Question

A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

Answer 1

Correct Answers:

Wound blanches with pressure
Blisters
Sensitive to touch

Rationale :

💎 Partial-thickness (second-degree) burns damage the epidermis and part of the dermis, leaving nerve endings exposed. This makes the area painful and sensitive to touch.

💎 The burn site often appears moist, red, and blistered, with blanching on pressure indicating viable circulation.

💎 The epidermis is not intact, and the surface is not dry as in full-thickness burns.

💎 Healing usually occurs within 2–3 weeks with minimal scarring.

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Answer 2

Correct Answers:

A child who has nephrotic syndrome

Rationale :

💎 A child with leukemia is immunocompromised due to bone marrow suppression from the disease and treatment.

💎 They must be placed with a noninfectious, non-contagious roommate to minimize infection risk.

💎 Nephrotic syndrome is not infectious, whereas cystic fibrosis, rheumatic fever, and ruptured appendix involve infection or risk of cross-contamination.

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Answer 3

Correct Answers:

Increased sleeping

Rationale :

💎 Early signs of increased ICP in infants include lethargy, irritability, bulging fontanel, poor feeding, and increased sleeping.

💎 As pressure rises, neurological responses slow, leading to decreased consciousness.

💎 Depressed fontanels indicate dehydration, not ICP. Brisk pupillary reaction and tachycardia are normal or unrelated to intracranial pressure changes.

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Answer 4

Correct Answers:

Bulging fontanel

Rationale :

💎 Bulging fontanel in an infant is a classic sign of increased intracranial pressure, commonly caused by meningitis or encephalitis.

💎 CNS infections cause inflammation and fluid accumulation, leading to elevated CSF pressure.

💎 Other manifestations include fever, poor feeding, irritability, and a high-pitched cry.

💎 Negative Brudzinski, jaundice, or oliguria are not direct CNS infection indicators.

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Answer 5

Correct Answers:

Respiratory rate

Rationale :

💎 Kerosene is a hydrocarbon, and aspiration can lead to chemical pneumonitis, a life-threatening respiratory complication.

💎 Therefore, the nurse’s priority assessment is respiratory status — rate, effort, breath sounds, and oxygen saturation.

💎 Inducing vomiting or gastric lavage is contraindicated because it increases aspiration risk.

💎 Other findings like mouth burns or bowel sounds are secondary.

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Answer 6

Correct Answers:

Apply a topical corticosteroid ointment to the affected area.

Rationale :

💎 Eczema (atopic dermatitis) is a chronic inflammatory skin disorder characterized by dryness, itching, and erythematous lesions.

💎 The nurse should teach the parent to apply prescribed topical corticosteroid ointments (e.g., hydrocortisone) to reduce inflammation and itching.

💎 Parents should avoid irritants such as wool clothing, bubble baths, and scented detergents, as these worsen the skin condition.

💎 After bathing, the skin should be patted dry and immediately moisturized to lock in hydration.

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Answer 7

Correct Answers:

Wilms' tumor

Rationale :

💎 Wilms’ tumor (nephroblastoma) is a malignant renal tumor most common in children under 5 years.

💎 It typically presents with a firm, non-tender abdominal mass and hematuria (pink-tinged urine).

💎 It is crucial not to palpate the abdomen, as this may cause tumor rupture and spread of cancerous cells.

💎 Diagnostic evaluation includes abdominal ultrasound or CT scan, and treatment involves nephrectomy and chemotherapy.

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Answer 8

Correct Answers:

Bleeding

Rationale :

🔷 Platelets are responsible for clot formation, and a critically low count (thrombocytopenia) places the child at high risk for spontaneous bleeding.

🔷 Bleeding precautions include minimizing invasive procedures, avoiding intramuscular injections, and using soft toothbrushes.

🔷 The nurse should monitor for petechiae, epistaxis, hematuria, and gum bleeding, which signal internal or external hemorrhage.

🔷 Clients with leukemia have suppressed bone marrow, reducing platelet production and increasing bleeding tendency.

🔷 Safety measures, such as using an electric razor and preventing injury, help avoid trauma that could cause uncontrollable bleeding.

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Answer 9

Correct Answers:

Candidiasis

Rationale :

💠 The white, milky plaques that do not rub off are classic signs of oral candidiasis (thrush).

💠 It’s caused by an overgrowth of Candida albicans, a yeast-like fungus common in immunocompromised or antibiotic-treated clients.

💠 The child’s immunosuppressant and corticosteroid therapy reduce the body’s ability to fight fungal infections.

💠 Smoking exposure can also disturb oral flora, increasing fungal colonization.

💠 Treatment includes nystatin oral suspension and maintaining proper oral hygiene after medication use.

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Answer 10

Correct Answers:

Position the child laterally.

Rationale :

🔶 Placing the child on the side (lateral position) prevents aspiration of saliva or vomitus during a seizure.

🔶 The airway remains open and the tongue naturally falls forward, preventing obstruction.

🔶 Never insert objects or restrain movements, as this increases the risk of injury.

🔶 After the seizure, maintain a patent airway and assess for injuries or postictal confusion.

🔶 Document seizure activity (duration, type, triggers) to assist in treatment planning.

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QLexNursing

1 :
A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

2 :
A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

3 :
A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

4 :
A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection?

5 :
A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

6 :
A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is assessing a 1-year-old toddler notices a large abdominal mass and pink-tinged urine on the diaper. Which of the following disorders should the nurse suspect?

8 :
A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

10 :
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

2 : A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

3 : A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

4 : A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection?

5 : A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

6 : A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching?

7 : A nurse is assessing a 1-year-old toddler notices a large abdominal mass and pink-tinged urine on the diaper. Which of the following disorders should the nurse suspect?

8 : A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

10 : A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

1 :
A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

2 :
A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

3 :
A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

4 :
A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection?

5 :
A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

6 :
A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is assessing a 1-year-old toddler notices a large abdominal mass and pink-tinged urine on the diaper. Which of the following disorders should the nurse suspect?

8 :
A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

10 :
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?