A 12 month old is admitted w/ a respiratory infection and possible pneumonia. He is
placed in a mist tent w/ O2. Which nsg intervention has the greatest priority? -
CORRECT ANSWER - Have a bulb syringe readily available to remove secretions
(patent airway has the highest priority. Humidification will liquefy the nasal secretions
- thereby increasing the amt of secretions and making that a priority)
A 14 yr old female tells the nurse that she is concerned about the acne she has
recently dvp'd. Which recommendation should the nurse provide? - CORRECT
ANSWER - Wash the hair and skin frequently w/ soap and hot water
,(washing the hair and skin w/ soap and water removes oil and debris from the skin and
helps prevent and tx acne. Oily skin is especially bothersome during adolescence when
hormones cause enlargement of sebaceous glands and increased glandular secretions
which predispose the teenager to acne.)
A 15 yr old girl tells the school nurse that all of her friends have started their periods
and she feels abnormal because she has not. Which response is best for the nurse
provide? - CORRECT ANSWER - Explain that menarche varies and occurs at 12-18 yrs
old
A 16 yr old is brought to the ER w/ a crushed leg after falling off a horse. The
adolescent's last tetanus toxoid booster was received eight yrs ago. What action
should the nurse take? - CORRECT ANSWER - Administer tetanus toxoid booster
(After the completion of the initial completion of the initial tetanus immunization
schedule, the recommended booster for an adolescent or adult is every 10 yrs or less if
,a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as
puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. the
adolescent's injury is considered a contaminated wound requiring prophylactic
therapy, so the tetanus toxoid booster should be administered)
A 17 yr old male student reports to the school clinic one morning for a scheduled
health exam. He tells the nurse that he just finished football practice and is on his way
to class. the nurse assesses his v/s: Temp 100F, Pulse 80, RR 20, and BP 122/82. what
is the best action for the nurse to take? - CORRECT ANSWER - Tell the student to
proceed directly to his regularly scheduled class
A 2 yr old child recently diagnosed w/ hemophilia A is discharged home. What info
should the nurse include in a teaching plan about home care? - CORRECT ANSWER -
Apply pressure and ice for bleeding while elevating and resting the extremity
, (Hemophilia, a blood disorder, causes joint bleeding which is treated w/ rest, ice,
compression, and elevation (RICE) )
A 2 yr old child w/ gastro-esophageal reflux has dvpd a fear of eating. What instruction
should the nurse include in the parents' teaching plan? - CORRECT ANSWER -
Consistently follow a set mealtime routine
(2 yr olds are comforted by consistency)
A 2 yr old w/ Down syndrome is brought to the clinic for his regular physical exam. The
nurse knows which problem is requently associated w/ Downs? - CORRECT ANSWER
- Congenital heart disease
(CHD is the most common associated defect w/ Downs. - also, remember Professor
Moore said that heart and ear problems go hand in hand)
placed in a mist tent w/ O2. Which nsg intervention has the greatest priority? -
CORRECT ANSWER - Have a bulb syringe readily available to remove secretions
(patent airway has the highest priority. Humidification will liquefy the nasal secretions
- thereby increasing the amt of secretions and making that a priority)
A 14 yr old female tells the nurse that she is concerned about the acne she has
recently dvp'd. Which recommendation should the nurse provide? - CORRECT
ANSWER - Wash the hair and skin frequently w/ soap and hot water
,(washing the hair and skin w/ soap and water removes oil and debris from the skin and
helps prevent and tx acne. Oily skin is especially bothersome during adolescence when
hormones cause enlargement of sebaceous glands and increased glandular secretions
which predispose the teenager to acne.)
A 15 yr old girl tells the school nurse that all of her friends have started their periods
and she feels abnormal because she has not. Which response is best for the nurse
provide? - CORRECT ANSWER - Explain that menarche varies and occurs at 12-18 yrs
old
A 16 yr old is brought to the ER w/ a crushed leg after falling off a horse. The
adolescent's last tetanus toxoid booster was received eight yrs ago. What action
should the nurse take? - CORRECT ANSWER - Administer tetanus toxoid booster
(After the completion of the initial completion of the initial tetanus immunization
schedule, the recommended booster for an adolescent or adult is every 10 yrs or less if
,a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as
puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. the
adolescent's injury is considered a contaminated wound requiring prophylactic
therapy, so the tetanus toxoid booster should be administered)
A 17 yr old male student reports to the school clinic one morning for a scheduled
health exam. He tells the nurse that he just finished football practice and is on his way
to class. the nurse assesses his v/s: Temp 100F, Pulse 80, RR 20, and BP 122/82. what
is the best action for the nurse to take? - CORRECT ANSWER - Tell the student to
proceed directly to his regularly scheduled class
A 2 yr old child recently diagnosed w/ hemophilia A is discharged home. What info
should the nurse include in a teaching plan about home care? - CORRECT ANSWER -
Apply pressure and ice for bleeding while elevating and resting the extremity
, (Hemophilia, a blood disorder, causes joint bleeding which is treated w/ rest, ice,
compression, and elevation (RICE) )
A 2 yr old child w/ gastro-esophageal reflux has dvpd a fear of eating. What instruction
should the nurse include in the parents' teaching plan? - CORRECT ANSWER -
Consistently follow a set mealtime routine
(2 yr olds are comforted by consistency)
A 2 yr old w/ Down syndrome is brought to the clinic for his regular physical exam. The
nurse knows which problem is requently associated w/ Downs? - CORRECT ANSWER
- Congenital heart disease
(CHD is the most common associated defect w/ Downs. - also, remember Professor
Moore said that heart and ear problems go hand in hand)
