The nurse is giving pre-op instructions to a 14 yr old female scheduled for surgery to correct a spinal curvature. Which stmt best demonstrates that leaning has taken place?
“I understand that I will be in a body cast and I will show you how you taught me to turn”
To take the v/s of a 4 month old, which ordered will give the most accurate results?
RR – HR – rectal temp
During routine screening at a school clinic, an otoscope exam reveals a tympanic mb that is pearly gray, slightly bulging, and not movable. What action should the nurse take next?
Ask the child if they have had a cold, runny nose, or any ear pain lately
Which restraint should be used for a toddler after a cleft palate repair?
Elbow
What pre-op nsg intervention should be included in the POC for an infant w/ pyloric stenosis?
Observe for projectile vomiting
(remember that projectile vomiting leads to metabolic alkalosis)
A 6 month old returns from surgery w/ elbow restraints in place. What nsg care should be included when caring for any restrained child?
Remove the restraints one at a time and provide ROM exercises
(Removing them 1 at a time is safer than all at once)
A 2 yr old w/ Down syndrome is brought to the clinic for his regular physical exam. The nurse knows which problem is requently associated w/ Downs?
Congenital heart disease
(CHD is the most common associated defect w/ Downs. – also, remember Professor Moore said that heart and ear problems go hand in hand)
When assessing a child w/ asthma, the nurse should expect intercostal retractions during
Inspriation
When planning the care for a child who has had a cleft lip repair, the nurse know that crying should be minimized because it
Stresses the suture line
A full-term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which sx’s is this newborn likely to have exhibited?
Choking , coughing, and cyanosis
(this answer includes the 3 “C”s of esophageal atresia caused by the overflow of secretions to the trachea)
Which behavior would the nurse expect a 2 yr old to exhibit?
Display possessiveness of toys
(they are egocentric and unable to share w/ others)
the other of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he has a tummy ache. After reminding her to check the label of all OTC meds for the presence of ASA, which instruction should the nurse include when replying to the mom’s question?
Do not give if they have chicken pox, the flue, or any other viral illness
(ASA can cause Reye’s syndrome)
the nurse observes a 4 yr old boy in a daycare. Which behavior should the nurse consider normal for this child?
Demonstrates aggressiveness by boasting when telling a story
A burned child is brought to the ER. In estimating the % of body burned, the nurse uses a modified “Rule of Nines.” Which part of the body is calculated as a larger % of total body surface than an adult?
Head and neck
(a child’s head and neck are proportionately larger to their body than an adult’s)
The nurse receives a lab report stating a child w/ asthma has a theophylline level of 15mcg/dL. What action will the nurse take?
Pass the info on in the report
(therapeutic level is 10-20)
A 12 month old is admitted w/ a respiratory infection and possible pneumonia. He is placed in a mist tent w/ O2. Which nsg intervention has the greatest priority?
Have a bulb syringe readily available to remove secretions
(patent airway has the highest priority. Humidification will liquefy the nasal secretions – thereby increasing the amt of secretions and making that a priority)
All of the following interventions can be used to eval the effectiveness of nsg and medical interventions used to tx diarrhea. Which intervention is the least useful in the nurse’s eval of a 20 month old child?
Assessing the fontanels
(Weighing diapers, checking skin turgor, and observing mucous mb’s for moisture evaluate fluid status in infants. But how old is this child? Posterior fontanel closes at 2 months and anterior closes by 18 months)
A 5 month old is admitted to the hospital w/ vomiting and diarrhea. The dr. prescribes dextrose 5% and 0.25% NS w/ 2 mEq KCl/ 100ml to be infused at 25mL/hr. Prior to initiating the infusion, the nurse should obtain which assessment finding?
Serum BUN and creatinine levels
(Regardless of the age, adequate renal fxn must be present b/f adding K+ IVF)
The nurse is assigning care for a 4 yr old w/ otitis media and is concerned about the child’s increasing temp over the last 24 hrs. When planning care for this child, it is important for the nurse to consider that
a tympanic measurement of temp will provide the most accurate reading
(A tympanic mb sensor is an excellent site because both the eardrum and hypothalamus (temp regulating center) are perfused by the same circulation. the sensor is unaffected by the cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for mgmt -sterile procedures should be assigned to licensed personnel. Mgmg skills be be tested on the NCLEX. An RN is not required)
The nurse is assessing an 8 month old who has a medical dx of Tetrology of Fallow. Which sx is this client likely to exhibit?
Clubbed fingers
OF is a cyanotic defect, it causes clubbing of fingers and toes)
As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child’s fontanel finding should be reported to the HCP?
A 6 month old w/ FTT that has a closed anterior fontanel
(At 6 months of age, the anterior fontanel should be open, and it should not be closed until about 18 months old)
A preschool child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?
Concern for body integrity
(Their major stressor is concern for body integrity)
An infant is born w/ VSD and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?
Prevent the return of oxygenated blood to the lungs
(Closure of VSDs stops oxygenated blood from being shunted from the LV to the RV)
A 3 month old weighing 10 #, 15 oz has an axillary temp of 98.9F. The nurse determines the daily caloric need for him as approximately
600 calories/ day
(10# 15 oz = 10.9#. Convert # to kg and rounded to 5.
10.9/2.2=4.954 = 5kg. An infant requires 108 calories/kg/day. So, 108 * 5 = 540 cal/day. however, this infant requires 10% more because he has a one degree tempt elevation. so 10% of 540 is 54. So 540 + 54 = 594)
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include info about prevention of accidental poisonings. It is most important for her to include which instruction?
Store all toxic agents and meds in locked cabinets
A 6 month old infant w/ CHF is receiving digoxin elixer. Which observation by the nurse warrants immediate intervention?
Apical HR of 60bpm.
(A HR of 60 is much lower than normal for a 6 month old. the normal HR for a 6 month old is 80 – 150 bpm when awake and 70 when sleeping is considered WNL)
At 8:00 a.m. the UAP informs the charge nurse that a female adolescent client w/ acute glomerulonephritis has a BP of 210/110. The 4 a.m. reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take 1st?
Administer PRN nifedipine (Procardia) sl. SL Procardia lowers BP very quickly, and this should be done 1st)
A premature newborn girl, born 24 hrs ago, is dx’d w/ a PDA and placed under an O2 hood at 35%. the parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?
“The O2 hood is holding the baby’s O2 level just at the point needed. You may stroke and talk to her”
(The baby is at 35%, which is much more than RA at 21%, and at this time, the baby should not be moved from under the hood. The nurse should offer the parents an alt such as to stroke and reassure the infant)
The nurse is dvp’g a POC for a 3 yr old who is scheduled for a cardiac cath. To assist in decreasing the anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?
Give the child a ride on a gurney to visit the cardiac cath lab and meet a nurse who works there
(familiarizing the child and mom w/ the dpt will help decrease anxiety of the child and mom. 3 is a difficult age to undergo a procedure that requires cooperation. Restraints and possible sedation may be required)
When taking the health hx of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?
Cessation of growth in a child that had been normal
(Since the thyroid gland is responsible for metabolism, cessation of growth which was previously WNL is the most common sign for hypothyroidism in kids. The child w/ hypothyroidism is likely to be HYPOactive)
The nurse is teaching a 12 yr old male and his family about taking injections of GH for idiopathic hypopituitarism. Which adverse sx’s commonly associated w/ GH therapy should the nurse plan to describe to the child and family?
Polyuria and polydipsia
(s/s of diabetes or hyperglycemia need to be reported. Those receiving GH should be monitored to detect elevated sugars and glucose intolerance)
The nurse is caring for a 12 yr old w/ SIADH (syndrome of inappropriate antidiruetic hormone). this child should be carefully assessed for which complication?
Chgs in LOC
(The child must be monitored for s/s hypOnatremia, which creates secondary CNS alterations such as chgs in LOC, seizure, and coma. Fluid overload occurs w/ SIADH)
A 4 yr old girl continues to interrupt her mom during a routine clinic visit. The mom appears irritated w/ the child and asks the nurse “Is this normal behavior for a child this age?” The nurse’s response should be based on which info?
Children need to retain a sense of initiative w/out impinging on the rights and privileges of others
(children 3-6 are in Erickson’s “Initiative vs Guilt” stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children dvp a conscience and must learn to retain a sense of initiative w/out impinging on the rights of others.
1-3 yrs is shame vs doubt
3-6 yrs is initiative vs guilt
6-12 yrs is industry vs inferiority
12-18 yrs is identity vs role confusion)
The mother of a 2 yr old boy consults the nurse about her son’s increased temper tantrums. The mother states, “yesterday he threw a fit in the grocery store and I did not know what to do. I was so embarrassed. What can I do if this occurs again?” Which recommendation is best for the nurse to provide this mother?
Walk away from him and ignore the behavior
(the best approach for a toddler is to ignore the attn seeking behavior. The parent should be somewhat nearby, w/in view of the child but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs)
A 14 yr old female tells the nurse that she is concerned about the acne she has recently dvp’d. Which recommendation should the nurse provide?
Wash the hair and skin frequently w/ soap and hot water
(washing the hair and skin w/ soap and water removes oil and debris from the skin and helps prevent and tx acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne.)
During d/c teaching of a child w/ juvenile RA, the nurse should stress to the parents the importance of obtaining which dx’c testing?
Eye exams
(Visual chgs leading to blindness can occur in children w/ JRA. Regular eye exams can help to prevent this complication
A hospitalized 16 yr old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the child’s social interaction, what intervention is best for the nurse to initiate?
Arrange for an internet connection in his room for email communication
(body image and peer acceptance are key concerns for the adolescent. This allows for social interaction w/out face to face contact, thus protecting his self-image while also promoting social interaction)
The nurse is assessing a 2 yr old. What behavior indicates the child’s language dvpmt is w/in normal limits?
Capable of making 3 word sentences
(at 1-3 yrs old, they are capable of making 2-3 word senstences)
when evaluating the effectiveness of interventions to improve the nutritional status of an infant w/ gastro-esophageal reflux, which intervention is most important for the nurse to implement?
Record wt daily
(the most definitive measure of improved nutrition in an infant is obtaining the child’s daily wt)
Which menu selection by a child w/ celiac disease indicates to the nurse that they understand necessary dietary considerations?
Oven baked potato chips and cola
(Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat, and barley. The child should avoid any products containing these ingredients to avoid sx’s such as diarrhea)
The parents of a 3 wk old infant report that the child eats well but vomits after each feeding. What info is most important for the nurse to obtain?
Description of vomiting episodes in the past 24 hrs
(A decription of the vomiting episodes will assist the nurse in determining the reason for the sx’s, which may be helpful in dvp’g a POC for the infant)
A 3 month old infant dvps oral thrush. Which pharmacologic agent should the nurse plan to administer for tx of this disorder?
Nystatin (Mycostatin)
(this is an antifungal drug that is effective in tx’g thrush, an oral fungal infection)
Which class of antinfective drugs is contraindicated for use in children under 8 yrs old?
Tetracyclines
(these meds cause enamel hypoplasia and tooth discoloration in kids under 8 yrs old)
A female teenager is taking oral tetracycline HCl (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client’s teaching plan?
Use sunscreen when lying by the pool
(photosensitivity is a common s/e of tetracycline HCL. Severe sunburn can occur w/ minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen)
The mother of a 6 month old asks the nurse when her baby will get the 1st measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization, schedule published by the CDC, which response is accurate?
12-15 months
(the 1st MMR should be given no sooner than 12 months and ideally 12-15 months old.)
Preoperative nsg care for a child w/ Wilms’ tumor should include which intervention?
Put a sign on the bed reading “DO NOT PALPATE ABD”
(prevention of abd palpation minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis)
A 4 yr old boy was admitted to the ER w/ a right ulna fx and a short arm cast was applied. When preparing the parents to take the child home, which d/c instruction has the highest priority?
Call the HCP immediately if his nail beds appear blue
(cyanosis indicates impaired circulation to fingers and should be reported immediately.)
An 18 month old is admitted to the hospital w/ possible Hirschsprung’s diseas. When obtaining a nsg hx, the nurse asks about the bowel habits. What description of the disease?
Ribbon-like and brown
(this disease is a mechanical obstruction caused by inadequate motility in part of the intestines. The condition results from failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis is the affected bowel segment causes constipation and small diameter, brown colored stools)
The nurse must prevent a 2 yr old w/ severe eczema on the face, neck, and scalp from scratching the affected areas. Which nsg intervention is most effective in preventing further excoriation due to pruritis?
Place elbow restraints on the child’s arms
(elbow restraints prevent arm flexion and scratching of involved areas, but do not inhibit use of the hands for play activities
The nurse assigning care for a 5 yr old w/ otitis media is concerned about the child’s increasing temp over the past 24 hrs. Which stmt is accurate and should be considered when planning care for the remainder of the shift?
Tympanic and oral temp are equally accurate
(A tympanic mb sensor approximates core temps because the hypothalamus and eardrum are perfused circulation. Tympanic readings obtained using proper technique correlated moderately to strongly w/ oral temps in recent research studies. the sensor is unaffected by cerumen or the presence of suppurative or unsuppurative otitis media. An RN is not required to take the temp, but must assess readings received from assistive personnel
a 3 yr old boy is brought to the ER because he swallowed an entire bottle of children’s vitamin pills. Which intervention should the nurse implement 1st?
determine the child’s pulse and respirations
(the most important principle in dealing w/ a poisoning is to tx the child first, not the poison. Initiate immediate life support measures w/ assessment of v/s, in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to NG placement for lavage
A 2 yr old child w/ gastro-esophageal reflux has dvpd a fear of eating. What instruction should the nurse include in the parents’ teaching plan?
Consistently follow a set mealtime routine
(2 yr olds are comforted by consistency)
A 6 month old boy and his mother are at the HCPs office for a well baby check up and routine immunizations. the HCP recommends to the mother that the child receive an influenza vaccine. What meds should the nurse plan to administer?
All the immunizations w/ the flue vaccine given at separate site from any other injection
(At 6 months routine immunizations include Hep B, DTaP, Hib, PCV, IPV, and flu. the influenza vaccine should be given at separate site from any other injection
The nurse is assessing a 13 yr old girl w/ suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview?
“Are you experiencing any type of nervousness?”
(assessing the physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism. Wt loss (even w/ a hearty appetite) occurs in those w/ hyperthyroidism, but assessing the neurological state has a higher priority. )
The nurse is planning care for school-aged children at a community care center. Which activity is best for the children?
Playing follow-the-leader
(School-aged kids strive for independence and productivity (Erikson’s industry vs inferiority) and enjoy individual and group activities r/t real life situations, such as playing follow the leader
Surgery is being delayed for an infant w/ undescended testes. In collaboration w/ the HCP and the family, which prescription should the nurse anticipate?
A trial of human chorionic gonadrophic hormone
(A trial of HCG may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric reflex
A 3 yr old client w/ sickle cell anemia is admitted to the ED w/ abd pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis?
Sequestration
(The finding support sequestration crisis, where blood pools in the spleen, and is characterized by abd’l pain and anemia)
To assess the effectiveness of an analgesic administered to a 4 yr old, what intervention is best for the nurse to implement?
Use a happy face / sad face pain scale
(a 4 yr old can readily identify w/ simple pictures to show the nurse how they are feeling)
In dvpg a teaching plan for a 5 yr old child w/ diabetes, which component of diabetic mgmt should the nurse plan for the child to manage first?
Process of glucose testing
(dvpmt’ly, a 5 yr old has the cognitive and psychomotor skills to use a glucometer and read the number – it is especially helpful if the nurse presents this activity as a game)
A 17 yr old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. the nurse assesses his v/s: Temp 100F, Pulse 80, RR 20, and BP 122/82. what is the best action for the nurse to take?
Tell the student to proceed directly to his regularly scheduled class
The v/s of a 4 yr old child w/ polyuria are : BP 80/40;
P 118; RR 24. the child’s pedal pulses are present w/ a volume of +1 and no edema is observed. What action should the nurse implement first?
Start an IV infusion of NS
(the current v/s readings and the decreased peripheral pulse volume indicate that the child is experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume)
A 3 wk old newborn is brought to the clinic for f/u after a home birth. the mother reports that her child bottle feeds for 5 min only and then falls asleep. the nurse auscultates a loud murmur characteristic of a VSD, and finds the newborn is acyanotic w/ a RR 64. What instruction should then nurse provide the mother to ensure the infant is receiving adequate intake?
- Monitor the infant’s wt and # of wet diapers per day
- Increase the infant’s intake per feeding by 1-2 oz per week
- Allow the infant to rest and refeed on demand or every 2 hrs
- Use a softer nipple or increase the size of the nipple opening
(Neonates who have VSD may fatigue quickly during feeding and ingest inadequate amts. They should be monitored for wt gain at least 6 wet diapers/day. A 1 month old infant should ingest 2-4 oz of formula per feeding and progress to about 30 uz / day by 4 months of age. Due to fatigue, the infant should rest, but feed at least q2h to ensure adequate intake. A softer preemie nipple or a larger slit in the nipple helps to reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more w/ less effort )
When discussing discipline w/ the mother of a 4 yr old child, the nurse should include which guideline?
Parental control should be consistent
(Discipline should be a positive and necessary component of childrearing that is started in infancy and should teach socially acceptable behavior, help children protect themselves from danger, and channel undesirable behavior into constructive activity. Misbehavior may result from inconsistent rules or messages, so parental attn should be clear, reasonable, and consistent)
Which action by the nurse is most helpful in communicating w/ a preschool-aged child?
Use a doll to play and communicate
(Communicating thru play w/ a doll or other toy gives time for the child to feel comfortable w/ a stranger)
The nurse is having difficulty communicating w/ a hospitalized 6 yr old child. Which approach by the nurse is most helpful in establishing communication?
engage the child thru drawing pictures
(drawing pictures is a valuable form of non-verbal communication. As the nurse and child look at the drawings, a verbal story can be told that projects the child’s thinking)
A child falls on the playground and is brought to the school nurse w/ a small laceration on the forearm. Which action should the nurse implement 1st?
Wash the wound gently w/ mild soap and water
(a small, superficial laceration to the skin should be washed gently w/ mild soap and water for several minutes, followed by thorough rinsing)
A 6 yr old is admitted to the pediatric unit after falling off a bicycle. Which interventions should the nurse implement to asst the child’s adjustment to hospitalization?
Explain hospital schedules to the child, such as mealtimes
(altered daily schedules and loss of rituals are upsetting to children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules and establishing individual schedule familiarizes the child to the hospital environment and decreases anxiety)
A 16 yr old is brought to the ER w/ a crushed leg after falling off a horse. The adolescent’s last tetanus toxoid booster was received eight yrs ago. What action should the nurse take?
Administer tetanus toxoid booster
(After the completion of the initial completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult is every 10 yrs or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. the adolescent’s injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered)
A child w/ cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?
Steatorrhea
(Steatorrhea is defined as stools w/ an abnormally high fat content that are usually foul smelling and float on water)
the clinic nurse is taking the hx for a new 6 month old client. the mother reports that she took a great deal of ASA while pregnant. Which assessment should the nurse obtain?
Type of reaction to loud noises
(Ototoxicity diminishes hearing acuity and causes sx’s of tinnitus and vertigo in older children who can express subjective sx’s, so assessing an infant’s reaction to loud noises helps to determine an infant’s risk for a hearing deficit r/t a hx of the mother taking an ototoxic drug, such as ASA while pregnant)
The nurse is giving a liquid iron prep to a 3 yr old child. Which technique should the nurse implement to engage the child’s cooperation?
Use a colorful straw
(A liquid iron prep administered thru a straw may help the child to accept the medication since young children consider drinking from a colorful straw fun)
The nurse is teaching a mother to give 4 mL of a liquid antibiotic to a 10 month old infant. Which stmt by the parent indicates a need for further teaching?
“Using a tsp will help me measure this correctly”
(the prescribed meds is 4 mL per dosage and is measured w/ the most accuracy using ayringe, so if the parent uses a tsp, which is equivalent to 5mL, further teaching is indicated)
Which growth / dvpmt characteristic should the nurse consider when monitoring the effects of a topical medication for an infant?
A thin stratum corneum that increases topical absorption
(Infants have a thin outer skin layer (stratum corneum) , so the nurse should monitor the infant for a prompt onset and response to the application of topical medication)
A 2 yr old child recently diagnosed w/ hemophilia A is discharged home. What info should the nurse include in a teaching plan about home care?
Apply pressure and ice for bleeding while elevating and resting the extremity
(Hemophilia, a blood disorder, causes joint bleeding which is treated w/ rest, ice, compression, and elevation (RICE) )
A nurse provides the parents w/ info on health maintenance for their child w/ sickle cell disease. Which info reflected by the parents indicates understanding of the child’s care?
Plenty of fluids should be consumed daily
(Adequate fluid intake decreases the viscosity of the blood which affects the incidence of vasocclusive crisis)
The nurse reviews the latest lab results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nsg dx has the highest priority for this child?
Risk for infection
(Chemo suppresses phagocytotic neutrophils and places the child at risk for infection, which is the priority nsg dx)
During administration of a blood transfusion, a child c/o chills, HA, nausea. Which action should the nurse implement?
Stop the infusion immediately and notify the HCP
(the child is exhibiting signs of a reaction to the blood transfusion. the blood transfusion should be stopped immediately and the HCP notified. AFTER the transfusion is dc’d, IV access should be maintained w/ fluids that do not introduce any more cellular products)
The nurse is teaching the parents of a 5 yr old w/ cystic fibrosis about respiratory txs. Which stmt indicates to the nurse that the parents understand?
“Administer aerosol therapy followed by postural drainage b/f meals”
(Postural drainage for a child w/ cystic fibrosis is most effective when performed after nebulization and b/f meals or at least 1 hr after eating to prevent N/V. Postural drainage uses gravity to promote mucous removal after nebulization txs which open the airways. Pulmonary toileting or respiratory txs should be give 3-4 times/day, not episodically)
The nurse is assessing the neurovascular status of a child in Russell’s traction. Which finding should the nurse report to the HCP?
Pale bluish coloration of the toes
(Russell’s traction is used for fx’s of the femur in young children and adolescents whose growth plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can compress the peroneal nerve and arteries that supply the foot. Assessment of adequate circulation, mvmt, and sensation of the toes and skin distal to the application is made to identify compromised blood flow, so cyanosis should be reported immediately)
A child is rescued from a burning house and brought to the ER w/ partial thickness burns on the face and chest. Which action should the nurse implemented 1st?
Assess the child’s respiratory status
(Assessing the airway and the respiratory status is the highest priority since burns to the face and chest place the child at risk for smoke inhalation injury and compromised airway)
the mother of a 4 yr old child asks the nurse what she can do to help her other children cope w/ their sibling’s repeated hospitalizations. Which is the best response that the nurse should offer?
Encourage the mother to have the children visit the hospitalized sibling
(Needs of a sibling will be better met w/ factual info and contact w/ the ill child, so sibling visitation should be encouraged. Parents are experts on their children and should determine when their children are old enough to visit in the hospital. Separation from family and home may intensify fear and anxiety. Children may have difficulty expressing questions, so the support of parents and other caregivers are needed to help alleviate their fears)
Which finding in a 19 yr old female client should trigger further assessment by the nurse?
Menstruation has not occurred
(Menstruation is an expected secondary sex characteristic that occurs w/ pubescence and typically occurs by age 18)
A 15 yr old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide?
Explain that menarche varies and occurs at 12-18 yrs old
Which measurements should be used to accurately calculate a pediatric medication dosage?
- Child’s ht and wt
- body surface area of a child
- Nomogram determined mathematical constant
(the most accurate calculations of pediatric dosages use the child’s ht / wt. the BSA is calculated using the square root of wt in kg multiplied by ht in cm, divided by 3600 or the square root of wt in pounds multiplied by ht in inches, divided by 3131, then the child’s BSA is multiplied by the recommended published dose per BSA)
A 9-month-old child is seen in the well clinic. Which of the following behaviors would the nurse expect to see? SATA
(A) Plays peek-a-boo
(B) Walks independently
(C) Feeds self with a spoon
(D) Stacks 2 blocks together
(E) Transfers objects from hand to hand
A, E
-walks independently at 15 months
-feeds self with spoon at 18 months
-stacks 2 blocks together at 18 months
The mother of a six-year-old child arrives at the clinic because the child has been experiencing red and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the lab. Chlamydia conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?
(A) Possible trauma to the eye
(B) Possible sexual abuse
(C) Presence of an allergy
(D) Presence of a respiratory infection
(B) Possible sexual abu