RICCI CHAPTER 37 EXAM QUESTIONS
AND ANSWERS
1. The nurse is caring for a neonate who is suspected of having sepsis. Which
assessment
findings would the nurse interpret as most indicative of sepsis?
A. Rash on face
B. Edematous neck
C. Hypothermia
D. Coughing - Correct Answers -Answer: C
Rationale: Hypothermia is a sign of sepsis in neonates. A rash on the face is a symptom
of scarlet
fever. An edematous neck is a sign of diphtheria. Paroxysmal coughing is a symptom of
pertussis.
2. The nurse is preparing a plan of care for a 5-year-old boy with chickenpox. Which
nursing
intervention should be questioned?
A. Administer antipyretics as ordered.
B. Keep the child's fingernails short.
C. Monitor fluid intake and output.
D. Provide alcohol baths as needed. - Correct Answers -Answer: D
Rationale: Treatments such as sponging the child with alcohol or cold water are not
appropriate
interventions for fever management. Rather, the nurse would use tepid sponge baths
and cool
compresses. Administering antipyretics, keeping the child's fingernails short, and
monitoring
intake and output are appropriate.
3. The nurse is developing a teaching plan for the mother of a 4-year-old girl with cold
and fever.
What would the nurse include in this teaching plan?
A. Keeping the child covered and warm
B. Calling the doctor if the child's fever lasts more than 36 hours
C. Ensuring fluid intake to prevent dehydration
, D. Observing for changes in alertness resulting from brain damage - Correct Answers -
Answer: C
Rationale: Teaching the mother to ensure fluid intake is important because fever can
cause
dehydration. The child should be dressed lightly. There is no need to call the doctor
unless the
child's fever lasts more than 3 to 5 days or the fever is greater than 105ºF. A rapid rise
to a high
fever can cause a febrile convulsion, but it does not lead to brain damage.
4. After teaching a mother how to remove a tick from her 6-year-old boy's arm, the
nurse
determines that additional teaching is needed when the mother makes what statement?
A. "I'll protect my fingers with a paper towel."
B. "I'll grasp the tick and pull it away quickly."
C. "I should put the tick in a plastic bag in the freezer."
D. "I need to grasp the tick close to the child's skin." - Correct Answers -Answer: B
Rationale: Grasping the tick and pulling it away quickly would indicate the need for
additional
teaching. When removing a tick, the mother should use fine-tipped tweezers while
protecting her
fingers with a tissue, paper towel, or latex gloves. The mother should grasp the tick as
close to
the skin as possible and pull upward with steady, even pressure. Once removed, the
mother
should place the tick in a sealable plastic bag in the freezer in case the child becomes
sick and
identification of the tick is needed.
5. The nurse is performing a physical examination of an 8-year-old girl who was bitten
by her
kitten. Which assessment would lead the nurse to suspect cat-scratch disease?
A. Swollen lymph nodes
B. Strawberry tongue
C. Infected tonsils
D. Swollen neck - Correct Answers -Answer: A
Rationale: Lymph nodes, especially under the arms, can become painful and swollen
due to catscratch
disease. Strawberry tongue is typical of scarlet fever. Infected tonsils and an edematous
neck are symptoms of diphtheria.
6. A group of nursing students are reviewing the six links in the chain of infection and
the
nursing implications for each. The students demonstrate understanding of the
information when
AND ANSWERS
1. The nurse is caring for a neonate who is suspected of having sepsis. Which
assessment
findings would the nurse interpret as most indicative of sepsis?
A. Rash on face
B. Edematous neck
C. Hypothermia
D. Coughing - Correct Answers -Answer: C
Rationale: Hypothermia is a sign of sepsis in neonates. A rash on the face is a symptom
of scarlet
fever. An edematous neck is a sign of diphtheria. Paroxysmal coughing is a symptom of
pertussis.
2. The nurse is preparing a plan of care for a 5-year-old boy with chickenpox. Which
nursing
intervention should be questioned?
A. Administer antipyretics as ordered.
B. Keep the child's fingernails short.
C. Monitor fluid intake and output.
D. Provide alcohol baths as needed. - Correct Answers -Answer: D
Rationale: Treatments such as sponging the child with alcohol or cold water are not
appropriate
interventions for fever management. Rather, the nurse would use tepid sponge baths
and cool
compresses. Administering antipyretics, keeping the child's fingernails short, and
monitoring
intake and output are appropriate.
3. The nurse is developing a teaching plan for the mother of a 4-year-old girl with cold
and fever.
What would the nurse include in this teaching plan?
A. Keeping the child covered and warm
B. Calling the doctor if the child's fever lasts more than 36 hours
C. Ensuring fluid intake to prevent dehydration
, D. Observing for changes in alertness resulting from brain damage - Correct Answers -
Answer: C
Rationale: Teaching the mother to ensure fluid intake is important because fever can
cause
dehydration. The child should be dressed lightly. There is no need to call the doctor
unless the
child's fever lasts more than 3 to 5 days or the fever is greater than 105ºF. A rapid rise
to a high
fever can cause a febrile convulsion, but it does not lead to brain damage.
4. After teaching a mother how to remove a tick from her 6-year-old boy's arm, the
nurse
determines that additional teaching is needed when the mother makes what statement?
A. "I'll protect my fingers with a paper towel."
B. "I'll grasp the tick and pull it away quickly."
C. "I should put the tick in a plastic bag in the freezer."
D. "I need to grasp the tick close to the child's skin." - Correct Answers -Answer: B
Rationale: Grasping the tick and pulling it away quickly would indicate the need for
additional
teaching. When removing a tick, the mother should use fine-tipped tweezers while
protecting her
fingers with a tissue, paper towel, or latex gloves. The mother should grasp the tick as
close to
the skin as possible and pull upward with steady, even pressure. Once removed, the
mother
should place the tick in a sealable plastic bag in the freezer in case the child becomes
sick and
identification of the tick is needed.
5. The nurse is performing a physical examination of an 8-year-old girl who was bitten
by her
kitten. Which assessment would lead the nurse to suspect cat-scratch disease?
A. Swollen lymph nodes
B. Strawberry tongue
C. Infected tonsils
D. Swollen neck - Correct Answers -Answer: A
Rationale: Lymph nodes, especially under the arms, can become painful and swollen
due to catscratch
disease. Strawberry tongue is typical of scarlet fever. Infected tonsils and an edematous
neck are symptoms of diphtheria.
6. A group of nursing students are reviewing the six links in the chain of infection and
the
nursing implications for each. The students demonstrate understanding of the
information when
