Kendall Harrison - nursing care of children nCLEX PDF

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nursing care of children nCLEX...

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Week 12 – NCLEX worksheet sv 1. A mother refuses to have her child be immunized with measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which response by the nurse is most appropriate? a. Honor her request because she is the parent. b. Explain that antibodies can fight many diseases. c. Tell her that not immunizing her infant may protect pregnant women. d. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases. 2. A parent reports that her school-age child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which disease process does the nurse suspect based on the parent’s description? a. Chicken pox (varicella) b. Fifth disease (erythema infectiosum) c. German measles (rubella) d. Roseola (exanthem subitum) 3. The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which needle, size and length, injection type, and injection site? a. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh. b. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal. c. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid. d. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh. 4. The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. Which statement by the nurse indicates a correct understanding of the concepts presented? a. “It is important to separate clients according to age and illness to prevent the spread of disease.” b. “I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room.” c. “It is important to dispose blood-contaminated needles in the lead-lined container.” d. “I will initiate isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA).” 5. The nurse is teaching a prenatal class about infant care. Under which circumstances should the nurse emphasize that parents should call their healthcare provider immediately? Select all that apply. a. Child 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0 degrees C (100.4 degrees F) b. Child under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F) c. Child difficult to awaken and has a pulsing fontanel d. Child has purple spots on the skin and is lethargic. e. Child has a stiff neck and has been irritable for three days.

6. The nurse is planning care for a 3-month-old infant diagnosed with eczema. Which should be the focus of the nurse’s care for this infant? a. Maintaining adequate nutrition b. Keeping the baby content c. Preventing infection of lesions d. Applying antibiotics to lesions 7. The nurse is examining a 12-month-old who is brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with bright red scaly plaques and small papules. Satellite lesions are also present. What is the most likely cause of this client’s diaper rash? a. Impetigo (staph) b. Urine and feces c. Infrequent diapering d. Candida albicans (yeast) e. 8. The school nurse is conducting pediculosis capitis (head lice) checks. Which findings would indicate a “positive” head check? a. White, flaky particles throughout the entire scalp region b. Maculopapular lesions behind the ears c. Lesions in the scalp that extend to the hairline or neck d. White sacs attached to the hair shafts in the occipital area 9. The nurse explains to the parents of a child with a severe burn that wearing of an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help with the prevention of which complication? a. Poor circulation b. Hypertrophic scarring c. Pain d. Formation of thrombus in the burn area 10. The nurse is teaching a group of students about wound healing. Which items will the nurse include as occurring during the hemostasis and inflammation stage of wound healing? Select all that apply. a. Clot formation to seal the wound b. Production of collagen and granulation tissue c. Scar formation and strengthening d. Swelling as a result of increased capillary permeability e. Release of inflammatory mediators by platelets...