The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

Correct Answer: B

Rationale: In this scenario, the most appropriate action is to select option B, which is to refer the child for immediate medical evaluation. This choice is correct because the child is presenting with signs of meningitis, a serious and potentially life-threatening condition that requires urgent medical attention. The presence of hyperextension of the head (opisthotonos) and pain on flexion are classic signs of meningitis in children, indicating inflammation of the meninges. Option A, asking the parent when the neck was injured, is incorrect because the symptoms described are not indicative of a neck injury but rather of a medical emergency like meningitis. Option C, continuing the assessment to determine the cause of neck pain, is inappropriate because the symptoms already suggest a serious condition that requires immediate intervention. Option D, recording head lag on the assessment record and continuing the assessment, delays critical medical care for a child who is showing signs of a potentially life-threatening condition. Educationally, this question highlights the importance of recognizing key clinical manifestations of serious conditions in pediatric patients. It emphasizes the need for prompt and appropriate action in situations where a child presents with concerning symptoms that may indicate an urgent medical issue. Understanding and responding to such signs promptly can make a significant difference in the outcomes for pediatric patients.

Correct Answer: B

Rationale: In nursing care of children, detecting strabismus early is crucial for optimal vision development. The correct answer is B) Amblyopia, a type of blindness, may result. Strabismus, if left untreated, can lead to amblyopia, where the brain starts to favor one eye over the other, causing vision loss in the weaker eye. This highlights the importance of early detection and intervention to prevent long-term visual impairment. Option A) Color vision deficit may result is incorrect because strabismus primarily affects binocular vision and eye alignment, not color vision. Option C) Epicanthal folds may develop in the affected eye is incorrect as epicanthal folds are unrelated to strabismus but are a common feature in some individuals. Option D) Corneal light reflexes may fall symmetrically within each pupil is incorrect because this statement describes a normal finding, not a consequence of strabismus. Educationally, understanding the implications of untreated strabismus emphasizes the importance of regular vision screenings in children to detect and address visual abnormalities early to promote optimal eye health and development. Nurses play a vital role in advocating for comprehensive eye exams and timely interventions to prevent complications like amblyopia.

Correct Answer: A

Rationale: The most frequently used test for measuring visual acuity is the Snellen letter chart (Option A). This test is widely recognized and utilized in clinical settings due to its simplicity and effectiveness. The Snellen chart consists of rows of letters in varying sizes, with the patient asked to read the smallest line they can see clearly from a standardized distance. This test provides a numerical measurement of visual acuity, such as 20/20 or 20/40, with 20/20 indicating normal vision. The other options (B, C, and D) are not commonly used for measuring visual acuity in the same way as the Snellen chart. The Ishihara vision test (Option B) is specifically designed for color blindness screening, not visual acuity measurement. The Allen picture card test (Option C) is used to assess visual-motor coordination and perception in children. The Denver eye screening test (Option D) is a tool for screening vision problems in children but does not measure visual acuity as precisely as the Snellen chart. In an educational context, understanding the importance of using the appropriate assessment tools for specific purposes is crucial for nursing students. Mastery of common tests like the Snellen chart is essential for accurate assessment and diagnosis in pediatric nursing care. By knowing the strengths and limitations of various tests, nurses can provide quality care and collaborate effectively with other healthcare professionals to meet the needs of pediatric patients.

Correct Answer: C

Rationale: In assessing an infant's visual acuity, it is crucial to understand the developmental milestones related to vision. Infants typically develop the ability to fixate on and follow a target between 3 to 4 months of age. At this stage, their visual system is becoming more coordinated, allowing them to track moving objects with their eyes. This ability is a key indicator of visual maturation and neurological development in infants. Option A (1 month) is incorrect because infants at this age do not yet possess the visual acuity and coordination required to fixate and follow a target accurately. Option B (1 to 2 months) is also incorrect as it falls within the same reasoning as option A. Option D (6 months) is incorrect as well because by this age, infants should have already developed the ability to fixate on and follow a target. Infants who have not achieved this milestone by 6 months may require further evaluation for potential visual or neurological issues. Understanding these developmental milestones is essential for nurses caring for infants as it allows for early detection of any visual or neurological abnormalities. By recognizing the expected age range for visual acuity development, nurses can provide appropriate interventions and referrals to support optimal infant growth and development.

Correct Answer: C

Rationale: In an otoscopic examination on an infant, the correct direction to pull the pinna is down and back (Option C). This technique is used to straighten the ear canal in infants, as their ear canals are angled differently than in adults. Pulling the pinna down and back helps to align the ear canal for better visualization and to prevent any potential injury to the infant's delicate ear structures. This direction also helps in opening up the ear canal for a clearer view of the tympanic membrane. The other options (A) Up and back, (B) Up and forward, and (D) Down and forward are incorrect because pulling the pinna in those directions can lead to a more acute angle of the ear canal, making it harder to visualize the tympanic membrane and potentially causing discomfort or harm to the infant. Educationally, understanding the correct technique for an otoscopic examination in infants is crucial for nursing students to provide safe and effective care. It ensures proper assessment of the ear structures and helps prevent complications that may arise from incorrect manipulation of the pinna. Practicing and mastering this skill is essential for pediatric nursing care.