Question

A nurse prepares to administer an intramuscular (IM) injection to a child. Which of the following muscle groups is contraindicated?

Answer 1

Correct Answers:

Dorsogluteal

Rationale :

🧸 The dorsogluteal muscle is contraindicated for IM injections in infants and young children because of the high risk of sciatic nerve injury and poor muscle development at this age.

🧸 Safer sites include the vastus lateralis (preferred for infants and toddlers due to large muscle mass and easy access) and the ventrogluteal (safe for children over 7 months with adequate muscle development).

🧸 The deltoid can be used for small volumes in older children but is not ideal for infants due to limited muscle mass.

🧸 Correct site selection prevents nerve damage, ensures medication absorption, and reduces complications.

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Answer 2

Correct Answers:

A private room with contact/droplet precautions

Rationale :

✔️RSV (respiratory syncytial virus) is highly contagious and spreads by both direct contact with respiratory secretions and droplet transmission.

✔️The safest placement is in a private room with contact/droplet precautions to prevent cross-infection to other vulnerable children.

✔️Cohorting is possible only if another child has RSV, not different infections such as croup or pneumonia.

✔️Protective isolation is for immunocompromised clients, not those with contagious respiratory illness.

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Answer 3

Correct Answers:

Red macule with honey-colored crusts

Rationale :

♦️Impetigo contagiosa is a common superficial bacterial skin infection, usually caused by Staphylococcus aureus or Streptococcus pyogenes.

♦️The hallmark lesion is a red macule or vesicle that ruptures, leaving honey-colored crusts.

♦️Other options describe unrelated conditions: scaly patches with clear centers suggest tinea (ringworm); firm brown papules suggest warts (HPV); white exudates suggest other infections but not impetigo.

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Answer 4

Correct Answers:

Scoliosis

Rationale :

🧍Routine adolescent screenings include scoliosis checks, especially during growth spurts, to detect spinal curvature early.

🧍PKU screening is done in the newborn period, not adolescence.

🧍Tuberculosis screening is done based on risk factors, not universally in healthy adolescents.

🧍Anemia screening is more common in infants, toddlers, or high-risk groups (e.g., menstruating females with symptoms).

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Answer 5

Correct Answers:

The patient is diagnosed with acquired immunodeficiency syndrome (AIDS)

Rationale :

🧬 AIDS diagnosis is made when a client with HIV has a CD4 count below 200 cells/mcL OR develops an AIDS-defining opportunistic illness.

🧬 This patient has CD4 = 184 plus respiratory symptoms (likely Pneumocystis pneumonia), which fits AIDS criteria.

🧬 “Seroconversion” refers to the early stage when HIV antibodies develop, not at this late immunocompromised stage.

🧬 “Latent stage” occurs when HIV is asymptomatic with higher CD4 counts (>500).

🧬 These findings are not expected in someone who is simply HIV-positive; they indicate progression to AIDS.

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Answer 6

Correct Answers:

Cardiovascular

Rationale :

⭐ Kawasaki disease primarily affects the cardiovascular system, especially the coronary arteries.

⭐ It is an acute systemic vasculitis that can lead to aneurysm formation, myocardial infarction, or long-term coronary artery disease if not treated.

⭐ Early signs include fever, rash, conjunctivitis, and mucous membrane changes, but the main concern is heart involvement.

⭐ Treatment with IV immunoglobulin (IVIG) and high-dose aspirin reduces inflammation and prevents coronary artery complications.

⭐ Nurses should monitor for cardiac function, arrhythmias, and evidence of heart failure during care.

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Answer 7

Correct Answers:

Candidiasis

Rationale :

🔹 Children with AIDS have a weakened immune system, making them highly susceptible to opportunistic fungal infections like oral candidiasis (thrush).

🔹 Candidiasis presents as white, curdlike patches inside the mouth that can be scraped off, sometimes leaving a reddened surface.

🔹 This condition can interfere with feeding, swallowing, and hydration, especially in toddlers.

🔹 Nurses should inspect the mouth daily, provide oral care, antifungal medications (like nystatin suspension), and monitor nutritional intake.

🔹 Early recognition and treatment help prevent systemic spread of the infection.

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Answer 8

Correct Answers:

"I'll discard his toothbrush and buy another

Rationale :

💠 A child with streptococcal infection can harbor bacteria on personal items like toothbrushes, which can lead to reinfection.

💠 Parents should be taught to replace the toothbrush after 24 hours of antibiotic therapy to minimize transmission and recurrence.

💠 Encouraging good hygiene, handwashing, and not sharing utensils also reduces the spread of infection.

💠 This teaching is vital in preventing rheumatic fever or glomerulonephritis, which are complications of untreated strep infections.

💠 The nurse reinforces these prevention strategies as part of family-centered education.

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Answer 9

Correct Answers:

1 mL

Rationale :

♦ When weighing diapers, 1 g of weight gain equals 1 mL of urine output, since the density of water and urine is approximately the same.

♦ This method is used in infants and non–toilet-trained children, where accurate measurement of urine is essential.

♦ Monitoring output is crucial in dehydration, as infants are at high risk for fluid and electrolyte imbalances.

♦ Nurses compare urine output with expected values (≥1 mL/kg/hr) to evaluate hydration and renal function.

♦ This calculation helps guide fluid replacement and treatment effectiveness.

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Answer 10

Correct Answers:

The fingers on the right hand have a capillary refill of 4 seconds.

Rationale :

🟣 A capillary refill > 3 seconds indicates impaired circulation and perfusion, which can signal compartment syndrome in a child with a fresh cast.

🟣 Compartment syndrome is a medical emergency that occurs when swelling compromises blood flow, leading to ischemia and possible limb loss if untreated.

🟣 The nurse should report this immediately and anticipate actions such as loosening or bivalving the cast.

🟣 Other findings like swelling and bruising may be expected after a fracture, but delayed capillary refill is a red flag.

🟣 Prompt recognition prevents irreversible nerve and tissue damage.

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QLexNursing

1 :
A nurse prepares to administer an intramuscular (IM) injection to a child. Which of the following muscle groups is contraindicated?

2 :
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV). Which of the following rooms should the nurse assign the infant?

3 :
A nurse in a pediatric clinic is collecting data from a preschool-age child who has suspected impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection?

4 :
A nurse is reviewing routine screenings for adolescents. Which of the following screenings should the nurse expect to be included?

6 :
A nurse is caring for a child who has Kawasaki disease. Which of the following systems is primarily affected by this disease?

7 :
A nurse is collecting data from a 2-year-old toddler who has AIDS. The nurse should inspect inside the toddler's mouth for which of the following opportunistic infections?

8 :
A nurse is reinforcing teaching about preventing disease transmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include?

9 :
A nurse is calculating the output of an infant admitted who has dehydration. When weighing the diaper, the nurse should equate 1 g of wet diaper weight to which of the following amounts of urine?

10 :
A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?

QLexNursing

1 : A nurse prepares to administer an intramuscular (IM) injection to a child. Which of the following muscle groups is contraindicated?

2 : A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV). Which of the following rooms should the nurse assign the infant?

3 : A nurse in a pediatric clinic is collecting data from a preschool-age child who has suspected impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection?

4 : A nurse is reviewing routine screenings for adolescents. Which of the following screenings should the nurse expect to be included?

6 : A nurse is caring for a child who has Kawasaki disease. Which of the following systems is primarily affected by this disease?

7 : A nurse is collecting data from a 2-year-old toddler who has AIDS. The nurse should inspect inside the toddler's mouth for which of the following opportunistic infections?

8 : A nurse is reinforcing teaching about preventing disease transmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include?

9 : A nurse is calculating the output of an infant admitted who has dehydration. When weighing the diaper, the nurse should equate 1 g of wet diaper weight to which of the following amounts of urine?

10 : A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?

1 :
A nurse prepares to administer an intramuscular (IM) injection to a child. Which of the following muscle groups is contraindicated?

2 :
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV). Which of the following rooms should the nurse assign the infant?

3 :
A nurse in a pediatric clinic is collecting data from a preschool-age child who has suspected impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection?

4 :
A nurse is reviewing routine screenings for adolescents. Which of the following screenings should the nurse expect to be included?

6 :
A nurse is caring for a child who has Kawasaki disease. Which of the following systems is primarily affected by this disease?

7 :
A nurse is collecting data from a 2-year-old toddler who has AIDS. The nurse should inspect inside the toddler's mouth for which of the following opportunistic infections?

8 :
A nurse is reinforcing teaching about preventing disease transmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include?

9 :
A nurse is calculating the output of an infant admitted who has dehydration. When weighing the diaper, the nurse should equate 1 g of wet diaper weight to which of the following amounts of urine?

10 :
A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?