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1. Which should the nurse assess last when examining a 5-year-old child?
a. Heart.
b. Lungs.
c. Throat.
d. Abdomen.: c. Throat.
Examination of the mouth, throat, and perineum is considered to be more invasive than other
parts of a physical examination. Invasive procedures should be left for the end of the
examination for a preschooler.
2. The community health nurse teaches the parents of school-age children about the
need for fluoride as part of a dental health program.Which statement by the parents
indicates that they understand the teaching?
a. "Excessive amounts of fluoride will make teeth turn brittle and yellow."
b. "Having our children brush with fluoride toothpaste is not effective."
c. "Use of fluoride in water is mostly effective during initial tooth formation."
d. "Dental caries can be prevented through fluoridation of public water.": d. "Dental
caries can be prevented through fluoridation of public water."
Dental caries can be prevented through fluoridation of public water.
3. The nurse is assessing an infant with diarrhea and lethargy. Which finding should the
,nurse identify that is consistent with early dehydration?
a. Tachycardia.
b. Bradycardia.
c. Dry mucous membranes.
d. Increased skin turgor.: a. Tachycardia.
In early dehydration (during the first 2 days), fluid loss occurs first from the extracel- lular and
intravascular fluid spaces. Blood pressure falls and heart rate increases in response to a
diminished blood volume.
4. When conducting a hygiene class for adolescent girls, it is important for the nurse to
include which instruction about preventing toxic shock syndrome?
a. Wash your hands before inserting a tampon.
b. Use super absorbent tampons.
c. Wear cotton underwear.
d. Douche following menstruation.: a. Wash your hands before inserting a tam-
,pon.
The single most effective means of preventing infection is handwashing.
5. The nurse is caring for an irritable, lethargic 18-month-old child who swal- lowed
several over-the-counter (OTC) antihistamine tablets an hour ago. Which intervention
should the nurse implement?
a. Initiate gastric lavage.
b. Administer naloxone.
c. Give a dose of ipecac syrup.
d. Encourage oral intake of water or milk.: a. Initiate gastric lavage.
Gastric lavage should be implemented within 2 hours of ingestion to ensure gastric removal
of a noncorrosive substance, such as an OTC antihistamine.
6. Which sign of malignant hyperthermia should the nurse assess for during the
perioperative period in a child receiving general anesthesia?
a. Apnea.
b. Tachypnea.
c. Bradycardia.
d. Decreased blood pressure.: b. Tachypnea.
Malignant hyperthermia, a potentially fatal autosomal genetic myopathy, can cause a change
in vital signs that demands immediate attention in the perioperative period when these
individuals are exposed to anesthetic agents. Early symptoms of the disorder include
tachycardia and tachyarrhythmia, tachypnea, hypercarbia, and metabolic and respiratory
, acidosis. An elevated temperature is a late sign of the disorder.
7. A child with a penetrating eye injury comes to the school clinic.Which action should the
nurse implement?
a. Remove the object impaled in the eye and then apply a regular eye patch.
b. Place an ice bag over the eye until the healthcare provider is seen
c. .Irrigate the affected eye copiously with a cool sterile saline solution.
d. Apply a Fox shield to the affected eye and any type of patch to the other eye.: d.
Apply a Fox shield to the affected eye and any type of patch to the other eye.
The treatment for a penetrating eye injury is not to remove or manipulate the impaled