A nurse is checking a school-age child for pediculosis capitis (head lice). Which of the following findings is a definitive indication of this condition?

Itching and scratching of the head

Patchy areas of hair loss

Firmly attached white particles on the hair

Thick, yellow-crusted lesions on a red base

Answer and Explanation

The Correct Answer is C

A. Itching and scratching of the head. While itching is a common symptom, it is not a definitive sign of head lice. Other conditions (e.g., dandruff, seborrheic dermatitis, or dry scalp) can also cause itching.

B. Patchy areas of hair loss. Hair loss is not a characteristic sign of head lice. It may indicate alopecia areata or tinea capitis (scalp ringworm) instead.

C. Firmly attached white particles on the hair. The presence of nits (lice eggs) that are firmly attached to the hair shaft near the scalp is a definitive sign of pediculosis capitis. Nits do not flake off like dandruff and are difficult to remove.

D. Thick, yellow-crusted lesions on a red base. This describes impetigo, a bacterial skin infection, not head lice.

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Correct Answer is C

Explanation

A. Nasal flaring present. Nasal flaring is a separate sign of respiratory distress, but it does not describe retractions.

B. Suprasternal retractions present. Suprasternal retractions occur above the sternum, not between the ribs.

C. Intercostal retractions present. Intercostal retractions occur between the ribs and indicate difficulty breathing due to increased respiratory effort.

D. Subcostal retractions present. Subcostal retractions occur below the ribcage, not between the ribs.

A. Press the skin over the client's ankle bone. B. Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen. C. Lightly palpate the skin using the fingertips. D. Grasp a fold of skin on the client's forearm or near the sternum.

Correct Answer is D

Explanation

A. Press the skin over the client's ankle bone. Skin over the bony prominences is not ideal for assessing turgor, as it may not accurately reflect dehydration.

B. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. This describes petechiae, which is a sign of bleeding disorders, not hydration status.

C. Lightly palpate the skin using the fingertips. Palpation does not assess elasticity.

D. Grasp a fold of skin on the client's forearm or near the sternum. The best way to check for dehydration is by pinching the skin on the sternum or forearm and observing how quickly it returns to normal.

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A nurse is checking a school-age child for pediculosis capitis (head lice). Which of the following findings is a definitive indication of this condition?

Nursing Test Bank

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Correct Answer is D

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