Practice questions for this set
Terms in this set (59)
,A charge nurse in an B- symmetric Burns of the lower extremities; The nurse
emergency department is should include in the teaching that symmetric burns of the
lower extremities are a suggestive clinical manifestation of
preparing an in-service for a
physical abuse. The patterns are usually characteristic of the
group of newly licensed method or object used, such as cigar or cigarette burns, or
nurses on the clinical burns in the shape of an iron.
manifestations of child
maltreatment. Which of the
followingclinical
manifestations should the
charge nurse include as
suggestive of potential
physical abuse?
A- Recurrent urinary
tractinfections
B- symmetric Burns of
thelower extremities C-
growth failure
D- lack of subcutaneous fat
,A nurse at an urgent care C- dry, hacking cough; The nurse should recognize that a
clinic is assessing an dry, hacking cough is a manifestation of pertussis. This
disease usually begins with indications of an upper
adolescent client who has an
respiratory tract infection, which includes a dry, hacking
upper respiratory tract cough that is sometimes more severe at night.
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 coughD-
koplik spots on buccal
mucosa
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 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
, A nurse in an emergency D- administer IM epinephrine to the child; When using the
department is caring for a urgent vs no urgent approach to client care, the nurse
determines that the priority action is administering IM
school-age child who is
epinephrine to the child. During an anaphylactic reaction,
experiencing an anaphylactic histamine release causes bronchoconstriction and
reaction. Which of the vasodilation. This is an emergency becauseultimately it
following is the priority causes decreased blood return to the heart.
action by the nurse?
A- Elevate the head of
thechild's bed
B- insert a large-bore
IVcatheter for the child C-
determine the allergen that
caused the child's reaction
D- administer IM
epinephrine to the
child
D- substernal retractions; When using the airway,
breathing, circulation approach to client care, the nurse
A nurse in an emergency should determine that the priority finding to report to the
department is performing a provider is substernal retractions. This finding indicates the
physical assessment on a 2- infant is experiencing acute respiratory distress and
increased respiratory effort, which could quickly progress
week old male infant. Which
to respiratory failure.
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
posteriorfontanel
D- substernal retractions