Eye/Ear
Classify the following as bacterial, viral, or allergic conjunctivitis:
a. Itchy eyes
b. Eyes crusted shut
c. Bilateral watery discharge
A. allergic
B. Bacterial
C. viral and/or allergic
A nurse is providing discharge teaching to parents of an infant with metatarsus adductus. Which statement by a parent indicates the need for further teaching?
A) “We will perform stretching exercises as directed by the doctor.”
B) “We should avoid placing our baby’s feet in tight shoes.”
C) “Our baby may need surgery if this does not improve.”
D) “This condition is caused by weak bones.”
“This condition is caused by weak bones.”
A nurse is caring for a child diagnosed with croup. Which of the following signs and symptoms are most commonly associated with this condition? (Select all that apply)
Croup (Acute Laryngotracheobronchitis)
Correct answers: A, B
The typical symptoms of croup include a distinctive barking cough and stridor. Cyanosis and high fever are not the hallmark signs of croup, and while hoarseness can occur, it is not the primary symptom.
a nurse is assessing an 11 month old infant. which of the following manifestations is associated with a CNS infection?
Oliguria
Bulging fontanel
Negative Brudzinski sign
Jaundice
Bulging fontanel
A CNS infection causes increased intracranial pressure. Therefore, a bulging fontanel is a manifestation of a CNS infection.
What is PGE1 and what do we use it for
Keeps the ductus arteriosus open and it is used in mixed defects
The nurse is educating the parents of a child with amblyopia. Which intervention should the nurse recommend to improve vision?
A) Wearing corrective glasses with no other treatments
B) Eye exercises performed every day
C) Applying eye drops that blur vision in the stronger eye
D) Patching both eyes to strengthen muscles
Correct Answer: C) Applying eye drops that blur vision in the stronger eye
✅ Correct! Blurring the vision in the stronger eye with drops (atropine) forces the weaker eye to work harder, similar to patching.
A school nurse is screening adolescents for scoliosis. Which of the following findings is most indicative of scoliosis?
A) Even shoulder height
B) A symmetric waistline
C) Uneven shoulder or hip height
D) Equal leg length
Uneven shoulder or hip height.
A 9-month-old infant presents with wheezing, respiratory distress, and nasal congestion. Which of the following are priority interventions for RSV bronchiolitis? (Select all that apply)
Correct answers: B, D, E
Suctioning the nasal passages helps clear mucus in RSV bronchiolitis. Humidified oxygen can help with respiratory distress, and fluid intake is essential to prevent dehydration. Inhaled bronchodilators (A) are generally not recommended unless there is a history of wheezing. Prone position (C) is not advised because it can worsen breathing difficulties.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. which of the following actions is the nurse's priority?
A. Place a pillow under childs head
B. Position them side lying
C. Remove restrict clothing
D. Remove any hazards out of the environment
C-- This is priority and will help to prevent aspiration from the vomiting
A nurse is assessing a child with suspected Coarctation of the Aorta. Which findings are expected? (Select all that apply.)
A) Strong pulses in the upper extremities
B) Decreased urine output
C) Weak pulses in the lower extremities
D) Systolic murmur heard at the left sternal border
E) Pink upper body and cyanotic lower body
Rationale:
During a visual acuity screening of a 5-year-old child using a Snellen chart, the nurse notes the child has difficulty reading the 20/40 line with both eyes. What is the appropriate next step?
A) No further action is needed, as this is normal for the child’s age
B) Refer the child for further evaluation by an eye specialist
C) Reassess visual acuity in 6 months
D) Prescribe glasses immediately
Correct Answer: B) Refer the child for further evaluation by an eye specialist
❌ A visual acuity of 20/40 is concerning for a 5-year-old, and referral for further evaluation is necessary to rule out underlying issues.
Which of the following interventions should be included in the plan of care for a child with Duchenne muscular dystrophy?
A) Encouraging high-impact physical activities
B) Teaching energy conservation techniques
C) Restricting the use of assistive devices
D) Encouraging a high-protein diet to reverse muscle weakness
Teaching energy conservation techniques.
Which of the following are side effects of Racemic Epinephrine by nebulization? Select ALL
A. Decreased blood pressure
B. Tachycardia
C. Oral thrush
D. Bradycardia
E. Hypertension
F. Mucosal decongestion
B and C
In what order would you see the following patients:
A. 16-year-old with ataxia and slurred speech thatappears disoriented. Parents report he came home from a friend's house like this.
B. 2-year-old with history of brain tumor with removal 6 months ago. Parents report the toddler has been sleeps all the time and is difficult to arouse. Now presents with rigid extension and pronation of arms and legs
C. 6-year-old who parents report has had complaint of headache every morning for the last five days that is often relieved by emesis. No recent illness or trauma. Is alert and interactive with parents.
B. 2-year-old with history of brain tumor with removal 6
months ago. Parents report the toddler has been sleeps all the time
and is difficult to arouse. Now presents with rigid extension
and pronation of arms and legs
A. 16-year-old with ataxia and slurred speech that
appears disoriented. Parents report he came home from a friend's
house like this.
C. 6-year-old who parents report has had complaint of headache
every morning for the last five days that is often relieved by emesis.
No recent illness or trauma. Is alert and interactive with parents.
A 4-month-old infant with a congenital heart defect is showing signs of heart failure (HF), including tachypnea, diaphoresis while feeding, and poor weight gain. Which intervention should the nurse implement first?
A) Administer furosemide as prescribed
B) Increase the caloric density of formula
C) Position the infant in a semi-Fowler’s position
D) Encourage the infant to feed longer to promote weight gain
C) Position the infant in a semi-Fowler’s position
Rationale:
The priority intervention in a 4-month-old infant with heart failure (HF) showing signs such as tachypnea, diaphoresis while feeding, and poor weight gain is to promote respiratory comfort and reduce pulmonary congestion. Positioning the infant in a semi-Fowler’s position helps to reduce the work of breathing, improve oxygenation, and allow for better lung expansion.
The nurse is caring for a 4-year-old with suspected strabismus. Which assessment finding is consistent with this condition?
A) Both eyes aligned when looking straight ahead
B) A red reflex in both eyes
C) One eye drifts inward or outward
D) Pain and swelling around the eyes
Correct Answer: C) One eye drifts inward or outward
✅ Correct! Strabismus is characterized by misalignment of the eyes, such as one eye drifting inward or outward.
A parent of a child with Duchenne muscular dystrophy asks about the expected progression of the disease. Which response by the nurse is most appropriate?
A) “Your child will experience symptoms only in adulthood.”
B) “This disease progresses slowly and does not affect mobility.”
C) “Muscle weakness will gradually worsen, and respiratory muscles may eventually be affected.”
D) “Physical therapy can completely reverse the condition.”
“Muscle weakness will gradually worsen, and respiratory muscles may eventually be affected.”
Which of the following pulmonary assessments are NOT expected in cystic fibrosis?
A. Wet, loose, productive cough
B. Rhonchi that will progress to high pitched wheezing over time
C. Dyspnea
D. Clubbing that develops over time
E. Barking, brassy quality to cough
F. Tenacious secretions
A and E
A. Wet, loose, productive cough – This would be a persistent, dry, non-productive cough
E. Barking, brassy quality to cough – this is croup, not cystic fibros
A school nurse suspects that a 6-year-old child is being abused after noticing bruises in various stages of healing. Which actions should the nurse take? (Select all that apply.)
A) Contact child protective services (CPS)
B) Notify the child’s parents before making a report
C) Document objective findings and statements made by the child
D) Conduct a detailed interview to verify if the child is being abused
E) Ensure the child is in a safe environment
As a mandatory reporter, the nurse is legally and ethically required to report suspected child abuse. The goal is to ensure the child's immediate safety while allowing authorities to conduct a proper investigation.
A) Contact child protective services (CPS) – Correct ✅
C) Document objective findings and statements made by the child – Correct ✅
E) Ensure the child is in a safe environment – Correct ✅
A 2-year-old child is diagnosed with Kawasaki disease, a condition that can lead to coronary artery complications. Which interventions should the nurse anticipate? (Select all that apply.)
A) High-dose IV immunoglobulin (IVIG)
B) Administration of aspirin therapy
C) Monitoring for signs of coronary aneurysms
D) Initiating strict isolation precautions
E) Encouraging the family to delay routine vaccinations for several months
Kawasaki disease is an inflammatory condition that can cause coronary artery complications, including aneurysms, and the primary treatment focuses on reducing inflammation and preventing damage to the coronary arteries.
Incorrect Answers:
Which of the following signs is typically seen in a child with otitis media with effusion (OME)?
A) High fever and irritability
B) Pulling at the ear and vomiting
C) Hearing loss and a feeling of fullness in the ear
D) Thick, yellow-green ear drainage
Correct Answer: C) Hearing loss and a feeling of fullness in the ear
❌ Fever and irritability are common in acute otitis media (AOM), but OME presents with hearing loss and ear fullness without significant pain or fever.
A nurse is assessing an infant diagnosed with metatarsus adductus. Which of the following findings is expected?
A) The forefoot is turned outward, away from the midline
B) The foot has a rigid deformity that cannot be corrected manually
C) The forefoot is turned inward while the hindfoot remains neutral
D) The entire foot is twisted downward and inward
The forefoot is turned inward while the hindfoot remains neutral.
Which of the following are expected in the care of a patient with chronic lung disease?
A. Racemic epinephrine
B. Surfactant
C. 30 kcal/oz formula
D. Pancrealipase
E. Infant stimulation program
F. Furosemide (Lasix) or Chlorothiazide (Diuril)
B,C,E,F
Which characteristic best differentiates neonatal seizures from febrile seizures?
A) Neonatal seizures are always generalized, while febrile seizures are focal
B) Neonatal seizures often present as subtle movements, while febrile seizures are generalized
C) Febrile seizures occur in infants younger than 1 month, while neonatal seizures occur between 6 months and 5 years
D) Neonatal seizures are always caused by high fever, while febrile seizures are due to brain abnormalities
B) Neonatal seizures often present as subtle movements, while febrile seizures are generalized
Rationale:
Why the Other Options Are Incorrect:
A) Neonatal seizures are always generalized, while febrile seizures are focal ❌
C) Febrile seizures occur in infants younger than 1 month, while neonatal seizures occur between 6 months and 5 years ❌
D) Neonatal seizures are always caused by high fever, while febrile seizures are due to brain abnormalities ❌
(SATA) Post-Op Care for a Child After Congenital Heart Surgery
A 5-year-old child is recovering from surgical repair of a congenital heart defect. Which interventions should the nurse prioritize? (Select all that apply.)
A) Encourage deep breathing and coughing with a pillow for splinting
B) Monitor for signs of cardiac tamponade, such as muffled heart sounds
C) Restrict fluids to prevent pulmonary congestion
D) Encourage early ambulation to prevent complications
E) Monitor urine output to assess renal perfusion
The correct answers are:
✅ A) Encourage deep breathing and coughing with a pillow for splinting
✅ B) Monitor for signs of cardiac tamponade, such as muffled heart sounds
✅ D) Encourage early ambulation to prevent complications
✅ E) Monitor urine output to assess renal perfusion
Postoperative care for a child recovering from congenital heart surgery focuses on preventing complications, promoting recovery, and ensuring cardiac function remains stable.
🚫 C) Restrict fluids to prevent pulmonary congestion – Fluid restriction is not routinely required unless the child shows signs of fluid overload or worsening heart failure. Instead, fluid balance should be closely monitored, and IV fluids should be adjusted based on cardiac and renal function.
Post-op care for congenital heart surgery should focus on respiratory support, monitoring for cardiac complications, early mobilization, and ensuring adequate perfusion. 🚑4o
O