Question 1

The nurse completes postoperative discharge teaching to the parents of a child who had a tonsillectomy. Which statement by the parents indicates correct understanding of the teaching session?

Accepted Answer

Administering acetaminophen (Tylenol) for pain is an appropriate intervention for postoperative pain following a tonsillectomy. A child should not be kept on bed rest for 10 days, as this can increase the risk of complications such as blood clots. Citrus juices should be avoided as they can irritate the surgical site. Ear pain is not a common complication of tonsillectomy, although parents should contact the physician if there are any signs of bleeding, vomiting, or difficulty breathing.

Question 2

A 22-month-old child is seen in the office for reoccurring otitis media. The child weighs 25 pounds. The healthcare provider orders:
Amoxicillin 45 mg/kg/day by mouth in divided doses every 12 hours.
Medication on hand: Amoxicillin 125 mg/5 mL
Calculate how many mL/dose of amoxicillin will be given by mouth.

Accepted Answer

10.2 or 10 mL/dose

Question 3

An infant is diagnosed with acute otitis media. Which intervention is most appropriate for the nurse to teach the infant's parents?

Accepted Answer

Administering acetaminophen (Tylenol) to relieve discomfort is the most appropriate intervention for acute otitis media. Keeping the baby in a flat lying position during sleep may worsen symptoms, administering a decongestant is not typically recommended for infants, and placing a baby to sleep with a pacifier may increase the risk of developing an ear infection.

Question 4

A nurse is caring for a visually impaired school-age child. Which nursing intervention is the highest priority for this child during the admission process?

Accepted Answer

Orienting the child to where furniture is placed in the room is the highest priority for a visually impaired school-age child during the admission process as it helps them navigate and avoid accidents or injuries.

Question 5

A nurse is assessing infants for visually related developmental milestones. Which infant is showing a delay in meeting an expected milestone?

Accepted Answer

At 8 months, infants should be able to inspect and manipulate their own hands. Failure to do so may indicate a delay in vision or motor development. The other milestones listed are appropriate for their respective ages.

Question 6

A child is diagnosed with group A beta-hemolytic streptococcus (GABHS) infection of the throat. Which item will the nurse include in the teaching plan for the parents?

Accepted Answer

Completing the full course of antibiotics is essential for treating the GABHS infection and preventing potential complications such as rheumatic fever.

Answer: C 
 The child can continue normal activities as long as they are feeling well enough and not experiencing any symptoms such as fever or difficulty swallowing.

Answer: D 
 Gargling with saltwater can actually worsen the symptoms of a GABHS infection and should be avoided.

Question 7

The nurse teaches parents how to care for their child who has tympanostomy tubes inserted. Which actions by the parents indicate appropriate understanding of the teaching session? Select all that apply.

Accepted Answer

The answer of The nurse teaches parents how to care...

Question 8

The nurse suspects that an infant has a visual disorder caused by abnormal musculature. Which test will the nurse perform to detect this disorder?

Accepted Answer

A cover/uncover test is used to detect abnormal muscle movement in the eyes, which can indicate various visual disorders. It involves covering one eye while the other eye focuses on an object, then uncovering the covered eye and observing any movement or deviation of the eyes.

Question 9

A nurse is caring for a visually impaired 20-month-old who has not begun to walk. Which nursing diagnosis is the most appropriate for this client?

Accepted Answer

Delayed growth and development is the most appropriate diagnosis because the child has not begun to walk by 20 months, which is later than the typical developmental milestone for walking, indicating a delay that could be related to their visual impairment.

Question 10

A neonate has been diagnosed with a herpes simplex viral infection of the eye. Which medication will the nurse prepare to administer?

Accepted Answer

Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment are the medications of choice for a neonate with a herpes simplex viral infection of the eye. These medications can cross the blood-brain barrier and help prevent systemic dissemination of the virus. Fluoroquinolone eye drops or ointment are used for bacterial eye infections, intravenous penicillin is used for systemic bacterial infections, and oral erythromycin is used for some bacterial infections such as chlamydia.

Question 11

Which action by the nurse can assist a child who has a mild hearing loss and reads lips to adapt to hospitalization?

Accepted Answer

Touching the child lightly before speaking allows the child with a mild hearing loss who reads lips to know that the nurse is about to speak and to focus their attention on the nurse's lips for better communication. Speaking in a loud voice may not be helpful and could be uncomfortable for the child, using a picture board as the main means of communication may not be necessary for a child with mild hearing loss who reads lips, and speaking directly to the parents rather than the child does not support the child in adapting to the hospitalization.

Question 12

The child who had a tonsillectomy earlier today is now awake and tolerating fluids. The child asks for something to eat. Which food choice is most appropriate for this client?

Accepted Answer

Applesauce is the best choice for a client who has had a tonsillectomy. It is a soft and smooth food, which can reduce the chances of irritation to the throat. Other foods, like citrus fruits and juices, should be avoided as they are acidic and can be irritating to the newly healed area. Additionally, lemonade and grapefruit juice can burn the throat, which can cause discomfort and increase the risk of bleeding.

Question 13

A 2-year-old child is seen in the clinic with swelling in the eyelid, mattering and difficulty opening the eye in the morning, the healthcare provider is ordering an antibiotic for bacterial conjunctivitis. What organisms could be causing this infection? Select all that apply.

Accepted Answer

Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis are common bacterial causes of conjunctivitis in children. Pneumococcal pneumoniae is not a recognized organism for conjunctivitis.

Question 14

A nurse is planning to teach school-age children about the common cold. Which information should the nurse include in the teaching session?

Accepted Answer

Proper handwashing can help prevent the spread of the common cold, which is primarily caused by a viral infection. Vaccinations are not currently available for most strains of the common cold, and antibiotics are ineffective as they only work against bacterial infections. Aspirin is not recommended for children with viral infections due to the risk of developing Reye's syndrome.

Question 15

The nurse is caring for four clients. Which client has the highest risk of developing retinopathy of prematurity?

Accepted Answer

Premature infants who require long-term oxygen therapy are at the highest risk for developing retinopathy of prematurity. The other infants in the question either did not require oxygen or were on short-term oxygen therapy, which decreases their risk.

Question 16

A school-age child has epistaxis. Which intervention by the school nurse is the most appropriate?

Accepted Answer

Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose is the appropriate intervention for epistaxis. Tilting the head forward helps to prevent blood from flowing down the back of the throat and potentially causing vomiting. Squeezing the nares helps to apply direct pressure to the nasal septum, which can help to stop bleeding. Applying ice also helps to constrict blood vessels and stop bleeding. Tilting the head back or lying the child down could cause blood to flow into the stomach or lungs, which can be dangerous. Neo-Synephrine should only be used under the direction of a healthcare provider.

Question 17

During an admission assessment, the nurse notes that the child has impaired oral mucous membranes. Which intervention is most appropriate for the nurse to implement for this child?

Accepted Answer

Impaired oral mucous membranes can be a result of malnutrition or inadequate intake of nutrients. Therefore, promoting an adequate intake of nutrients is the most appropriate intervention to improve the child's oral mucous membranes. Administering topical analgesics, using lemon and glycerin for oral hygiene, and administering antibiotics may not be effective interventions for improving impaired oral mucous membranes.

Quiz 19: Alterations in Eye, Ear, Nose, and Throat Function