents that, when administering the drops, which action is appropriate? A. Wear gloves. B. Pull the ear up and back. C. Hold the child in a sitting position. D. Position the child so that the affected ear is facing downward.

B. Pull the ear up and back. Rationale: To administer eardrops in a child who is more than 3 years old, the ear is pulled upward and back. The ear is pulled down and back in children less than 3 years old. Gloves do not need to be worn by the parents, but hand washing before and after the procedure must be performed. The child needs to be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal with the help of gravity.

The nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt who will be discharged from the hospital. Which instruction should the nurse include in the plan of care? A. Expect an increased urine output from the shunt. B. Call the health care provider if the infant is fussy. C. Call the health care provider if the infant has a high-pitched cry. D. Position the infant on the side of the shunt when the infant is put to bed.

C. Call the health care provider if the infant has a high-pitched cry. Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricular part of the brain will not be diverted to the peritoneal cavity, and the cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which then causes a high-pitched cry in the infant. This type of shunt affects the gastrointestinal system rather than the genitourinary system, and an increased urinary output is not expected. Option 2 is only a concern if other signs that are indicative of a complication are occurring. The infant should not be positioned on the side of the shunt, because this will cause pressure on the shunt as well as skin breakdown.

A mother brings her 15-month-old child to the health care provider's office with complaints that the child has suddenly developed a bright red rash on her cheeks. She has no other symptoms and has been playing and eating as usual. Based on the appearance of the child, what might the nurse suspect the child's diagnosis to be? A. Rubella B. Roseola C. Fifth disease D. Chicken pox

C. Fifth disease Rationale: Fifth disease has the general appearance of "slapped cheeks." Many children do not have any symptoms prior to the appearance of the reddened cheeks. This characteristic is not associated with the communicable diseases identified in options 1, 2, or 4.

A school-age child sustains a fracture along the epiphyseal line of the femur following a fall from the garage roof. What long-term effect might result with this type of fracture? A. Osteomyelitis B. Muscle atrophy C. Growth disturbance D. Paresthesias and/or paralysis

C. Growth disturbance Rationale: Growth takes place at the epiphysis of the long bone. A fracture at this level can destroy the layer of germinal cells of the epiphysis, resulting in growth disturbance. Osteomyelitis is an infection of the bone and would be more likely to occur with a compound (open) fracture rather than an epiphyseal fracture. Muscle atrophy may result from immobility or casting but will resolve as activity increases. Paresthesias and paralysis can result from edema and constriction by a cast, not specifically from fracture of the epiphysis.

The nurse receives a telephone call from the emergency department and is told that a 7-month-old infant with febrile seizures will be admitted to the pediatric unit. What should the nurse anticipate the need for when planning care for the admission of the infant? A. Restraints at the bedside B. A code cart at the bedside C. Suction equipment and an airway at the bedside D. A padded tongue blade taped to the head of the bed

C. Suction equipment and an airway at the bedside Rationale: Suctioning may be required during a seizure to remove secretions that obstruct the airway. An airway should also be readily available. During a seizure, the infant should be placed in a side-lying position, but he or she should not be restrained. It is not necessary to place a code cart at the bedside, but a cart should be readily available on the nursing unit. A padded tongue blade should never be used; in fact, nothing should be placed in the mouth during a seizure.

In the health care clinic, an adolescent is seen with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of Epstein-Barr virus (infectious mononucleosis). The clinic nurse calls the mother of the adolescent to inform her of the test results and provides her instructions regarding the care of the adolescent. Which statement by the mother indicates an understanding of the care measures? A. "I need to keep my child on bedrest for 3 weeks." B. "I will call the health care provider if my child is still feeling tired in 1 week." C. "I need to isolate my child so that the respiratory infection is not spread to others." D. "I need to call the health care provider if my child complains of abdominal pain or left shoulder pain."

D. "I need to call the health care provider if my child complains of abdominal pain or left shoulder pain." Rationale: The mother needs to be instructed to notify the health care provider if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bedrest is not necessary, and children usually self-limit their activity. The child may still feel tired in 1 week as a result of the virus. No isolation precautions are required, although transmission can occur via saliva, intimate contact, or contact with infected blood.

Veronica is a 14-year-old girl who wears a brace for structural scoliosis; which of the following statements indicate effective use of the brace? A. "I sure am glad that I only have to wear this awful thing at night." B. "I'm really glad that I can take this thing off whenever I get tired." C. "I wonder if I can take the brace off when I go to the homecoming dance." D. "I'll look forward to taking this thing off to take my bath every day."

D. "I'll look forward to taking this thing off to take my bath every day." Rationale: Option D: The brace should be dropped for simply 1 hour of every 24-hour period for hygiene and skin care. Option A: Wearing the brace at night would be true only following radiologic studies indicate the spine has bone marrow maturity and the adolescent has been weaned from off whenever 1 to 2 years. Option B: Taking the brace off whenever tired indicates poor understanding of the brace. Option C: Although physical appearance and social activities with peers are significant, the brace should not be excluded during these times.

The nurse evaluates the effectiveness of preventive teaching done with the parents of an infant with recurring acute otitis media. Which statement indicates that more teaching is needed? A. "My baby will continue to be breast-fed." B. "No one is permitted to smoke around the baby." C. "The baby received Haemophilus influenzae (Hib) vaccine." D. "We stopped giving the antibiotics to the baby when her fever subsided."

D. "We stopped giving the antibiotics to the baby when her fever subsided." Rationale: All antibiotics should be given for the prescribed time even if symptoms disappear, because the infection may not be completely eradicated, and then recurs. This basic principle of antibiotic therapy applies in this situation. Breast-feeding is done in a more upright position than is bottle-feeding. This reduces reflux, which is a predisposing factor in ear infections. Some infection protection and allergy protection comes from breast milk. Passive smoke can cause upper respiratory irritation. Hib is a common cause of acute otitis media, so the vaccine should reduce this source.

A child, age 10, is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as ordered. The child's left leg is immobilized in a splint. What is an appropriate expected outcome for this child? 1. "The child will change position with minimal discomfort." 2. "The child will bear weight on the affected limb." 3. "The child will ambulate with crutches." 4. "The child will participate in age-appropriate activities."

1. "The child will change position with minimal discomfort."

A teenager is suffering from osteomyelitis. The nurse would expect which of the following symptoms? Select all that apply. A. Fever B. Irritability C. Pallor D. Tenderness E. Swelling

A, B, D, E Rationale: Options A, B, D, and E: The symptoms for acute and chronic osteomyelitis are very similar and include fever, irritability, fatigue, nausea, tenderness, redness (not pallor in option C), and warmth in the area of the infection, swelling around the affected bone, and lost range of motion.

4 year old is scheduled for routine immunizations. As the nurse you know the physician will most likely order what vaccinations? A. DTaP (diphtheria, Tetanus, Pertussis) B. Polio C. Hepatitis B D. RV (Rotavirus) E. MMR (Measles, Mumps, Rubella) F. Hib (Haempophilus Influenzae Type B) G. Varicella

A, B, E, G The immunizations ordered at 4-6 years of age include: DTaP, Polio, MMR, and Varicella.

The school nurse assesses Brook, a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following symptoms are characteristic of the disorder? Select all that apply. A. Constant fidgeting and squirming B. Excessive fatigue and somatic complaints C. Difficulty paying attention to details D. Easily distracted E. Running away F. Talking constantly, even when inappropriate

A, C, D, and F These behaviors are all characteristic of ADHD and indicate that the child is inattentive, hyperactive, and impulsive.

The clinic nurse is providing home care instructions to the mother of a child with human immunodeficiency virus (HIV) infection. Which statement by the mother indicates a need for further teaching? A. "I should delay the polio virus vaccine." B. "I should not allow my child to share toothbrushes with the other children." C. "I should call the health care provider if my child has a fever greater than 101° F." D. "If any blood spills occur from a cut on my child, I should wash the area with soap and water, rinse it with bleach and water, and allow it to air dry."

A. "I should delay the polio virus vaccine." Rationale: The mother should be instructed to keep immunizations up to date. Additionally, the child will receive inactivated polio vaccine. The other options are correct instructions regarding the care of the child with human immunodeficiency virus (HIV) infection

Nurse Kim is teaching a group of parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature? A. Eustachian tubes B. Nasopharynx C. Tympanic membrane D. External ear canal

A. Eustachian tubes

Which assessment finding found while assessing a patient with a fracture who has traction requires immediate intervention? A. The weights are freely hanging on the floor. B. Pin sites are free from drainage. C. Patient uses the overhead trapeze bar to move around in the bed. D. Patient's extremities have a capillary refill of less than 2 seconds

A. The weights are freely hanging on the floor.

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness)

B. 2nd Degree (partial-thickness)

A 5 year old has a fracture of the right upper arm. The x-ray showed that one side of the bone is bent while the other is broken. This known as a __________ fracture? A. Spiral B. Greenstick C. Oblique D. Transverse

B. Greenstick This is a greenstick fracture. These types of fractures are more common in the pediatric population because their bones tend to be more flexible and the periosteum is stronger than an adult.

The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness

B. Partial-thickness superficial Option B: The characteristics of the wound meet the criteria for a superficial partial-thickness injury (color that is pink or red; blisters; pain present and high).

Which factors impact burn severity? A. Duration of contact and causative agent B. Duration of contact and child's age C. Temperature and duration of contact D. Temperature and consistency of substance

C. Temperature and duration of contact

A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg P.O. every 12 hours. If the child weighs 22 lb, how many milligrams will the nurse administer with each dose? 1. 50 mg 2. 100 mg 3. 110 mg 4. 220 mg

1. 50 mg The dose is 5 mg/kg and the child weighs 10 kg. To determine the dose, the nurse would calculate: 5 mg/1 kg × 10 kg = 50 mg per dose.

When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information? 1. Fifth disease is transmitted by respiratory secretions. 2. Fifth disease has an unknown transmission mode. 3. Fifth disease is transmitted by respiratory secretions, stool, and urine. 4. Fifth disease is transmitted by stool.

1. Fifth disease is transmitted by respiratory secretions. RATIONALE: Fifth disease is transmitted by respiratory secretions. The transmission mode for roseola is unknown. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal parasitic conditions, such as giardiasis and pinworm infection, are transmitted by stool.

When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening? 1. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed. 2. Listen for a clicking sound as the child abducts the hips. 3. Have the child run the heel of one foot down the shin of the other leg while standing. 4. Have the child shrug the shoulders as the nurse applies mild pressure to the shoulders.

1. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed. RATIONALE: To screen for scoliosis, a lateral curvature of the spine, the nurse has the child stand firmly on both feet with the trunk exposed and examines the child from behind, checking for asymmetry of the shoulders, scapulae, or hips. The nurse then asks the child to bend forward at the hips and inspects for a rib hump, a sign of scoliosis. Listening for a clicking sound while the child abducts the hips is appropriate when screening for congenital hip dysplasia. The heel-to-shin test evaluates cerebellar function and having the child shrug the shoulders against mild resistance helps evaluate the integrity of cranial nerve XI.

A 6-year-old child is being discharged from the emergency department after being diagnosed with varicella (chickenpox). The nurse knows the parents need more medication teaching when they state they will give the child which over-the-counter medication? 1. Ibuprofen 2. Aspirin 3. Acetaminophen 4. Naproxen

2. Aspirin RATIONALE: The parents require additional teaching if they state they will give their child aspirin because using aspirin during a viral infection has been linked to Reye's syndrome, a serious illness that can lead to brain damage and death in children. If the child requires medication for fever or discomfort, the nurse should recommend acetaminophen (Tylenol) or ibuprofen (Motrin). Naproxen (Aleve) isn't indicated for the treatment of fever.

A school-age child begins to have a seizure while walking to the bathroom. What should the nurse do first? 1. Call the physician caring for the child. 2. Ease the child to the floor and turn him on his side. 3. Administer diazepam (Valium) through the I.V. tubing. 4. Notify the parents so they can be with their child.

2. Ease the child to the floor and turn him on his side. RATIONALE: Because the child is standing, he should first be eased to the floor and turned to the side to prevent aspiration. Notifying the physician wouldn't be the first action the nurse would take because the child's safety is of primary importance. Diazepam would be administered only if it had been ordered. Notifying the parents, although important, isn't the priority. They can be informed after the seizure is over.

A nurse is developing a plan to teach a mother how to reduce her infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan? 1. Administer antibiotics whenever the infant has a cold. 2. Place the infant in an upright position when giving a bottle. 3. Avoid getting the infant's ears wet while bathing or swimming. 4. Clean the infant's external ear canal daily.

2. Place the infant in an upright position when giving a bottle.

Which of the following is the recommended immunization schedule for diphtheria, tetanus toxoids, and acellular pertussis (DTaP)? 1. Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 2. 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years 4. Birth, 3 months, 6 months, 12 months, and 4 to 6 years

3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years RATIONALE: According to the American Academy of Pediatrics and the Committee on Infectious Diseases, the DTaP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school).

A nurse in a well-child clinic is assessing children for scoliosis. Which child is most at risk for scoliosis? 1. 8-year-old boy 2. Teenage boy 3. 6-year-old girl 4. 10-year-old girl

4. 10-year-old girl RATIONALE: The 10-year-old girl is most at risk because scoliosis is five times more common in girls than boys, and its peak age of incidence is between ages 8 and 15. The 8-year-old boy or a teenage boy may develop scoliosis but it's more common in females. A 6-year-old girl is typically too young to be diagnosed with scoliosis.

An infant is having his 2-month checkup at the pediatrician's office. The physician tells the parents that she's assessing for Ortolani's sign. The nurse explains that the presence of Ortolani's sign indicates dislocation of what joint? 1. Shoulder 2. Elbow 3. Knee 4. Hip

4. Hip RATIONALE: To assess for Ortolani's sign, the nurse abducts the infant's hips while flexing the legs at the knees. This is performed on all infants to assess for congenital hip dislocation. The examiner listens and feels for a "click" as the femoral head enters the acetabulum during the examination. This finding indicates a congenitally dislocated hip.

A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? 1. Reverse isolation 2. Strict hand washing 3. Standard precautions 4. Respiratory isolation

4. Respiratory isolation RATIONALE: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the child's room wears a mask. Reverse isolation is unnecessary because it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.

A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? A. Orienting the parents to the pediatric unit B. Instituting droplet precautions C. Administering acetaminophen (Tylenol) D. Obtaining history information from the parents

B. Instituting droplet precautions Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn't take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don't take priority.

The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Superficial

B. Partial-thickness superficial The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and superficial burns, and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns are red to white in color.

How are kids different compared to adults? A. They have 1/3 the TBSA as adults B. They have 3X the TBSA as adults C. They have lessened fluid requirements D. They have more resilient skin and subcutaneous tissue

B. They have 3X the TBSA as adults

Russell's traction, a type of skin traction, is prescribed for a child with a lower leg fracture. The mother of the child asks the nurse the purpose of the traction, and the nurse explains to the mother that this type of traction is used primarily for which purpose? A. To relieve the child's pain B. To reduce or realign a fracture site C. To provide a form of restraint for the child D. To keep the child from moving around in bed

B. To reduce or realign a fracture site

The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar puncture from a child who is suspected of having bacterial meningitis. Which result would most likely confirm this diagnosis? A. Clear CSF with low protein and low glucose B. Cloudy CSF with low protein and low glucose C. Cloudy CSF with high protein and low glucose D. Decreased pressure and cloudy CSF with high protein

C. Cloudy CSF with high protein and low glucose Rationale: A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure and cloudy CSF with high protein and low glucose. Therefore, options 1, 2, and 4 are incorrect.

A 4 year old is admitted to your unit with a severe case of impetigo. It is important the nurse follows _______________ while providing care to this patient: A. Droplet precautions B. Standard precautions only C. Contact precautions D. Airborne precaution

C. Contact precautions Rationale: The nurse will follow contact precautions, which includes following standard precautions as well. Impetigo is a HIGHLY contagious skin infection. Therefore, the nurse should always where a gown and gloves when providing care to the patient to prevent transmission of the infection.

An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching the infant's mother, which action should the nurse instruct the mother to take? A. Check the anterior fontanel for bulging and the sutures for widening each day. B. Feed the infant in an upright position with the head and chest tilted slightly back to avoid aspiration. C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool. D. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to swallow air.

C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool. Rationale: Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the pathology associated with HIV.

The nurse is assisting in planning an educational session regarding rubella (German measles) for the parents of school children. What incubation period should the nurse tell the parents? A. 1 to 3 days B. 3 to 5 days C. 7 to 14 days D. 14 to 21 days

D. 14 to 21 days

You're providing a free educational clinic to new moms about immunizations. You inform the attendees that the Measles, Mumps, and Rubella (MMR) vaccine is given? A. at 6 and 12 months B. 12 months and 4-6 years C. at 4 and 6 months D. at 2 and 12 months

B. 12 months and 4-6 years

A child is suspected of having amblyopia ("lazy eye"). To help diagnose this disorder, the child will undergo which test? 1. Snellen's test 2. Near vision test 3. Weber's test 4. Peripheral vision test

1. Snellen's test RATIONALE: To help diagnose amblyopia, the child will undergo the Snellen's test. Snellen's test assesses visual acuity and a child with amblyopia will have decreased visual acuity in the affected eye. The near vision test evaluates near vision. Weber's test is used to determine hearing loss. The peripheral vision test evaluates peripheral vision.

When assessing a family suspected of abusing its 4-year-old child, which behavior is the most important criterion that would suggest abuse? 1. Attempts by the child to defend or verify what the parent states 2. Incompatibility between the history (mechanism) and the injury 3. Responsibility taken by the child for the act 4. A complaint other than the one associated with the signs of abuse

2. Incompatibility between the history (mechanism) and the injury RATIONALE: The most important criterion on which to base a decision for reporting suspected abuse is an incompatibility between the history and the injury. A maltreated child will rarely betray his parents by saying he has been abused and will, instead, attempt to defend the parent's action and verify the story. The child may even take responsibility for the act in attempt to vindicate them. However, these factors aren't as important as an incompatibility between the history and the injury. A complaint other than the one associated with the signs of abuse (for example, a complaint of being cold when second-degree burns are visible) is a warning sign of abuse but isn't the most important criterion.

An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note: 1. symmetrical thigh and gluteal folds. 2. Ortolani's sign. 3. increased hip abduction. 4. femoral lengthening.

2. Ortolani's sign.

An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include: 1. slapping, kicking, and punching others. 2. poor hygiene and weight loss. 3. loud crying and screaming. 4. pulling hair and hitting.

2. poor hygiene and weight loss.

An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.7 kg). The physician orders ceftriaxone (Rocephin), 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial containing 500 mg, to which the nurse adds 2 ml of preservative-free normal saline solution. The nurse should administer how many milliliters? 1. None because this isn't a safe dosage 2. 0.08 ml 3. 1.08 ml 4. 1.8 ml

3. 1.08 ml Rationale: Because the infant weighs 17 lb (7.7 kg), the safe dosage range is 385 to 578 mg daily. The ordered dosage, 540 mg daily, is safe. To calculate the amount to administer, the nurse may use the following fraction method: 500 mg/2 ml = 270 mg/X ml 500X = 270 × 2 500X = 540 X = 540/500 X = 1.08 ml

Select all the signs and symptoms that will present in compartment syndrome? A. Capillary refill less than 2 seconds B. Pallor C. Pain relief with medication D. Feeling of tingling in the extremity E. Affected extremity feels cooler to the touch than the unaffected extremity

B, D, E These symptoms may present with compartment syndrome. Option A and C are normal findings. Remember in compartment syndrome nerve and blood vessel function is being compromised, so expect signs and symptoms that occur when these structures are affected.

Nurse Taylor suspects that a child, age 4, is being neglected physically. To best assess the child's nutritional status, the nurse should ask the parents which question? A. "Is your child a picky eater?" B. "What did your child eat for breakfast?" C. "Has your child always been so thin?" D. "Do you think your child eats enough?"

B. "What did your child eat for breakfast?" The nurse should obtain objective information about the child's nutritional intake, such as by asking about what the child ate for a specific meal. The other options ask for subjective replies that would be open to interpretation.

During a routine pediatric visit, a 2 month old patient will need which of the following vaccines?* A. MMR (Measles, Mumps, Rubella) B. Hepatitis A C. Hepatitis B D. DTaP (Diphtheria, Tetanus, Pertussis) E. Hib (Haemophilus Influenzae Type B) F. Varicella G. Polio H. RV (Rotavirus) I. PCV (Pneumococcal Conjugate Vaccine)

C, D, E, G, H, and I Rationale: At 2 months the patient should receive: DTaP, Hepatitis B, Hib, Polio, RV, and PCV.

A female child, age 6, is brought to the health clinic for a routine checkup. To assess the child's vision, the nurse should ask: A. "Do you have any problems seeing different colors?" B. "Do you have trouble seeing at night?" C. "How are you doing in school?" D. "Do you have problems with glare?"

C. "How are you doing in school?" A child's poor progress in school may indicate a visual disturbance. The other options are more appropriate questions to ask when assessing vision in a geriatric patient

A patient has deep partial thickness burns on 37% of her body. The patient weighs 150 lbs. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? A. 14,960 mL B. 12,512 mL C. 10,064 mL D. 16,896 mL

C. 10,064 mL

Which finding would indicate the presence of Kernig's sign? A. Calf pain when the foot is dorsiflexed B. Pain when the chin is pulled down to the chest C. The inability of the child to extend the legs fully when lying supine D. The flexion of the hips when the neck is flexed from a lying position

C. The inability of the child to extend the legs fully when lying supine Rationale: Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis, and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is elicited when pain occurs in the calf region when the foot is dorsiflexed.

An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessment is most important in the immediate postoperative period? A. Pain level B. Ability to flex and extend the feet C. Ability to turn using the logroll technique D. Capillary refill, sensation, and motion in all extremities

D. Capillary refill, sensation, and motion in all extremities Rationale: When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular checks including circulation, sensation, and motion should be done at least every 2 hours. Level of pain is an important postoperative assessment, but circulatory status is more important. Assessment of flexion and extension of the lower extremities is a component of option 4, which includes checking motion. Logrolling is performed by nurses

The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness

D. Full thickness Option D: The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm and inelastic).

A 1 year and 2-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the patient's room, the nurse anticipates using which traction system? A. Bryant's traction B. Overhead suspension traction C. Buck's extension traction D. 90-90 traction

A. Bryant's traction Bryant's traction is used to treat femoral fractures of congenital hip dislocation in children under age 2 who weigh less than 30 lb (13.6 kg). Buck's extension traction is skin traction used for short-term immobilization or to correct bone deformities or contractures; overhead suspension traction is used to treat fractures of the humerus; and 90-90 traction is used to treat femoral fracture in children over age 2.

The registered nurse (RN) is reviewing a plan of care developed by a nursing student for a child who is being admitted to the pediatric unit with a diagnosis of seizures. The RN determines that the student nurse needs further teaching and should revise the plan of care if which incorrect intervention is documented? A. Maintain the bed in a low position. B. Restrain the child if a seizure occurs. C. Place pads on the side rails of the bed. D. Place the child in a side-lying lateral position if a seizure occurs.

B. Restrain the child if a seizure occurs. Rationale: Restraints are not to be applied to a child with a seizure because they could cause injury to the child. The bed is maintained in low position to provide safety in the event that the child has a seizure. The side rails of the bed are padded with blankets to prevent injury. Positioning the child on his or her side will prevent aspiration as the saliva drains out of the child's mouth during the seizure.

When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is: A. Depression B. Excessive sleepiness C. A history of cocaine use D. A preoccupation with death

D. A preoccupation with death Rationale: An adolescent who demonstrates a preoccupation with death (such as by talking about death frequently) should be considered at high risk for suicide. Although depression, excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents, they also occur in adolescents who are not suicidal.

A parent has a question about the Rotavirus vaccine and when it is administered. As the nurse you know that ________ doses are given, and the last dose is given at ________? A. 2; 6 months B. 3; 4 months C. 4; 4-6 years D. 3; 6 months

D. 3; 6 months

A child has just returned from surgery and has a hip spica cast. What is the priority nursing action at this time? A. Elevate the head of the bed. B. Abduct the hips, using pillows. C. Turn the child on the right side. D. Assess the child's circulatory status.

D. Assess the child's circulatory status. Rationale: During the first few hours after a cast is applied, the chief concern is swelling that may cause the cast to act as a tourniquet and obstruct circulation, resulting in compartment syndrome; therefore, circulatory assessment is the priority. Elevating the head of the bed of a child in a hip spica cast would cause discomfort. Using pillows to abduct the hips is not necessary because a hip spica cast immobilizes the hip and knee. Turning the child side to side at least every 2 hours is important because it allows the body cast to dry evenly and prevents complications related to immobility; however, it is not a higher priority than checking circulation.

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a: A. 1st degree (superficial) burn B. 2nd degree (partial-thickness) burn C. 3rd degree (full-thickness) burn D. 4th degree (deep full-thickness) burn

A. 1st degree (superficial) burn

The nurse is developing a plan of care for a child with rubella (German measles). In gathering items to provide direct care to the child, what should the nurse obtain? A. Goggles and gloves B. Mask, gloves, and gown C. Mask, gown, and goggles D. Gloves, gown, and goggles

B. Mask, gloves, and gown Rationale: Care of the child with rubella involves contact isolation. Contact isolation requires the use of masks, gowns, and gloves for contact with any infectious material. Contaminated articles are also bagged and labeled per agency protocol. Goggles are not necessary to care for the child with German measles.

The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen's chart test expecting to note which of the following? A. 20/20 vision B. 20/40 vision C. 20/60 vision D. 20/200 vision

D. 20/200 vision Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye.

A parent brings her child into the clinic due to skin lesions that fail to heal. The lesions are red, reported to be itchy, and exhibit exudate. You suspect the child may have impetigo. What is a hallmark finding with this condition? A. Round patches with light pink centers B. Short grey lines on the skin C. Silver colored scales over the lesions D. Yellow crusts over the lesions

D. Yellow crusts over the lesions Yellow crusted over lesions are a hallmark of impetigo. Option A is a hallmark found with ringworm (tinea corporis), Option C is psoriasis, and Option B is scabies.

A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the nurse assess for? Select all that apply. A. Chest asymmetry B. Equal waist angles C. Unequal rib heights D. Equal rib prominences E. Equal shoulder heights F. Lateral deviation and rotation of each vertebra

A, C, F Rationale: Scoliosis is a lateral curvature of the spine. To ensure early detection and treatment, children ages 9 through 15 years should be screened for scoliosis; those at greatest risk are girls from 10 years of age through adolescence. The child should be unclothed or wearing only underpants so that the chest, back, and hips can be clearly seen. The child should stand with her or his weight equally on both feet, legs straight, and arms hanging loosely at the sides. The nurse then observes for the signs of scoliosis. These signs include nonpainful lateral curvature of the spine, a curve with one turn (C curve) or two compensating curves (S curve), lateral deviation and rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences and chest asymmetry, and unequal rib heights.

When should a child receive the first dose of the Hepatitis B vaccine? A. Birth B. 2 months C. 4 months D. 6 months

A. Birth

A child requires the use of Pavlik harness; which of the following would the nurse do to best assess the mother's ability to care for her child? A. Demonstrate to the mother how to remove and reapply the device. B. Have the mother remove and reapply the harness before discharge. C. Have the mother verbalize the purpose for using the device. D. Request a home health care nurse visit after discharge.

B. Have the mother remove and reapply the harness before discharge. Rationale: Option B: Having the mother remove and reapply the harness before discharge allows the nurse to directly observe the mother's method and comfort level. It also provides time for reinstruction if needed. Option A: Although the nurse's demonstration is a good teaching method, it does not permit evaluation of the mother's routine. Option C: Verbalization is significant to allow the nurse to assess the mother's understanding, but it does not allow evaluation of the mother's psychomotor skills. Option D: Requesting a home visit is further means of evaluation but does not provide instant feedback.

A female patient has deep partial thickness burns on 58.5% of her body. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr

A. 921 mL/hr

An 18-month-old boy who reportedly fell down the stairs earlier in the day just isn t acting right, according to his caregivers. Assessment reveals multiple bruises on his thighs and back and a deformity of his right thigh. He is alert and crying. What is the best way to interact with the caregivers? A. Explain that you are very concerned about the child's condition and that he needs to be examined at the hospital for a possible a broken leg. B. Confront them by telling them you know that this injury could not have occurred from a fall; therefore, you are obligated to take him to the hospital. C. Contact the local law enforcement agency to request that the caregiver be arrested while you transport the child. D. Ask them why they waited so long to call for help; the delay has made the child very sick; therefore, you will need to administer oxygen and establish an IV.

A. Explain that you are very concerned about the child's condition and that he needs to be examined at the hospital for a possible a broken leg.

A mother calls the pediatric clinic to ask when her daughter will receive the Varicella vaccine. Your answer to her question is: A. at 2, 4, and 6 months B. at 12 months and 4-6 years C. at 6 and 12 months D. at 4 months and 4-6 years

B. at 12 months and 4-6 years

Which of the following findings in a 2-year-old child assists in identifying the cause of a grand mal (Tonic-Clonic) seizure? A. Crackles in the lungs B. Cardiac dysrhythmia C. Fever D. Abdominal tendernes

C. Fever

A patient has full thickness burns on 81% of his body. The patient weighs 186 lbs. Use the Parkland Burn Formula: You've already infused fluids during the first 8 hours. Now what will you set the flow rate during the next 16 hours (mL/hr) based on the total you calculated? A. 563 mL/hr B. 854 mL/hr C. 289 mL/hr D. 861 mL/hr

D. 861 mL/hr

The nurse provides home care instructions to the mother of a child with chickenpox about preventing the transmission of the virus. Which instruction should the nurse include? A. Isolate the child until the skin vesicles have dried and crusted. B. Ensure that the child uses a separate bathroom for elimination. C. Bring all household members to the clinic immediately for a varicella vaccine. D. Ask the health care provider for a prescription for antibiotics for all household members.

A. Isolate the child until the skin vesicles have dried and crusted. Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.

A 12 month old receives a series of vaccinations which includes the Hepatitis A vaccine. When should the child receive the 2nd dose of this vaccine? A. in 3 months B. at the 18 month visit C. when the child is 4-6 years old D. in 2 months

B. at the 18 month visit Rationale: The first dose of HepA is given at 12 months and then the second dose is given 6 months from that dose, which would be at the 18 month visit.

When providing care for a child in cervical traction with Crutchfield tongs, which actions should the nurse take? A. Promote mobility. B. Provide emotional support. C. Monitor intake and output (I&O). D. Maintain proper alignment and prevent infection.

D. Maintain proper alignment and prevent infection. Rationale: Caring for a child in traction includes ensuring that the child's body is in proper alignment. Crutchfield tongs are a type of cervical skeletal traction that requires pin-site assessment and pin care to prevent infection. Fluid balance (I&O) should not be affected by cervical traction. Immobilization until bone healing occurs is an essential goal of cervical traction

A child is brought to the emergency department following a thermal burn injury. On assessment, the nurse should expect to find which manifestation(s)? A. Cardiac fibrillation B. Headache and dizziness C. Nausea and dehydration D. Singed eyebrow and nasal hairs

D. Singed eyebrow and nasal hairs Rationale: Exposure to or contact with flames, hot liquids, or hot objects causes thermal burns. Thermal burns are those sustained in residential fires, explosive accidents, scald injuries, or ignition of clothing or liquids. If the nurse notes facial burns or singed eyebrow or nasal hairs, the victim likely experienced the burn in an enclosed smoke-filled space, such as in a residential fire. Electrical burns are caused by heat that is generated by the electrical energy as it passes through the body, and cardiac fibrillation is a potential complication. Chemical burns are caused by tissue contact with strong acids, alkalis, or organic compounds. Headache and dizziness may be related to a chemical burn. Radiation burns are caused by exposure to a radioactive source. This may be radiation therapy or the ultraviolet rays of the sun. Radiation burns related to the sun may be manifested by nausea and dehydration.

Which finding is characteristic during the emergent period after a deep full thickness burn injury? A. Blood pressure of 170/100 mm Hg B. Foul-smelling discharge from wound C. Pain at site of injury D. Urine output of 10 mL/hr

D. Urine output of 10 mL/hr During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreaseD. Foul-smelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns.

An adolescent presents with a large round ring with a swollen border on his left arm. He states that he often plays football in a field behind the school. The nurse suspects that he has: 1. Lyme disease. 2. Kopliks spots. 3. impetigo. 4. mononucleosis.

1. Lyme disease. RATIONALE: Lyme disease, which results from a tick bite, is characterized by a large round ring with a raised swollen border at the site of the bite. Treatment at this stage can prevent systemic involvement that could lead to cardiac, neurologic, and musculoskeletal symptoms.

A nurse formulates a nursing diagnosis of Risk for infection for a child with Down syndrome. Which condition typically seen in children with this syndrome supports this nursing diagnosis? 1. Muscular hypotonicity 2. Muscle spasticity 3. Increased mucus viscosity 4. Hypothyroidism

1. Muscular hypotonicity RATIONALE: Several conditions make the child with Down syndrome highly vulnerable to respiratory infections. For example, the hypotonicity of chest muscles in children with Down syndrome leads to diminished respiratory expansion and pooling of secretions, and an underdeveloped nasal bone impairs mucus drainage. Down syndrome isn't associated with muscle spasticity or increased mucus viscosity. Although hypothyroidism is common in children with Down syndrome, it doesn't increase the risk of infection.

Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery? 1. Risk for infection 2. Impaired physical mobility 3. Disturbed body image 4. Constipation

1. Risk for infection RATIONALE: Because infection is a serious risk for a client in the early stages of burn recovery, a diagnosis of Risk for infection takes highest priority. Diagnoses of Impaired physical mobility, Disturbed body image, and Constipation may be relevant but take lower priority at this time.

A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: 1. ensuring that the suspected child abuse is reported to local authorities. 2. contacting the infant's next of kin to begin discharge planning. 3. reporting her suspicions to the hospital's chief of pediatric services. 4. contacting the local children's protective service office with an anonymous tip.

1. ensuring that the suspected child abuse is reported to local authorities. RATIONALE: Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report. Reporting suspected abuse to the hospital's chief of pediatric services isn't appropriate. Contacting the infant's next of kin to begin discharge planning is inappropriate because the infant may not be discharged to his next of kin. Providing an anonymous tip isn't appropriate behavior for a professional nurse. The hospital record is important to the legal process, and the nurse must handle it professionally.

A nurse is caring for a preschooler who sustained deep partial-thickness burns on his hands as a result of touching a hot pot on the stove. When performing discharge teaching, the nurse should: 1. include the child in the teaching process. 2. go into the hallway with the parent to do the teaching. 3. be sure that the child has learned a lesson and won't repeat the action. 4. delay the teaching until both parents are present.

1. include the child in the teaching process. RATIONALE: The nurse should include preschoolers in any discharge teaching she performs. Preschoolers have developed reasoning skills and are beginning to understand the concepts of right and wrong and cause and effect. It isn't necessary for both parents to be present during teaching, although it's desirable.

A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms does the nurse expect to find during the initial assessment? Select all that apply. 1. Bulging anterior fontanel 2. Fever 3. Nuchal rigidity 4. Petechiae 5. Irritability 6. Photophobia

2, 3, 5, 6 RATIONALE: Common signs and symptoms of viral meningitis include fever, nuchal rigidity, irritability, and photophobia. A bulging anterior fontanel is a sign of hydrocephalus, which isn't likely to occur in a toddler because the anterior fontanel typically closes by age 24 months. A petechial, purpuric rash may be seen with bacterial meningitis.

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents: 1. "Does water ever get into the baby's ears during shampooing?" 2. "Do you give the baby a bottle to take to bed?" 3. "Have you noticed a lot of wax in the baby's ears?" 4. "Can the baby combine two words when speaking?"

2. "Do you give the baby a bottle to take to bed?" RATIONALE: In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so.

A pediatric nurse is caring for a child suspected of having been sexually abused. Which finding would best support the nurse's suspicions? 1. Poor hygiene 2. Swelling of the genitals 3. Fear of parents 4. Poor eye contact

2. Swelling of the genitals RATIONALE: The most likely finding for suspected sexual abuse would be difficulty walking or sitting; pain, swelling, or itching in the genitals; or bruises, bleeding, or lacerations of the genital area. Poor hygiene is a sign of physical neglect. Poor eye contact and fear of parents are common signs of physical, not sexual, abuse.

A 13-year-old girl visits the school nurse because she's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the girl may have scoliosis. The nurse should first: 1. send the girl home to recover. 2. inspect the girl for uneven shoulder height or uneven hip height. 3. arrange for the girl to have spinal X-rays as soon as possible. 4. ask the girl's parents to take her to a physician immediately.

2. inspect the girl for uneven shoulder height or uneven hip height. RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the girl's parents.

Parents of a 6-year-old tell a physician that the child has been having periods of unawareness with short periods of staring. Based on his history, the child is probably having which type of seizure? 1. Complex partial 2. Myoclonic 3. Typical absence 4. Tonic

3. Typical absence RATIONALE: This child is probably having typical absence seizures. Typical absence seizures have an onset between ages 3 and 12. This type of seizure is exhibited by an abrupt loss of consciousness, amnesia, or unawareness characterized by staring and a 3-cycle/second spike and waveform on an EEG. The attack lasts from 10 to 30 seconds and may occur as frequently as 50 to 100 times a day. No postictal or confused state follows the attack. A complex partial seizure causes a brief impairment of consciousness. A myoclonic seizure occurs in older children and is exhibited by lightning jerks without loss of consciousness. An abrupt increase in muscle tone, loss of consciousness, and marked autonomic signs and symptoms characterize the tonic seizure.

A 2-year-old child is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: 1. question the mother about the child's allergies. 2. initiate standard precautions. 3. evaluate the child's neurologic status. 4. examine the child's throat and ears.

3. evaluate the child's neurologic status. RATIONALE: Petechiae across the child's chest, abdomen, and back are signs of meningitis. The priority is to evaluate neurologic status. Petechiae aren't allergic reactions, so the nurse shouldn't ask about allergies. Standard precautions should be used when there is risk of contacting body fluids. Contact precautions should be instituted for the client diagnosed with meningitis. Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis.

A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother: 1. how long the child has been like this. 2. if the child is able to walk without holding onto furniture. 3. how the child's condition today differs from his normal condition. 4. if the child always drools.

3. how the child's condition today differs from his normal condition. RATIONALE: The nurse should ask how the child's condition differs from his normal condition in order to identify the chief complaint. Asking how long the child has been like this may be interpreted poorly by the caregiver. The nurse shouldn't ask if the child can walk without holding onto furniture because focusing on what the child can do — not on what he can't do — preserves the family's self-esteem. Focusing on negative aspects of the child's behavior, such as constant drooling, is inappropriate.

he clinic nurse is performing an assessment of a 5-month-old infant suspected of having unilateral developmental dysplasia of the hip (DDH). Which assessment finding should the nurse expect to note in this condition? A. Full range of motion in the affected hip B. An apparent short femur on the unaffected side C. Asymmetrical adduction of the affected hip when placed supine with the knees and hips flexed D. Asymmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

D. Asymmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table Rationale: Asymmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table is noted in unilateral developmental dysplasia of the hip (DDH). Asymmetrical abduction of the affected hip, when the client is placed supine with the knees and hips flexed, would also be an assessment finding in this condition in infants beyond the newborn period. An apparent short femur on the affected side and limited range of motion are noted

The nurse is performing an assessment on a 3-year-old child with chickenpox. The child's mother tells the nurse that the child keeps scratching at night, and the nurse teaches the mother about measures that will prevent an alteration in skin integrity. Which statement by the mother indicates that teaching was effective? A. "I need to place white gloves on my child's hands at night." B. "I will apply generous amounts of a cortisone cream to prevent itching." C. "I will give my child a glass of warm milk at bedtime to help my child sleep." D. "I need to keep my child in a warm room at night so that the covers will not cause my child to scratch."

A. "I need to place white gloves on my child's hands at night." Rationale: Gloves will keep the child from causing an alteration in skin integrity from scratching. Generous amounts of any topical cream can lead to medication toxicity. Warm milk will have no effect on itching. A warm room will increase the child's skin temperature and make the itching worse.

When planning care for a 8-year-old boy with Down syndrome, the nurse should: A. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays B. Plan interventions according to the developmental level of a 7-year-old child because that's the child's age C. Direct all teaching to the parents because the child can't understand D. Assess the child's current developmental level and plan care accordingly

D. Assess the child's current developmental level and plan care accordingly Nursing care plan should be planned according to the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome is capable of learning, especially a child with mild limitations.

An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching? A. Apply cool air under the cast with a blow-dryer B. Apply hydrocortisone cream under the cast using sterile applicator. C. Apply cool water under the cast D. Use sterile applicators to scratch the itch

A. Apply cool air under the cast with a blow-dryer Itching underneath a cast can be relieved by directing blow-dyer, set, on the cool setting, toward the itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore, the client should be cautioned not to put any object down the cast in an attempt to scratch.

A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? 1. "I told my husband to give my son aspirin for his fever." 2. "I'll ask the physician about giving the baby an immunization shot." 3. "I don't have to worry because I've had the measles." 4. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."

4. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." RATIONALE: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Tylenol should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella

A child, age 3, who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond? 1. "Make sure the child uses disposable plates and utensils." 2. "Use isopropyl alcohol to clean surfaces contaminated with the child's blood or body fluids." 3. "Don't let the child share toys with other children." 4. "Wear gloves when you're likely to come into contact with the child's blood or body fluids."

4. "Wear gloves when you're likely to come into contact with the child's blood or body fluids." HIV is transmitted by blood and body fluids. Therefore, the nurse should respond by telling family members they should wear gloves when anticipating contact with the child's blood or body fluids. Standard household methods for cleaning dishes and utensils are adequate, so the child needn't use disposable plates and utensils. To disinfect HIV-contaminated surfaces, the nurse should instruct the foster parents to use a solution of 1 part bleach to 10 parts water. The child may share toys; any toys that become soiled with the child's blood or body fluids should be disinfected with the bleach solution.

An adolescent is diagnosed with scoliosis. Which statements regarding scoliosis are correct? Select all that apply. A. Scoliosis is an abnormal lateral curvature of the spine. B. Scoliosis is most typically diagnosed in the adolescent child. C. Surgical intervention may be necessary when severe curves exist. D. Spinal damage is reversible when compliant with bracing recommendations. E. Scoliosis screening definitely identifies all children at risk for this condition. F. Selection of instrumentation systems to be used during surgery depends on client needs and surgeon's preferences.

A, B, C, F Rationale: Scoliosis is defined as an abnormal lateral curvature in any area of the spine. When the adolescent faces a growth spurt, this is a common time for this condition to occur. If the spinal curve is very severe, surgery may be the only and best option for the child. Which instrumentation system is selected for the spinal fusion process is dependent on the client's needs and surgeon's preferences. Definitive diagnosis of this condition is done via radiographic testing. Bracing only has the ability to halt or slow the progress of change. It cannot reverse the damage that has occurred.

The nurse is providing instructions to the mother of an infant who is seen in the clinic for recurrent episodes of otitis media. Which statement by the mother should indicate an understanding of the methods to decrease the risk of reoccurrence? A. "I will feed my infant in an upright position." B. "I will stop breast-feeding as soon as possible." C. "I will maintain bottle feeding as long as possible." D. "I will allow my infant to have a bottle during nap time."

A. "I will feed my infant in an upright position." Rationale: To decrease the risk of recurrent otitis media, the mother should be encouraged to breast-feed during infancy and to discontinue bottle-feeding as soon as possible. The infant also is fed in an upright position and should never be given a bottle while in bed. The mother also is instructed not to smoke in the child's presence, because passive smoke increases the risk of otitis media.

The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action should the nurse take? A. Document the findings. B. Lower the head of the bed. C. Notify the health care provider immediately. D. Place the infant on nothing per mouth (NPO) status.

A. Document the findings. Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant and normally closes by 18 to 24 months of age. The posterior fontanel closes by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased ICP. If the nurse notes a bulging fontanel when the infant cries, this is a normal finding that should be documented and monitored. It is not necessary to notify the health care provider for this finding. Options 2 and 4 are inappropriate actions.

When caring for a child with severe impetigo, the nurse should include which intervention in the plan of care? A. Placing mitts on the client's hands B. Administering systemic antibiotics as prescribed C. Applying topical antibiotics as prescribed D. Continuing to administer antibiotics for 21 days as prescribed

B. Administering systemic antibiotics as prescribed Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication. The client's nails should be kept trimmed to avoid scratching; however, mitts aren't necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetigo.

The nurse is caring for a child with a fracture who has been placed in skeletal traction. The nurse should monitor for the most serious complication associated with this type of traction by assessing for which specific finding? A. A lack of appetite B. An elevated temperature C. A decrease in the urinary output D. An increase in the blood pressure

B. An elevated temperature Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis can occur with any open fracture. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature.

Nurse Kevin is assessing a newborn for developmental dysplasia of the hip (DDH); he would expect to assess which of the following? A. Characteristic limp B. Ortolani's sign C. Symmetrical gluteal folds D. Trendelenburg's signs

B. Ortolani's sign Rationale: Option B: Ortolani's sign is felt and heard when newborn's or neonate's hip is flexed and abducted. Option A: A characteristic limp would be noted in the ambulatory child. Option C: Asymmetrical gluteal folds would be noted in DDH. Option D: Trendelenburg's sign is noted in the weight-bearing child when the child stands on the affected hip and the pelvis tilts downward on the normal side instead of upward.

The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? A. Both eyes are assessed together, followed by the assessment of the right and then the left eye. B. The right eye is tested followed by the left eye, and then both eyes are tested. C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. D. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.

B. The right eye is tested followed by the left eye, and then both eyes are tested. Visual acuity is assessed in one eye at a time, and then in both eyes together with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes then are tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20ft. from the chart.

The nurse assesses a client's burn injury and determines that the client sustained a full-thickness burn. Based on this determination, which finding did the nurse note? A. A dry wound surface B. Charring at the wound site C. Absence of wound sensation D. A wet, shiny, weeping wound surface

C. Absence of wound sensation Rationale: Decreased or absence of wound sensation would occur in full-thickness or deep full-thickness burns. A partial-thickness superficial burn appears wet, shiny, and weeping, or it may contain blisters. The wound blanches with pressure, is painful, and is very sensitive to touch or air currents. A dry wound surface occurs in a more serious injury. Charring would occur in a deep full-thickness burn

A child is sent to the school nurse by the teacher. On assessment, the school nurse notes that the child has a rash. The nurse suspects that the child has erythema infectiosum (fifth disease), because the skin assessment revealed a rash that has which characteristics? A. A discrete rose-pink maculopapular rash on the trunk B. A highly pruritic, profuse macule to papule rash on the trunk C. An erythema on the face that has a "slapped face" appearance D. A discrete pinkish red maculopapular rash that is spreading to the trunk

C. An erythema on the face that has a "slapped face" appearance Rationale: The classic rash of erythema infectiosum, or fifth disease, is the erythema on the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule to papule rash is the rash of varicella (chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles).

A 1-year-old child is seen in the pediatrician's office with complaints of an elevated temperature the preceding night. When gathering subjective assessment data from the mother, which statement would most likely indicate that the child has an acute otitis media infection? A. The child is crying and irritable. B. The child's temperature currently is 40° C (104° F). C. The child is pulling at her ear and rolling her head from side to side. D. The mother noted purulent discharge from the child's ear last night.

D. The mother noted purulent discharge from the child's ear last night. Rationale: Subjective data are what the mother tells the nurse during the initial assessment. This is apparent in option 4 because the mother is explaining the child's ear drainage that occurred last night. The other options are considered objective data, which are observations that the nurse makes.