An 11-year-old boy is admitted after being hit in the head with a baseball during a Little League game. Which subject is most important for the practical
... [Show More] nurse to explore during history taking?
A. Inspection of wound for lacerations and bleeding.
B. Description of the character and quality of pain.
C. Independent observer's account of the event.
D. The level of consciousness exhibited after the injury.
{{ANS}}D. The level of consciousness exhibited after the injury.
Rationale:The priority concern when taking the history involving a head injury is to determine the level of consciousness following the injury.
What is the most important information for the practical nurse (PN) to review with a 12-year-old who is receiving long-term and rescue medications for routine management of asthma?
a. Drink a large amount of cold fluids after exercising to restore hydration.
b. Avoid swimming, which increases the need for oxygen while underwater.
c. Use albuterol for prevention of exercise-induced bronchospasm.
d. Keep a prescription for a premeasured dose of epinephrine available.
{{ANS}}c. Use albuterol for prevention of exercise-induced bronchospasm.
Rationale:When used before exercise, the beta-adrenergic agonist albuterol can prevent an asthma attack.
A 15-year-old male with mild mental retardation who is hospitalized for minor surgery tells a female practical nurse (PN), "Wow, you have big ones." Which response is best for the PN to make?
a. "Do you really think so?"
b. "That language is not permitted."
c. "You should nt speak to me like that, such language offends me."
d. "Ill notify your parents if you continue to talk that way."
{{ANS}}b. "That language is not permitted."
Rationale:Limit setting is necessary for inappropriate behavior or suggestive interaction. Sets limits without threatening or degrading the client.
A 5-year-old tells the practical nurse (PN) that she "needs a Band-Aid" when she has an injection. Which action is best for the PN to take?
a. Show her that the bleeding has already stopped.
b. Explain why a Band-Aid is not needed.
c. Ask her why she wants a Band-Aid.
d. Apply a Band-Aid over the injection site.
{{ANS}}d. Crowing respiration
Rationale:Preschool children sometimes think that any hole (e.g., an injection or incision) made in their bodies allows their "insides to leak out," so applying a Band-Aid over the hole prevents this from occurring.
The practical nurse (PN) is caring for a child with an acute respiratory condition. When the PN is monitoring for impending respiratory distress, what sign is the child likely to exhibit first?
a. Cyanosis
b. Sternal retraction
c. Restlessness
d. Crowing respiration
{{ANS}}c. Restlessness
Rationale:Restlessness is an early sign of hypoxemia.
A full-term infant is admitted to the newborn nursery. During the initial PO feeding, the practical nurse (PN) observes the infant for possible tracheal esophageal atresia. Which symptoms are likely to be exhibited during the feeding if this condition is present?
a. Choking, coughing, and cyanosis
b. Projectile vomiting and cyanosis
c. Apneic spells and grunting
d. Scaphoid abdomen and anorexia
{{ANS}}a. Choking, coughing, and cyanosis
Rationale:Choking, coughing, and cyanosis are the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea.
The parents of a 7-month-old infant with spastic cerebral palsy bring him to the pediatric clinic. Which symptom reported by the parents warrants immediate intervention by the practical nurse (PN)?
a. Choking while being fed.
b. The child's legs continually cross each other.
c. Child gets stiff when shifting to a sitting position.
d. Older sibling is jealous of the younger sibling.
{ANS}}a. Choking while being fed.
Rationale:Aspiration is a priority when caring for an infant with cerebral palsy and dysphagia.
Which intervention should the practical nurse implement when a child cannot swallow prescribed tablets?
a. Give the tablets with a very cold beverage of the child's choice.
b. Put intact tablets in 1 tablespoon of corn syrup.
c. Place the crushed tablet in a gelatin capsule and give with food.
d. Crush tablets to a fine powder and mix with a small amount of soft food.
{{ANS}}d. Crush tablets to a fine powder and mix with a small amount of soft food. [Show Less]