Question

A school nurse is completing routine health evaluations for school-age children. Which of the following manifestations should alert the nurse to the possibility of pediculosis capitis?

Answer 1

Correct Answers:

Reports of scalp itchiness

Rationale :

🌀 Scalp pruritus (itching) is the most common symptom of pediculosis capitis (head lice) due to hypersensitivity to louse saliva.

🌀 Children often scratch persistently behind the ears or at the nape of the neck where lice tend to congregate.

🌀 Detection is confirmed by visual identification of lice or nits near the scalp, but itchiness is often the earliest reported symptom.

🌀 Early recognition based on this symptom helps in prompt treatment and prevention of spread in schools.

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Answer 2

Correct Answers:

"Bring your infant into the clinic today to be seen."

Rationale :

🔥 Projectile vomiting with hunger in a 2-month-old can indicate hypertrophic pyloric stenosis, a surgical emergency.

🔥 This condition causes a gastric outlet obstruction and requires prompt diagnostic evaluation, typically an ultrasound.

🔥 Telling the parent to come to the clinic ensures timely diagnosis and prevents severe dehydration or electrolyte imbalance.

🔥 Other suggestions like changing formula or giving ORS may delay essential care and are not appropriate first-line responses.

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Answer 3

Correct Answers:

Promote hydration with IV and oral fluids.

Rationale :

💧 Hydration is critical during a sickle cell crisis to reduce blood viscosity and prevent further sickling of red blood cells.

💧 Both oral and IV fluids are used to promote circulation and oxygen delivery, minimizing pain and complications.

💧 Pain management and rest are also essential, but fluid therapy is a core intervention.

💧 Avoid cold compresses and active ROM as they may trigger or worsen pain during acute crisis episodes.

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Answer 4

Correct Answers:

"I will keep my baby in an upright position after feeding."

Rationale :

🧸 Positioning the infant upright for 20–30 minutes after feeding helps reduce reflux episodes in infants with GER.

🧸 Upright posture uses gravity to prevent stomach contents from flowing back into the esophagus.

🧸 Breastfeeding is encouraged, and thickening of formula is only done under provider guidance.

🧸 Side-lying is not safe for sleep; supine is the safest position per SIDS guidelines.

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Answer 5

Correct Answers:

Test the urine for ketones.

Rationale :

💉 During illness, stress hormones can cause hyperglycemia and ketosis, even if food intake is reduced.

💉 Urine ketone testing helps detect diabetic ketoacidosis early—a dangerous complication in type 1 diabetes.

💉 Insulin should never be withheld during illness, and hydration should be maintained, not limited.

💉 The provider should be notified for persistent hyperglycemia, especially with ketones or altered mental status.

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Answer 6

Correct Answers:

Keep children's nails short.

Rationale :

🍃 Short nails reduce the risk of fecal-oral transmission of pinworm eggs, which are often transferred by scratching the perianal area.

🍃 Eggs can lodge under fingernails and spread to surfaces or be ingested again, causing reinfection.

🍃 Other methods like bleach cleaning or hot water for laundry may be helpful, but trimming nails is the simplest and most effective first step.

🍃 Hand hygiene and nail care are foundational in managing pinworm infections.

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Answer 7

Correct Answers:

"I will expect dark, tarry stools."

Rationale :

🟢 Ferrous sulfate commonly causes dark, tarry or greenish-black stools due to unabsorbed iron.

🟢 This is a normal and expected side effect, not a sign of gastrointestinal bleeding unless accompanied by symptoms like abdominal pain.

🟢 Teaching the client about this change helps prevent alarm and ensures medication adherence.

🟢 Urine color, bruising, or immune changes are not linked to ferrous sulfate therapy.

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Answer 8

Correct Answers:

"I should not take my regular insulin when I am sick."

Rationale :

🔵 Clients with type 1 diabetes should continue insulin during illness to prevent diabetic ketoacidosis, even if they are eating less.

🔵 Illness often causes increased blood glucose, and insulin needs may even rise.

🔵 Skipping insulin can lead to severe hyperglycemia and ketone buildup.

🔵 Rotating sites, testing blood sugar frequently, and eating before sports are correct practices.

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Answer 9

Correct Answers:

Empty bladder completely with each void
Avoid bubble baths
Watch for manifestations of infection

Rationale :

Empty bladder completely with each void

🟢 Incomplete bladder emptying allows urine to pool, which promotes bacterial growth and increases UTI risk.

🟢 Teaching the child to take time when voiding ensures full bladder drainage.

🟢 This measure helps prevent recurrence and supports effective UTI treatment.

Avoid bubble baths

🟠 Bubble baths contain fragrances and soaps that can irritate the urethra, leading to inflammation and infection.

🟠 This is especially important in children, as their mucosa is more sensitive to chemical irritants.

🟠 Avoiding bubble baths is a simple, preventative measure to reduce UTI recurrence.

Watch for manifestations of infection

🔵 Early signs of UTI such as fever, urgency, frequency, or foul-smelling urine should be promptly reported.

🔵 Educating parents about these signs ensures timely intervention and prevention of complications like pyelonephritis.

🔵 Prompt recognition and action are essential in reducing morbidity associated with pediatric UTIs.

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Answer 10

Correct Answers:

Assess respiratory status.

Rationale :

🟣 Burns to the face and chest increase the risk for airway injury due to smoke inhalation or swelling.

🟣 Airway patency is always the first priority in emergency burn care—per the ABCs (Airway, Breathing, Circulation).

🟣 Interventions like removing clothing or pain control are secondary once the airway is secured.

🟣 Respiratory assessment includes watching for hoarseness, stridor, or soot in the mouth/nose.

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QLexNursing

1 :
A school nurse is completing routine health evaluations for school-age children. Which of the following manifestations should alert the nurse to the possibility of pediculosis capitis?

2 :
A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

3 :
A nurse is contributing to the plan of care for a child who has sickle cell crisis. Which of the following actions should the nurse recommend to include?

4 :
A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

5 :
A nurse is reinforcing teaching with a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?

6 :
What instruction will the nurse give to parents about preventing the spread and reinfection of pinworms?

7 :
A nurse is reinforcing teaching with a client who is prescribed ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is providing teaching to a school-age child who has a diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?

9 :
A nurse is reinforcing teaching with the guardian of a child who has a urinary tract infection. Which of the following instructions should the nurse include? (Select All that Apply.)

10 :
A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

QLexNursing

1 : A school nurse is completing routine health evaluations for school-age children. Which of the following manifestations should alert the nurse to the possibility of pediculosis capitis?

2 : A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

3 : A nurse is contributing to the plan of care for a child who has sickle cell crisis. Which of the following actions should the nurse recommend to include?

4 : A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

5 : A nurse is reinforcing teaching with a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?

6 : What instruction will the nurse give to parents about preventing the spread and reinfection of pinworms?

7 : A nurse is reinforcing teaching with a client who is prescribed ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is providing teaching to a school-age child who has a diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?

9 : A nurse is reinforcing teaching with the guardian of a child who has a urinary tract infection. Which of the following instructions should the nurse include? (Select All that Apply.)

10 : A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

1 :
A school nurse is completing routine health evaluations for school-age children. Which of the following manifestations should alert the nurse to the possibility of pediculosis capitis?

2 :
A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

3 :
A nurse is contributing to the plan of care for a child who has sickle cell crisis. Which of the following actions should the nurse recommend to include?

4 :
A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

5 :
A nurse is reinforcing teaching with a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?

6 :
What instruction will the nurse give to parents about preventing the spread and reinfection of pinworms?

7 :
A nurse is reinforcing teaching with a client who is prescribed ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is providing teaching to a school-age child who has a diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?

9 :
A nurse is reinforcing teaching with the guardian of a child who has a urinary tract infection. Which of the following instructions should the nurse include? (Select All that Apply.)

10 :
A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?