Question

55. A nurse is caring for a 5-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage?

a. Blood pressure 95/56mmHg

b. Heart rate 54/min

c. Continuous swallowing

d. Flushing of the face

56. A nurse is assessing a school-age child’s cranial nerve function. Which of the following actions should the nurse ask the child to take when assessing the accessory nerve?

a. Show their teeth while smiling

b. Shrug their shoulders against mild pressure

c. Follow a light in the six cardinal positions

d. Move their tongue in all directions

57. A nurse in an urgent care clinic is prioritizing care for four children. Which of the following children should the nurse assess first?

a. A preschool-age child who has a muffled voice and no spontaneous cough

b. A toddler who has nephrotic syndrome and facial edema

c. A school-age child who has diabetes mellitus and a blood glucose of 200mg/dL

d. An adolescent who has crohn’s disease and a recent weight loss of 5kg (11lb)

58. A school nurse is assessing a 7-year old student. The nurse should identity which of the following findings as a potential indicator of physical abuse?

a. Bruising around the wrists

b. Front deciduous teeth missing

c. Weight in 45^th percentile

d. Abrasions on the knees

Answer 1

55.A nurse is caring for a 5 - year - old child following a tonsillectomy and adenoidectomy.

The following findings the nurse has to identify as an indication of hemorrhage is -​​​​​​

c - Continuous swallowing.

Note:

Frequent swallowing and throat clearing following tonsilectomy and adenoidectomy are the typical signs which indicates bleeding at operated site.

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56.A nurse is assessing a school age childs cranial nerve function.The following actions should the nurse ask the child to take when assessing the accessory nerve is -

b.shrugg their shoulders against mild pressure.

Note:

a.show their teeth while smiling - VII th cranial nerve (Facial Nerve) assessment.

c.Follow a light in the six cardinal positions - VI th cranial nerve( Abducence).

d.Move their tongue in all directions- XII th cranial nerve (Hypoglossal )Assessment.

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57.A nurse in urgent care clinic is prioritizing care for four children.

The following child should be assessed first by the nurse -

a.A preschool age child who has a muffed voice and no spontaneous cough.

Note:

Muffed voice and no spontaneous cough are the classical signs of epiglottitis,which is an true medical emergency as the inflammed,swollen epiglottis causes block for air entry into lungs.

b. A toddler who has nephrotic syndrome and facial edema, c. A school-age child who has diabetes mellitus and a blood glucose of 200mg/dL, d. An adolescent who has crohn’s disease and a recent weight loss of 5kg (11lb) are not the medical emergency which needs urgent care.

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58.A school nurse is assessing a 7 year old student .The nurse should identify the following finding as a potential indicator of physical abuse-

a.Bruishing around the wrists.

Note:

Unexplained bruishing around the wrist is the potential indicator of physical abuse.

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