Question

The nurse is providing care to several children who have been brought to the clinic by the parents reporting cold-like symptoms. The nurse would most likely suspect sinusitis in which child?

Answer 1

Correct Answers:

None of the above

Rationale :

✏️ None of the children has enough information to distinguish acute bacterial sinusitis from an uncomplicated viral upper respiratory infection.

✏️ Pediatric bacterial sinusitis is suspected when nasal discharge or daytime cough persists for more than 10 days without improvement.

✏️ It may also be suspected when symptoms initially improve and then worsen, or when a child develops a fever of at least 39°C (102.2°F) with purulent nasal discharge for at least 3 consecutive days.

✏️ Sneezing, coughing, congestion, sore throat, and thin watery nasal discharge commonly occur with viral colds and do not independently establish sinusitis.

✏️ Because the question provides no prolonged duration, worsening pattern, high fever, purulent drainage, or facial pain, none of the listed children clearly meets the criteria for sinusitis.

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Answer 2

Correct Answers:

"My child just got over a head cold with sore throat."

Rationale :

♦️ Acute post-streptococcal glomerulonephritis can develop after an infection caused by group A Streptococcus, particularly streptococcal pharyngitis.

♦️ The kidney disorder commonly appears approximately 10 days after strep throat or scarlet fever.

♦️ Antibodies produced against the infection form immune complexes that become deposited in the glomeruli and cause inflammation.

♦️ Expected manifestations include dark reddish-brown urine, decreased urine output, edema, hypertension, and proteinuria.

♦️ Therefore, a recent sore throat is an important historical finding that the nurse should report to the primary healthcare provider.

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Answer 3

Correct Answers:

Jerky movements of the face and upper extremities

Rationale :

🖍️ Jerky, purposeless movements of the face and extremities are characteristic of Sydenham chorea, a major manifestation of acute rheumatic fever.

🖍️ These movements are abrupt, involuntary, nonrhythmic, and often become more noticeable during stress or intentional activity.

🖍️ The child may also demonstrate muscle weakness, emotional instability, poor handwriting, facial grimacing, or difficulty performing coordinated activities.

🖍️ Sydenham chorea results from an autoimmune response following infection with group A Streptococcus.

🖍️ Chorea is included among the major Jones criteria used in evaluating suspected acute rheumatic fever.

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Answer 4

Correct Answers:

Deliver oxygen in the least invasive manner.

Rationale :

🌹 Epiglottitis can cause rapid, life-threatening upper-airway obstruction, making airway support the immediate priority.

🌹 Oxygen should be provided gently in the least invasive manner tolerated, such as blow-by oxygen, while avoiding anything that agitates the child.

🌹 The child should be allowed to remain upright or in the preferred position because forcing another position may worsen airway obstruction.

🌹 The nurse should keep emergency airway equipment and personnel available because endotracheal intubation or another advanced airway intervention may become necessary.

🌹 Unnecessary examinations and procedures should be delayed until the airway can be assessed in a controlled environment with specialists prepared to secure it.

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Answer 5

Correct Answers:

antiemetic
maintenance IV fluids

Rationale :

Antiemetic

🍊 An antiemetic may be prescribed because the child has frequent vomiting and cannot retain oral fluids.

🍊 Controlling vomiting can reduce ongoing fluid loss and improve the child’s ability to tolerate oral rehydration once the condition stabilizes.

🍊 Ondansetron is commonly used in children with gastroenteritis-related vomiting when persistent emesis interferes with rehydration.

🍊 Reducing nausea and vomiting may decrease the need for prolonged intravenous therapy and support an earlier return to oral intake.

🍊 The nurse should monitor the child’s response and continue assessing hydration status, electrolyte balance, urine output, and ongoing gastrointestinal losses.

Maintenance IV fluids

🍊 Intravenous fluids are appropriate because the child shows moderate dehydration and is currently unable to keep oral fluids down.

🍊 The 6% weight loss, tachycardia, dry mucous membranes, delayed capillary refill, sluggish skin recoil, and decreased urine output indicate a clinically significant fluid deficit.

🍊 Elevated hemoglobin and hematocrit reflect hemoconcentration, while increased BUN and creatinine suggest reduced kidney perfusion associated with dehydration.

🍊 After assessment and any necessary initial fluid replacement, prescribed maintenance fluids provide ongoing water and electrolytes while vomiting and diarrhea continue.

🍊 The nurse should closely monitor vital signs, capillary refill, mental status, intake and output, urine concentration, daily weight, and laboratory values during IV therapy.

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Answer 6

Correct Answers:

Perform small, frequent feedings.

Rationale :

✏️ Neonates with congenital heart defects often have increased energy requirements but limited endurance during feeding.

✏️ Small, frequent feedings provide needed calories while reducing the amount of energy the infant must expend during each feeding session.

✏️ Infants with cardiac disease may develop tachypnea, sweating, fatigue, or poor sucking when fed large volumes for prolonged periods.

✏️ Feedings may be offered every 1 to 3 hours, with rest periods and close monitoring for respiratory distress or exhaustion.

✏️ This approach supports growth while decreasing cardiac workload and the risk of feeding-related fatigue.

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Answer 7

Correct Answers:

"If my child is in the yellow zone, I need to continue the Green zone medications plus the quick relief medication".

Rationale :

♦️ The yellow zone indicates worsening asthma symptoms or reduced peak expiratory flow, generally between 50% and 79% of the child’s personal best.

♦️ The child should usually continue prescribed daily controller medication and add the quick-relief medication according to the individualized asthma action plan.

♦️ The parent should assess whether symptoms and peak-flow readings improve after the rescue medication is administered.

♦️ The healthcare provider should be contacted when symptoms do not improve, recur frequently, or require more medication than directed.

♦️ Following the yellow-zone instructions promptly may prevent progression to a severe red-zone asthma exacerbation.

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Answer 8

Correct Answers:

Hypoplastic left heart syndrome

Rationale :

🖍️ In hypoplastic left heart syndrome, the left ventricle, mitral valve, aortic valve, and ascending aorta are severely underdeveloped.

🖍️ The left side of the heart cannot provide adequate systemic blood flow after birth.

🖍️ Blood must pass from the pulmonary artery through the patent ductus arteriosus into the aorta to supply the body.

🖍️ Prostaglandin E1 is administered after birth to keep the ductus arteriosus open until staged surgery or transplantation can be performed.

🖍️ Closure of the ductus can rapidly cause profound systemic hypoperfusion, shock, acidosis, cardiovascular collapse, and death.

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Answer 9

Correct Answers:

Apply ice 10 to 20 minutes three times daily

Rationale :

🌹 Applying ice soon after an ankle sprain helps reduce pain, swelling, inflammation, and tissue bleeding.

🌹 The ice pack should be wrapped in a thin cloth to protect the child’s skin from cold injury.

🌹 Cold therapy should be limited to approximately 15 to 20 minutes at a time and repeated several times during the day.

🌹 The child’s skin color, temperature, sensation, and circulation should be checked during treatment.

🌹 Ice is one component of early sprain care, along with rest, gentle compression, and elevation of the injured ankle.

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Answer 10

Correct Answers:

Currant jelly-like

Rationale :

✍️ Intussusception occurs when one portion of the intestine telescopes into an adjacent intestinal segment.

✍️ The trapped bowel becomes compressed, causing venous congestion, edema, mucosal injury, and decreased blood flow.

✍️ Blood from the injured intestinal lining mixes with mucus and produces the classic dark-red, currant jelly-like stool.

✍️ Other manifestations may include intermittent severe abdominal pain, drawing the knees toward the chest, vomiting, lethargy, and a sausage-shaped abdominal mass.

✍️ Currant jelly stool is often a later finding and indicates progressing bowel ischemia that requires urgent evaluation and reduction of the intussusception.

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QLexNursing

1 :
The nurse is providing care to several children who have been brought to the clinic by the parents reporting cold-like symptoms. The nurse would most likely suspect sinusitis in which child?

2 :
The nurse is taking a health history of a child with suspected acute post-streptococcal glomerulonephritis. Which response by the client's parent will the nurse highlight for the primary health care provider as an indicator of this condition?

3 :
After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding?

4 :
A nurse is caring for a pre-school age child who has suspected epiglottitis. Which of the following actions should the nurse take?

5 :
Patient data.

Answer Options

6 :
The nurse is performing teaching regarding feeding to the mother of a neonate with congenital heart defect. Which recommendation should be included in the teaching plan?

7 :
The nurse is preparing education for the parents of a pediatric patient diagnosed with asthma. An asthma action plan is developed to help the parents determine when to step up or step down treatment. Which choice below indicates that the parents understand the teaching?

8 :
Which of the following defects depend on a patent ductus arteriosus for survival?

9 :
A child is brought to the clinic after tripping over a rock. The child states "I twisted my ankle" and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?

10 :
The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality?

QLexNursing

1 : The nurse is providing care to several children who have been brought to the clinic by the parents reporting cold-like symptoms. The nurse would most likely suspect sinusitis in which child?

2 : The nurse is taking a health history of a child with suspected acute post-streptococcal glomerulonephritis. Which response by the client's parent will the nurse highlight for the primary health care provider as an indicator of this condition?

3 : After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding?

4 : A nurse is caring for a pre-school age child who has suspected epiglottitis. Which of the following actions should the nurse take?

5 : Patient data.

Answer Options

6 : The nurse is performing teaching regarding feeding to the mother of a neonate with congenital heart defect. Which recommendation should be included in the teaching plan?

7 : The nurse is preparing education for the parents of a pediatric patient diagnosed with asthma. An asthma action plan is developed to help the parents determine when to step up or step down treatment. Which choice below indicates that the parents understand the teaching?

8 : Which of the following defects depend on a patent ductus arteriosus for survival?

9 : A child is brought to the clinic after tripping over a rock. The child states "I twisted my ankle" and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?

10 : The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality?

1 :
The nurse is providing care to several children who have been brought to the clinic by the parents reporting cold-like symptoms. The nurse would most likely suspect sinusitis in which child?

2 :
The nurse is taking a health history of a child with suspected acute post-streptococcal glomerulonephritis. Which response by the client's parent will the nurse highlight for the primary health care provider as an indicator of this condition?

3 :
After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding?

4 :
A nurse is caring for a pre-school age child who has suspected epiglottitis. Which of the following actions should the nurse take?

5 :
Patient data.

6 :
The nurse is performing teaching regarding feeding to the mother of a neonate with congenital heart defect. Which recommendation should be included in the teaching plan?

7 :
The nurse is preparing education for the parents of a pediatric patient diagnosed with asthma. An asthma action plan is developed to help the parents determine when to step up or step down treatment. Which choice below indicates that the parents understand the teaching?

8 :
Which of the following defects depend on a patent ductus arteriosus for survival?

9 :
A child is brought to the clinic after tripping over a rock. The child states "I twisted my ankle" and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?

10 :
The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality?