Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a preschooler who has Kawasaki disease. Which of the following findings should the nurse expect?
A. Pale conjunctiva
Pale conjunctiva is more commonly associated with anemia rather than Kawasaki disease. Children with Kawasaki disease typically present with bilateral nonpurulent conjunctival injection, meaning the eyes appear red rather than pale. Conjunctival redness is a classic diagnostic feature, while pallor is not expected.
B. Swollen lymph nodes in the groin
Swollen lymph nodes in the groin are not typical of Kawasaki disease. The characteristic lymphadenopathy usually involves unilateral enlargement of the cervical lymph nodes in the neck. Inguinal lymph node swelling would suggest another infectious or inflammatory process rather than Kawasaki disease.
C. Strawberry tongue
Strawberry tongue is a classic finding in Kawasaki disease and results from inflammation of the oral mucosa and prominent red papillae on the tongue. It is often accompanied by red, cracked lips and erythema of the mouth and throat. These mucous membrane changes are key diagnostic indicators of the condition.
D. Vesicular rash on the axilla
Vesicular rash on the axilla is not characteristic of Kawasaki disease. The rash associated with Kawasaki disease is usually polymorphous, diffuse, and nonvesicular, often appearing on the trunk and extremities. Vesicular lesions suggest other conditions such as viral infections like varicella rather than vasculitis.
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Full Explanation
Kawasaki disease is an acute systemic vasculitis that primarily affects young children, especially those under 5 years of age. It involves inflammation of medium-sized blood vessels and can lead to serious complications such as coronary artery aneurysms if not treated promptly. Classic manifestations include prolonged fever, conjunctival redness, mucous membrane changes, rash, extremity swelling, and cervical lymphadenopathy. Recognizing these characteristic findings is essential for early diagnosis and treatment.
Rationale:
A. Pale conjunctiva is more commonly associated with anemia rather than Kawasaki disease. Children with Kawasaki disease typically present with bilateral nonpurulent conjunctival injection, meaning the eyes appear red rather than pale. Conjunctival redness is a classic diagnostic feature, while pallor is not expected.
B. Swollen lymph nodes in the groin are not typical of Kawasaki disease. The characteristic lymphadenopathy usually involves unilateral enlargement of the cervical lymph nodes in the neck. Inguinal lymph node swelling would suggest another infectious or inflammatory process rather than Kawasaki disease.
C. Strawberry tongue is a classic finding in Kawasaki disease and results from inflammation of the oral mucosa and prominent red papillae on the tongue. It is often accompanied by red, cracked lips and erythema of the mouth and throat. These mucous membrane changes are key diagnostic indicators of the condition.
D. Vesicular rash on the axilla is not characteristic of Kawasaki disease. The rash associated with Kawasaki disease is usually polymorphous, diffuse, and nonvesicular, often appearing on the trunk and extremities. Vesicular lesions suggest other conditions such as viral infections like varicella rather than vasculitis.
Similar Questions
A nurse is communicating with a child who has hearing loss. Which of the following actions should the nurse take?
A. Change positions frequently to maintain the child's attention.
Changing positions frequently to maintain the child’s attention is not effective because it can be distracting and may interfere with the child’s ability to focus on visual cues such as lip reading or facial expressions. Consistency in positioning, preferably facing the child at eye level, improves communication clarity. Frequent movement can reduce comprehension rather than enhance attention.
B. Exaggerate the pronunciation of words.
Exaggerating the pronunciation of words is incorrect because it distorts natural lip movements and makes speech reading more difficult. Clear, normal articulation is more effective than overemphasized or exaggerated speech. Maintaining a natural speaking pattern allows the child to better interpret visual cues from the lips and facial expressions.
C. Use light touch when initiating conversation.
Using light touch when initiating conversation is appropriate because it helps gain the child’s attention before speaking, especially when auditory cues are limited. Gentle touch on the shoulder or arm can signal the start of communication in a respectful and non-threatening way. This supports engagement and prepares the child to focus on visual communication cues.
D. Maintain a neutral facial expression when speaking to the child.
Maintaining a neutral facial expression is incorrect because facial expressions are an important component of communication for children with hearing loss. Expressive facial cues help convey meaning, emotion, and intent, supporting better understanding. A neutral expression may reduce communication effectiveness and make messages harder to interpret.
Full Explanation
Communication with a child who has hearing loss requires the nurse to use nonverbal cues and supportive strategies to enhance understanding and engagement. Because auditory input is limited, visual, tactile, and contextual cues become essential in establishing communication. Effective interaction promotes trust, reduces anxiety, and ensures that the child receives accurate information during care. Nursing interventions should be developmentally appropriate and adapted to the child’s sensory needs.
Rationale:
A. Changing positions frequently to maintain the child’s attention is not effective because it can be distracting and may interfere with the child’s ability to focus on visual cues such as lip reading or facial expressions. Consistency in positioning, preferably facing the child at eye level, improves communication clarity. Frequent movement can reduce comprehension rather than enhance attention.
B. Exaggerating the pronunciation of words is incorrect because it distorts natural lip movements and makes speech reading more difficult. Clear, normal articulation is more effective than overemphasized or exaggerated speech. Maintaining a natural speaking pattern allows the child to better interpret visual cues from the lips and facial expressions.
C. Using light touch when initiating conversation is appropriate because it helps gain the child’s attention before speaking, especially when auditory cues are limited. Gentle touch on the shoulder or arm can signal the start of communication in a respectful and non-threatening way. This supports engagement and prepares the child to focus on visual communication cues.
D. Maintaining a neutral facial expression is incorrect because facial expressions are an important component of communication for children with hearing loss. Expressive facial cues help convey meaning, emotion, and intent, supporting better understanding. A neutral expression may reduce communication effectiveness and make messages harder to interpret.
A nurse is caring for a school-age child who is postoperative following surgical removal of their tonsils. Which of the following manifestations should the nurse identify as a potential complication?
A. Continuous swallowing
Continuous swallowing is a key early sign of postoperative hemorrhage after tonsillectomy. Blood from the surgical site may trickle into the throat and be swallowed repeatedly, especially in children who cannot verbalize symptoms effectively. This behavior often precedes visible bleeding and requires immediate assessment and intervention.
B. Inflamed throat
Inflamed throat is an expected postoperative finding following tonsillectomy due to surgical tissue trauma. Mild to moderate throat inflammation, pain, and redness are normal during the healing process. This finding alone does not indicate a complication unless it is accompanied by signs of infection or bleeding.
C. impaired taste
Impaired taste is not a common or clinically significant complication following tonsillectomy. Temporary taste changes may occur due to swelling or discomfort, but they are not considered a warning sign of postoperative complications. This symptom is usually transient and resolves with healing.
D. Dark blood in emesis
Dark blood in emesis may indicate partially digested blood but is not as reliable or early a sign of hemorrhage as continuous swallowing. It can suggest bleeding, but it often appears after blood has accumulated in the stomach. Early detection is more effectively achieved by observing swallowing patterns and throat assessment rather than waiting for emesis.
Full Explanation
Postoperative care following a tonsillectomy focuses on monitoring for complications such as hemorrhage, airway obstruction, and dehydration. Because the surgical site is highly vascular, bleeding is the most serious early complication. Children may swallow blood instead of spitting it out, making subtle signs of hemorrhage especially important to detect. Nurses must closely observe for early indicators of bleeding and airway compromise to ensure prompt intervention.
Rationale:
A. Continuous swallowing is a key early sign of postoperative hemorrhage after tonsillectomy. Blood from the surgical site may trickle into the throat and be swallowed repeatedly, especially in children who cannot verbalize symptoms effectively. This behavior often precedes visible bleeding and requires immediate assessment and intervention.
B. Inflamed throat is an expected postoperative finding following tonsillectomy due to surgical tissue trauma. Mild to moderate throat inflammation, pain, and redness are normal during the healing process. This finding alone does not indicate a complication unless it is accompanied by signs of infection or bleeding.
C. Impaired taste is not a common or clinically significant complication following tonsillectomy. Temporary taste changes may occur due to swelling or discomfort, but they are not considered a warning sign of postoperative complications. This symptom is usually transient and resolves with healing.
D. Dark blood in emesis may indicate partially digested blood but is not as reliable or early a sign of hemorrhage as continuous swallowing. It can suggest bleeding, but it often appears after blood has accumulated in the stomach. Early detection is more effectively achieved by observing swallowing patterns and throat assessment rather than waiting for emesis.
A nurse is caring for a school-age child who has a new prescription for Buck's traction. Which of the following actions should the nurse take?
A. Adjust the weights to allow the child to turn.
Adjusting the weights to allow the child to turn is incorrect because the traction system must remain continuous and properly aligned at all times. Weights should hang freely without interference to maintain consistent traction force. Altering or adjusting weights can disrupt alignment and compromise treatment effectiveness.
B. Perform pin care every 24 hr.
Performing pin care every 24 hours is incorrect because Buck’s traction is a skin traction system and does not involve pins. Pin care is only required for skeletal traction where pins are inserted into bone. Since Buck’s traction uses straps and adhesive, pin care is not applicable.
C. Ensure the pulley mechanism is attached to the child' skin.
Ensuring the pulley mechanism is attached to the child’s skin is incorrect because the pulley system is not attached to the skin but to the traction frame or bed. The skin is only involved through adhesive traction materials. Attaching mechanical components to the skin would be unsafe and inappropriate.
D. Offer opioid medications frequently to reduce pain.
Offering opioid medications frequently to reduce pain is appropriate because Buck’s traction and underlying fracture can cause significant pain. Adequate pain control promotes comfort, cooperation, and effective alignment. Opioids are commonly used for moderate to severe pain in pediatric orthopedic injuries when appropriately prescribed and monitored.
Full Explanation
Buck’s traction is a form of skin traction commonly used in pediatric clients with lower extremity fractures to reduce muscle spasms, maintain alignment, and promote comfort prior to definitive treatment. It involves applying a pulling force using weights and a pulley system. Proper nursing care focuses on maintaining correct alignment, preventing complications, and ensuring adequate pain control. Because fractures and traction can cause significant discomfort, effective analgesia is an important part of care.
Rationale:
A. Adjusting the weights to allow the child to turn is incorrect because the traction system must remain continuous and properly aligned at all times. Weights should hang freely without interference to maintain consistent traction force. Altering or adjusting weights can disrupt alignment and compromise treatment effectiveness.
B. Performing pin care every 24 hours is incorrect because Buck’s traction is a skin traction system and does not involve pins. Pin care is only required for skeletal traction where pins are inserted into bone. Since Buck’s traction uses straps and adhesive, pin care is not applicable.
C. Ensuring the pulley mechanism is attached to the child’s skin is incorrect because the pulley system is not attached to the skin but to the traction frame or bed. The skin is only involved through adhesive traction materials. Attaching mechanical components to the skin would be unsafe and inappropriate.
D. Offering opioid medications frequently to reduce pain is appropriate because Buck’s traction and underlying fracture can cause significant pain. Adequate pain control promotes comfort, cooperation, and effective alignment. Opioids are commonly used for moderate to severe pain in pediatric orthopedic injuries when appropriately prescribed and monitored.