test 3

A nurse is providing teaching to the parent of a child newly diagnosed with amblyopia. Which statement by the parent indicates understanding of the treatment?

select all that apply

• A. “My child may need eyeglasses if they have nearsightedness or farsightedness.”

• B. “We will patch the weaker eye so the stronger eye has to work harder.”

• C. “Daytime patching may be enough to strengthen the weaker eye.”

• D. “Keeping the patch on all the time is always required.”

Answer explanation

Correct Answer:
A, C

Rationale:

• A is correct: Eyeglasses are used for refractive errors like hyperopia or myopia.

• B is incorrect: The good eye is patched to force the weaker eye to be used, not the weaker one.

• C is correct: Daytime/part-time patching may be sufficient in some cases.

• D is incorrect: Full-time patching is not always necessary; therapy can vary and be challenging to maintain.

A nurse is teaching parents about febrile seizures in children. Which statement by the parent indicates correct understanding of the cause?

• “They are caused by a rapid rise in temperature, usually above 38.8°C (102 °F).”

• “They happen because of brain damage from the fever.”

• “They occur when a fever stays high for several days.”

• “They are always caused by an infection in the brain.”

Answer explanation

Correct Answer:
A

Rationale:

• A is correct: Febrile seizures occur in response to a rapid rise in temperature, often above 38.8°C (102 °F).

• B is incorrect: Febrile seizures are not caused by brain damage.

• C is incorrect: They are related to the rapid rise in temperature, not the duration.

• D is incorrect: Although fever may be from infection, other causes must be ruled out.

The nurse is teaching a group of parents about bacterial meningitis in children. Which statement best describes the cause of the infection?

• “Only one specific bacteria causes bacterial meningitis in all age groups.”

• “In newborns, Group B streptococcus is the primary cause.”

• “The organisms may reach the meninges through the bloodstream or nearby infections.”

• “The infection can only spread directly from the ear.”

Answer explanation

Correct Answer:
B, C

Rationale:

• B is correct: In newborns, Group B streptococcus is the main cause.

• C is correct: Organisms may spread indirectly through the bloodstream (sepsis) or from infections in the teeth, sinuses, tonsils, or lungs.

• A is incorrect: Bacterial meningitis can be caused by various organisms, not just one.

• D is incorrect: While meningitis can spread directly from the ear (otitis media) or skull fractures, this is not the only route.

The nurse is teaching a client about cholesterol. Which statement correctly describes the difference between LDL and HDL?

• “LDL carries cholesterol to the cells, while HDL carries cholesterol to the liver for excretion.”

• “LDL contains more protein than HDL.”

• “HDL contains little cholesterol and high levels of protein, while LDL has high cholesterol and some protein.”

• “HDL carries cholesterol to the cells for steroid production.”

Answer explanation

Correct Answer:
A, C

Rationale:

• A is correct: LDL delivers cholesterol to the cells, while HDL returns cholesterol to the liver for excretion.

• B is incorrect: HDL (not LDL) has the higher protein content.

• C is correct: HDL = high protein, little cholesterol; LDL = high cholesterol, some protein.

• D is incorrect: LDL (not HDL) carries cholesterol for metabolism and steroid production.

A nurse is reviewing risk factors for primary (essential) hypertension with a client. Which factors increase the risk?

• Heredity

• Obesity

• Stress

• Poor diet and lack of exercise

• Presence of kidney disease

Answer explanation

Correct Answer:
A, B, C, D

Rationale:

• A, B, C, D are correct: Heredity, obesity, stress, and poor diet/exercise habits contribute to the development of hypertension.

• E is incorrect: Kidney disease is an underlying cause, which would make the hypertension secondary, not primary.

A pediatric nurse is explaining transitional objects to the parents of a hospitalized toddler. Which statement indicates understanding?

• “A transitional object, like a blanket or favorite toy, can help my child feel secure.”

• “A transitional object should only be used at bedtime.

• “A transitional object prevents my child from forming attachments to people.”

• “A transitional object increases my child’s anxiety in the hospital.”

Answer explanation

Correct Answer:
A

Rationale:

• A is correct: A blanket or favorite toy from home can provide comfort and security.

• B is incorrect: Transitional objects can be used anytime, not just at bedtime.

• C is incorrect: They do not interfere with personal attachments.

• D is incorrect: They decrease, not increase, anxiety.

A nurse is caring for a child who just had a tonsillectomy. Which foods or drinks would be appropriate to offer?

• Small amounts of clear liquids

• Red gelatin

• Brown-colored soda

• An ice pop

• Soft foods once clear liquids are tolerated

Answer explanation

Correct Answer:
A, D, E

Rationale:

• A is correct: Small amounts of clear liquids are given first as tolerated.

• B is incorrect: Red-colored foods are avoided because they can mask blood in emesis.

• C is incorrect: Brown-colored drinks are avoided for the same reason.

• D is correct: Ice pops may appeal to the child and are safe.

• E is correct: If liquids are tolerated, the diet can progress to soft foods.

The nurse is caring for an infant with respiratory syncytial virus (RSV). Which interventions are appropriate?

• Assign the infant to personnel who are not caring for high-risk patients.

• Use contact isolation precautions.

• Wash hands frequently with liquid soap.

• Place a bar of soap at the sink for staff to use.

• Implement strict infection prevention and control measures.

Answer explanation

Correct Answer:
A, B, C, E

Rationale:

• A is correct: Care should be assigned to staff not caring for high-risk patients, to prevent cross-infection.

• B is correct: Contact isolation precautions help prevent spread of RSV by fomites.

• C is correct: Hand hygiene is essential, and liquid soap is recommended since RSV can survive on bar soap.

• D is incorrect: Bar soap can harbor the virus; liquid soap should be used.

• E is correct: Standard infection control techniques (gloves, gowns, cleaning equipment) must be used.

The nurse is making room assignments for hospitalized clients. Which room assignment is most appropriate for an adolescent?

• A semiprivate room with another adolescent

• A private room away from other patients

• A room next to a dying elderly patient in the adult unit

• A room next to an infant in the pediatric unit

Answer explanation

Correct Answer:
A

Rationale:

• A is correct: Adolescents usually do better with one or more roommates, preferably peers of a similar age group.

• B is incorrect: A single room is not ideal unless absolutely necessary, since adolescents benefit from social interaction.

• C is incorrect: Adolescents should not be placed next to severely debilitated or dying adult patients, as this is emotionally distressing.

• D is incorrect: Adolescents should not be placed with infants in the pediatric unit, as the developmental gap is too wide.

A nurse is caring for a child with a soft tissue injury. Which interventions are appropriate?

• Apply a cold pack and elastic wrap in 30-minute intervals.

• Elevate the injured extremity above the level of the heart.

• Perform frequent neurovascular checks when using an elastic bandage.

• Keep the cold pack in place continuously to maximize pain relief.

• Encourage rest of the injured area.

Answer explanation

Correct Answer:
A, B, C, E

Rationale:

• A is correct: Cold packs and elastic wraps reduce edema, bleeding, and pain. They should be applied for 30 minutes at a time to avoid ischemia.

• B is correct: Elevating the extremity helps reduce edema.

• C is correct: Neurovascular checks are essential when compression is used, to ensure adequate perfusion.

• D is incorrect: Continuous cold application can cause ischemia.

• E is correct: Rest is part of the RICE method (Rest, Ice, Compression, Elevation).