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A charge nurse in an emergency department is preparing an in-service for a
group of newly licensed nurses on the clinical manifestations of child
maltreatment. Which of the followingclinical manifestations should the charge
nurse include as suggestive of potential physical abuse?
A- Recurrent urinary tract infections
B- symmetric Burns of the lower extremities
C- growth failure
D- lack of subcutaneous fat
- answer-B- symmetric Burns of the lower extremities; The nurse should include in
the teaching that symmetric burns of the lower
extremities are a suggestive clinical manifestation of physical abuse. The patterns
are usually characteristic of the method or object used, such as cigar or cigarette
burns, or burns in the shape of an iron.
A nurse at an urgent care clinic is assessing an adolescent client who has an
upper respiratory tract infection. Which of the following findings should the
nurse recognize as a manifestation of pertussis?
A- Inflamed throat with exudate
B- purulent eye drainage
C- dry, hacking cough
D- koplik spots on buccal mucosa
- answer-C- dry, hacking cough; The nurse should recognize that a dry, hacking
cough is a manifestation of
pertussis. This disease usually begins with indications of an upper respiratory
tract infection, which includes a dry, hacking cough that is sometimes more
severe at night.
A nurse in a provider's office is caring for a school-age child who has
varicella. The parent askthe nurse when her child will no longer be
contagious. Which of the following responses should the nurse make?
A- When your child no longer has an increased temperature
B- three days after you first noticed the rash appear on your child
C- when your child lesions are crusted, 6 days after they appear
D- 2 - 3 weeks, when your child's lesions completely disappear
- answer-C- when your child lesions are crusted, 6 days after they appear; The
,nurse should inform the parent that the child is contagious 1 day prior to lesion
eruption and until the vesicles have crusted over, which usually takes about
6 days.
A nurse in a provider's office is preparing to administer immunizations to a
toddler during awell-child visit. Which of the following actions should the
nurse plan to take?
Prescriptions:
-tuberculin skin test (TST)
-measles mumps rubella
vaccine
-inactivated influenza vaccine
-diphtheria, tetanus, and pertussis (DTaP vaccine)
Vital signs
-respiratory rate 24/minute
-heart rate 115/minute
-temperature 37.4 degrees Celsius or 99.3 degrees Fahrenheit
History and physical
-Age 12 months 9 days
-height 71.1cm/28-in
allergies
neomycin - anaphylactic reaction
caregiver reports:
-rhinitis with clear nasal drainage for 2days
-occasional non productive cough for 2 days
-history of asthma
A- Withhold the measles mumps and rubella MMR vaccine
B- withhold the DTaP vaccine
C- withhold the influenza vaccine
D- withhold the tuberculin skin test TST
- answer-A- Withhold the measles mumps and rubella MMR vaccine; The nurse
should recognize that an allergy to neomycin with an anaphylactic
reaction is a contraindication to receiving the MMR vaccine. Clients who have a
severe allergy to eggs orgelatin should not receive this vaccine.
A nurse in an Emergency Department is assessing a three-month-old infant
who has rotavirusand is experiencing acute vomiting and diarrhea. Which of
the following manifestations should the nurse identify as an indication that
, the infant has moderate to severe dehydration?
A- Heart rate 124/ minute
B- increase tear production
C- sunken anterior fontanel
D- capillary refill 2 seconds
- answer-C- sunken anterior fontanel; The nurse should recognize that a sunken
anterior fontanel is an indication of
moderate to severe dehydration due to the acute loss of fluid.
A nurse in an emergency department is caring for a school-age child who is
experiencing an anaphylactic reaction. Which of the following is the
priority action by the nurse?
A- Elevate the head of the child's bed
B- insert a large-bore IV catheter for the child
C- determine the allergen that caused the child's reaction
D- administer IM epinephrine to the
child
- answer-D- administer IM epinephrine to the
child; When using the urgent vs no urgent approach to client care, the nurse
determines that
the priority action is administering IM epinephrine to the child. During an
anaphylactic reaction, histamine release causes bronchoconstriction and
vasodilation. This is an emergency becauseultimately it causes decreased blood
return to the heart.
A nurse in an emergency department is performing a physical assessment
on a 2-week old male infant. Which of the following manifestations is the
priority for the nurse to report to the provider?
A- Excoriated scrotal area
B- multiple capillary hemangiomas
C- depressed posterior fontanel
D- substernal retractions
- answer-D- substernal retractions; When using the airway, breathing, circulation
approach to client care, the nurse
should determine that the priority finding to report to the provider is substernal
retractions. This finding indicates the infant is experiencing acute respiratory
distress and increased respiratory effort, which could quickly progress to
respiratory failure.
A nurse in the emergency department is caring for a school-age child who has