1.

The pediatric nurse specialist provides an educational session to the nursing students about
childhood communicable diseases, mumps. The pediatric nurse informs the students that which
clinical manifestation is indicative of the most common complication of this communicable disease?
1. Pain
2. Deafness
3. Nuchal rigidity
4. A red swollen testicle

Answer: 3
Rationale: The most common complication of mumps is aseptic meningitis, with the virus being
identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting.
Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a
common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it
does not occur frequently. A red swollen testicle may be indicative of orchitis. Although this
complication appears to cause most concern among parents, it is not the most common
complication. Swollen and tender salivary glands under the ears on one or both sides of the head
(parotitis) is the most common sign of the most common complication.
Priority Nursing Tip: Transmission of mumps is via direct contact or
droplet spread from an infected person.
Test-Taking Strategy: Focus on the subject, mumps and the strategic
word, most. Recalling that aseptic meningitis is the most common
complication of mumps will direct you to the correct option. Review:
mumps

2. The nurse provides home care instructions to the mother of a child with chickenpox
about preventing the transmission of the virus. Which instruction should the nurse include?

1. Isolate the child until the skin vesicles have dried and crusted.
2. Ensure that the child uses a separate bathroom for elimination.
3. Bring all household members to the clinic immediately for a varicella vaccine.
4. Ask the health care provider for a prescription for antibiotics for all household members.

Answer: 1
Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1
to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have
formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated
objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The
recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age
(first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to
the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial
infections.
Priority Nursing Tip: The skin is the first line of defense against infec
tion. Altered skin integrity can lead to a skin or systemic infection.
Test-Taking Strategy: Focus on the subject, preventing the transmission of chickenpox. Eliminate
option 4 first recalling that antibiotics are not used to treat a viral infection. Eliminate option 3
because of the word “immediately” in this option and recalling that recommended schedule for the
administration of the varicella vaccine. Next, eliminate option 2 recalling the mode of transmission of
the virus. Review: home care measures for the child with chickenpox.

3. An emergency department nurse is a member of an All-Hazards Disaster Preparedness planning

group. The group is developing a specific emergency response plan in the event that a client with
smallpox arrives in the emergency department. Which interventions should be included in the plan?
Select all that apply.
1. Isolate the client.
2. Don protective equipment immediately.
3. Notify infectious disease specialists, public health officials, and the police.
4. Lock down the emergency department and the entire hospital immediately.
5. Identify all client contacts, including transport services to the emergency department and clients in
the waiting room.
6. Administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the
emergency department waiting room immediately.

Answer: 1, 2, 3, 5
Rationale: An All-Hazards Disaster Preparedness group is a multi
faceted internal and external disaster preparedness group that establishes action plans for every
type of disaster or combination of disaster
events. In the event of emergency department exposure to a communicable disease such as
smallpox, the client would be isolated immediately and the staff would immediately don protective
equipment. The emergency department would be locked down immediately. Locking down the entire
hospital may not be necessary and infectious disease specialists and public health officials will
determine whether it is necessary to take this action. Infectious disease specialists, public health
officials, and the police are notified. All client contacts (name, addresses, telephone numbers),
including transport services to the emergency department and clients in the waiting room, would be
identified so that the public health department can follow through
on notifying and treating these individuals appropriately. Although getting the vaccine within 3 days
after exposure will help prevent the disease or make it less severe, it is unreasonable and
unnecessary to administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in
the emergency department waiting room.
Priority Nursing Tip: Smallpox is transmitted in air droplets and by handling contaminated materials
and is highly contagious.
Test-Taking Strategy: Focus on the subject, a client with smallpox in the emergency department.
Next read each option carefully, noting that the client is in the emergency department. Eliminate
option 4 because of the words entire hospital and option 6 because of the
words all hospital staff. Review: disaster preparedness guidelines and small pox.

4. The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation
room. In addition, which action should the nurse take before entering the client’s room?
1. Wash the hands.
2. Wash the hands and wear a gown and gloves.
3. Wash the hands and place a high-efficiency particulate air(HEPA)respirator over the nose and
mouth.
4. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and
nose when coughing or sneezing.

Answer: 3
Rationale: Tuberculosis is a highly communicable disease caused by Mycobacterium tuberculosis.
The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are
always thoroughly washed before and after caring for the client. Option 1 is an incomplete action.
Option 2 is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of
contaminating clothing. Option 4 is an incorrect statement because special
precautions are needed.
Priority Nursing Tip: A positive Mantoux skin test reaction does not mean that active tuberculosis is
present, but it does indicate previous exposure to tuberculosis or the presence of inactive (dormant)
disease.
Test-Taking Strategy: Focus on the subject, caring for the client with tuberculosis. Recalling the
route of transmission and the need for airborne precautions will direct you to the correct option.
Review: airborne precautions and tuberculosis.

5. A hospitalized child develops exanthema (rash) that covers the trunk and extremities. The nurse
reviews the child’s health history and notes that the child was exposed to varicella 2 weeks ago.
Which nursing intervention is most appropriate to implement?
1. Immediately admit the client to any available bed.
2. Place the child in a private room on strict isolation.
3. Assess the progression of the exanthema and report it to the health care provider.
4. Allow the child to play in the playroom until the health care provider can be contacted.

Answer: 2
Rationale: The child with undiagnosed exanthema needs to be placed on strict isolation. Varicella
causes a profuse rash on the trunk with a sparse rash on the extremities. The incubation period is 14
to 21 days. It is important to prevent the spread of this communicable disease by placing the child in
isolation until further diagnosis and treatment are made. Options 1 and 4 are inaccurate, and option
3 is not the most appropriate intervention.
Priority Nursing Tip: Varicella-zoster virus can be transmitted via direct contact, droplet(airborne)
spread, or contaminated objects.
Test-Taking Strategy: Noting the strategic words most appropriate and the subject, exposure to
varicella will direct you to option 2. This action will prevent exposure of this communicable disease to
others. Review: care of the child with varicella.

6. Which clients require contact precautions? Select all that apply.

CLIENTS
1. A child with mumps
2. A client with scabies
3. A child with streptococcal pharyngitis
4. A client with pulmonary tuberculosis
5. A child with respiratory syncytial virus (RSV)
6. A client infected with a multidrug-resistant organism

Answer: 2, 5, 6
Rationale: Contact precautions are initiated when disease transmission occurs from direct contact
with the client or his or her environment. Diseases that require the use of contact precautions include
colonization or infection with multidrug-resistant organisms, respiratory syncytial virus, shigella and
other enteric pathogens, wound infections, herpes simplex, scabies, and disseminated varicella
zoster. Clients with mumps or streptococcal pharyngitis require droplet
precautions. A client with pulmonary tuberculosis requires airborne precautions.
Priority Nursing Tip: Contact precautions require placing the client in a private room or with a
cohort client.
Test-Taking Strategy: Focus on the subject, clients who require contact precautions. Read each
client diagnosis. Determining the mode of transmission for each illness will assist in answering this
question correctly. Review: the modes of transmission for communicable diseases and the
diseases that require contact precautions.

7. The nurse is caring for a client diagnosed with brain death who is a potential organ donor. Before
approaching the family to discuss organ donation, the nurse reviews the client’s medical record for
potential contraindications to organ donation. Which finding is a contraindication to organ donation?
1. Allergy to penicillin
2. Hepatitis B infection
3. Older than 20 years old
4. History of foreign travel

Answer: 2
Rationale: A decedent who had a hepatitis B infection cannot donate organs because the organ
recipient may contract the infection. Contraindications to organ donation do not include penicillin
allergies or foreign travel. Although foreign travel increases the risk of contracting certain
communicable diseases, foreign travel alone does not constitute a contraindication. Age may or may
not be a contraindication depending on the organ involved.
Priority Nursing Tip: An individual who is at least 18 years old may indicate a wish to become a
donor on his or her driver’s license (state specific) or in an advance directive.
Test-Taking Strategy: Focus on the subject, contraindications to organ donations. Noting the word
infection in option 2 will direct you to this option. Review: the contraindications for organ donation.

8. A child is seen in the health care clinic, and testing for human immunodeficiency virus (HIV) is
performed because of the child’s exposure to HIV infection. Which home care instruction should the
nurse provide to
the parents of the child?
1. Avoid sharing toothbrushes.
2. Avoid all immunizations until the diagnosis is established.
3. Wipe up any blood spills with a rag, and allow them to air dry.
4. Wash your hands with half-strength bleach if they come in contact with the child’s blood.

Answer: 1
Rationale: Parents are instructed that toothbrushes are not to be shared. Immunizations must be
kept up to date. Blood spills are wiped up with a paper towel; the area is then washed with soap and
water, rinsed with bleach and water, and allowed to air dry. Hands
are washed with soap and water if they come in contact with blood.
Priority Nursing Tip: Human immunodeficiency virus (HIV) infects CD4 + T cells. A gradual
decrease in the count occurs, and this results in a progressive immunodeficiency. The risk for
opportunistic infections is present.
Test-Taking Strategy: Note the subject, a child exposed to HIV infection. Eliminate option 2 first
because of the closed-ended word “all.” Eliminate option 3 next on the basis of the knowledge that
blood spills must be cleaned with a bleach solution. Eliminate option 4 because bleach would be
irritating and caustic to the skin. Review: the home care instructions for the child exposed to human
immunodeficiency virus (HIV)

9. A hospitalized client with active pulmonary tuberculosis has been receiving multidrug therapy for
the past month and is being prepared for discharge. Which indicates that respiratory isolation is no
longer required and that medication therapy has been effective?
1. Stools are clay colored.
2. The Mantoux test is negative.
3. Sputum cultures are negative.
4. Nausea and vomiting have stopped.

Answer: 3
Rationale: The primary diagnostic tool for pulmonary tuberculosis is a sputum culture. A negative
culture indicates the effectiveness of treatment. Nausea, vomiting, and clay-colored stools are side
effects of the medication that is used to treat tuberculosis; their presence or absence does not
measure the therapeutic effectiveness of the medication. The Mantoux test is a screening tool rather
than a diagnostic test for tuberculosis. Because the Mantoux test indicates exposure to the
organism but not active disease, the test results will remain positive.
Priority Nursing Tip: Tuberculosis has an insidious onset and many clients are not aware of
symptoms until the disease is well advanced.
Test-Taking Strategy: Note the strategic word, effective. Remember that the absence of infectious
organisms is a desired outcome in clients with communicable diseases. The sputum is the only
diagnostic test that will determine the absence of infectious organisms. Review: pulmonary
tuberculosis

10. The home care nurse visits a child with scarlet fever who is being treated with penicillin G
potassium (Pfizerpen). The mother tells the nurse that the child has only voided a small amount of
tea-colored urine since the previous day. The mother also reports that the child’s appetite has
decreased and that
the child’s face was swollen this morning. How should the nurse interpret these new symptoms?
1. Nothing to be concerned about
2. Signs/symptoms of acute glomerulonephritis
3. Signs/symptoms of the normal progression of scarlet fever
4. Symptoms of an allergic reaction to penicillin G potassium

Answer: 2
Rationale: Scarlet fever is an infectious and communicable disease caused by group A beta-
hemolytic streptococci. The symptoms identified in the question indicate acute glomerulonephritis,
indicative of nephrotoxicity. These symptoms are not normal and should not be ignored. Although the
child is receiving penicillin G potassium, these are not symptoms of an allergic reaction.
Priority Nursing Tip: Scarlet fever is transmitted by direct contact with an infected person or droplet
spread or indirectly by contact with contaminated articles or the ingestion of contaminated milk or
other foods.
Test-Taking Strategy: Eliminate options 1 and 3 because they are
comparable or alike. From the remaining options, recalling the complications of scarlet fever and
the symptoms of a medication reaction will direct you to the correct option. Review the complications
of scarlet fever and the symptoms of acute glomerulonephritis.

11. A nursing instructor asks a nursing student to describe live or attenuated vaccines. What should
the student tell the instructor about these types of vaccines?
1. Live or attenuated vaccines contain bacterial toxins that have been made inactive by either
chemicals or heat.
2. Live or attenuated vaccines contain pathogens made inactive by either chemicals or heat.
3. Live or attenuated vaccines have their virulence (potency) diminished so as to not produce a
full-blown clinical illness.
4. Live or attenuated vaccines have been obtained from the pooled blood of many people and
provide antibodies to a variety of diseases.

Answer: 3
Rationale: Live or attenuated vaccines have their virulence (potency) diminished so as to not
produce a full-blown clinical illness. In response to vaccination, the body produces antibodies and
causes immunity to be established. Option 1 identifies toxoids. Option 2 identifies killed or inactivated
vaccines. Option 4 identifies human immune globulin.
Priority Nursing Tip: An immunocompromised individual should not receive a vaccine without first
consulting with the health care provider.
Test-Taking Strategy: Focus on the subject, live or attenuated vaccines. Noting the word live in the
question will assist you in eliminating options 1, 2, and 4. Review the different types of vaccines.

12. The nurse is performing an assessment on a 3-year-old child with chickenpox. The child’s mother
tells the nurse that the child keeps scratching at night, and the nurse teaches the mother about
measures that will prevent an alteration in skin integrity. Which statement by the mother indicates
that teaching was effective?

1. “I need to place white gloves on my child’s hands at night.”

2. “I will apply generous amounts of a cortisone cream to prevent itching.”
3. “I will give my child a glass of warm milk at bedtime to help my child sleep.”
4. “I need to keep my child in a warm room at night so that the covers will not cause my child to
scratch.”

Answer: 1
Rationale: Gloves will keep the child from causing an alteration in skin integrity from scratching.
Generous amounts of any topical cream can lead to medication toxicity. Warm milk will have no
effect on itching. A warm room will increase the child’s skin temperature and make the itching worse.
Priority Nursing Tip: Isolate high-risk children, such as children who have immunosuppressive
disorders, from a child with a communicable disease.
Test-Taking Strategy: Note the strategic word, effective. Note the subject preventing an alteration
in skin integrity in a 3-year-old child with chickenpox. Eliminate option 4 first because this action will
promote itching. Option 3 is eliminated next because it is unrelated to skin integrity. From the
remaining options, the words generous amounts in option 2 should provide you with a clue that this
option is incorrect. Review the measures related to the child with chickenpox.
Reference(s): Hockenberry, Wilson (2013), p. 424.

13. A preschooler has just been diagnosed with impetigo. The child’s mother tells the nurse, “But my
children take baths every day.” Which therapeutic response should the nurse make to the mother?

1. “You are concerned about how your child got impetigo?”

2. “There is no need to worry. We will not tell your day care provider why your child is absent.”
3. “Not only do you have to do a better job of keeping your children clean, you must also wash your
hands more frequently.”
4. “You should have seen the doctor before the wound became infected, and then you would not
have had to worry about the child having impetigo.”

Answer: 1
Rationale: By paraphrasing what the parent tells the nurse, the nurse is addressing the parent’s
thoughts. Option 1 demonstrates the therapeutic technique of paraphrasing. Options 2, 3, and 4 are
blocks to communication because they make the parent feel guilty for the child’s illness.
Priority Nursing Tip: A child with an integumentary disorder needs to be monitored for signs of a
skin infection or a systemic infection.
Test-Taking Strategy: Use therapeutic communication techniques to answer the question.
Option 1 is the only therapeutic technique, and it demonstrates paraphrasing. This is the only option
that will provide the client with an opportunity to verbalize her concerns. Options 2, 3, and 4 are
blocks to communication. Review: therapeutic communication techniques and impetigo.

14. The nurse is planning care for a child with an infectious and communicable disease. The nurse
should identify which as the primary goal?
1. The child will experience mild discomfort.
2. The public health department will be notified.
3. The child will not spread the infection to others.
4. The child will experience only minor complications.

Answer: 3
Note the strategic word, primary. The primary goal for a child with an infectious and communicable
disease is to prevent the spread of the infection to others. It is also important for the nurse to prevent
discomfort as much as possible, but this is not the primary goal based on the options provided.
Although the health department may need to be notified at some point, it is not the primary goal. The
child should experience no complications. Review: goals of care for a child with an infectious and
communicable disease.

Nursing Process: Implementation

15. The nurse in the postpartum unit checks the temperature of a client who delivered a healthy
newborn 4 hours ago. The mother’s temperature is 100.8 °F. The nurse provides oral hydration to
the mother and encourages fluid intake. Four hours later, the nurse rechecks the temperature and
notes that it is still 100.8 ° F. Which appropriate nursing action should the nurse take at this time?

1. Document the temperature.

2. Increase the intravenous fluids.
3. Notify the health care provider.
4. Continue hydration and recheck the temperature in 4 hours.

Answer: 3
Focus on the subject, a temperature of 100.8 ° F in a postpartum client. In the postpartum client, a
temperature of more than 100.4 ° F at two consecutive readings is considered febrile,
and the health care provider should be notified. Options 1, 2, and 4 are inappropriate actions at this
time. Although the nurse should document the temperature, this action delays necessary
intervention. A health care provider’s prescription is needed to increase intravenous fluids.
Continuing hydration and rechecking the temperature in 4 hours also delays necessary intervention.
Review: normal postpartum assessment finding.

16. The nurse is planning discharge teaching for a client diagnosed and treated for tuberculosis (TB).
Which instruction should be included in order to minimize the spread of TB? Select all that apply.

1. All used dishes should be sterilized.

2. Close contacts should be tested for TB.
3. Soiled tissues should be disposed of properly.
4. House isolation is required for at least 8 months.
5. The mouth should always be covered when coughing.

Answer: 2, 3, 5
Rationale: Tuberculosis is a communicable disease, and the nurse must teach the client measures
to prevent its spread. Any close contacts with the client must be tested and treated if the results of
the screening test are positive. Because it is an airborne disease, the client
must properly dispose of used tissues and needs to cover the mouth
when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of
infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the
house. Once the client is treated and results of three sputum cultures are negative, she or he will not
spread the infection.
Priority Nursing Tip: Multidrug resistant strains of tuberculosis can result from improper
compliance, noncompliance with treatment programs, or development of mutations in tubercle
bacillus; the nurse must include the importance of medication compliance when teaching the client
with tuberculosis (TB).
Test-Taking Strategy: Focus on the subject, minimizing the spread of tuberculosis. Also focusing
on the pathophysiology of TB and the associated communicability factors and risks will assist you in
answering correctly. Review: the home care principles related to tuberculosis
(TB) and airborne disease transmission precautions.

17. The nurse caring for a child diagnosed with rubeola (measles) notes that the health care provider
has documented the presence of Koplik’s spots. On the basis of this documentation, which
observation is expected?

1. Pinpoint petechiae noted on both legs

2. Whitish vesicles located across the chest
3. Petechiae spots that are reddish and pinpoint on the soft palate
4. Small, blue-white spots with a red base found on the buccal mucosa

Answer: 4
Rationale: In rubeola (measles), Koplik’s spots appear approximately 2 days before the appearance
of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa.
The spots last approximately 3 days, after which time they slough off. Options 1, 2, and 3 are
incorrect.
Priority Nursing Tip: Rubeola (measles) is transmitted via airborne particles, direct contact with
infectious droplets, or transplacental contact. The nurse must implement airborne precautions when
caring for the hospitalized client with rubeola.
Test-Taking Strategy: Eliminate options 1 and 3 first because they are comparable or alike and
address petechiae spots. Focusing on the subject of Koplik’s spots will direct you to the correct
option. Review: the presentation of Koplik’s spots and rubeola (measles).

18. The nurse is performing an assessment of a child who is to receive a measles, mumps, and
rubella (MMR) vaccine. The nurse notes that the child is allergic to eggs. Which intervention has
priority?
1. Eliminating this vaccine from the immunization schedule
2. Administering epinephrine (Adrenalin) before the administration of the MMR
3. Administering diphenhydramine (Benadryl) and acetaminophen (Tylenol) before administering the
MMR vaccine
4. Taking a careful history about the allergy and reporting this to the health care provider before
administering the MMR vaccine

Answer: 4
Rationale: Live measles vaccine is produced by chick embryo cell culture, so the possibility of an
anaphylactic hypersensitivity in children with egg allergies should be considered. The nurse should
take a thorough history of the allergy to a previous MMR and report this to the health care provider. If
this is the first MMR, the health care provider should be aware of the egg sensitivity before
administering the vaccine or any pre-injection medication.
Priority Nursing Tip: Contraindications of the measles, mumps, and rubella (MMR) vaccine include
severe allergic reaction to a previous dose or vaccine component (gelatin, neomycin, eggs),
pregnancy, or known immunodeficiency.
Test-Taking Strategy: Use the steps of the nursing process and the strategic word, priority, to
direct you to option 4. Option 1 can be eliminated first because a vaccine would not be eliminated
from the immunization schedule. Options 2 and 3 can be eliminated next, knowing that the use of
medications before a vaccine is not normal procedure. Review: the procedures related to the
administration of vaccines and the measles, mumps, and rubella (MMR) vaccine.

19. A mother of a child with mumps calls the health care clinic to tell the nurse that the child has
been lethargic and vomiting. What instruction should the nurse give to the mother?

1. To continue to monitor the child

2. That lethargy and vomiting are normal manifestations of mumps
3. To bring the child to the clinic to be seen by the health care provider
4. That, as long as there is no fever, there is nothing to be concerned about

Answer: 3
Rationale: Mumps generally affects the salivary glands, but it can also affect multiple organs. The
most common complication is septic meningitis, with the virus being identified in the cerebrospinal
fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the
health care provider.
Priority Nursing Tip: Inform the parents of a child with mumps that bed rest should be encouraged
until the parotid swelling subsides.
Test-Taking Strategy: Focus on the subject, a child with mumps who has been lethargic and
vomiting. Recalling that meningitis is a complication of mumps will direct you to option 3. Review: the
complications of mumps and the associated clinical manifestations.

20. A newborn infant receives the first dose of hepatitis B vaccine (Recombivax HB, Engerix-B)
within 12 hours of birth. The nurse instructs the mother regarding the immunization schedule for this
vaccine and should tell the mother that the second vaccine is administered at which time periods?

1. 3 years of age and then during the adolescent years

2. 8 months of age and then 1 year after the initial dose
3. 6 months of age and then 8 months after the initial dose
4. 1 to 2 months of age and then 6 months after the initial dose

Answer: 4
Rationale: The vaccination schedule for an infant whose mother tests negative for hepatitis B
consists of a series of 3 immunizations given at 0 months (birth), 1 to 2 months of age, and then 6
months after the initial dose. An infant whose mother tests positive receives hepatitis B immune
globulin (HepaGam B) along with the first dose of the hepatitis vaccine within 12 hours of birth.
Priority Nursing Tip: Immunization schedules must be followed. The nurse needs to document
immunization administration on a vaccination card for parents to maintain a record of immunizations
administered.
Test-Taking Strategy: Focus on the subject, the hepatitis B vaccine
schedule. Knowledge regarding the immunization schedule for hepatitis B vaccine is required to
answer this question. Remember that the vaccination schedule consists of a series of three
immunizations given at 0 months (birth), 1 to 2 months of age, and then 6 months after the initial
dose. Review the hepatitis B vaccine schedule if you are unfamiliar with it.

21. A child is brought to the emergency department after being bitten in the arm by a neighborhood
dog. The nurse performs a focused assessment, cleanses the wound as prescribed, and continues
to perform a thorough assessment on the child. Which is the priority question for the nurse to ask
the mother of the child?

1. “How old is the dog?”

2. “Did the dog have rabies?”
3. “Are the child’s immunizations up-to-date?”
4. “Did the dog have all of its recommended shots?”

Answer: 3
Rationale: When a bite occurs, the injury site of the bite should be cleansed carefully and the child
should be given tetanus prophylaxis if immunizations are not up-to-date. Option 3 is the priority
consideration. Options 1, 2, and 4 identify information that may have to be obtained, but are not the
priority questions. Additionally the mother may not have the answers to these questions.
Priority Nursing Tip: Always obtain an immunization history from the parent when the child is
brought to the emergency department.
Test-Taking Strategy: Note the strategic word, priority. Option 3 is the only option that focuses on
the needs of the child. Review: care of a child who receives a dog bite.

22. The parents of a child with mumps express concern that their child will develop orchitis as a
result of having mumps and ask the nurse about the signs of this complication. What should the
nurse tell the parents is a sign of this complication?
1. Fever
2. Facial swelling
3. Swollen glands
4. Difficulty urinating

Answer: 1
Rationale: Unilateral orchitis occurs more frequently than bilateral orchitis. About 1 week after the
appearance of parotitis, there is an abrupt onset of testicular pain, tenderness, fever, chills,
headache, and vomiting. The affected testicle becomes red, swollen, and tender. Atrophy, resulting
in sterility, occurs only in a small number of cases. Facial swelling and swollen glands normally occur
in mumps. Difficulty urinating is not a sign of this complication.
Priority Nursing Tip: Warmth and local support with snug, fitting underpants can be used to relieve
orchitis.
Test-Taking Strategy: Focus on the subject, orchitis. Eliminate options 2 and 3 first because they
are comparable or alike. Recalling that “-itis" indicates inflammation will direct you to option 1.
Review: the characteristics of orchitis.

22. The clinic nurse provides home care instructions to an adult client diagnosed with influenza.
Which instructions should the nurse provide to the client? Select all that apply.

1. Practice frequent hand washing.

2. Remain at home until feeling better.
3. Sneeze or cough into the upper sleeve.
4. Return in 1 week for an influenza vaccine.
 5. Take acetaminophen (Tylenol) for myalgia.
6. Completely isolate self in a room from other family members and use a separate bathroom until
feeling better.

Answer: 1, 2, 3, 5
Rationale: Influenza (commonly known as the flu) refers to an acute viral infection of the respiratory
tract. It is a communicable disease spread by droplet infection, and measures are instituted to
prevent its spread. The client is instructed to practice frequent handwashing, remain at home, and
cover the nose and mouth when sneezing and coughing. Supportive measures to relieve fever and
myalgia such as the use of acetaminophen are also encouraged. It is unrealistic to completely isolate
oneself in a room from other family members, and there is no useful reason to use a separate
bathroom because the infection is spread through droplets. Influenza immunization is administered
before the start of the “flu” season, not after developing the infection.
Priority Nursing Tip: For controlling the spread of influenza, the client is taught to sneeze or cough
into the upper sleeve on the arm rather than into the hand. Respiratory droplets on the hands can
contaminate surfaces and cause transmission to other people.
Test-Taking Strategy: Focus on the subject, the client’s diagnosis, influenza. Recalling that this
infection is spread by droplets will assist you in selecting the correct instructions. Also remember that
the influenza immunization is administered before the start of the “flu” season, not after developing
the infection. Review: home care measures for treating influenza.

Malcolm is newly assigned as a triage nurse, on his first day of work, the following clients arrive
at the ED. Which among the clients require the most rapid action to protect other clients in the
ED from infection?

A. An infant with a runny nose and whose older brother has pertussis.

 B. A travel blogger who needs tuberculosis testing after exposure to a person with TB during his
trip.

C. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg
wound infection.

D. A pregnant woman with a blister-like rash on the face and is possibly having varicella.

Correct Answer: D. A pregnant woman with a blister-like rash on the face and is possibly
having varicella.

 Option D: Chickenpox (Varicella) is transmitted by airborne and can be easily

transferred to the other clients in the emergency unit. The pregnant woman with the
rash should be isolated right away from other clients through placement in a negative-
pressure room.
 Options A and C: Droplet and contact precautions should be instituted for the clients
with pertussis and MRSA infection, but this can be done after isolating the client with
possible varicella.
 Option B: The client who has been exposed to TB does not place the other clients at
risk for infection because there are no symptoms of active TB.

24. Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests
poison, what should the parents do first?

1. Call an ambulance immediately

 2. Administer ipecac syrup
3. Punish the child for being bad
4. Call the poison control center

Correct Answer: D. Call the poison control center

 Option D: Before interviewing in any way, the parents should call the poison control
center for specific directions to avoid death or permanent disability associated with
ingestion of poisonous substances.
 Option A: The parents may have to call an ambulance after calling the poison control
center.
 Option B: Ipecac syrup is no longer used and recommended by the poison control
center.
 Option C: Punishment for being bad isn’t appropriate because the parents are
responsible for making the environment safe.

25. While working in a pediatric clinic, you receive a telephone call from the parent of a 10-year-old who is
receiving chemotherapy for leukemia. The client’s sibling has chickenpox. Which of these actions will you
anticipate taking next?

1. Administer varicella-zoster immune globulin to the client

2. Educate the parent about the correct use of acyclovir (Zovirax)
3. Prepare the client for admission to a private room in the hospital
4. Teach the parents regarding contact and airborne precaution

Correct Answer: A. Administer varicella-zoster immune globulin to the client

 Option A: Varicella-zoster immune globulin administration can prevent the

development of chickenpox in high-risk clients and will typically be prescribed.
 Options B and C: Hospitalization and acyclovir therapy may be required if the child
develops a varicella-zoster virus infection.
 Option D: Contact and airborne precautions will be implemented to prevent the
spread of infection to other children if the child develops varicella.

5.