Integument
2-month-old infant is brought to the clinic with white patches on the tongue and inner cheeks, consistent with oral candidiasis. Which nursing intervention is most appropriate?
A. Advise the caregiver to clean the infant’s mouth with a baking soda solution.
B. Administer nystatin suspension, ensuring it coats the oral mucosa.
C. Encourage the caregiver to remove the patches with a gauze pad.
D. Recommend withholding feedings for two hours after medication administration.
Answer: B. Administer nystatin suspension, ensuring it coats the oral mucosa.
Rationale: Nystatin suspension is the treatment of choice for oral candidiasis and must coat the affected area. Cleaning with baking soda is not effective, and forcibly removing patches can cause bleeding.
A nurse is educating nursing students about the differences between childhood and adult cancers. Which statement is accurate about childhood cancers?
A. "They are often linked to lifestyle factors like smoking or diet."
B. "They primarily involve epithelial cells in the lungs and liver."
C. "They often occur in deep tissues, such as the bones or central nervous system."
D. "They are typically detected early due to specific symptoms."
Answer: C. "They often occur in deep tissues, such as the bones or central nervous system."
Rationale: Childhood cancers, such as leukemia, neuroblastoma, or bone cancers, often originate in deep tissues. Unlike adult cancers, they are rarely linked to lifestyle factors and often present with nonspecific symptoms, leading to later detection.
A 5-year-old child presents to the clinic with fever, malaise, and a vesicular rash consistent with varicella. The provider orders a varicella antibody titer. What is the nurse's priority intervention before performing the test?
A. Ensure the child is well-hydrated before the test.
B. Educate the parents about the purpose of the test.
C. Confirm the child is not on antiviral medication.
D. Place the child in a private room under airborne precautions.
Place the child in a private room under airborne precautions.
Rationale: Varicella is highly contagious and requires airborne precautions to prevent transmission. Education is important but secondary to preventing the spread of infection.
During a prenatal education class, a nurse discusses ways to prevent neural tube defects. Which statement by the parent indicates understanding?
A. "I should increase my iron intake throughout pregnancy."
B. "I will take folic acid supplements before and during pregnancy."
C. "I should avoid dairy products during the first trimester."
D. "I will avoid strenuous exercise to prevent neural tube defects."
Answer: B. "I will take folic acid supplements before and during pregnancy."
Rationale: Folic acid supplementation before conception and during early pregnancy significantly reduces the risk of neural tube defects like spina bifida. Iron and exercise are important for other reasons but do not prevent these defects.
A parent asks why their toddler seems to get colds more often than adults. How should the nurse respond?
A. "Children's immune systems are fully developed by age one, but exposure to viruses increases their susceptibility."
B. "Younger children have immature immune systems, making it harder to fight infections."
C. "Frequent colds are due to inadequate nutrition in younger children."
D. "This is a sign of an underlying autoimmune disorder."
Answer: B. "Younger children have immature immune systems, making it harder to fight infections."
Rationale: Children's immune systems, particularly their adaptive immunity, are underdeveloped, making them more susceptible to infections. Frequent colds in toddlers are normal and typically not indicative of an autoimmune disorder.
A nurse is educating a parent about the neuromuscular development of their 8-month-old child. Which statement by the nurse explains why fine motor skills are still developing?
A. "The myelination of motor nerves is incomplete at this age."
B. "Spinal curvature limits the development of motor function."
C. "Muscle fibers in infants are immature compared to adults."
D. "The nervous system is not fully developed until adolescence."
Answer: A. "The myelination of motor nerves is incomplete at this age."
Rationale: The myelination process, which enhances the speed and efficiency of nerve impulse transmission, is incomplete in infants, delaying fine motor skill development. Spinal curvature and muscle immaturity are less significant factors.
A 6-year-old child with autism spectrum disorder (ASD) has difficulty adjusting to changes in routine and becomes distressed during transitions. Which nursing intervention is most appropriate?
A. Provide a visual schedule to help the child anticipate transitions.
B. Encourage the child to verbalize feelings to build communication skills.
C. Praise the child for their willingness to engage with others during transitions.
D. Limit social interaction during transitions to prevent overstimulation.
Answer: A. Provide a visual schedule to help the child anticipate transitions.
Rationale: Children with autism often struggle with changes in routine. Using visual schedules helps them prepare for transitions, reducing anxiety. Encouraging verbalization is helpful but may not address the child’s immediate distress.
A 6-year-old child sustains partial-thickness burns on their chest and arms. What is the priority nursing intervention upon arrival to the emergency department?
A. Apply antibiotic ointment and sterile dressings to the burns.
B. Assess airway patency and signs of inhalation injury.
C. Begin fluid resuscitation using lactated Ringer's solution.
D. Administer pain medication to reduce discomfort.
Answer: B. Assess airway patency and signs of inhalation injury.
Rationale: Airway assessment is the priority for burn patients, especially with burns near the upper torso. Fluid resuscitation and pain management are critical but follow after securing the airway.
A child with sickle cell disease is admitted to the hospital with severe joint pain and fever. What is the priority nursing assessment?
A. Assess for signs of infection, such as elevated white blood cell count.
B. Monitor for signs of hypoxia and respiratory distress.
C. Check for skin changes, such as jaundice or pallor.
D. Assess hydration status by monitoring urine output.
Answer: B. Monitor for signs of hypoxia and respiratory distress.
Rationale: Sickle cell crises can cause vaso-occlusion, leading to hypoxia and acute chest syndrome, which are life-threatening. While infection and hydration are important, hypoxia takes precedence in a crisis.
A 7-year-old child is admitted with a diagnosis of bacterial meningitis. What is the priority nursing action upon admission?
A. Place the child on droplet precautions.
B. Administer antipyretics to reduce fever.
C. Start an IV line to administer antibiotics.
D. Obtain a urine culture to rule out concurrent infections.
Answer: A. Place the child on droplet precautions.
Rationale: Bacterial meningitis is highly contagious, requiring droplet precautions to prevent transmission. Antibiotic administration is essential but follows after ensuring proper isolation.
A nurse is caring for a 6-month-old infant with suspected hydrocephalus. Which assessment finding is most indicative of this condition?
A. Bulging anterior fontanelle and rapid head growth.
B. Shrill crying and cyanosis during feeding.
C. High fever and nuchal rigidity.
D. Poor weight gain and persistent vomiting.
Answer: A. Bulging anterior fontanelle and rapid head growth.
Rationale: Hydrocephalus leads to increased intracranial pressure, causing fontanel bulging and accelerated head growth in infants. Fever and nuchal rigidity suggest meningitis, not hydrocephalus.
A nurse is explaining diagnostic tests for systemic lupus erythematosus (SLE) to a group of nursing students. Which laboratory result would be most indicative of SLE?
A. Decreased hemoglobin and hematocrit levels.
B. Positive antinuclear antibody (ANA) test.
C. Elevated blood glucose levels.
D. Low potassium levels.
Answer: B. Positive antinuclear antibody (ANA) test.
Rationale: A positive ANA test is a hallmark diagnostic indicator for autoimmune diseases like SLE. Other findings, such as anemia, may occur but are not specific to SLE.
A child undergoes a myelography to evaluate suspected spinal cord compression. Which complication should the nurse monitor for post-procedure?
A. Urinary retention.
B. Headache and nausea.
C. Hypotension and bradycardia.
D. Respiratory distress.
Answer: B. Headache and nausea.
Rationale: Headache and nausea are common complications of myelography due to the potential leakage of cerebrospinal fluid (CSF) from the puncture site. These symptoms may indicate a CSF leak and require prompt intervention.
A nurse is caring for a 10-year-old with OCD who engages in repetitive hand-washing rituals. Which intervention is most appropriate to help reduce the child's anxiety related to this behavior?
A. Allow the child to wash their hands for a set time to reduce anxiety.
B. Gradually limit the amount of hand-washing allowed per day.
C. Encourage the child to talk about their obsessional thoughts.
D. Provide praise each time the child resists the urge to wash their hands.
Answer: B. Gradually limit the amount of hand-washing allowed per day.
Rationale: Gradual exposure to anxiety-provoking situations and reducing compulsive behaviors through structured interventions is an effective strategy in managing OCD. Allowing hand-washing or praising the child for resisting may inadvertently reinforce the behavior.
A nurse is creating a care plan for an infant with diaper dermatitis. Which intervention should be included to promote healing?
A. Use scented baby wipes for frequent cleaning.
B. Apply a thick layer of zinc oxide barrier cream with each diaper change.
C. Increase the infant’s fluid intake to dilute urine acidity.
D. Use talcum powder to reduce skin friction.
Answer: B. Apply a thick layer of zinc oxide barrier cream with each diaper change.
Rationale: Zinc oxide forms a protective barrier that promotes healing and protects against further irritation. Scented wipes and talcum powder can worsen irritation or pose safety risks.
A child undergoing chemotherapy is neutropenic. Which intervention should the nurse prioritize?
A. Encourage the child to consume fresh fruits and vegetables.
B. Limit visitors to immediate family members without signs of infection.
C. Perform daily wound care using sterile technique.
D. Allow the child to attend school to maintain normalcy.
Answer: B. Limit visitors to immediate family members without signs of infection.
Rationale: Neutropenic precautions focus on minimizing exposure to infection. Fresh produce and crowded settings like schools increase the risk of bacterial exposure.
A nurse is assessing a child with fever, difficulty breathing, and crackles on auscultation of the lungs. The provider suspects pneumonia. What nursing assessment finding supports this diagnosis?
A. White patches on the tongue and oral mucosa.
B. A bull’s-eye rash on the child’s leg.
C. Increased work of breathing and oxygen desaturation.
D. Pruritic vesicles scattered on the trunk.
Answer: C. Increased work of breathing and oxygen desaturation.
Rationale: Pneumonia commonly presents with respiratory distress and decreased oxygen levels. White patches indicate oral candidiasis, and a bull’s-eye rash is a sign of Lyme disease.
A school-aged child is admitted with behavioral changes after a head injury. Which intervention is a priority for the nurse?
A. Perform hourly neuro checks, including level of consciousness.
B. Allow the child to nap frequently to promote healing.
C. Monitor the child’s intake and output for signs of dehydration.
D. Provide a quiet environment to minimize sensory stimulation.
Answer: A. Perform hourly neuro checks, including level of consciousness.
Rationale: Behavioral changes after head trauma may indicate worsening intracranial pressure, making frequent neuro assessments critical. Sensory minimization and hydration are important but not the priority.
A 12-year-old with juvenile idiopathic arthritis is prescribed NSAIDs and physical therapy. The child reports pain and stiffness despite treatment. Which nursing intervention is most appropriate?
A. Encourage the child to avoid exercise to reduce joint inflammation.
B. Educate the family about adding low-dose corticosteroid therapy.
C. Assess the child for adherence to the prescribed medication regimen.
D. Advise the child to take NSAIDs on an empty stomach to enhance absorption.
Answer: C. Assess the child for adherence to the prescribed medication regimen.
Rationale: Non-adherence to the treatment regimen can result in persistent symptoms. Addressing adherence is crucial before adjusting or adding treatments. Exercise and NSAIDs with food are also important but not the immediate priority.
A nurse is caring for a 6-year-old with Duchenne muscular dystrophy (DMD) who has been prescribed prednisone. What is the nurse’s priority intervention?
A. Monitor the child’s blood glucose levels.
B. Encourage high-protein meals to support muscle repair.
C. Advise the parents to limit physical activity to conserve energy.
D. Assess for signs of infection, such as fever or lethargy.
Answer: D. Assess for signs of infection, such as fever or lethargy.
Rationale: Prednisone suppresses the immune system, increasing the risk of infection. Monitoring for glucose is important but secondary to infection surveillance in this population.
A 9-year-old child with ADHD has been prescribed methylphenidate. The child’s parent asks how the medication will help. Which response by the nurse is most accurate?
A. "The medication will help the child calm down and improve focus by stimulating the brain."
B. "The medication will reduce impulsive behaviors by relaxing the brain's activity."
C. "The medication improves attention and impulse control by increasing dopamine and norepinephrine levels in the brain."
D. "The medication will slow the child’s activity and help with sleep patterns."
Answer: C. "The medication improves attention and impulse control by increasing dopamine and norepinephrine levels in the brain."
Rationale: Methylphenidate is a stimulant that increases the levels of neurotransmitters like dopamine and norepinephrine, improving attention, focus, and impulse control in children with ADHD. It does not primarily affect sleep patterns or calm the child by relaxing the brain.
A 15-year-old with psoriasis expresses embarrassment about their skin and avoids social activities. What is the best nursing intervention to address the psychosocial impact?
A. Teach the adolescent about the importance of medication adherence.
B. Recommend joining a support group for teens with chronic skin conditions.
C. Encourage the adolescent to wear clothing that covers affected areas.
D. Explain that psoriasis often improves with age.
Answer: B. Recommend joining a support group for teens with chronic skin conditions.
Rationale: Support groups provide a safe space for adolescents to share experiences and learn coping strategies, reducing feelings of isolation and promoting self-acceptance.
A 10-year-old is diagnosed with pernicious anemia. What is the nurse's priority intervention?
A. Encourage the child to increase red meat and poultry consumption.
B. Administer prescribed intramuscular vitamin B12 injections.
C. Monitor the child for signs of hypoglycemia and electrolyte imbalances.
D. Provide an iron supplement to improve hemoglobin levels.
Answer: B. Administer prescribed intramuscular vitamin B12 injections.
Rationale: Pernicious anemia is caused by the inability to absorb vitamin B12 from the gastrointestinal tract. IM injections bypass this issue and are the treatment of choice.
A nurse is teaching parents about pinworm management for their 4-year-old child. Which statement by the parents indicates understanding of the teaching?
A. "We will stop treatment once symptoms improve."
B. "Hand hygiene is important, especially after using the toilet."
C. "The medication requires a daily dose for two weeks."
D. "We’ll use a topical cream to relieve itching."
Answer: B. "Hand hygiene is important, especially after using the toilet."
Rationale: Pinworms are spread through fecal-oral transmission, making hand hygiene critical. Treatment often involves a single dose, repeated after two weeks.
A nurse is developing a care plan for a child with epilepsy who has been prescribed a ketogenic diet. What dietary teaching should be prioritized?
A. "Ensure the child consumes low-fat, high-protein meals."
B. "Avoid foods with high carbohydrate content like bread and pasta."
C. "Increase intake of fruits and vegetables to meet calorie needs."
D. "Provide frequent snacks to prevent hypoglycemia."
Answer: B. "Avoid foods with high carbohydrate content like bread and pasta."
Rationale: The ketogenic diet is a high-fat, low-carbohydrate diet used to manage epilepsy. Restricting carbohydrates is essential to induce ketosis, which helps control seizures. Fruits and vegetables are limited due to their carbohydrate content.
A 5-year-old experiences a severe allergic reaction to a bee sting, presenting with bronchospasm and swelling. What is the nurse’s priority intervention?
A. Administer an oral antihistamine.
B. Inject intramuscular epinephrine.
C. Apply a cold compress to the sting site.
D. Ensure the child drinks fluids to prevent dehydration.
Answer: B. Inject intramuscular epinephrine.
Rationale: IM epinephrine is the first-line treatment for anaphylaxis and bronchospasm caused by severe allergic reactions. Antihistamines and cold compresses are supportive but not the priority.
A nurse is developing a home care plan for a child with muscular dystrophy. Which intervention is most important for the family to implement?
A. Schedule physical therapy sessions to maintain joint mobility.
B. Restrict the child’s calorie intake to prevent weight gain.
C. Limit social activities to avoid overexertion.
D. Encourage the child to avoid using assistive devices for as long as possible.
Answer: A. Schedule physical therapy sessions to maintain joint mobility.
Rationale: Physical therapy is essential for maintaining mobility and preventing contractures in children with muscular dystrophy. Social and dietary considerations are important but secondary to mobility preservation.
A nurse is developing a care plan for a child with ADHD. Which intervention should be prioritized in the child’s care plan?
A. Encourage the child to engage in group activities to improve social skills.
B. Provide a quiet, distraction-free environment for homework and tasks.
C. Help the child identify their feelings to increase emotional regulation.
D. Recommend physical exercise to decrease hyperactivity and increase concentration.
Answer: B. Provide a quiet, distraction-free environment for homework and tasks.
Rationale: A quiet, structured environment helps the child with ADHD focus better and complete tasks more effectively. While physical exercise and group activities are important, minimizing distractions during task completion is crucial for success.
A nurse is teaching the parents of a 4-year-old with atopic dermatitis about home management. Which statement by the parents indicates effective learning?
A. "We will bathe our child daily using scented soaps."
B. "We’ll apply a moisturizer immediately after bathing."
C. "We'll use alcohol-based creams to reduce itching."
D. "We will limit our child’s fluid intake to prevent skin dryness."
Answer: B. "We’ll apply a moisturizer immediately after bathing."
Rationale: Applying moisturizer immediately after bathing helps lock in moisture and prevent skin dryness, which is essential in managing atopic dermatitis. Scented soaps and alcohol-based creams can worsen irritation.
The parents of a child newly diagnosed with AML express fear and helplessness. What is the best nursing intervention to address their psychosocial needs?
A. Provide detailed information about chemotherapy side effects.
B. Encourage the parents to focus on positive outcomes.
C. Offer emotional support and refer them to a pediatric oncology support group.
D. Suggest the family limit discussions about the illness around the child.
Answer: C. Offer emotional support and refer them to a pediatric oncology support group.
Rationale: Connecting families to support groups helps them cope with the emotional and social challenges of managing a child’s cancer diagnosis. While education is important, addressing emotional needs takes priority.
A nurse is developing a teaching plan for a family whose child is recovering from varicella. Which of the following instructions should the nurse prioritize?
A. Avoid giving the child warm baths to prevent spreading the rash.
B. Report any new fever or difficulty breathing to the provider.
C. Restrict the child from attending school for six weeks.
D. Use aspirin to manage fever and discomfort.
Answer: B. Report any new fever or difficulty breathing to the provider.
Rationale: Fever or difficulty breathing after varicella could indicate complications such as secondary bacterial infection or pneumonia. Aspirin is contraindicated due to Reye’s syndrome risk.
A nurse is caring for a newborn diagnosed with spina bifida. Which factor is most likely associated with this condition?
A. Maternal history of diabetes during pregnancy.
B. Inadequate maternal intake of folic acid before conception.
C. Prolonged labor and delivery trauma.
D. Excessive protein intake during the first trimester.
Answer: B. Inadequate maternal intake of folic acid before conception.
Rationale: Neural tube defects, including spina bifida, are strongly associated with insufficient maternal folic acid intake during the early stages of pregnancy.
A nurse is educating a teenager with SLE and their family about long-term corticosteroid use. Which complication should the nurse emphasize?
A. Increased risk of hyperglycemia and weight loss.
B. Increased susceptibility to infections and growth suppression.
C. Enhanced bone density and rapid wound healing.
D. Decreased appetite and anemia.
Answer: B. Increased susceptibility to infections and growth suppression.
Rationale: Long-term corticosteroid use can suppress the immune system, increasing infection risk, and may inhibit growth in children. Hyperglycemia and bone loss are also common, but these are secondary to the focus on immune suppression.
A 5-year-old with a hip spica cast is discharged home. What should the nurse emphasize during discharge teaching?
A. "Monitor the child’s temperature daily to check for infection."
B. "Keep the cast clean and dry to prevent skin breakdown."
C. "Encourage weight-bearing activities to promote healing."
D. "Administer pain medication only if the child reports severe pain."
Answer: B. "Keep the cast clean and dry to prevent skin breakdown."
Rationale: Proper care of the cast is essential to avoid complications such as skin irritation or breakdown. Weight-bearing is contraindicated in children with hip spica casts.
A nurse is teaching a family about managing depression in their adolescent child. Which of the following teaching points is most appropriate?
A. "Depression is a normal part of growing up, and your child will outgrow it."
B. "Be sure to encourage your child to be active and maintain their normal routine."
C. "Depressed children may need to be isolated to focus on their feelings."
D. "Monitor your child for any signs of self-harm and immediately remove harmful objects."
Answer: B. "Be sure to encourage your child to be active and maintain their normal routine."
Rationale: Encouraging the adolescent to stay active and maintain a routine is essential in managing depression. Isolation may worsen depression, and while self-harm monitoring is important, the priority is supporting engagement in regular activities.