Question

A nurse is caring for an infant in the emergency department.

Answer 1

Correct Answers:

Stabilize the infant's spine.
Palpate fontanel level.
Assess pupillary reaction to light.
Measure the infant's head circumference.

Rationale :

🛑Stabilizing the infant’s spine is crucial after a fall involving stairs, especially with a head injury, due to the risk of cervical spine trauma.

🧠Palpating the fontanel can provide important information regarding intracranial pressure, especially in infants with subdural hematoma.

🔦Assessing pupil reaction evaluates for neurological deterioration and helps monitor for signs of increased intracranial pressure.

📏Measuring head circumference helps identify progressive swelling or hematoma expansion, which is essential in monitoring infants with head trauma.

🍽️Feeding should not be encouraged when the infant is hard to arouse; this may indicate neurological compromise, and feeding could pose an aspiration risk.

📌Core Message

In infants with head injuries, monitoring neurological status, spinal alignment, and intracranial changes is critical for early detection of deterioration.

Answer 2

Correct Answers

Blank 1 Correct Option: Stevens-Johnson syndrome
Blank 2 Correct Option: Skin rash

Rationale :

💊Phenytoin is associated with rare but life-threatening skin reactions, including Stevens-Johnson syndrome, especially when the drug level is subtherapeutic.

🌡️Dry, itchy, hyperpigmented patches with scratch marks may be an early presentation of a severe drug reaction, not just simple eczema.

💁‍♂️The end-expiratory wheeze and nonproductive cough are consistent with asthma, but the primary risk here is the skin involvement, not pulmonary complications.

🧴Skin rash is a hallmark of Stevens-Johnson syndrome and must prompt immediate evaluation to prevent progression to systemic involvement.

📌Core Message

A skin rash in a child on phenytoin may indicate Stevens-Johnson syndrome, a serious adverse effect requiring urgent attention.

Answer 3

Correct Answers:

The child prefers being with their friends rather than family

Rationale :

👥Preferring friends over family is developmentally appropriate for adolescents and does not usually indicate depression.

⚖️Weight changes (gain or loss) can be a sign of altered mood, appetite, or energy, commonly seen in depression.

🛌Excessive sleep or insomnia are classic symptoms of depression in adolescents and must be evaluated.

📉Declining academic performance can reflect decreased concentration, low motivation, or anhedonia, all related to depression.

📌Core Message

Adolescent depression is marked by changes in sleep, weight, and performance, not necessarily social preference.

Answer 4

Correct Answers:

Foster self-care activities.

Rationale :

👐Fostering self-care builds independence and promotes functional development, especially for children with hemiplegic cerebral palsy.

🧠While modifying the environment is important, it is secondary to building autonomy in daily tasks.

🗣️Improving communication is valuable but not the most urgent goal if the child already has basic communication skills.

🧩Respite care supports the family but does not directly impact the child's development, which is the nurse’s priority.

📌Core Message

For children with cerebral palsy, supporting self-care skills is a priority to foster independence and enhance quality of life.

Answer 5

Correct Answers:

"I only need to catheterize myself twice every day."

Rationale :

🧪Catheterizing only twice daily is inadequate for clients with neurogenic bladder, which can lead to urinary retention, UTIs, and renal damage.

🚽Intermittent catheterization is typically required every 4–6 hours to maintain bladder health and prevent complications.

🏋️‍♂️Wheelchair exercises promote circulation and muscle tone, which is appropriate.

💧High fluid intake and bowel programs using suppositories are standard management practices in clients with spina bifida.

📌Core Message

Children with spina bifida need consistent bladder management—infrequent catheterization can cause urinary complications.

Answer 6

Correct Answers:

"If child is not able to eat solid foods, you can offer fluids with some carbohydrates."
"Test the blood/urine for ketones."

Rationale :

🥣Offering fluids with carbohydrates helps maintain blood glucose during illness when solid food intake is poor.

🔬Testing for ketones in blood or urine helps monitor for diabetic ketoacidosis, a dangerous complication of illness in type 1 diabetes.

🚫Protein testing is not a relevant sick-day precaution—it’s more related to nephropathy screening.

🍭Fluids with sugar may actually be needed during hypoglycemia, so non-sugar fluids are not always appropriate.

💉Insulin should never be withheld, even during illness; the body may require more insulin due to stress hormones.

📌Core Message

During illness in type 1 diabetes, maintain glucose intake, test for ketones, and continue insulin therapy.

Answer 7

Correct Answers:

Perform a neurovascular assessment.

Rationale :

🦶Neurovascular assessment is essential to detect compartment syndrome, which can occur early after cast placement.

❄️Applying ice may help swelling but is not a priority over circulatory checks.

📖Discharge teaching and reassurance are important but should come after safety assessments.

🩺Assessment of pulses, sensation, and movement ensures tissue perfusion and should always be prioritized in clients with new casts.

📌Core Message

After cast application, performing a neurovascular assessment is the top priority to prevent limb ischemia.

Answer 8

Correct Answers:

SLE is an autoimmune disorder that I will always have, with times of flare-ups and times of minimal to no symptoms.

Rationale :

🔄Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with flares and remissions, not a condition that resolves permanently.

🌡️It can affect multiple systems, including the kidneys, joints, skin, and CNS—not just the skin.

💊There is no cure, but management with immunosuppressive drugs can reduce flares and inflammation.

🧬It is not strictly a rheumatic disease, although joint involvement is common.

📌Core Message

SLE is a lifelong autoimmune condition with flare-ups and systemic involvement that must be monitored long-term.

Answer 9

Correct Answers:

Place the child in isolation.

Rationale :

🦠Bacterial meningitis is highly contagious, and immediate droplet isolation is required to protect others and control spread.

💉Antibiotic therapy is important but should follow isolation and culture collection.

🩸Blood cultures are necessary but not as urgent as infection control.

🧪Lumbar puncture is needed for diagnosis but is not done until the child is stable and infection control is in place.

📌Core Message

In suspected bacterial meningitis, initiating isolation is the first and most critical step before diagnostics or treatment.

Answer 10

Correct Answers:

Airway obstruction

Rationale :

🔥Burns to the face, neck, and chest put the client at immediate risk for airway compromise due to swelling, which can develop rapidly.

💧Fluid loss is a major concern but occurs after airway threats are addressed.

🦠Infection is a longer-term complication and is not the immediate threat.

🥴Paralytic ileus may develop with stress or sepsis but is not the priority over maintaining the airway.

📌Core Message

In burn injuries involving the head and neck, airway obstruction is the most urgent and life-threatening risk.

1 :
A nurse is caring for an infant in the emergency department.

Answer Options

2 :
A nurse is caring for a client.

Correct Answers

3 :
The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 :
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 :
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 :
A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 :
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 :
An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 :
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 :
A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

1 : A nurse is caring for an infant in the emergency department.

Answer Options

2 : A nurse is caring for a client.

Correct Answers

3 : The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 : A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 : A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 : A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 : A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 : An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 : A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 : A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

1 :
A nurse is caring for an infant in the emergency department.

2 :
A nurse is caring for a client.

3 :
The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 :
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 :
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 :
A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 :
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 :
An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 :
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 :
A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?