A 13-year-old boy visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first:
send the child home to recover.
inspect the child for uneven shoulder height or uneven hip height.
arrange for the ch...
A 13-year-old boy visits the school nurse because he's experiencing back pain, fatigue, and
dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first:
send the child home to recover.
inspect the child for uneven shoulder height or uneven hip height.
arrange for the child to have spinal X-rays as soon as possible.
ask the child's mother to take him to a physician immediately. - ANS Inspect the child for
uneven shoulder height or uneven hip height.
Explanation:
Before deciding on any specific intervention, the school nurse should perform a basic
assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will
then have more specific information to give to the parent. The parent bears responsibility for
seeking further medical care for the child.
An older adult client who has chronic respiratory disease comes to the clinic for a 6- month
check. The nurse informs the client that it's time for the pneumococcal and flu vaccines. What
would be the nurse's best explanation to the client for these injections?
All clients are recommended to have these vaccines.
These vaccines produce bronchodilation and improve oxygenation.
These vaccines help reduce the tachypnea these clients experience.
Respiratory infections can cause severe hypoxia and possibly death in clients with chronic
respiratory diseases. - ANS Respiratory infections can cause severe hypoxia and possibly
death in clients with chronic respiratory diseases.
Explanation:
It's highly recommended that clients with respiratory disorders be given vaccines to protect
against respiratory infection. Infections can cause respiratory failure, and these clients may
need to be intubated and mechanically ventilated. The vaccines have no effect on respiratory
rate or bronchodilation.
The nurse is assisting with the discharge of a client with acute pyelonephritis. What should the
nurse be sure to include in the client instructions?
Avoid taking any dairy products.
Return for follow-up urine cultures.
Stop taking the prescribed antibiotics when the symptoms subside.
Recurrence is unlikely because of treatment with antibiotics. - ANS Return for follow-up
urine cultures.
Explanation:
,The client needs to return for follow-up urine cultures because bacteriuria may be present but
may not produce symptoms. Intake of dairy products will not contribute to pyelonephritis.
Antibiotics must be taken for the full course of therapy regardless of symptoms. Pyelonephritis
commonly recurs as a relapse or new infection, usually within 2 weeks of completing therapy.
The nurse is planning sex and contraceptive education for adolescents. Which factor should the
nurse consider?
Neither sexual activity nor contraception requires planning.
Most teenagers today are knowledgeable about reproduction.
Most teenagers use pregnancy as a way to rebel against their parents.
Most teenagers are open about contraception, but inconsistently use birth control. - ANS
Most teenagers are open about contraception, but inconsistently use birth control.
Explanation:
Adolescents receive most of their information on reproduction and sexuality from their peers,
who generally do not have correct information. Teenagers generally become pregnant because
they fail to use birth control for reasons other than rebelling against their parents. Contraception
should always be part of sex education and requires planning. Most teenagers today are open
about discussing contraception and sexuality, but they may get caught up in the moment of
sexuality and forget about birth control measures.
The nurse is obtaining data from a new client in the cardiovascular clinic. When asking about
childhood diseases and disorders associated with structural heart disease, the nurse should
consider which finding significant?
croup
rheumatic fever
severe staphylococcal infection
medullary sponge kidney - ANS rheumatic fever
Explanation:
Childhood diseases and disorders associated with structural heart disease include rheumatic
fever and severe streptococcal (not staphylococcal) infections. Croup—a severe upper airway
inflammation and obstruction that typically strikes children ages 3 months and 3 years—may
cause latent complications, such as ear infection and pneumonia. However, it doesn't affect
heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal
pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to
hypertension but doesn't damage heart structures.
The nurse is preparing to administer an intramuscular (I.M.) injection to a 6-month-old infant.
Which appropriate site would the nurse inject the infant?
Vastus lateralis muscle
Ventrogluteal area
Deltoid muscle
Gluteus maximus muscle - ANS Vastus lateralis muscle
Explanation:
, The nurse should administer an I.M. injection to a 6-month-old infant in the vastus lateralis
muscle. The ventrogluteal area should be used only after the child has been walking for about a
year. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children.
The nurse is planning a health teaching session for parents of a toddler. When describing a
toddler's typical eating pattern, the nurse should mention that many children of this age exhibit:
consistent table manners.
an increased appetite.
strong food preferences.
a preference for eating alone. - ANS strong food preferences.
Explanation:
A toddler typically exhibits strong food preferences, eating one type of food for several days and
excluding others. A toddler can't be expected to use consistent table manners. Generally, the
appetite decreases during the toddler stage because of a slowed growth rate. A toddler typically
enjoys socializing during meals and often imitates others.
During a prenatal visit, the nurse measures a client's fundal height at 19 cm. The client asks
what does this mean. How should the nurse respond?
"This measurement indicates that the fetus has reached approximately 12 weeks."
"This measurement indicates that the fetus has reached approximately 19 weeks."
"This measurement indicates that the fetus has reached approximately 24 weeks."
"This measurement indicates that the fetus has reached approximately 28 weeks." - ANS
"This measurement indicates that the fetus has reached approximately 19 weeks."
Explanation:
The fundal height measurement in centimeters equals the approximate gestational age in
weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28
weeks, 28 cm.
The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should
document this client's blood loss as:
50 ml
100 ml
150 ml
200 ml - ANS 100 ml
Explanation:
One gram of weight is approximately equivalent to 1 ml of fluid. Therefore, the blood loss
estimate for a perineal pad weighing 100 g would be approximately 100 ml.
A client arrives to the clinic with reports of a rash. The nurse observes the client and documents
the lesion as a papule. What is the best way for the nurse to document this finding?
0.5-cm fluid filled lesion
0.5-cm red, flat pinpoint rash
0.5-cm elevated area
0.5-cm wheal - ANS 0.5-cm elevated area
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