A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention?
Apical heart rate of 60.
Sweating across the forehead.
Doesn’t suck well.
Respiratory rate of 30 breaths per minute.
Apical heart rate of 60.
A heart rate of 60 (A) is much lower than normal for a 6-month-old and warrants immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM when awake, and a rate of 70 while sleeping is considered within normal limits. (B and C) are expected symptoms of heart failure in an infant. (D) is within normal limits for an infant.
The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand?
Perform postural drainage before starting aerosol therapy.
Give respiratory treatments when the child is coughing a lot.
Administer aerosol therapy followed by postural drainage before meals.
Ensure respiratory therapy is done daily during any respiratory infection.
Administer aerosol therapy followed by postural drainage before meals.
Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and before meals (C) or at least 1 hour after eating to prevent nausea and vomiting. Postural drainage uses gravity to promote mucous removal after nebulization (A) treatments which open the airways. Pulmonary toileting or respiratory treatments should be given 3 to 4 times daily, not episodically (B and D).
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.
Cleanse the skin at least 4 times a day.
Take the medication with a glass of milk.
Menstrual periods may become irregular.
Use sunscreen when lying by the pool.
Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) therapy. Severe sunburn can occur with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen (A). (B and D) are not related to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy products interfere with the absorption of tetracyclines.
What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?
Monitor for signs of metabolic acidosis.
Estimate the quantity of diarrhea stools.
Place in a supine position after feeding.
Observe for projectile vomiting.
Observe for projectile vomiting.
Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the classic sign of pyloric stenosis. (B) is not indicated. (C) is dangerous, due to the potential for aspiration with frequent vomiting.
An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?
Stop the flow of unoxygenated blood into systemic circulation.
Increase the flow of unoxygenated blood to the lungs.
Prevent the return of oxygenated blood to the lungs.
Reduce peripheral tissue hypoxia and nailbed clubbing
Prevent the return of oxygenated blood to the lungs.
Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.)
A. Monitor the the infant’s weight and number of wet diapers per day.
B. Increase the infant’s intake per feeding by 1 to 2 ounces per week.
C. Mix the dose of prophylactic antibiotic in a full bottle of formula.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening.
A. Monitor the the infant’s weight and number of wet diapers per day.
B. Increase the infant’s intake per feeding by 1 to 2 ounces per week.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening.
Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is consumed.
They should be monitored for weight gain and at least 6 wet diapers per day (A). A one-month old infant should ingest 2 to 4 ounces of formula per feeding and progress to about 30 ounces per day by 4-months of age (B)
Preoperative nursing care for a child with Wilms’ tumor should include which intervention?
Gently percuss the abdomen for evidence of trapped air.
Observe the abdomen for any noticeable discolorations.
Apply cold compresses to the abdomen to reduce edema.
Put a sign on the bed reading, “DO NOT PALPATE ABDOMEN.”
Put a sign on the bed reading, “DO NOT PALPATE ABDOMEN.”
Prevention of abdominal palpation (D) minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis. (A) is unnecessary, and this action could traumatize the tumor in the same manner as palpation. (B and C) are incorrect since the abdomen is not discolored and cold compresses are not indicated.
At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure 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 first?
Give the client her 9 a.m. prescription for an oral diuretic early.
Administer PRN prescription of nifedipine (Procardia) sublingually.
Notify the healthcare provider and inform the nursing supervisor of the client’s condition.
Attempt to calm the client and retake the blood pressure in thirty minutes.
Administer PRN prescription of nifedipine (Procardia) sublingually.
Sublingual Procardia (B) lowers blood pressure very quickly, and this should be done first. (A) may also be done, but oral diuretics do not work as rapidly as the sublingual antihypertensive. When notifying the healthcare provider, the first thing he/she will want to know is if the PRN antihypertensive has been administered (C). (D) does not consider the seriousness of this finding. The nurse should stay with the client until the blood pressure is reduced.
The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit?
Bradycardia.
Machinery murmur.
Weak pedal pulses.
Clubbed fingers.
Clubbed fingers.
Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of congenital heart disease. (B) is a classic sign of ventricular septal defect. (C) is characteristic of coarctation of the aorta.
Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate?
A trial of adrenocorticotrophic hormone injections.
Frequent stimulation of the cremasteric reflex.
A trial of human chorionic gonadotrophic hormone.
Frequent warm baths to gently dilate the scrotal area.
A trial of human chorionic gonadotrophic hormone.
A trial of HCG (human chorionic gonadotrophic hormone) (C) 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) is not indicated. Stimulation of the cremasteric reflex causes the testes to ascend rather than descend in the scrotum (B). (D) may relax the cremasteric muscle, but may not cause the testes to descend.
A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?
Ability to communicate verbally.
Response to separation from family.
Concern for body integrity.
Socialization with other children.
Concern for body integrity.
The preschooler’s major stressor is concern for his body integrity (C). He fears that his “insides will leak out.” A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most concern to the toddler. (D) is not a prime concern in this situation.
A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child?
Keep restraints on at all times.
Remove restraints one at a time and provide range of motion exercises.
Remove all restraints simultaneously and provide play activities.
Renew the healthcare provider’s prescription for restraints every 72 hours.
Remove restraints one at a time and provide range of motion exercises.
Removing restraints one at a time (B) is safer than removing all of them at once (C). The child needs to exercise and should not be kept in restraints at all times (A). The renewal of the healthcare provider’s prescription varies with hospitals (D), and it does not really answer the question.
All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse’s evaluation of a 20-month-old child?
Weighing diapers.
Assessing fontanels.
Checking skin turgor.
Observing mucous membranes for moisture.
Assessing fontanels.
All of these interventions evaluate fluid status in infants. But, how old is this child? Posterior fontanel closes at 2 months and anterior fontanel closes by 18 months of age (B)! Remember normal growth and development!
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 healthcare provider?
A 6-month-old with failure to thrive that has a closed anterior fontanel.
A 24-month-old with gastroenteritis that has a closed posterior fontanel.
A 2-month-old with chickenpox that has an open posterior fontanel.
A 28-month-old with hydrocephalus that has an open anterior fontanel.
A 6-month-old with failure to thrive that has a closed anterior fontanel.
At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. (B and C) are normal findings. A child with hydrocephalus may have a delayed closing of the fontanel (D).
The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take?
Pass the information on in the report.
Notify the healthcare provider because the value is high.
Repeat the lab study because the value is too high.
Hold the next dose of theophylline.
Pass the information on in the report.
The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child’s level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse’s report (A). (B, C, and D) would be inappropriate actions in view of the laboratory finding.
The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?
Engage the child through drawing pictures.
Suggest that the parent read a book to the child.
Provide paper and pencil for the child to keep a diary.
Ask the parent if the child is always uncommunicative.
Engage the child through drawing pictures.
Drawing pictures (A) 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. (B) may distract the child, but does not establish communication with the nurse. (C) is useful for an older child who is able to write. (D) is important, but engaging the child is more effective in establishing communication patterns.
The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication?
Poor skin turgor resulting from dehydration.
Changes in level of consciousness.
Premature aging as the disease progresses.
Severe edema from an excess of water and sodium.
Changes in level of consciousness.
The child must be monitored for signs and symptoms of hyponatremia, which creates secondary central nervous system alterations such as changes in level of consciousness, seizure, and coma (B). Fluid overload occurs with SIADH, not (A) (which occurs with diabetes insipidus). (C) is caused by hypersecretion of growth hormone, not SIADH. (D) is not found in children with SIADH because edema is caused by an excess of both water and sodium.
The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child’s increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that
A. Only an RN should be assigned to monitor this child’s temperature. Incorrect
B. A tympanic measurement of temperature will provide the most accurate reading.
C. The licensed practical nurse should be instructed to obtain rectal temperatures on this child.
D. The healthcare provider should be asked to prescribe the method for measurement of the child’s temperatures.
B. A tympanic measurement of temperature will provide the most accurate reading.
(B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management–sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less accurate because of the possibility of stool in the rectum. (D) is unnecessary.
A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children’s vitamin pills. Which intervention should the nurse implement first?
Insert N/G tube for gastric lavage.
Determine the child’s pulse and respirations.
Assess the child’s level of consciousness.
Administer an IV D5/0.25 NS as prescribed.
Determine the child’s pulse and respirations.
The most important principle in dealing with a poisoning is to treat the child first, not the poison. Initiate immediate life support measures with assessment of vital signs (B), in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to (A). (C and D) should occur after assessing the airway.
To take the vital signs of a 4-month-old child, which order provides the most accurate results?
Respiratory rate, heart rate, then rectal temperature.
Heart rate, rectal temperature, then respiratory rate.
Rectal temperature, heart rate, then respiratory rate.
Rectal temperature, respiratory rate, then heart rate.
Respiratory rate, heart rate, then rectal temperature.
The respiratory rate should be taken first (A) in infants, since touching them or performing unpleasant procedures usually makes them cry, elevating the heart rate and making respirations difficult to count (B). Rectal temperature is the most invasive procedure, and is most likely to precipitate crying, so should be done last (C and D).
The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain?
Description of vomiting episodes in past 24 hours.
Number of wet diapers in last 24 hours.
Feeding and sleep schedule.
Amount of formula consumed during the past 24 hours.
Description of vomiting episodes in past 24 hours.
A description of the vomiting episodes (A) will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant. (B and C) provide related information but are not as helpful as (A). (D) may be related to the vomiting, but the nurse should first obtain a better description of the vomiting episodes.
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
Frequency of emesis in the last 8 hours.
Serum BUN and creatinine levels.
Current blood sugar level.
Appearance of the stool.
Serum BUN and creatinine levels.
Regardless of a client’s age, adequate renal function must be present before adding potassium to IV fluids (B). (A) is important in determining the need for fluid replacement. (C) is not indicated. (D) is useful information, but will not impact administration of the prescribed IV solution.
Which finding in a 19-year-old female client should trigger further assessment by the nurse?
Menstruation has not occurred.
Reports no tetanus immunization since childhood.
Denies having any wisdom teeth.
History of painful, inward growth on bottom of foot.
Menstruation has not occurred.
Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically occurs by age 18, so (A) should prompt further investigation to determine the cause of this primary amenorrhea. Children receive tetanus as part of the DPT childhood immunization series, and a booster is not typically given until age 16 (B). Wisdom teeth are the third molar teeth of the permanent dentition and are the last to erupt, so (C) is a normal finding. (D) describes a plantar surface wart, harmless but painful because of the pressure with walking or standing.
The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child’s cooperation?
Use a colorful straw.
Mix the medication in water.
Administer the medication using an oral syringe.
Ask the pharmacy to provide an enteric tablet.
Use a colorful straw.
A liquid iron preparation administered through a straw may help the child to accept the medication since young children consider drinking from a colorful straw fun (A). (B) may cause staining of the child’s teeth. (C) is often used if the child is uncooperative. (D) is ineffective and should be requested from the healthcare provider.
When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement?
Record weight daily.
Assess for signs of anemia.
Document sleeping patterns.
Teach parenting skills.
Record weight daily.
The most definitive measure of improved nutrition in an infant is obtaining the child’s daily weight (A). (B, C, and D) may also be useful, but they are not as definitive as a daily weight measurement.
A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The nurse determines the daily caloric need for this child is approximately
400 calories per day.
500 calories per day.
600 calories per day.
700 calories per day.
600 calories per day.
10 lbs 15 oz = 10.9 lbs. Convert lbs to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954 kg, rounded to 5 kg. An infant requires 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day. Tough question! You know that 400 calories are too few and 700 are too much, and a temperature elevation necessitates consumption of more calories, so choose the higher of the two choices left!
Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.)
Child’s height and weight.
Adult dosage of medication.
Body surface area of child.
Average adult’s body surface area.
Average pediatric dosage of medication.
Nomogram determined mathematical constant.
Child’s height and weight.
Body surface area of child.
Nomogram determined mathematical constant.
Correct selections are (A, C, and F). The most accurate calculations of pediatric dosages use the child’s height and weight (A). The child’s BSA is calculated using the square root of weight in kg times height in cm divided by 3600 or the square root of weight in lb times height in inches divided by 3131 (C), then the child’s BSA is multiplied by the recommended published dose per BSA. The nomogram (F) is used to plot the child’s height and weight, and the point at which they intersect is the BSA mathematical constant used to calculate the child’s dose. (B, D, and E) are not used to calculate pediatric dosages.
The nurse is assessing a 2-year-old. What behavior indicates that the child’s language development is within normal limits?
Is able to name four colors.
Can count five blocks.
Is capable of making a three word sentence.
Half of child’s speech is understandable.
Half of child’s speech is understandable.
Between approximately 15 and 24 months of age, a child’s speech is only half understandable (D). (A and B) usually occur between 3 and 5 years of age. (C) is usually accomplished by 18 months of age.
The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?
Risk for infection.
Risk for hemorrhage.
Altered skin integrity.
Disturbance in body image.
Risk for infection.
Chemotherapy (CT) suppresses phagocytotic neutrophils and places the child at risk for infection (A), which is the priority nursing diagnosis. (B, C, and D) may be related to the care of a child receiving CT are not related to neutropenia.
A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?
Slowly pour hydrogen peroxide over the open wound.
Apply ice to the area before rinsing with cold water.
Wash the wound gently with mild soap and water.
Gently cleanse with a sterile pad using povidone-iodine.
Wash the wound gently with mild soap and water.
A small, superficial laceration to the skin should be washed gently with mild soap and water (C) for several minutes, followed by thorough rinsing. (A and D) are antiseptics that can be traumatic (painful) when cleaning fresh, open wounds. Applying ice (B) may reduce or prevent further edema, but the wound should be washed with mild soap and water first.
The nurse observes a 4-year-old boy in a daycare setting. Which behavior would the nurse consider normal for this child?
Has a temper tantrum when told he must share his toys.
Plays by himself most of the day.
Demonstrates aggressiveness by boasting when telling a story.
Begins to cry and is fearful when separated from his parents.
Demonstrates aggressiveness by boasting when telling a story.
Four-year-old children are aggressive in their behavior and enjoy “tale telling” (C). Behaviors in (A and D) are typical of toddlers. The play of a preschooler is cooperative, so playing alone (B) is not typical.
The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?
Reassure the parents that 3-year-olds are cooperative and therefore are less likely to be anxious.
Obtain a video film of a cardiac catheterization to show to the child prior to the procedure.
Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.
Obtain a cardiac catheter and demonstrate the procedure by pretending to put the catheter in a doll or stuffed animal.
Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.
Familiarizing the child and mother with the department (C) will help decrease anxiety of the child and mother (who may have more anxiety than the child). Three is a difficult age to undergo a procedure that requires cooperation. Restraints and possibly sedation may be required (A). At three, the child is too young to understand why this must be done, and (B) is not indicated. (D) is also not indicated because it is likely to be interpreted as painful.
A 6-month-old boy and his mother are at the healthcare provider’s office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today?
The routine immunizations and schedule another appointment to administer the influenza vaccine. Incorrect
All the immunizations with the influenza vaccine given at a separate site from any other injection.
The influenza vaccine and schedule another appointment to administer the immunizations.
The influenza vaccine and the polio vaccine and schedule another appointment to administer the remaining immunizations.
All the immunizations with the influenza vaccine given at a separate site from any other injection.
At 6-months of age, the routine immunizations include Hepatitis B, DTaP, Hib (Haemophilus influenza type b), PCV (Pneumococcal), IPV (inactivated poliovirus) and influenza. The influenza vaccine should be given at a separate site from any other injection (B). Scheduling a return visit (A, B, or C) increases the risk that the mother will not bring the child back for the immunizations.
When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline?
Parental control should be consistent.
Children as young as 4 years rarely need reprimand or punishment.
Withdrawal of approval is effective.
Parents should enforce rigid rules to be followed without question.
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 attention should be clear, reasonable, and consistent (A). (B and C) are not helpful to the child. Children need boundaries that are firm but not rigid (D).
The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching?
I will give this antibiotic to my child until it is finished.
Using a teaspoon will help me measure this correctly.
I will call the clinic if my child develops a rash or itching.
My baby should begin to feel better within a few days.
Using a teaspoon will help me measure this correctly.
The prescribed medication is 4 ml per dosage and is measured with the most accuracy using a syringe, so if the parent uses a teaspoon (B), which is equivalent to 5 ml, further teaching is indicated. (A, C, and D) indicate correct understanding and require no further intervention by the nurse.
The nurse is planning care for school-aged children at a community care center. Which activity is best for the children?
Building model airplanes.
Playing follow-the-leader.
Stringing large and small beads.
Playing with Playdough and clay.
Playing follow-the-leader.
School-aged children strive for independence and productivity (Erikson’s Industry vs. Inferiority) and enjoy individual and group activities related to real-life situations, such as playing follow-the-leader (B). (A) is an individual activity that could contribute to feelings of inferiority and inadequacy if the task is too complex. Although school-aged children enjoy crafts, (C and D) are more appropriate for pre-school children.
To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?
Use a happy-face/sad-face pain scale.
Ask the mother if she thinks the analgesic is working.
Assess for changes in the child’s vital signs.
Teach the child to point to a numeric pain scale.
Use a happy-face/sad-face pain scale.
A 4-year-old can readily identify with simple pictures (A) to show the nurse how he/she is feeling. (B) could be used to validate what the child is telling the nurse via the “faces” pain scale, but it is best to elicit the child’s assessment of his/her pain level. (C) may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables, such as fear. (D) requires abstract number skills beyond the level of a 4-year-old.
A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, “Is this normal behavior for a child this age?” The nurse’s response should be based on which information?
Children need to retain a sense of initiative without impinging on the rights and privileges of others.
Negative feelings of doubt and shame are characteristic of 4-year-old children.
Role conflict is a common problem of children this age. She is just wondering where she fits into society.
At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.
Children need to retain a sense of initiative without impinging on the rights and privileges of others.
Children aged 3 to 6 are in Erickson’s “Initiative vs. Guilt” stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others (A). (B) describes the “Autonomy vs. Shame and Doubt,” stage (1 to 3 years of age). (C) describes an adolescent (12 to 18 years of age), the “Identity vs. Role Confusion” stage. (D) describes a child 6 to 12 years of age, the “Industry vs. Inferiority” stage.
A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?
Insert an indwelling urinary catheter.
Administer IV pain medication.
Collect blood specimen for laboratory studies.
Assess the child’s respiratory status.
Assess the child’s respiratory status.
Assessing the airway and the respiratory status is the highest priority (D) since burns to the face and chest place the child at risk for smoke inhalation injury and compromised airway. (A, B, and C) are implemented after (D).
A 17-year-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 vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?
Tell the student to proceed directly to his regularly scheduled class.
Call the parent and suggest re-taking the student’s temperature at home.
Give the student a glass of cool fluids, then retake his temperature.
Send the student to class, but re-verify his temperature after lunch.
Tell the student to proceed directly to his regularly scheduled class.
This student has just completed football practice, and increased muscle activity increases body heat production. A temperature of 100° F is normal for this student at this time. The student should attend class (A) since no further nursing action is required. (B) would alarm the parents unnecessarily. (C) would provide a false reading of body temperature. (D) is unnecessary since these findings are within normal limits.
A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child’s adjustment to hospitalization?
Explain hospital schedules to the child, such as mealtimes.
Use terms, such as “honey” and “dear,” to show a caring attitude.
Provide a list of rules that limits visitation of siblings in the hospital.
Orient the parents to the hospital unit and refreshment areas.
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 (A) and establishing an individual schedule familiarizes the child to the hospital environment and decreases anxiety. (B) depersonalizes the child who should be addressed by name. Family and sibling visitation should be recommended and encouraged without limitation (C). Although (D) should be implemented, the direct involvement of the school-aged child incorporates the child’s sense of initiate and cooperation.
The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?
I will read all the literature you gave me before surgery.
I have had surgery before when I broke my wrist in a bike accident, so I know what to expect.
All the things people have told me will help me take care of my back.
I understand that I will be in a body cast and I will show you how you taught me to turn.
I understand that I will be in a body cast and I will show you how you taught me to turn.
Outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration (D). A 14-year-old may or may not follow through with (A), and there is no measurement of that learning. Having previous surgery (B) may help the client understand the surgical process, but wrist surgery is very different from spinal surgery and emergency surgery is different from elective surgery. In (C), the client may be saying what the nurse wants to hear, without expressing any real understanding of what to do after surgery.
A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified “Rule of Nines.” Which part of a child’s body is calculated as a larger percentage of total body surface than an adult’s?
Head and neck.
Arms and chest.
Legs and abdomen.
Back and abdomen.
Head and neck.
A child’s head and neck are proportionately larger to their body than an adult’s (A). The standard “Rule of Nines” is inaccurate for determining burned body surface areas with children, and must be modified for use with children. Specially designed charts for children are commonly used to determine body surface area involvement. (B, C, and D) are not proportionately different.
A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?
Ability to communicate verbally.
Response to separation from family.
Concern for body integrity.
Socialization with other children.
Concern for body integrity.
The preschooler’s major stressor is concern for his body integrity (C). He fears that his “insides will leak out.” A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most concern to the toddler. (D) is not a prime concern in this situation.
A nurse who is working in the Poison Control Center receives several telephone calls from parents whose children have ingested possible poisons. The nurse should recommend inducing vomiting for which child?
8-month-old who ate 4 to 6 ibuprofen tablets.
3-year-old who drank an unknown amount of charcoal lighter fluid.
16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir.
2-year-old who ate a handful of automatic dishwasher detergent.
16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir.
Emesis should be induced for the child who drank the large dose of acetaminophen (Tylenol) elixir (C) because this medication is hepatotoxic. Vomiting is contraindicated for: children under 1 year of age (A), petroleum distillates (B) such as charcoal lighter fluid, and corrosives (D) such as dishwasher detergents.
A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client’s social interaction, what intervention is best for the nurse to initiate?
Encourage the client to use a hand-held video game that is popular with all his friends.
Assign a 25-year-old female nursing student to offer support to the client.
Arrange for an Internet connection in the client’s room for email communication.
Encourage the client’s mother to arrange a surprise get together in the cafeteria.
Arrange for an Internet connection in the client’s room for email communication.
Body image and peer acceptance are key concerns for the adolescent. (C) allows for social interaction without face to face contact, thus protecting his self-image while also promoting social interaction. (A) does not promote social interaction. (B) does not encourage interaction with his own peer group, which is of greater importance. (D) does not respect the client’s concern about his body image.
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 symptoms are this newborn likely to exhibit?
Choking, coughing, and cyanosis.
Projectile vomiting and cyanosis.
Apneic spells and grunting.
Scaphoid abdomen and anorexia.
Choking, coughing, and cyanosis.
(A) includes the “3 Cs” of esophageal atresia caused by the overflow of secretions into the trachea. Projectile vomiting (B) is characteristic of pyloric stenosis in the infant. Apneic spells often occur with prematurity or sepsis, and grunting (C) is a sign of respiratory distress. A scaphoid abdomen (D) is characteristic of diaphragmatic hernia.
A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?
Insert an indwelling urinary catheter.
Administer IV pain medication.
Collect blood specimen for laboratory studies.
Assess the child’s respiratory status.
Assess the child’s respiratory status.
Assessing the airway and the respiratory status is the highest priority (D) since burns to the face and chest place the child at risk for smoke inhalation injury and compromised airway. (A, B, and C) are implemented after (D)
A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?
Minimize interactive play with other children to lessen chances for injury.
Give low-dose children’s chewable aspirin in orange flavor for joint discomfort.
Use a firm and dry toothbrush to clean teeth at least twice per day.
Apply pressure and ice for bleeding while elevating and resting the extremity.
Apply pressure and ice for bleeding while elevating and resting the extremity.
Hemophilia, a blood disorder, causes joint bleeding which is treated with rest, ice, compression, and elevation (RICE) (D). (A, B, and C) are inaccurate.
A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?
Remove all blackheads and follow with an alcohol scrub.
Use medicated cosmetics only to help hide the blemishes.
Wash the hair and skin frequently with soap and hot water.
Encourage her to see a dermatologist as soon as possible.
Wash the hair and skin frequently with soap and hot water.
Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and helps prevent and treat 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. (A) is contraindicated. Cosmetics (“medicated” or not) should be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at a later time, if healthcare recommendations are not successful.
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?
Give small, frequent feedings of fluids.
Accurately chart observations regarding breath sounds.
Have a bulb syringe readily available to remove secretions.
Encourage older siblings to visit.
Have a bulb syringe readily available to remove secretions.
A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making (C) the highest priority. (A) maintains hydration and prevent tiring, but an open airway has a higher priority! (B) is important for evaluation of therapy. When asked “priority” questions, REMEMBER MASLOW! Physical needs usually have a higher priority than psychosocial needs (D) and an open airway is the highest physiological need!
When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?
Hyperactive behavioral traits.
Delay in the eruption of permanent teeth.
Slow sexual development, but within normal range.
Cessation of growth in a child that had been normal.
Cessation of growth in a child that had been normal.
Since the thyroid gland is responsible for metabolism, cessation of growth (D) which was previously within normal range, is the most common sign for hypothyroidism in children. The child with hypothyroidism is likely to be HYPOactive, not (A). Although (B and C) may occur with hypothyroidism, they are late signs (not early indications) and are signs more often associated with a lack of growth hormone.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents’ teaching plan?
Invite other children home to share meals.
Accept that he will eat when he is hungry.
Reward the child with a nap after eating.
Consistently follow a set mealtime routine.
Consistently follow a set mealtime routine.
A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-year-olds may participate in parallel activities with other children but are too young to feel comfort and support by the presence of other children when anxious or afraid. (B) may or may not be true and does not address the child’s fears. The child with reflux should remain upright at least two hours after eating (C) to reduce symptoms.
The nurse is planning the care of a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis?
Obtain gloves for the child’s hands.
Apply finger cots on the child’s fingers.
Place elbow restraints on the child’s arms.
Apply soft restraints to the child’s wrists.
Place elbow restraints on the child’s arms.
Elbow restraints (C) prevent arm flexion and scratching of involved areas, but do not inhibit use of the hands for play activities. (A and B) can be easily removed by the child and would restrict hand movement. (D) would be ineffective in preventing the child from scratching because the upper body could be moved within reach of restrained hands, and would also create the greatest restriction of hand movement.
During routine screening at a school clinic, an otoscope examination of a child’s ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next?
No action required, as this is an expected finding for a school-aged child.
Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible.
Call the parents and have them take the child home from school for the rest of the day.
Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
More information is needed to interpret these findings (B). The tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child’s findings are not completely normal, further assessment of history and related signs and symptoms is indicated for accurate interpretation of the findings. (A, C, and D) are inappropriate actions based on the data obtained from the otoscope examination.
A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?
Diarrhea.
Rhinorrhea.
Galactorrhea.
Steatorrhea.
Steatorrhea.
Steatorrhea (D) is defined as stools with an abnormally high fat content that are usually foul smelling and float on water. (A, B, and C) do not describe this finding.
A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?
Call the healthcare provider immediately if his nail beds appear blue.
Check his fingers hourly for the first 48 hours to see that he is able to move them without pain.
Be sure his arm remains above his heart for the first 24 hours.
Take his temperature q4h for the next two days and call if an elevation is noted.
Call the healthcare provider immediately if his nail beds appear blue.
Cyanosis (A) indicates impaired circulation to fingers and should be reported immediately. Although the actions described in (B, C, and D) may be indicated, they are implemented rather excessively–and might tend to frighten the parents. It is not necessary to check the child’s ability to move his fingers hourly for 2 days (B). Elevating the arm above the heart will help to decrease swelling but (C) is stated in a frightening way. It is not necessary to take the child’s temperature q4h unless indicated by other symptoms.
he vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child’s pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first?
Insert an indwelling urinary catheter.
Start an IV infusion of normal saline.
Send a specimen to the lab for urinalysis.
Document the child’s vital signs and pulses.
Start an IV infusion of normal saline.
The current vital sign 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 (B). (A) is useful in obtaining a precise urine output measure, but is a lower priority than restoring fluid volume at this time. (C) is not indicated based on the current assessment data, and (D) does not recognize the need for immediate action to combat the fluid volume deficit.
The mother 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 the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother’s question?
If the child’s tongue darkens, discontinue the Pepto Bismol immediately.
Do not give if the child has chickenpox, the flu, or any other viral illness.
Avoid the use of Pepto Bismol until the child is at least 16 years old.
Pepto Bismol may cause a rebound hyperacidity, worsening the “tummy ache.”
Do not give if the child has chickenpox, the flu, or any other viral illness.
Pepto Bismol contains aspirin and there is the potential of Reye’s syndrome (B). (A) is a common effect of Pepto Bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D), which is a complication of antacids containing calcium.
Which restraint should be used for a toddler after a cleft palate repair?
Clove hitch.
Mummy.
Elbow.
Jacket.
Elbow
Elbow restraints prevent children from bending their arms and bringing their hands to the oral surgical site. (A) restrains the hands, but the child can bend and bring their head to their hands. (B) is used during procedures. (D) restrains the body torso and is not appropriate.
When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it
increases salivation.
increases the respiratory rate.
leads to vomiting.
stresses the suture line.
stresses the suture line.
Prevention of stress on the lip suture line (D) is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes (A, B, and C), these conditions do not create a problem for the child with a cleft lip repair.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?
Congenital heart disease.
Fragile X chromosome.
Trisomy 13.
Pyloric stenosis.
Congenital heart disease.
Congenital heart disease (A) is the most common associated defect in children with Down syndrome. (C) might have seemed possible since Down syndrome is a trisomal chromosomal abnormality of chromosome 21. (B) is a sex-linked abnormality also causing mental retardation. (D) is not associated with Down syndrome.
A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child’s care?
Daily iron supplements should be given.
Plenty of fluids should be consumed daily.
Immunizations should be delayed for a few years.
Protective equipment should be worn for contact sports.
Plenty of fluids should be consumed daily.
Adequate fluid intake (B) decreases the viscosity of the blood which affects the incidence of vasocclusive crisis. (A and D) are not commonly indicated for a child with sickle cell disease. A routine immunization schedule (C) is recommended for a children with SCD because of their increased susceptibility to infection that predisposes to sickling phenomena.
The nurse assigning care for a 5-year-old child with otitis media is concerned about the child’s increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift?
An RN should be assigned to take temperatures frequently.
Tympanic and oral temperatures are equally accurate.
The PN should take rectal temperatures on this child.
The pediatrician should decide how to assess the temperature.
Tympanic and oral temperatures are equally accurate.
A tympanic membrane sensor approximates core temperatures because the hypothalamus and eardrum are perfused by the same circulation. Tympanic readings obtained using proper technique correlated moderately to strongly with oral temperatures in recent research studies (B). The sensor is unaffected by cerumen or the presence of suppurative or unsuppurative otitis media. An RN is not required to take the child’s temperature, but must assess readings received from assistive personnel (A). Although rectal readings are highly accurate (C), such an invasive procedure is unnecessary. (D) is not required.
In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first?
Food planning and selection.
Administering insulin injections.
Process of glucose testing.
Drawing up the correct insulin dose.
Process of glucose testing.
Developmentally, a 5-year-old has the cognitive and psychomotor skills to use a glucometer (C) and to read the number (it is especially helpful if the nurse presents this activity as a game). (A, B, and D) require more advanced cognitive and psychomotor skills and have greater potential for errors
A 15-year-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?
Refer the adolescent to the healthcare provider for a pregnancy screen.
Schedule a conference with her parents to recommend hormone therapy.
Explain that menarche varies and occurs between the ages of 12 and 18 years.
Suggest that she use diversions to help her not worry about delayed menarche.
Explain that menarche varies and occurs between the ages of 12 and 18 years.
The nurse should provide a factual and reassuring explanation that focuses on individual variations of menarche, which can normally occur between 12 and 18 years of age (C). (A) does not address the adolescent’s concern and is judgmental. Menarche is influenced by hereditary, general health, and nutritional status, so (B) is not indicated. (D) dismisses the adolescent’s concerns and does not offer factual information.
Which action by the nurse is most helpful in communicating with a preschool-aged child?
Speak clearly and directly to the child.
Use a doll to play and communicate.
Approach when a parent is not present.
Play a board game with the child.
Use a doll to play and communicate.
Communicating through play with a doll (B) or other toy gives time for the child to feel comfortable with a stranger. (A) may frighten some children and is usually not as effective as (B). To provide security and comfort, preschool-aged children should be approached when a parent is present, not (C). (D) is too advanced for a preschooler.
When assessing a child with asthma, the nurse should expect intercostal retractions during
inspiration.
coughing.
apneic episodes.
expiration.
inspiration.
Intercostal retractions result from respiratory effort to draw air into restricted airways (A).
The mother of a 2-year-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?
Paddle him gently as soon as the behavior is initiated.
Immediately put him in “time-out.”
Quietly remind him that others are watching him.
Walk away from him and ignore the behavior.
Walk away from him and ignore the behavior.
The best approach for a toddler is to ignore the attention-seeking behavior (D). The parent should be somewhat nearby, within 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, B, and C) would all provide attention for the inappropriate behavior.
Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations?
Oven-baked potato chips and cola.
Peanut butter and banana sandwich.
Oatmeal-raisin cookies and milk.
Graham crackers and fruit juice.
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 symptoms such as diarrhea. (A) is the selection which avoids all of these ingredients. (B, C, and D) contain gluten in one form or another.
Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?
Aminoglycosides.
Tetracyclines.
Penicillins.
Quinolones.
Tetracyclines.
Tetracyclines (B) cause enamel hypoplasia and tooth discoloration in children under 8 years of age. (A, C, and D) are not contraindicated for use in children.
A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal 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?
Aplastic.
Sequestration.
Hyperhemolytic.
Vaso-occlusive.
Sequestration.
The findings support a sequestration crisis (B), where blood pools in the spleen, and is characterized by abdominal pain and anemia. (A and C) crises produce anemia but no abdominal pain or splenic enlargement. (D) crisis may produce abdominal pain, but no splenic enlargement or exacerbation of anemia.
An 18-month-old is admitted to the hospital with possible Hirschsprung’s disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?
Foul-smelling and fatty.
Bile-colored and watery.
Semi-solid and yellow.
Ribbon-like and brown.
Ribbon-like and brown.
Hirschsprung’s disease is a mechanical obstruction caused by inadequate motility in a 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 in the affected bowel segment causes constipation and small diameter, brown-colored stools (D). (A) is associated with cystic fibrosis. (B) is common in gastroenteritis. (C) is normal in breastfed neonates.
A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?
Nystatin (Mycostatin).
Nitrofurantoin (Macrodantin).
Norfloxacin (Noroxin).
Neomycin sulfate (Mycifradin).
Nystatin (Mycostatin).
Nystatin (Mycostatin) (A) is an antifungal drug that is effective in treating thrush, an oral fungal infection. (B, C, and D) are not indicated for the treatment of oral thrush.
The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview?
Have you lost any weight in the last month?
Are you experiencing any type of nervousness?
When was the last time you took your synthroid?
Are you having any problems with your vision?
Are you experiencing any type of nervousness?
Assessing the client’s physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism (B). Weight loss (even with a hearty appetite) (A) occurs in those with hyperthyroidism, but assessing the client’s neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid (C). The client may have exophthalmus (bulging eyes) but hyperthyroidism does not cause vision problems (D).
During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?
Hearing tests.
Eye exams.
Chest x-rays.
Fasting blood glucose tests.
Eye exams.
Visual changes leading to blindness can occur in children with JRA. Regular eye exams (B) can help to prevent this complication. (A, C, and D) are not routinely necessary for management of JRA.
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?
Tell children they should not taste anything but food.
Store all toxic agents and medicines in locked cabinets.
Provide special play areas in the house and restrict play in other areas.
Punish children if they open cabinets that contain household chemicals.
Store all toxic agents and medicines in locked cabinets.
The only reliable way to prevent poisonings in young children is to make them inaccessible (B). Teaching children not to taste is important (A), but ineffective for young children. (C and D) will not control a child’s curiosity.
The nurse is assessing the neurovascular status of a child in Russell’s traction. Which finding should the nurse report to the healthcare provider?
Pale bluish coloration of the toes.
Skin is warm and dry to the touch.
Toes are wiggled upon command.
Capillary refill less than 3 seconds.
Pale bluish coloration of the toes.
Russell’s skin traction is used for fractures 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 adequare circulation, movement, and sensation of the toes and skin distal to the application is made to identify compromised blood flow, so cyanosis (A) should be reported immediately. (B, C and D) are normal findings.
A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?
Studies have shown that handling a sick newborn is not good for the baby and upsets the parents.
The oxygen hood is holding the baby’s oxygen level just at the point which is needed. You may stroke and talk to her.
Since your baby has been doing well under oxygen for 24 hours, I can let you hold the baby without oxygen.
You can hold the baby with the oxygen blowing in the baby’s face since the level is very close to room air.
The oxygen hood is holding the baby’s oxygen level just at the point which is needed. You may stroke and talk to her.
The baby is at 35% which is much more than room air (21%) and at this time the baby should not be moved from under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant (B). Holding sick babies benefits the infant and the parents (A). The first consideration now has to be the infant’s oxygenation. The nurse should not take the baby out from under the hood without a prescription from the healthcare provider, as this could severely compromise the infant (C). A PO2 of 35% cannot be readily achieved with “blow by” oxygen (D).
The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?
3 to 6 months.
12 to 15 months.
18 to 24 months.
4 to 6 years.
12 to 15 months.
The first measles, mumps, and rubella (MMR) vaccine should be given no sooner than 12 months of age, and ideally between 12 and 15 months of age (B). (A) should not receive the MMR vaccine due to the presence of maternal antibodies. MMR is not routinely administered at (C), but other immunizations, such as DTaP and Hepatitis B may be given at that time. The second dose of MMR is routinely administered at (D), provided that at least 4 weeks have elapsed since the first dose, and if both doses were administered beginning at or after 12 months.
The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family?
Polyuria and polydipsia.
Lethargy and fatigue.
Increased facial hair.
Facial bone structure changes.
Polyuria and polydipsia.
Signs and symptoms of diabetes or hyperglycemia (A) need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance. (B) is associated with any number of heath alterations, but is not associated with the growth hormone therapy. (C and D) are normal changes that occur with 12-year-old males.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent’s last tetanus toxoid booster was received eight years ago. What action should the nurse take?
Dispense a tetanus antitoxin.
Prepare human tetanus immune globulin.
Administer tetanus toxoid booster.
Delay the tetanus toxoid booster until due.
Administer tetanus toxoid booster.
After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult is every ten years 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 (C). (A, B, and D) are not indicated.
The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling’s repeated hospitalizations. Which is the best response that the nurse should offer?
Inform the parent that the child is too young to visit the hospital.
Suggest that the child visit a grandmother until the sibling returns home.
Ask the mother if the child asks when the sibling will be discharged.
Encourage the mother to have the children visit the hospitalized sibling.
Encourage the mother to have the children visit the hospitalized sibling.
Needs of a sibling will be better met with factual information and contact with the ill child, so sibling visitation should be encouraged (D). Parents are experts on their children and should determine when their children are old enough to visit (A) in the hospital. Separation from family and home (B) may intensify fear and anxiety. Children may have difficulty expressing questions (C), so the support of parents and other caregivers are needed to help alleviate their fears.
Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant?
A lower sensitivity reactions to skin irritants.
A thin stratum corneum that increases topical absorption.
A smaller percentage of muscle mass.
A greater body surface area that requires larger dosages.
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 (B). (A, C, and D) are unrelated to topical medication administration.
The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain?
Type of reaction to loud noises.
Any surgeries on the ears since birth.
Drainage from the infant’s ears.
Number of ear infections since birth.
Type of reaction to loud noises.
Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant’s reaction to loud noises (A) helps to determine an infant’s risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant. (B, C, and D) are not associated with exposure to aspirin in utero.
- A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.)
A. Monitor the the infant’s weight and number of wet diapers per day. – child should at least have 6 wet diapers per day.
B. Increase the infant’s intake per feeding by 1 to 2 ounces per week.- child is always fatigue, need to increase to 30 oz a day
D. Allow the infant to rest and re-feed on demand or every 2 hours.- child is always fatigue, this will ensure adequate feeding.
E. Use a softer nipple or increase the size of the nipple opening.- this will save energy - A 15-year-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 between the ages of 12 and 18 years. - Which finding in a 19-year-old female client should trigger further assessment by the nurse?
Menstruation has not occurred- menarche usually occur between the ages of 12 and 18 years old - At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure 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 first?
Administer PRN prescription of nifedipine (Procardia) sublingually.
-CA channel blocker
-always assess physiological needs - A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal 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.- pooling of blood causes and pain and anemia d/t blockage of blood in the spleen - Aplastic anemia- anemia d/t drugs
- Hyperhemolytic anemia- anemia d/t the breakdown of RBC
3.Vaso-occlusive anemia- sickle cells are clogging up small capillaries- and pain but not enlarged spleen and liver - A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?
pre school age children are conceded about lost of body mutilation or body integrity.
nurse should explain- they did not cause the illness, procedure is not punishment, restoring body image with a band-aid.
- The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child’s pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first?
Start an IV infusion of normal saline- patient is experiencing fluid vole deficit - A 6-month-old boy and his mother are at the healthcare provider’s office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today?
6 month shots: DTAP; HEP -B (1st dose: birth, 2nd dose: 1-2 months, 3rd dose 6-9 months); PCV; IPV; INFLUENZA~ adminster at a different site - A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children’s vitamin pills. Which intervention should the nurse implement first?
Determine the child’s pulse and respiration~ always ABC
assess: respiratory, cardiac, and neuro - The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain?
Description of vomiting episodes in past 24 hours.- assessment of what cause vomiting episodes leaning towards treatment - 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.
Erikson: industry vs inferiority
achieve independence and productivity - The mother of a 2-year-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
-temper tantrums are normal, just ignore the behavior. - A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents’ teaching plan?
Consistently follow a set mealtime routine
- always follow a consistent home schedule
- 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 healthcare provider?
A 6-month-old with failure to thrive that has a closed anterior fontanel. - Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate?
A trial of human chorionic gonadotrophic hormone
Frequent stimulation of the cremasteric reflex~ causes the testes to ascend, not descend.
- When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement?
Record weight daily = nutrition for infants - The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview?
Are you experiencing any type of nervousness? – physiological answers: nervousness, apprehension, palpitations, hyper excitability
*hyperthrydoism will have exopthalamus, not double vision
- Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations?
Oven-baked potato chips and cola
avoid: oats, wheat, rye and barley; intolerance to protein gluten
- Which action by the nurse is most helpful in communicating with a preschool-aged child?
Use a doll to play and communicate. Correct - To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?
Use a happy-face/sad-face pain scale.
-faces pain scale
minimm of age 3 years old
nonverbal signs of pain
vital signs of pain
pain rating scale (PRS)
when to use cries
when to use verbal report
when to use numeric pain scale
-grimacing
-irritability
-restlessness
-difficulty in sleeping or feeding
-increased HR
-increased RR
-diaphoresis
-decreased 0xygen saturation levels
14-36 months of age
36-60 weeks
3 year old can point out location and degree of pain
minimum of 9 years old
- A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child’s adjustment to hospitalization?
Explain hospital schedules to the child, such as mealtimes.
-always keep a consistent schedule, if possible try to copy home schedule. This will help to decrease separation anxiety - The mother 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 the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother’s question?
Do not give if the child has chickenpox, the flu, or any other viral illness.
-pepto bismol: contains aspirin, aspirin + any viral, flu or infection = reyes syndrome
–>reyes syndrome (encephalophy + hepatic dysfunction) - A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
Serum BUN and creatinine levels.
adding potassium = need adequate renal function + urine output
- The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit?
Clubbed fingers r/t hypoxia
-tachycardia not bradycardia - An infant is born with a ventricular septal defect (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 - The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing 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 catheterization lab and meet a nurse who works there. - When taking the health history 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.
hypothyrodism–>d/t metabolism–> decrease metabolism–> cessation of the growth
- The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family?
Polyuria and polydipsia
growth hormone causes increase in blood sugar
*monitor for diabetes
- The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication?
Changes in level of consciousness.
fluid retention + DILUTED s/s hyponatremia
- A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, “Is this normal behavior for a child this age?” The nurse’s response should be based on which information?
Children need to retain a sense of initiative without impinging on the rights and privileges of others.
-Children aged 3 to 6 are in Erickson’s “Initiative vs. Guilt” stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others
- A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?
Wash the hair and skin frequently with soap and hot water.
teenage growth hormones causes increase in sebaceous glands and increased glandular secretions which predispose the teenager to acne.
- During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?
EYE EXAM
JRA= EYE EXAM
- The nurse is assessing a 2-year-old. What behavior indicates that the child’s language development is within normal limits?
Half of child’s speech is understandable (15-24 months)
by 18 months is capable of making a three word sentence.
3-5 years old is able to name four colors & count five blocks
- A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?
Nystatin (Mycostatin). - Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?
Tetracyclines
causes destruction of enamel and tooth discoloration
able to give: aminoglycodides, penicillins, Quinolones.
- 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.
also avoid taking with milk because it interferes with absoprtion - 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 symptoms are this newborn likely to exhibit?
Choking, coughing, and cyanosis. - The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?
12 to 15 months.
second dose: 4- 6 years old - Preoperative nursing care for a child with Wilms’ tumor should include which intervention?
Put a sign on the bed reading, “DO NOT PALPATE ABDOMEN.”
*prevents rupture of the encapsulated tumor and spreading to other organs - An 18-month-old is admitted to the hospital with possible Hirschsprung’s disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?
Ribbon-like and brown.
Hirschsprung’s is a mechanical obstruction in part of the intestines resulting in inadequate motility.
Bile-colored and watery = gastroenteritis
Foul-smelling and fatty = cystic fibrosis
Semi-solid and yellow= normal in breast fed neonates
- The nurse is planning the care of a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the 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-year-old child with otitis media is concerned about the child’s increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift?
Tympanic and oral temperatures are equally accurate.
hypothalamus and eardrum are perfused by the same circulation & causes the same core temp by ear and oral
- A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention?
Apical heart rate of 60.
normal HR 80-150bpm
- In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first?
5 year old = process of glucose testing (think of it as playing a game)
9 year old = can self administer the medication with proper demonstration
- The nurse observes a 4-year-old boy in a daycare setting. Which behavior would the nurse consider normal for this child?
Demonstrates aggressiveness by boasting when telling a story. - A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified “Rule of Nines.” Which part of a child’s body is calculated as a larger percentage of total body surface than an adult’s?
child= head + neck
adult= chest + arms - The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take?
Pass the information on in the report
theophylline: 10-20 mcg/dl (normal range)
- A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?
Have a bulb syringe readily available to remove secretions.
a patent airway is highest priority and humidification will liquefy the nasal secretions
- All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse’s evaluation of a 20-month-old child?
Assessing fontanels.
by 20 months, the fontanels are suppose to be closed already.
- The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child’s increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that
A tympanic measurement of temperature will provide the most accurate reading. - A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The nurse determines the daily caloric need for this child is approximately
600 calories per day.
10.9 divide by 2.2 = 5kg x 108 kg/cal/day = x 5 = 540. since there is a 10% increase, 54 +540= 594, 600 calories per day.
- The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?
Store all toxic agents and medicines in locked cabinets. - The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning 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 vital signs of a 4-month-old child, which order provides the most accurate results?
Respiratory rate, heart rate, then rectal temperature. - During routine screening at a school clinic, an otoscope examination of a child’s ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next?
Ask the child if he/she has had a cold, runny nose, or any ear pain lately. - What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?
Observe for projectile vomiting leads to metabolic alkalosis - A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child?
Remove restraints one at a time and provide range of motion exercises.
*needs to have movement and passive ROM exercises. - A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?
Congenital heart disease is the most common defect found in those with DS - When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it
stresses the suture line
*need to maintain the skin integrity
- Which behavior would the nurse expect a 2-year-old child to exhibit?
Display possessiveness of toys.
*egocentric thinking - When assessing a child with asthma, the nurse should expect intercostal retractions during
inspiration! inspiraiton causes show the presence of intercostal retractions - A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client’s social interaction, what intervention is best for the nurse to initiate?
Arrange for an Internet connection in the client’s room for email communication.
adolescent: body image and peer acceptance are the main concerns; email communication will still allow peer communication and acceptance while preserving his body image
- A 17-year-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 vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?
Tell the student to proceed directly to his regularly scheduled class.
-he just came from football practice, which increases his muscle activity. 100.4 is a regular temp.
- A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?
Wash the wound gently with mild soap and water.
-hydrogen peroxide +povidone-iodine = will irritate the wound.
clean the wound first to prevent infection then put ice
- A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent’s last tetanus toxoid booster was received eight years ago. What action should the nurse take?
Administer tetanus toxoid booster.
Detanus is part of DTAP vaccine.
-first dose: 6 months
-booster shoot: adolescent or adults
-booster shot: traumatic injury–>contaminated with by dirt, feces, soil or saliva
puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite
- During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?
Stop the infusion immediately and notify the healthcare provider.
-adjust IV fluids
-TPN- cannot d/c or increase fluids–> hypoglycemia
-blood transfusion–> can d/c it –>anaphylic reaction
- The nurse is assessing the neurovascular status of a child in Russell’s traction. Which finding should the nurse report to the healthcare provider?
Pale bluish coloration of the toes.
-skin traction: force is applied to the skin
-skeletal traction: pin or wire applies pull directly to the distal bone fragment
- A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?
The oxygen hood is holding the baby’s oxygen level just at the point which is needed. You may stroke and talk to her.
-room air is 21%, since the oxygen hood is at 35% the baby needs the oxygen hood. offer an alternative like stroke the infant and offer reassurance
- The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand?
aersol therapy then postural drainage before meals or 1 hour after
aerosl therapy loosens up the secretions, then posutral drainage moves it up
- The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain?
Type of reaction to loud noises.
ototoxicity can cause tinnitus and vertigo in children if the mother uses aspirin during pregnancy; aspirin side effect of tinnitus only occurs during utero.
-NO RISK FOR BLEEDING FOR THE INFANT, ONLY THE MOTHER
- The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with 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.
*incorporate a home environment, prevent separation anxiety (toddler or pre schooler’s greatest threat/fear) and allow sibling visitors to decrease stress and anxiety - A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?
Call the healthcare provider immediately if the nail beds appear blue - The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?
Engage the child through drawing pictures.
-since babies are egocentric, they do things on their own and draw. this will allow the nurse to assess the picture
- The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching?
Using a teaspoon will help me measure this correctly. - Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.)
A. child height + weight
C. body surface area of the child
F. nomogram determined mathematical consent - Which restraint should be used for a toddler after a cleft palate repair?
Elbow restraints post op
during procedure–use mummy restraint - When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline?
Parental control should be consistent.
consistent parenting will prevent misbehavior of children; consistent parents will prevent misinterpretation of rules.
- A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?
Steatorrhea is foul smelling stools and float because of excess fat/grease on the feces - The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child’s cooperation?
Use a colorful straw
iron causes staining of the teeth - Which growth and development 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 skin called the stratum corneum, this will aid increased topical absorption
- A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?
RICE =
REST
ICE
COMPRESSION
ELEVATE - A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child’s care?
Plenty of fluids should be consumed daily
hydration #1 priority to prevent viscosity of blood; since the sickle cell can impact the spleen, liver, kidney, bones and CNS this can increase the risk for infection w/ decreased or no function of the spleen a routine immunization schedule is needed
- The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?
low neutrophil count = risk for infection because body is no longer fighting the infection
high neutrophil count= an infection and body is fighting it off
- A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?
any burn patient: always remember ABC!
Clinical Manifestations of Type 1 Diabetes
polyuria, polydipsia, polyphagia, weight loss, weakness, fatigue
what is an early sign of ketoacidosis?
Ketonuria in the presence of hyperglycemia
whats the most common sign of DKA?
acetone breath “fruity smell”
signs of hypoglycemia
nausea
vomiting
jittery, restless, shaky
sweaty (diaphoresis)
what is hypopituitarism?
diminished secretion of one or more pituitary hormones and depends on the degree of the dysfunction.
may require GH injections daily
signs of diabetes insipidus
polyuria polydipsia
key nursing priority for diabetes insipidus
assess current vital signs
signs of Cushing syndrome
fat accumilating on the cheeks, chin, and trunk (moon face)
-hyperpigmentation to the face
what is epilepsy?
a condition characterized by two or more unprovoked seizures more than 24 hours apart and caused by a variety of pathological processes in the brain
nursing priority for a child having a seizure
maintain a safe environment
nursing teaching for after a lumbar puncture
encourage the child to lie flat and still for at least 30 min
what medication puts children at risk for Reye’s syndrome?
aspirin
what is near drowining defned as?
survival for at least 24 hours from suffocation by submersion
what is pyloris stenosis?
classified by projectile vomiting, and an olive shaped mass in the epigastric area
what does a ruptured appendix put the child at risk for?
peritonitis
how to prevent Hep A in children?
washing your hands
What is scurvy?
Vitamin C deficiency
what is rickets?
Vitamin D deficiency
What is marasmus?
protein-calorie malnutrition
what foods should people with celiac disease avoid?
wheat, barley, ots, rye, batter fried food
what age is the peak insidence in children for GERD?
age 4 months then it spontaneously resolves by 12 months
what is failure to thrive in children a sign of?
imapired renal function
what is the priority nursing diagnosis for a patient with nephrotic syndrome?
excess fluid volume related to excessive protein loss in the urine
clinical manifestations of nephrotic syndrome
massive proteinuria
hypoalbuminemia
hyperlipidemia
edema (salt is restricted)
What is hypospadias?
meatal opening on the ventral surface of the penis
what is epispadias?
meatal or urethral opening on the dorsal surface of the penis
what is cryptorchidism
undescended testes
nursing care for a patient getting a renal biopsy
-NPO 4-6 hrs before procedure
-premedicate as ordered
-VS and apply pressure bandage after procedure (sandbag if possible)
-bed rest 24 hours
-monitor intake and output
what is the most common cause of osteomyelitis
staphylococcus aureus
Systemic Lupus Erythematosus teaching
-avoid sunlight and UVB rays
-maintain regular appointments with physician
-use steroids and prophylactic antibiotics before procedures
-carry a medic alert bracelet or tag
A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child’s growth and development, which intervention is most important for the nurse to implement?
Encourage the parents to participate in a planned program of play with the infant.
Refer the parents for psychological counseling to identify parental detachment.
Demonstrate feeding strategies and infant cues that indicate hunger and satiation.
Provide instructions about formula preparation and feeding schedules.
Demonstrate feeding strategies and infant cues that indicate hunger and satiation.
The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse’s immediate intervention?
Prolonged exhalations.
Thick yellow rhinorrhea.
Frequent nonproductive cough.
Oxygen saturation is 95% by pulse oximeter.
Prolonged exhalations.
The nurse is assessing the coping behaviors of the parents whose child has been recently diagnosed with a chronic illness. What reaction by the parents is a positive step in the ability to cope with this new situation?
Endowing the illness with meaning.
Refusing to believe the child is ill.
Entertaining an unrealistic future plan for the child.
Placing complete faith in religion to the point of relinquishing own responsibility.
Endowing the illness with meaning.
A 15-year-old girl tells the school nurse that she wants to have a baby. How should the nurse respond?
“Will you be able to support the baby?”
“Do you have plans to continue school?”
“Have you talked with your parents about this?”
“Can you tell me how your life will be if you have an infant?”
“Can you tell me how your life will be if you have an infant?”
The nurse is caring for a premature infant who needs an IV access restarted. What action should the nurse take when using adhesive tape?
Remove adhesives with water, mineral oil, or petrolatum.
Avoid using tape and adhesives until skin is more mature.
Use scissors carefully to remove tape instead of pulling tape off.
Employ solvents to remove adhesives instead of pulling on skin.
Remove adhesives with water, mineral oil, or petrolatum.
The nurse calculates a 4 ml dose of prescribed digoxin a 9-month-old infant. What action should the nurse implement?
Mix dose with juice to disguise its taste.
Suspect dosage error and do not give dose.
Check heart rate and administer dose by placing it to the back and side of mouth.
Check heart rate and administer dose by letting the infant suck it through a nipple.
Suspect dosage error and do not give dose.
The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents?
A child is insecure because trust is not fostered and developed during infancy.
A toddler should be exposed to different routines to promote adapting to new experiences.
Children of this age are comfortable with ritualism and display global thinking.
Objects should be frequently moved in the environment to teach the child to acclimate to change.
Children of this age are comfortable with ritualism and display global thinking.
How should the nurse measure the length of a 14-month-old child ?
Standing height.
Prone recumbent position.
Supine recumbent position.
Side-lying position.
Supine recumbent position.
A 5-year-old child who is one day postoperative has bilateral eye patches in place and should be out of bed. What nursing intervention should be implemented first before leaving the bedside?
Speak to the child when entering the room.
Allow the child to assist in feeding himself.
Orient the child to the immediate surroundings.
Allow the parents to stay in the room with the child.
Orient the child to the immediate surroundings.
The nurse observes the interactions of a 2-year-old child who says, “No,” even when “Yes” is what the child really wants to say. The parent says to the nurse, “We, as parents, are such positive people, why is our child so negative?” How should the nurse respond?
A 2-year-old often acts in the opposite way to get attention.
This age child is testing the limits of the parent’s patience.
The toddler is exhibiting an example of ritualistic behavior.
The child is trying to assert autonomy through negativism.
The child is trying to assert autonomy through negativism.
A newborn who is breastfeeding is diagnosed with galactosemia. What action should the nurse implement?
Stop the infant breastfeeding.
Add amino acids to breast milk.
Give galactokinase with breast milk.
Substitute a lactose-containing formula.
Stop the infant breastfeeding.
A 4-year-old child who is ventilator-dependent is receiving tube feedings in the home setting. The family wants to begin oral feeding of the child, and asks the home health nurse to feed the child baby food orally. After explaining the risks for aspiration to the family, list in order which actions the nurse should implement. (Rank in the priority order from first action to last action.)
- Refuse to feed the child orally, because the risk is too high.
- Ask the parents to negotiate a change in feeding methods with the healthcare provider.
- Set additional goals for feeding the child with the parents.
- Acknowledge the request and then explore with the family the available options for care.
- Acknowledge the request and then explore with the family the available options for care.
- Set additional goals for feeding the child with the parents.
- Refuse to feed the child orally, because the risk is too high.
- Ask the parents to negotiate a change in feeding methods with the healthcare provider.
What is a priority nursing diagnosis for a child in the subacute stage of Kawasaki disease?
Alterations in skin integrity.
High risk for altered tissue perfusion, cardiopulmonary.
Risk for imbalanced body temperature, hyperthermia.
High risk for fluid volume deficit.
High risk for altered tissue perfusion, cardiopulmonary.
A mother brings her 6-month-old infant to the clinic for a well-child checkup. She comments, “I want to go back to work, but I don’t want my baby to suffer because I’ll have less time at home.” How should the nurse respond to the mother?
Stay home until the child starts school.
Find a good baby-sitter close to the house.
Let’s talk about the child care options that are best for the child.
Go back to work now so the infant will get used to being with others.
Let’s talk about the child care options that are best for the child.
When assessing the breath sounds of an 18-month-old child who is crying, what action should the nurse take?
Ask the parent to quiet the child so breath sounds can be auscultated.
Auscultate and document breath sounds, noting that the child was crying at the time.
Document that the assessment is not available because the child is crying.
Allow the child to initially play with the stethoscope, and distract during auscultation.
Allow the child to initially play with the stethoscope, and distract during auscultation.
During the well-child assessment of an 18-month-old male toddler, the nurse determines the child does not walk while holding on to furniture but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which nursing diagnosis should the nurse formulate?
Alteration in nutrition.
Alteration in parenting.
Delayed growth and development.
Alteration in health maintenance.
Delayed growth and development.
A 12-year-old male client tells the nurse that he is happy to be taking growth hormones because now he can expect to grow and be just as tall as all of his friends. What response is best for the nurse to provide?
“You must remember that this treatment regimen is not always effective.”
“Although being tall is important to you, remember there are far more important characteristics than height.”
“You will grow with this medicine, and are likely to be taller than anyone in your family.”
“Being taller is important to you and taking your injections will help achieve that goal.”
“Being taller is important to you and taking your injections will help achieve that goal.”
A 6-year-old child is admitted in the emergency department with a systolic blood pressure of 58 mm Hg. What action should the nurse take first?
Comfort the child.
Assess responsiveness.
Alert the healthcare provider.
Initiate IV fluid replacement.
Alert the healthcare provider.
An adolescent female’s susceptibility to vulvitis is most likely related to which causative factor?
Contact with fabric dyes.
Frequent sexual activity.
Urinary incontinence.
Menarche.
Contact with fabric dyes.
The low-birth-weight (LBW) infant requires a neutral thermal environment. What action should the nurse implement?
Use wool blankets for covers.
Avoid using disposable diapers.
Maintain a high-humidity atmosphere.
Continue cool oxygenation via a hood.
Maintain a high-humidity atmosphere.
When conducting a hygiene class for adolescent girls, it is important for the nurse to include which instruction about preventing toxic shock syndrome?
Wash your hands before inserting a tampon.
Use super absorbent tampons.
Wear cotton underwear.
Douche every month following menstruation.
Wash your hands before inserting a tampon.
The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority?
Potential for fluid volume deficit.
Alteration in bowel elimination.
Pain related to postoperative condition.
Anxiety of parents related to newborn’s condition.
Potential for fluid volume deficit.
An 8-year-old boy who is recently diagnosed with diabestes mellitus is admitted to the intensive care unit with diabetic ketoacidosis (DKA). Which nursing action has the highest priority?
Place on cardiac monitor.
Initiate an intravenous infusion.
Collect specimen for serum electrolytes.
Obtain fingerstick glucose.
Initiate an intravenous infusion.
What intervention should the nurse implement to help keep a 6-month-old infant calm during a physical assessment?
Give the infant a soft cuddly toy to hold.
Remove the pacifier from the infant’s mouth.
Encourage the parent to hold the infant.
Distract the infant with noise or bright lights.
Encourage the parent to hold the infant.
The nurse is assessing a child for neurological “soft” signs. Which finding is most likely demonstrated in the child’s behavior?
Presence of vertigo.
Loss of visual acuity.
Poor coordination and sense of position.
Inability to move tongue in all directions.
Poor coordination and sense of position.
A 12-year-old male client tells the nurse that he is happy to be taking growth hormones because now he can expect to grow and be just as tall as all of his friends. What response is best for the nurse to provide?
“You must remember that this treatment regimen is not always effective.”
“Although being tall is important to you, remember there are far more important characteristics than height.”
“You will grow with this medicine, and are likely to be taller than anyone in your family.”
“Being taller is important to you and taking your injections will help achieve that goal.”
“Being taller is important to you and taking your injections will help achieve that goal.”
The nurse notices that the hem of a skirt on a per-adolescent girl is uneven when she comes to the clinic. What procedure should the nurse follow to examine the girl for scoliosis? (Arrange the examination process from first on top to last on the bottom.)
- Ask the girl to remove her shirt but leave on her bra or swimsuit top
- Examine the scapular prominence
- Look for asymmetry in the hip area
- Instruct the girl to bend at the waist so back is parallel to the floor
- Ask the girl to remove her shirt but leave on her bra or swimsuit top
- Look for asymmetry in the hip area
- Instruct the girl to bend at the waist so back is parallel to the floor
- Examine the scapular prominence
When administering a gavage feeding to a school-age child, which action should the nurse implement?
Administer feedings over 5 to 10 minutes.
Position the child on the right side after administering the feeding.
Check the placement of the tube by inserting 20 ml of sterile water.
Lubricate the tip of the feeding tube with petroleum jelly to facilitate passage.
Position the child on the right side after administering the feeding.
A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority?
Insert an orogastric tube for gastric lavage.
Prepare a set-up for an endotracheal intubation.
Draw blood for stat chemistries and blood gases.
Insert a Foley catheter to monitor renal functioning.
Prepare a set-up for an endotracheal intubation.
What should the nurse assess last when examining a 5-year-old child?
Heart.
Lungs.
Throat.
Abdomen.
Abdomen.
A mother tells the nurse that her children are asking questions about divorce, but one male child tells her that he is sorry that he caused the divorce of the parents. Which age group is most likely to experience feelings of punishment or responsibity for the divorce of parents?
1 year.
4 years.
8 years.
13 years.
4 years.
What sign of malignant hyperthermia should the nurse assess for during the perioperative period in a child receiving general anesthesia?
Apnea.
Tachypnea.
Bradycardia.
Decreased blood pressure.
Tachypnea.
A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding?
Milk allergy.
Failure to thrive.
Inadequate milk supply in mother.
Normal growth curve of a breast-fed infant.
Normal growth curve of a breast-fed infant.
When assessing a preschooler, which finding warrants further assessment by the nurse?
Able to ride a tricycle.
Talks about an imaginary friend.
Dresses independently.
Gains 2 pounds (0.9kg) in 12 months.
Gains 2 pounds (0.9kg) in 12 months.
The nurse is examining a neonate at age 10 minutes. Which site should the nurse expect to see nonpathologic cyanosis?
Feet and hands.
Bridge of nose.
Circumoral area.
Mucus membranes
Feet and hands.
The nurse is developing a plan of care for a 10-year-old who is scheduled for a cardiac catheterization. Which intervention should the nurse implement to prepare the child for the procedure?
Reassure the parents that 10-year-olds are cooperative and are less likely to be anxious.
Obtain a video film of a cardiac catheterization to show to the child prior to the procedure.
Have another child the same age explain the procedure in “child” language.
Ask the parents to explain the procedure to influence the child’s behavior.
Obtain a video film of a cardiac catheterization to show to the child prior to the procedure.
The parents of a child with Asperger’s disorder asks the nurse to explain the differences between Asperger’s and autism. Which information should the nurse share with the parents about Asperger’s disorder that is not characteristic in autism?
Obsession with moving objects.
Repetitive patterns of behavior.
Age-appropriate language development.
Stereotypic movements and speech patterns.
Age-appropriate language development
Which finding should the nurse in the emergency department identify as an indicator that a 3-year-old child has been mistreated?
The toddler does not remember how the injury occurred.
The parents are extremely calm in the emergency room.
The injury sustained is highly unusual for 3-year-old children.
The child was doing something unsafe when the injury occurred.
The injury sustained is highly unusual for 3-year-old children.
The nurse is developing the plan of care for a school-aged boy with a chronic disability. The child frequently cries about being different from his siblings and wants others to do things for him that he is capable of doing for himself. To assist the family in coping with this child’s chronic illness, which intervention is most important for the nurse to implement?
Recommend the use of consistent discipline and reward for acceptable behavior.
Encourage the parents to role model ways to act when one is disappointed.
Suggest that all the children are included in family decision making.
Evaluate the proper use of equipment that is provided to improve the child’s lifestyle.
Recommend the use of consistent discipline and reward for acceptable behavior.
The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration?
Tachycardia.
Bradycardia.
Dry mucous membranes.
Increased skin turgor.
Tachycardia.
While assessing an 18-month-old during a well-child visit, the nurse notes that the toddler has a rounded “pot-belly” abdomen, marked lordosis or swayback, short, slightly bowed legs, and a large head. Based on these findings, what action should the nurse implement?
Refer the findings to the healthcare provider for diagnostic studies for hydrocephalus.
Document general physical appearance of a normally developed toddler.
Plot the findings on the growth chart within the parameters of delayed physical maturation.
Review the dietary intake for indications of a vitamin deficiency or malnutrition.
Document general physical appearance of a normally developed toddler.
An infant with developmental dysplasia of the hip is placed in a Pavlik harness. What instructions should the nurse include in a teaching plan for the parents?
Apply lotion or powder to minimize skin irritation.
Put clothing over harness for maximum effectiveness.
Check for red areas under the straps three times a day.
Use a thin absorbent disposable diaper over the harness.
Check for red areas under the straps three times a day.
The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose?
Syrup.
Applesauce.
Orange juice.
Formula or milk.
Applesauce.
A 4-year-old is brought to the emergency room for a laceration on the right foot. What action should the nurse implement to help the child in coping with the emergency room experience?
Avoid the use of bandages to keep wounds open to air.
Remind the preschooler how big children should act.
Give the child some time after explaining procedures.
Avoid using jargon, such as “shot,” when giving care.
Avoid using jargon, such as “shot,” when giving care
After discussing the introduction of solid foods with the mother of a 6-month-old infant, the nurse determines that the mother understands the information when she states that the first food she gives the infant is from which food group?
Fruits.
Egg yolks.
Rice cereal.
Yellow vegetables.
Rice cereal.
A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation?
Experiencing culture shock.
Lacks the maturity needed in school.
Refuses to participate in school activities.
Going through minority group discrimination.
Experiencing culture shock.
When caring for a child who has pertussis that is in the paroxysmal stage, which intervention should the nurse implement to support the child’s nutritional needs?
Provide small, frequent meals.
Increase protein intake.
Maintain a liquid diet.
Offer the child a regular diet.
Provide small, frequent meals.
During the well-child assessment, the parents of a 4-year-old express concern that their child often chatters while playing alone. What information should the nurse provide the parents?
The child is attempting to formulate a secondary language.
This is an attempt by the child to form an imaginary social base.
“Private speech” is normal at this age and serves as a problem-solving tool.
Concern for psychological development is warranted so further testing is required.
“Private speech” is normal at this age and serves as a problem-solving tool
The nurse is assessing a child’s skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding?
Adequate hydration.
Poor skin turgor.
Normal skin elasticity.
Assessment inconclusive.
Poor skin turgor.
The parents of an adolescent male with Ewing sarcoma ask the nurse what is the most significant factor contributing to their son’s prognosis. Which factor should the nurse include when answering the parent’s concern?
Age of onset.
Gender of child.
Appearance on X-ray.
Degree of metastasis.
Degree of metastasis.
The nurse determines the daily caloric need for a six-month old weighs 15 pounds. Considering an infant requires 108 calories/kg/day, how many calories should the infant be provided throughout the day? (Round at the end of the calculation to the nearest whole number.)
420 calories per day.
575 calories per day.
650 calories per day.
735 calories per day.
735 calories per day.
The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching?
“Excessive amounts of fluoride will make teeth turn brittle and yellow.”
“Having our children brush with fluoride toothpaste is not effective.”
“Use of fluoride in water is mostly effective during initial tooth formation.”
“Dental caries can be prevented through fluoridation of public water.”
“Dental caries can be prevented through fluoridation of public water.”
A 14-year-old returns to the pediatric unit after corrective surgery for scoliosis. In the immediate postoperative period, the nurse should include which action(s) in this client’s plan of care? (Select all that apply.)
Record intake and output every 8 hours.
Elevate the head of the bed 30 degrees.
Assess bowel sounds every 4 hours.
Initiate a logrolling schedule every 2 hours.
Ambulate for 5 minutes 12 hours postoperative.
Give morphine sulfate 2 mg IV every 4 hours PRN.
Record intake and output every 8 hours.
Assess bowel sounds every 4 hours.
Initiate a logrolling schedule every 2 hours.
Give morphine sulfate 2 mg IV every 4 hours PRN.
What is the best action for the nurse to take when initiating contact with a toddler for the first time?
Ask the toddler to point to where it hurts.
Tell the child your name and that you are the nurse.
Call the child by name while picking up the toddler.
Kneel in front of the toddler and speak softly to the child.
Kneel in front of the toddler and speak softly to the child.
The nurse is collecting a blood sample from a newborn for a screening test for phenylketonuria (PKU). When should the nurse obtain the blood sample?
At birth from cord blood.
Fourteen days after birth.
Before oral feedings are initiated.
After ingestion of a source of protein.
After ingestion of a source of protein.
A nurse who is working in the Poison Control Center receives a telephone call from a parent of a 16-month old child who drank 2 ounces of acetaminophen (Children’s Tylenol) elixir. What action should the nurse recommend to the parent?
Administer oral syrup of ipecac.
Give the child a glass of whole milk.
Transport to emergency center for gastric decontamination.
Obtain oral activated charcoal tablets from the pharmacy.
Transport to emergency center for gastric decontamination.
Which neurological test should the nurse implement to assess cerebellar function in a 5-year-old with symptoms of hyperactivity?
Finger-to-nose.
Quadriceps reflex.
Two-point discrimination.
Ability to follow directions.
Finger-to-nose.
A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement?
Notify the healthcare provider of the measurement.
Quiet the child and retake the blood pressure.
Ask the parent if the child has a history of hypertension.
Document the finding and recheck in 4 hours.
Quiet the child and retake the blood pressure.
The mother of a 2-month-old reports that she often lets the baby cry in the middle of the night instead of going to pick up or sooth the infant. What information should the nurse provide the mother?
Picking up the infant in the middle of the night fosters dependency on the mother.
A sense of trust is developed in an infant when others respond to the infant’s cry.
An infant is learning to manipulate others when the infant is picked up unnecessarily.
A 2-month-old who does not sleep through the night should be evaluated further.
A sense of trust is developed in an infant when others respond to the infant’s cry.
When plotting a 20-week-old infant’s weight on a standardized growth chart, the nurse determines that the child’s weight is between the 2 nd and 3 rd percentile. Based on this finding, which action should the nurse take?
Teach the parents about interventions for failure to thrive syndrome.
Compare this weight with previous weights recorded in the child’s record.
Evaluate the parent’s body build in relation to the infant’s weight.
Obtain a 24-hour nutritional history before making any conclusions.
Compare this weight with previous weights recorded in the child’s record.
A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. What action should the nurse implement?
Postpone the abdominal palpation until the next examination.
Place the child’s hand under the examiner’s hand while palpating.
Touch the abdomen firmly as the child takes short, quick breaths.
Press the abdomen with the child bearing down and holding the breath.
Place the child’s hand under the examiner’s hand while palpating.
A child is brought to the emergency department with sweating, chills, and snake fang-like puncture marks on the calf. What action should the nurse implement after the type of snake is identified?
Secure the antivenin.
Ambulate the child.
Apply a tourniquet to the leg.
Reassure the child and parent.
Secure the antivenin.
Which research finding provides evidence-based practice for an infant’s risk for sudden infant death syndrome (SIDS)?
Breastfeeding reduces the risk for and the incidence of SIDS.
Infants should be positioned supine or supported laterally to sleep.
The prone position should be used when an infant sleeps after feeding.
The peak incidence occurs between the ages of 1 and 2 months.
Infants should be positioned supine or supported laterally to sleep.
The nurse is preparing to catheterize an 8-year-old child. Before starting the procedure, which action should the nurse take first?
Obtain the parent’s cooperation before initiating the procedure.
Explain to the child and the parents that the procedure needs to be done.
After talking with the parents about the procedure, ask them to leave the room.
Provide the child with privacy by conducting the procedure in the treatment room.
Explain to the child and the parents that the procedure needs to be done.
While assessing the apical pulse of a 13-year-old, the nurse determines that the rate is 88 beats/minute, and the rhythm is irregular. The heart rate is phasic with respirations, increasing during inspiration and decreasing with expiration. What action should the nurse take?
Continue the cardiac examination.
Inquire about daily caffeine intake.
Re-assess the apical pulse in 15 minutes.
Schedule a consultation with a cardiologist.
Continue the cardiac examination.
A mother expresses concern to the nurse about the behavior of her 15-year-old adolescent who is frequently finding fault and criticizing her. What information should the nurse provide?
The family value system may need to be changed to meet the teen’s changing needs.
Teens create psychological distance from parents in order to separate from them.
Parents should relinquish their relationship with their teen to the teen’s peers.
Conflicts in the parent-teen relationship are to be expected during adolescence.
Teens create psychological distance from parents in order to separate from them.
A nurse reviews the methods for preventing recurring urinary tract infections (UTI) with the parent of a female child. Which response by the parent indicates that further teaching is needed in caring for the child?
Bathes the child nightly with liquid bubbles added.
Increases oral fluids and encourages the child to void frequently.
Provides the child with cotton underwear for daily use.
Teaches the child to cleanse perineal area from front to back.
Bathes the child nightly with liquid bubbles added.
The nurse is caring for a female client with scoliosis who had a posterior spinal fusion and is in a body jacket cast. Which assessment finding indicates to the nurse the client is developing cast syndrome?
Abdominal distention.
“Hot spot” felt on cast.
Diminished pulses in the foot.
Musty, unpleasant odor to cast.
Abdominal distention.
The nurse at the well-child clinic is advising the parents of an 8-month-old child about health and safety. What information should the nurse provide?
Install stair guards or gates in the home.
Use of a car seat is optional if a lap/shoulder belt is in place.
Start toilet training with a child-sized potty.
Give syrup of ipecac in case of accidental ingestion or poisoning.
Install stair guards or gates in the home.
The nurse is caring for an irritable, lethargic 18-month-old child who swallowed several over-the-counter (OTC)antihistamine tablets an hour ago. What intervention should the nurse implement?
Initiate gastric lavage.
Administer naloxone.
Give a dose of ipecac syrup.
Encourage oral intake of water or milk.
Initiate gastric lavage.
The mother of a 2-month-old infant who just received the first DTaP asks the nurse what symptoms to expect. What is the best response for the nurse to provide?
Most children do not experience any reaction.
Seizures are common and require anticonvulsant medication.
Mild reactions are common and most frequently include low-grade fever.
The most common reaction is a whole-body rash that develops into itchy vesicles.
Mild reactions are common and most frequently include low-grade fever.
An infant weighs 7 lb (3.18kg)at birth. How much should the nurse expect the infant to weigh at age 6-months?
12 lb (5.44kg).
14 lb (6.35kg)
17 lb (7.71kg).
21 lb (9.53).
14 lb (6.35kg)
Which site should the nurse assess to obtain the pulse rate for a 1-year-old child?
Radial.
Apical.
Carotid.
Femoral.
Apical.
The nurse is caring for a 9-year-old male child who frequently speaks about sex and uses correct sexual vocabulary. What action should the nurse implement with this child?
Ask the child whether he was sexually abused.
Ascertain what the child understands about sex.
Inquire where the child got this important information.
Involve the child in teaching sex information to peers.
Ascertain what the child understands about sex.
A 4-year-old boy is brought to the emergency department by his parent, who reports that the child has been pointing at his stomach and saying, “It hurts so bad.” Which pain-assessment tool should the nurse use?
Descriptor Scale.
Brief Pain Inventory.
A numeric rating scale.
Wong-Baker FACES Scale.
Wong-Baker FACES Scale.
Which clinical finding should the nurse expect a child with nephrosis to exhibit?
Elevated blood pressure.
Blood-tinged urine.
Elevated temperature.
Urine protein 3+ to 4+.
Urine protein 3+ to 4+.
The father of an 8-year-old child tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father?
The father should decrease his expectations to give the son a chance to succeed.
The child has an introverted personality and should be encouraged to play isolated games.
The father should encourage the son to participate in team sports instead of less physical activities.
The child should be given opportunities to achieve a sense of competency in an area he chooses.
The child should be given opportunities to achieve a sense of competency in an area he chooses.
The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse’s instruction to this client?
Anemia.
Cardiac arrhythmias.
Gastrointestinal reflux.
Heightened neurologic reflexes.
Cardiac arrhythmias.
A 2-year-old is receiving care in the emergency department (ED) for a deep laceration on the head. What action should the nurse implement to facilitate the child’s cooperation?
Allow the child to hold a favorite toy or blanket.
Direct the parents to remain outside the treatment room.
Keep the child physically restrained during nursing care.
Let the child decide whether to sit up or lie down for procedures.
Allow the child to hold a favorite toy or blanket
A mother brings her 6-month-old infant to the clinic for a well-baby routine exam. Which vaccine(s) should the nurse verify the infant has received? (Select all that apply.)
Meningococcal polysaccharide vaccine (MPSV4).
Haemophilus influenzae type b conjugate vaccine (Hib).
Inactivated poliovirus vaccine (IPV).
Hepatitis B virus vaccine (HepB).
Diphtheria, tetanus toxoids, and acellular pertussis (DTaP).
Measles, mumps, and rubella vaccine (MMR).
Inactivated poliovirus vaccine (IPV).
Hepatitis B virus vaccine (HepB).
Diphtheria, tetanus toxoids, and acellular pertussis (DTaP).
The parents of a 14-year-old girl tell the nurse that their daughter dresses as a tomboy and plays baseball one day and the next day dresses in feminine clothes and becomes a teenage “drama queen.” What information should the nurse use to respond to the parents?
Teenagers need a strong role mode to emulate.
Adolescents try on different roles while seeking their identity.
Such erratic behavior needs further investigation.
Forteen-year-olds often try to please parents with their role choices.
Adolescents try on different roles while seeking their identity.
What is the priority nursing intervention for a 12-year-old client newly diagnosed with bacterial meningitis?
Continue pain management and provide comfort measures.
Maintain seizure precautions to protect the client from injury.
Monitor for increased intracranial pressure and do frequent neural vital sign checks.
Administer broad-spectrum antibiotics before results of culture and sensitivity tests are returned.
Administer broad-spectrum antibiotics before results of culture and sensitivity tests are returned.
A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement?
Remove the object impaled in the eye and then apply a regular eye patch.
Place an ice bag over the eye until the healthcare provider is seen.
Irrigate the affected eye copiously with a cool sterile saline solution.
Apply a Fox shield to the affected eye and any type of patch to the other eye.
Apply a Fox shield to the affected eye and any type of patch to the other eye.
During a well-baby check, the nurse hides a block under the baby’s blanket, and the baby looks for the block. which normal growth and development is milestone is the baby developing?
Associative play
Object prehension
Object permanence
Separation anxiety
Object permanence
A 14-year-old is brought to the emergency room after a biking accident. How should the nurse interact with the adolescent?
Furnish rewards for cooperation during procedures.
Have the parents remain with the adolescent at all times.
Provide clear explanations while encouraging questions.
Limit the number of choices to be made by the adolescent.
Provide clear explanations while encouraging questions.
A mother brings her 8-month-old baby boy to the clinic because he has been vomiting and had diarrhea for the last 3 days. Which assessment is more important for the nurse to make?
A. Assess the infant’s abdomen for tenderness.
B. Determine if the infant was exposed to a virus.
C. Measure the infant’s pulse.
D. Evaluate the infant’s cry.
ANS: C
Measure the infant’s pulse
While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to minutes. Which assessment should the nurse implement?
A. Inspect the posterior oropharynx
B. Asses for teeth clenching or grinding.
C. Touch the tonsillar pillars to stimulate the gag reflex.
D. Ask the child to speak to evaluate change in voice tone.
ANS: A
Inspect the posterior oropharynx
The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, “How can our son have this disease? We are wondering if we should have any more children.” What information should the nurse provide to parents?
A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
B. The striated muscle groups of males can be impacted by a lack of protein dystrophin in their mothers.
C. The male infant had a viral infection that went unnoticed and untreated so muscle damage was incurred.
D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles.
ANS: A
This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her respiratory rate and heart rate have increased during the last hour. Which intervention should the nurse implement?
A. Notify the healthcare provider of these findings.
B. Administer a PRN analgesic prescription.
C. Record the findings in the child’s record.
D. Wrap the infant tightly and rock in rocking chair.
ANS: B
Administer a PRN analgesic prescription
A 2-year-old girl is brought to the clinic by her 17-year-old mother. When the nurse observes that the child is drinking sweetened soda from her bottle, what information should the nurse discuss with this mother? (Select all that apply)
A. A 2-year-old should be speaking in 2 word phrases.
B. Dental caries are associated with drinking soda.
C. Drinking soda is related to childhood obesity.
D. Toddlers should be sleeping 10 hours a night.
E. Toddlers should be drinking from a cup by age 2.
ANS: B, C, E
A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. What finding is most significant in planning care for this family?
A. The mother is a single parent and lives with her parents.
B. The mother states the baby is irritable during feedings.
C.The infant’s formula has been changed twice.
D. The diaper area shows severe skin breakdown.
ANS: D
The diaper area shows severe skin breakdown.
The nurses determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?
A. Document the finding.
B. Palpate scrotum for testicular descent.
C. Assess for bladder distention.
D. Auscultate bowl sounds.
ANS: A
Document the finding.
A 16-year-old with acute myelocytic leukemia is receiving chemotherapy (CT) via an implanted medication port at the out-patient oncology clinic. What action should the nurse implement when the infusion is complete?
A. Administer ondansetron (Zofran).
B. Obtain blood samples for RBCs, WBCs, and platelets.
C. Flush the mediport with saline and a heparin solution.
D. Initiate an infusion of normal saline.
ANS: C
Flush the mediport with saline and a heparin solutions.
A mother brings her 3-week old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant’s vomiting is projectile, and the child seems listless. Which additional finding indicates the possibility of a life-threatening complications?
A. Irregular palpable pulse.
B. Hyperactive bowel sounds.
C. Underweight for age.
D. Crying without tears.
ANS: A
Irregular palpable pulse.
The nurse is performing a routine assessment of a 3-year-old at a community health center. Which behavior by the child should alert the nurse to request a follow-up for a possible autistic spectrum disorder (ASD)?
A. Performs odd repetitive behaviors.
B. Shows indifference to verbal stimulation.
C. Strokes the hair of a hand held doll.
D. Has a history of temper tantrums.
ANS: A
Performs odd repetitive behaviors.
Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?
A. Encourage oral electrolyte solution intake.
B. Assist the child to a recumbent position.
C. Contact their healthcare provider immediately.
D. Provide a quiet time by holding or rocking the toddler.
ANS: C
Contact their healthcare provider immediately.
A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child’s oral temperature is 101.2 F. Which intervention should the nurse implement?
A. Ask the mother if the child has had a runny nose.
B. Cleanse purulent exudate from the affected ear canal.
C. Apply a topical antibiotic to the periauricle area.
D. Provide parent education to prevent recurrence
ANS: A
Ask the mother if the child has had a runny nose.
During a follow-up clinical visit a mother tells the nurse that her 5-month-old son who had surgical correction for Tetralogy of Fallot has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?
A. Stimulate the infant to cry to produce cyanosis.
B. Auscultate heart and lungs while infant is held.
C. Evaluate infant for failure to thrive.
D. Obtain a 12-lead electrocardiogram.
ANS: B
Auscultate heart and lungs while infant is held.
The mother of an 11-year-old boy who has juvenile arthritis tells the nurse, “I really don’t want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting.” What information is most important for the nurse to provide this mother?
A. The child should be encouraged to rest when he experiences pain.
B. Encourage quiet activities such as watching television as a pain distractor.
C. The use of hot baths can be used as an alternative for pain medication.
D. Giving pain medication around the clock helps control the pain.
ANS: D
Giving pain medication around the clock helps control the pain.
The mother of a 4-year-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, “My mother says I should put rice cereal in the baby’s bottle now.” The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
A. Stops rooting when hungry.
B. Opens mouth when food comes her way.
C. Awakens once for nighttime feedings.
D. Gives up a bottle for a cup.
ANS: B
Opens mouth when food comes her way.
A 6-year old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol (Proventil). The child’s mother tells the nurse that she uses this medication to open her son’s airway when he is having trouble breathing. What is the nurse’s best response?
A. Recommend that the mother bring the child in for immediate evaluation.
B. Advise the mother that over-use of the drug may cause chronic bronchitis.
C. Assure the mother that she is using the mediation correctly.
D. Confirm that the medication helps to reduce airway inflammation.
ANS: C
Assure the mother that she is using the medication correctly
A mother brings her school-aged daughter to the pediatric clinic for evaluation of her anti-epileptic medication regimen. What information should the nurse provide to the mother?
A. The medication dose will be tapered over a period of 2 weeks when being discontinued
B. If seizures return, multiple medications will be prescribed for another 2 years
C. A dose of valproic acid (Depakote) should be available in the event of status epilepticus
D. Phenytoin (Dilantin) and phenobarbital (Luminal) should be taken for life
ANS: A
The medication dose will be tapered over a period of 2 weeks when being discontinued
A child receives a prescription for amantadine 42 mg PO BID. Amantadine is available as a 50 mg/5 mL syrup. Using a supplied calibrated measuring device, how many mL should the nurse administer per dose? (round to nearest tenth)
ANS: 0.5 mL
A male toddler is brought to the emergency center approximately three hours after swallowing tablets from his grandmother’s bottle of digoxin (Lanoxin). What prescription should the nurse implement first?
Administer activated charcoal orally
a. Administer activated charcoal
b. Prepare gastric lavage
c. Obtain a 12-lead electrocardiogram
d. Give IV digoxin immune fab (Digibind)
ANS: D
Give IV digoxin immune fab (Digibind)
An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response?
a. Decreased urinary output
b. Decreased periorbital edema
c. Increased periods of rest
d. Weight gain 0.5 kg/day
ANS: B
Decreased periorbital edema
A mother of a 3-year old boy has just given birth to a new baby girl. The little boy asks the nurse, “why is my baby sister eating my mommy’s breast?” how should the nurse respond? Select all that apply
A. Remind him that his mother breastfed him too
B. Clarify that breastfeeding is the mother’s choice
C. Reassure the older brother that it does not hurt his mother
D. Explain that newborns get milk from their mothers in this way
E. Suggest that the baby can also drink from a bottle
ANS:
A, C, D
A middle school male student was recently diagnosed with attention-deficit hyperactivity disorder (ADHD) and is having trouble with his grades. He is referred to the school nurse by the teacher because he continues to have learning problems. Which action should the school nurse take?
A. Ask the parents to have the child seen by a clinical psychologist
B. Ask the parents to become involved in helping the child with his homework
C. Refer the child to the school counselor for educational testing
D. Seek the advice of the school principle regarding the child’s learning needs
ANS: A
Ask the parents to have the child seen by a clinical psychologist
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both his hands and feet. Which intervention should the nurse instruct the mother to implement first? *
A. Place the child in a quiet environment
B. Make a list of foods that the child likes
C.Encourage the parents to rest when possible
D. Apply lotion to hands and feet
ANS: A
Place the child in a quiet environment
The nurse is preparing a teaching plan for the parents of a 6 month-old infant with GERD. What instruction should the nurse include when teaching the parents measures to promote adequate nutrition?
a. Alternate glucose water with formula
b. Mix the formula with rice cereal
c. Add multivitamins with iron to the formula
d. Use water to dilute the formula
ANS: B
Mix the formula with rice cereal
A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child’s plan of care?
A. Obtain vital signs at onset of fluid overload
B. Change IV site dressing q3 days and PRN
C. Monitor for signs of facial swelling or urticartia
D. Assess for abdominal pain and vomiting
ANS: D
D. Assess for abdominal pain and vomiting
The nurse is conducting an admission assessment of an 11-month old infant with CHF who is scheduled for repair of restenosis of coarction of the aorta hat was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower extremities, pounding brachial pulses, and slightly palpable femoral pulses. What pathophysiologic mechanisms support these findings?
A. The aortic semilunar valve obstructs blood flow into the systemic circulation
B. The lumen of the aorta reduces the volume of the blood flow to the lower extremities
C. The pulmonic valve prevents adequate blood volume into the pulmonary circulation
D. An opening in the atrial septum causes a murmur due to a turbulent left to right shunt
ANS: B
The lumen of the aorta reduces the volume of the blood flow to the lower extremities
A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid base imbalance?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
ANS: C
Respiratory alkalosis
The mother of a toddler reports to the nurse working in the pediatric clinic that her child has had a fever and sore throat for the past two days. The nurse observes several swollen red spots in the child’s body, a few of which are fluid filled blisters. Which action should the nurse implement?
A. Obtain fluid culture from blisters
B. Administer a fever reducing salicylate
C. Cover drainage vesicles with a dressing
D. Implement transmission precautions
ANS: D
Implement transmission precautions
The mother of a 14-year old who had a below-the-knee amputation for osteosarcoma tells the nurse that her child is angry and blaming her for allowing the amputation to occur. Which response is best for the nurse to provide?
A. “I will ask the HCP for a psychiatric consult for your child”
B. “This type of acting out behavior is normal for adolescents”
C. “It is important to focus on your child’s needs at this difficult time”
D. “A reaction of anger is your child’s attempt to cope with this loss”
ANS: D
“A reaction of anger is your child’s attempt to cope with this loss”
The nurse provides information about the human papilloma virus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?
A. Use of protective barriers during sexual activity prevents most strains of HPV infection
B. Most adolescents are not honest about being sexually active
C. Not all strains of HPV will be covered if given at a later date
D. Immunity must be established to prevent future HPV infection and risk for cervical cancer
ANS: A
Use of protective barriers during sexual activity prevents most strains of HPV infection
An adolescent’s mother calls the primary HCP’s office to inquire about the results of her daughter’s serum test results that were drawn last week. Since it is the teenager’s 18th birthday, how should the nurse respond to this mother’s inquiry?
A. Ask when the adolescent was last seen in the clinic
B. Tell the mother to have the teenager call the clinic
C. Since the serum samples were drawn last week provide the mother with the findings
D. Explain that the information cannot be released without the 18-year olds permission
ANS: D
Explain that the information cannot be released without the 18-year olds permission
The parents of 15-month old boy tell the nurse that they are concerned because their son brings his spoon to his mouth but does not turn it over. What action should the nurse implement first?
A. Discuss referral to an occupational therapist
B. Question the parents about their concern
C. Tell the parents to hold the spoon correctly in the child’s hand
D. Suggest longer mealtimes so the child can finish eating
ANS: B
Question the parents about their concern
A child with Grave’s disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response?
A. Increased weight gain
B. Decreased heart rate
C. Reduce headaches
D. Diminished fatigue
ANS: B
Decreased heart rate
A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain?
A. Understanding of quality control process used to troubleshoot the pump
B. Interpretation of fingerstick glucose levels that influence diet selections
C. Knowledge of her glycosylated hemoglobin A1c levels for past year
D. Ability to perform the pump for basal insulin with mealtime boluses
ANS: A
Ability to perform the pump for basal insulin with mealtime boluses
In developing a behavior modification program for an extremely aggressive 10 year old boy, what should the nurse do first?
A. Determine what activities, foods, and toys the child enjoys
B. Evaluate the child’s previous reactions to punishment
C. Provide the child with positive feedback
D. Encourage other children on the unit to describe the token system
ANS: A
Determine what activities, foods, and toys the child enjoys
In assessing a 10-year old newly diagnosed with osteomyelitis, which information s most important for the nurse to obtain?
A. Family history of bone disorders
B. Recent occurrence of infection
C. Cultural heritage and beliefs
D. Occurrence of increased fluid intake
ANS: B
Recent occurrence of infection
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
A. Permanent life style changes need to be made to promote safety in the home
B. The chorea or movements are temporary and will eventually disappear
C. Muscle tension is decreased with fine motor project skills, so these activities should be encouraged
D. Consistent discipline is needed to help the child control the movements
ANS: B
The chorea or movements are temporary and will eventually disappear
A 3 year-old boy is receiving a weekly chemotherapy treatment. Which toy is best for the nurse to provide for this child?
A. Bouncy ball
B. Coloring book with crayons
C. Duck that squeaks
D. Remote-controlled care
ANS: B
Coloring book with crayons
A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
A. Red blood cell count of 2.3 million/mm3
B. White blood cell count of 10,000/mm3
C. Weight gain of 2 pounds since birth
D. Urine specific gravity is 1.011
ANS: A
Red blood cell count of 2.3 million/mm3
The nurse is caring for a 3-year old child who has been recently diagnosed with cystic fibrosis, which discharge instruction by the nurse is most important to promote pulmonary function?
A. Chest physiotherapy should be performed before meals and at bedtime
B. Cough suppressants can be used up to four times a day for relief
C. Oxygen should be given through a nasal cannula between 4-6 L/min
D. Exercise is discouraged in order to preserve pulmonary vital capacity
ANS: A
Chest physiotherapy should be performed before meals and at bedtime
An adolescent who is taking antiretroviral therapy for HIV infection arrives at the clinic for a follow up visit. Which information is most important for the nurse to obtain?
A. Missed medication doses
B. A 24-hour dietary recall
C. Barrier contraceptive use
D. Ingestion of illicit drugs
ANS: A
Missing medication doses
A 5-year-old boy with leukemia is receiving chemotherapy through a peripherally inserted central catheter (PICC). Twenty minutes after the infusion is begun, the child feels dizzy and complains of itching. Which intervention should the nurse implement first?
A. Discontinue the medication infusion
B. Flush IV line with saline
C. Obtain emergency resuscitation equipment
D. Measure current blood pressure and pulse
ANS: A
Discontinue the medication infusion
A school-aged male is brought to the school nurse after he was thrown off his bicycle into the trunk of a pine tree. The child’s face and arms are speckled with embedded pine bark. He has copious tearing and complains that “there is stuff in my eyes.” Which action should the nurse implement
A. Patch both of child’s eyes and send him to the family ophthalmologist
B. Use sterile tweezers to lift bark specks from the sclera of each eye
C. Instill pain relieving eye drops into each eye and keep head elevated
D. Encourage the child to blink frequently to increase bilateral tearing in the eyes
ANS: A
Patch both eyes and send him to the family ophthalmologist
A nurse is teaching a class for mothers of premature infants, and is asked about “a shot for respiratory virus.” What information about plaibizumab (Synagis) is correct?
A. It is required immunization for all infants under the age of 3 months
B. It must be repeated every two months to be effective
C. It is recommended for infants who meet established high-risk criteria
D. It provides protection for one year with a single injection
ANS: C
It is recommended for infants who meet established high-risk criteria
When assessing a 5-year-old, which ability should the nurse expect the child to be developing at this age?
A. Learning to ride a tricycle
B. Tying shoelaces
C. Buttoning clothes
D. Cutting with scissors
ANS: B
Tying shoelaces
A mother brings her 2-month old son to the clinic for a well-baby exam. During the assessment the nurse finds that the right testicle is not distended into the scrotum but the left is palpable. Which action should the nurse take?
A. Ask if the right testis has been seen in the scrotum before
B. Address possible concerns about the child’s future fertility
C. Schedule an IV pyelogram to validate presence of the testicle
D. Prepare to obtain a catheterized urine specimen for culture
ANS: A
Ask if the right testis has been seen in the scrotum before
An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LRHR) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?
A. “We should be sure to start our daughter on birth control pills”
B. “Our daughter will be on this hormone treatment the rest of her life”
C. “We should encourage her to dress in clothing that suits her sexual maturity level”
D. “Sexual maturity differences between my daughter and her peers will disappear within a few years”
ANS: D
“Sexual maturity differences between my daughter and her peers will disappear within a few years”
While auscultating the lung sounds of a 5 year-old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. Which action is best for the nurse to take?
A. Identify the antibiotic used to treat the pneumonia
B. Report suspected child abuse to the proper authorities
C. Inquire about the use of alternative methods of treatment
D. Ask the parents if the child has been in a recent accident
ANS: C
Inquire about the use of alternative methods of treatment
Which instructions should the nurse include in the discharge teaching plan of 7 year old girl with history of frequent urinary tract infections?
A. Take frequent bubble baths
B. Perform intermittent catheterization
C. Check oral temperature daily
D. Monitor for changes in urinary odor
ANS: D
Monitor for changes in urinary odor
A male infant with bronchiolitis is brought to the clinic by his mother. The infant is congested and febrile with a capillary refill of 2 seconds. Which information should the nurse discuss with the mother?
A. Encourage infant to play
B. Limit the amount of oral intake
C. Keep infant isolated from others
D. Lay infant on back for naps
ANS: C
Keep infant isolated from others
During a routine physical exam, a male adolescent client tells the nurse, “sometimes, my mother gets angry because I want to be with my own friends.” What is the best initial response by the nurse?
A. Offer reassurance that his mother’s concern is normal
B. Determine is his friends are engaged in unsafe behaviors
C. Ask about the client’s response to his mother’s anger
D. Offer to discuss his concerns together with his mother
ANS: C
Ask about the client’s response to his mother’s anger
Clinical Manifestations of Type 1 Diabetes
polyuria, polydipsia, polyphagia, weight loss, weakness, fatigue
what is an early sign of ketoacidosis?
Ketonuria in the presence of hyperglycemia
whats the most common sign of DKA?
acetone breath “fruity smell”
signs of hypoglycemia
nausea
vomiting
jittery, restless, shaky
sweaty (diaphoresis)
what is hypopituitarism?
diminished secretion of one or more pituitary hormones and depends on the degree of the dysfunction.
may require GH injections daily
signs of diabetes insipidus
polyuria polydipsia
key nursing priority for diabetes insipidus
assess current vital signs
signs of Cushing syndrome
fat accumilating on the cheeks, chin, and trunk (moon face)
-hyperpigmentation to the face
what is epilepsy?
a condition characterized by two or more unprovoked seizures more than 24 hours apart and caused by a variety of pathological processes in the brain
nursing priority for a child having a seizure
maintain a safe environment
nursing teaching for after a lumbar puncture
encourage the child to lie flat and still for at least 30 min
what medication puts children at risk for Reye’s syndrome?
aspirin
what is near drowining defned as?
survival for at least 24 hours from suffocation by submersion
what is pyloris stenosis?
classified by projectile vomiting, and an olive shaped mass in the epigastric area
what does a ruptured appendix put the child at risk for?
peritonitis
how to prevent Hep A in children?
washing your hands
What is scurvy?
Vitamin C deficiency
what is rickets?
Vitamin D deficiency
What is marasmus?
protein-calorie malnutrition
what foods should people with celiac disease avoid?
wheat, barley, ots, rye, batter fried food
what age is the peak insidence in children for GERD?
age 4 months then it spontaneously resolves by 12 months
what is failure to thrive in children a sign of?
imapired renal function
what is the priority nursing diagnosis for a patient with nephrotic syndrome?
excess fluid volume related to excessive protein loss in the urine
clinical manifestations of nephrotic syndrome
massive proteinuria
hypoalbuminemia
hyperlipidemia
edema (salt is restricted)
What is hypospadias?
meatal opening on the ventral surface of the penis
what is epispadias?
meatal or urethral opening on the dorsal surface of the penis
what is cryptorchidism
undescended testes
nursing care for a patient getting a renal biopsy
-NPO 4-6 hrs before procedure
-premedicate as ordered
-VS and apply pressure bandage after procedure (sandbag if possible)
-bed rest 24 hours
-monitor intake and output
what is the most common cause of osteomyelitis
staphylococcus aureus
Systemic Lupus Erythematosus teaching
-avoid sunlight and UVB rays
-maintain regular appointments with physician
-use steroids and prophylactic antibiotics before procedures
-carry a medic alert bracelet or tag
The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?
A. “I will read all the literature you gave me before surgery.”
B. “I have had surgery before when I broke my wrist in a bike accident, so I know what to expect.”
C. “All the things people have told me will help me take care of my back.”
D. “I understand that I will be in a body cast and I will show you how you taught me to turn.”
D. “I understand that I will be in a body cast and I will show you how you taught me to turn.”
To take the vital signs of a 4-month-old child, which order will give the most accurate results?
A. Respiratory rate, heart rate, then rectal temperature.
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate.
D. Rectal temperature, respiratory rate, then heart rate.
A. Respiratory rate, heart rate, then rectal temperature.
During routine screening at a school clinic, an otoscope examination of a child’s ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next?
A. No action required, as this is an expected finding for a school-aged child.
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible.
D. Call the parents and have them take the child home from school for the rest of the day.
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
Which restraint should be used for a toddler after a cleft palate repair?
A. Clove hitch.
B. Mummy.
C. Elbow.
D. Jacket.
C. Elbow.
What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?
A. Monitor for signs of metabolic acidosis.
B. Estimate the quantity of diarrhea stools.
C. Place in a supine position after feeding.
D. Observe for projectile vomiting.
D. Observe for projectile vomiting.
A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child?
A. Keep restraints on at all times.
B. Remove restraints one at a time and provide range of motion exercises.
C. Remove all restraints simultaneously and provide play activities.
D. Renew the healthcare provider’s prescription for restraints every 72 hours.
B. Remove restraints one at a time and provide range of motion exercises.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?
A. Congenital heart disease.
B. Fragile X chromosome.
C. Trisomy 13.
D. Pyloric stenosis.
A. Congenital heart disease.
When assessing a child with asthma, the nurse should expect intercostal retractions during
A. Inspiration.
B. Coughing.
C. Apneic episodes.
D. Expiration.
A. Inspiration.
When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it
A. Increases salivation.
B. Increases the respiratory rate.
C. Leads to vomiting.
D. Stresses the suture line.
D. 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 symptoms is this newborn likely to have exhibited?
A. Choking, coughing, and cyanosis.
B. Projectile vomiting and cyanosis.
C. Apneic spells and grunting.
D. Scaphoid abdomen and anorexia.
A. Choking, coughing, and cyanosis.
Which behavior would the nurse expect a two-year-old child to exhibit?
A. Build a house with blocks.
B. Ride a tricycle.
C. Display possessiveness of toys.
D. Look at a picture book for 15 minutes.
C. Display possessiveness of toys.
The mother 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 the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother’s question?
A. If the child’s tongue darkens, discontinue the Pepto Bismol immediately.
B. Do not give if the child has chickenpox, the flu, or any other viral illness.
C. Avoid the use of Pepto Bismol until the child is at least 16 years old.
D. Pepto Bismol may cause a rebound hyperacidity, worsening the “tummy ache.”
B. Do not give if the child has chickenpox, the flu, or any other viral illness.
The nurse observes a 4-year-old boy in a daycare setting. Which behavior should the nurse consider normal for this child?
A. Has a temper tantrum when told he must share his toys.
B. Plays by himself most of the day.
C. Demonstrates aggressiveness by boasting when telling a story.
D. Begins to cry and is fearful when separated from his parents.
C. Demonstrates aggressiveness by boasting when telling a story.
A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified “Rule of Nines.” Which part of a child’s body is calculated as a larger percentage of total body surface than an adult’s?
A. Head and neck.
B. Arms and chest.
C. Legs and abdomen.
D. Back and abdomen.
A. Head and neck.
The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take?
A. Pass the information on in the report.
B. Notify the healthcare provider because the value is high.
C. Repeat the lab study because the value is too high.
D. Hold the next dose of theophylline.
A. Pass the information on in the report.
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?
A. Give small, frequent feedings of fluids.
B. Accurately chart observations regarding breath sounds.
C. Have a bulb syringe readily available to remove secretions.
D. Encourage older siblings to visit.
C. Have a bulb syringe readily available to remove secretions.
All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse’s evaluation of a 20-month-old child?
A. Weighing diapers.
B. Assessing fontanels.
C. Checking skin turgor.
D. Observing mucous membranes for moisture.
B. Assessing fontanels.
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
A. Frequency of emesis in the last 8 hours.
B. Serum BUN and creatinine levels.
C. Current blood sugar level.
D. Appearance of the stool.
B. Serum BUN and creatinine levels.
The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child’s increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that
A. Only an RN should be assigned to monitor this child’s temperature.
B. A tympanic measurement of temperature will provide the most accurate reading.
C. The licensed practical nurse should be instructed to obtain rectal temperatures on this child.
D. The healthcare provider should be asked to prescribe the method for measurement of the child’s temperatures.
B. A tympanic measurement of temperature will provide the most accurate reading.
The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit?
A. Bradycardia.
B. Machinery murmur.
C. Weak pedal pulses.
D. Clubbed fingers.
D. Clubbed fingers.
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 healthcare provider?
A. A 6-month-old with failure to thrive that has a closed anterior fontanel.
B. A 24-month-old with gastroenteritis that has a closed posterior fontanel.
C. A 2-month-old with chickenpox that has an open posterior fontanel.
D. A 28-month-old with hydrocephalus that has an open anterior fontanel.
A. A 6-month-old with failure to thrive that has a closed anterior fontanel.
A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?
A. Ability to communicate verbally.
B. Response to separation from family.
C. Concern for body integrity.
D. Socialization with other children.
C. Concern for body integrity.
An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?
A. Stop the flow of unoxygenated blood into systemic circulation.
B. Increase the flow of unoxygenated blood to the lungs.
C. Prevent the return of oxygenated blood to the lungs.
D. Reduce peripheral tissue hypoxia and nailbed clubbing.
C. Prevent the return of oxygenated blood to the lungs.
A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9 F. The nurse determines the daily caloric need for this child is approximately
A. 400 calories per day.
B. 500 calories per day.
C. 600 calories per day.
D. 700 calories per day.
C. 600 calories per day.
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?
A. Tell children they should not taste anything but food.
B. Store all toxic agents and medicines in locked cabinets.
C. Provide special play areas in the house and restrict play in other areas.
D. Punish children if they open cabinets that contain household chemicals.
B. Store all toxic agents and medicines in locked cabinets.
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention?
A. Apical heart rate of 60.
B. Sweating across the forehead.
C. Doesn’t suck well.
D. Respiratory rate of 30 breaths per minute.
A. Apical heart rate of 60.
At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure 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 first?
A. Give the client her 9 a.m. prescription for an oral diuretic early.
B. Administer PRN prescription of nifedipine (Procardia) sublingually.
C. Notify the healthcare provider and inform the nursing supervisor of the client’s condition.
D. Attempt to calm the client and retake the blood pressure in thirty minutes.
B. Administer PRN prescription of nifedipine (Procardia) sublingually.
A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?
A. “Studies have shown that handling a sick newborn is not good for the baby and upsets the parents.”
B. “The oxygen hood is holding the baby’s oxygen level just at the point which is needed. You may stroke and talk to her.”
C. “Since your baby has been doing well under oxygen for 24 hours, I can let you hold the baby without oxygen.”
D. “You can hold the baby with the oxygen blowing in the baby’s face since the level is very close to room air.”
B. “The oxygen hood is holding the baby’s oxygen level just at the point which is needed. You may stroke and talk to her.”
The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?
A. Reassure the parents that 3-year-olds are cooperative and therefore are less likely to be anxious.
B. Obtain a video film of a cardiac catheterization to show to the child prior to the procedure.
C. Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.
D. Obtain a cardiac catheter and demonstrate the procedure by pretending to put the catheter in a doll or stuffed animal.
C. Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.
When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?
A. Hyperactive behavioral traits.
B. Delay in the eruption of permanent teeth.
C. Slow sexual development, but within normal range.
D. Cessation of growth in a child that had been normal.
D. Cessation of growth in a child that had been normal.
The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family?
A. Polyuria and polydipsia.
B. Lethargy and fatigue.
C. Increased facial hair.
D. Facial bone structure changes.
A. Polyuria and polydipsia.
The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication?
A. Poor skin turgor resulting from dehydration.
B. Changes in level of consciousness.
C. Premature aging as the disease progresses.
D. Severe edema from an excess of water and sodium.
B. Changes in level of consciousness.
A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, “Is this normal behavior for a child this age?” The nurse’s response should be based on which information?
A. Children need to retain a sense of initiative without impinging on the rights and privileges of others.
B. Negative feelings of doubt and shame are characteristic of 4-year-old children.
C. Role conflict is a common problem of children this age. She is just wondering where she fits into society.
D. At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.
A. Children need to retain a sense of initiative without impinging on the rights and privileges of others.
The mother of a 2-year-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?
A. Paddle him gently as soon as the behavior is initiated.
B. Immediately put him in “time-out.”
C. Quietly remind him that others are watching him.
D. Walk away from him and ignore the behavior.
D. Walk away from him and ignore the behavior.
A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?
A. Remove all blackheads and follow with an alcohol scrub.
B. Use medicated cosmetics only to help hide the blemishes.
C. Wash the hair and skin frequently with soap and hot water.
D. Encourage her to see a dermatologist as soon as possible.
C. Wash the hair and skin frequently with soap and hot water.
During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?
A. Hearing tests.
B. Eye exams.
C. Chest x-rays.
D. Fasting blood glucose tests.
B. Eye exams.
A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client’s social interaction, what intervention is best for the nurse to initiate?
A. Encourage the client to use a hand-held video game that is popular with all his friends.
B. Assign a 25-year-old female nursing student to offer support to the client.
C. Arrange for an Internet connection in the client’s room for email communication.
D. Encourage the client’s mother to arrange a surprise get together in the cafeteria.
C. Arrange for an Internet connection in the client’s room for email communication.
The nurse is assessing a 2-year-old. What behavior indicates that the child’s language development is within normal limits?
A. Is able to name four colors.
B. Can count five blocks.
C. Is capable of making a three word sentence.
D. Half of child’s speech is understandable.
C. Is capable of making a three word sentence.
When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement?
A. Record weight daily.
B. Assess for signs of anemia.
C. Document sleeping patterns.
D. Teach parenting skills.
A. Record weight daily.
Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations?
A. Oven-baked potato chips and cola.
B. Peanut butter and banana sandwich.
C. Oatmeal-raisin cookies and milk.
D. Graham crackers and fruit juice.
A. Oven-baked potato chips and cola.
The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain?
A. Description of vomiting episodes in past 24 hours.
B. Number of wet diapers in last 24 hours.
C. Feeding and sleep schedule.
D. Amount of formula consumed during the past 24 hours.
A. Description of vomiting episodes in past 24 hours.
A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?
A. Nystatin (Mycostatin).
B. Nitrofurantoin (Macrodantin).
C. Norfloxacin (Noroxin).
D. Neomycin sulfate (Mycifradin).
A. Nystatin (Mycostatin).
Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?
A. Aminoglycosides.
B. Tetracyclines.
C. Penicillins.
D. Quinolones.
B. Tetracyclines.
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?
A. “Use sunscreen when lying by the pool.”
B. “Cleanse the skin at least 4 times a day.”
C. “Take the medication with a glass of milk.”
D. “Menstrual periods may become irregular.”
A. “Use sunscreen when lying by the pool.”
The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?
A. 3 to 6 months.
B. 12 to 15 months.
C. 18 to 24 months.
D. 4 to 6 years.
B. 12 to 15 months.
Preoperative nursing care for a child with Wilms’ tumor should include which intervention?
A. Gently percuss the abdomen for evidence of trapped air.
B. Observe the abdomen for any noticeable discolorations.
C. Apply cold compresses to the abdomen to reduce edema.
D. Put a sign on the bed reading, “DO NOT PALPATE ABDOMEN.”
D. Put a sign on the bed reading, “DO NOT PALPATE ABDOMEN.”
A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast was applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?
A. “Call the healthcare provider immediately if his nail beds appear blue.”
B. “Check his fingers hourly for the first 48 hours to see that he is able to move them without pain.”
C. “Be sure your child’s arm remains above his heart for the first 24 hours.”
D. “Take his temperature every four hours for the next two days and call if an elevation is noted.”
A. “Call the healthcare provider immediately if his nail beds appear blue.”
An 18-month-old is admitted to the hospital with possible Hirschsprung’s disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?
A. Foul-smelling and fatty.
B. Bile-colored and watery.
C. Semi-solid and yellow.
D. Ribbon-like and brown.
D. Ribbon-like and brown.
The nurse must prevent a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis?
A. Obtain gloves for the child’s hands.
B. Apply finger cots on the child’s fingers.
C. Place elbow restraints on the child’s arms.
D. Apply soft restraints to the child’s wrists.
C. Place elbow restraints on the child’s arms.
The nurse assigning care for a 5-year-old child with otitis media is concerned about the child’s increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift?
A. An RN should be assigned to take temperatures frequently.
B. Tympanic and oral temperatures are equally accurate.
C. The PN should take rectal temperatures on this child.
D. The pediatrician should decide how to assess the temperature.
B. Tympanic and oral temperatures are equally accurate.
A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children’s vitamin pills. Which intervention should the nurse implement first?
A. Insert N/G tube for gastric lavage.
B. Determine the child’s pulse and respirations.
C. Assess the child’s level of consciousness.
D. Administer an IV D5/0.25 NS as prescribed.
B. Determine the child’s pulse and respirations.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents’ teaching plan?
A. Invite other children home to share meals.
B. Accept that he will eat when he is hungry.
C. Reward the child with a nap after eating.
D. Consistently follow a set mealtime routine.
D. Consistently follow a set mealtime routine.
A 6-month-old boy and his mother are at the healthcare provider’s office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today?
A. The routine immunizations and schedule another appointment to administer the influenza vaccine.
B. All the immunizations with the influenza vaccine given at a separate site from any other injection.
C. The influenza vaccine and schedule another appointment to administer the immunizations.
D. The influenza vaccine and the polio vaccine and schedule another appointment to administer the remaining immunizations.
B. All the immunizations with the influenza vaccine given at a separate site from any other injection.
The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview?
A. “Have you lost any weight in the last month?”
B. “Are you experiencing any type of nervousness?”
C. “When was the last time you took your synthroid?”
D. “Are you having any problems with your vision?”
B. “Are you experiencing any type of nervousness?”
The nurse is planning care for school-aged children at a community care center. Which activity is best for the children?
A. Building model airplanes.
B. Playing follow-the-leader.
C. Stringing large and small beads.
D. Playing with Playdough and clay.
B. Playing follow-the-leader.
Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate?
A. A trial of adrenocorticotrophic hormone injections.
B. Frequent stimulation of the cremasteric reflex.
C. A trial of human chorionic gonadotrophic hormone.
D. Frequent warm baths to gently dilate the scrotal area.
C. A trial of human chorionic gonadotrophic hormone.
A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal 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?
A. Aplastic.
B. Sequestration.
C. Hyperhemolytic.
D. Vaso-occlusive.
B. Sequestration.
To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?
A. Use a happy-face/sad-face pain scale.
B. Ask the mother if she thinks the analgesic is working.
C. Assess for changes in the child’s vital signs.
D. Teach the child to point to a numeric pain scale.
A. Use a happy-face/sad-face pain scale.
In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first?
A. Food planning and selection.
B. Administering insulin injections.
C. Process of glucose testing.
D. Drawing up the correct insulin dose.
C. Process of glucose testing.
A 17-year-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 vital signs: temperature 100 F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?
A. Tell the student to proceed directly to his regularly scheduled class.
B. Call the parent and suggest re-taking the student’s temperature at home.
C. Give the student a glass of cool fluids, then retake his temperature.
D. Send the student to class, but re-verify his temperature after lunch.
A. Tell the student to proceed directly to his regularly scheduled class.
The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child’s pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first?
A. Insert an indwelling urinary catheter.
B. Start an IV infusion of normal saline.
C. Send a specimen to the lab for urinalysis.
D. Document the child’s vital signs and pulses.
B. Start an IV infusion of normal saline.
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.)
A. Monitor the the infant’s weight and number of wet diapers per day.
B. Increase the infant’s intake per feeding by 1 to 2 ounces per week.
C. Mix the dose of prophylactic antibiotic in a full bottle of formula.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening.
A. Monitor the the infant’s weight and number of wet diapers per day.
B. Increase the infant’s intake per feeding by 1 to 2 ounces per week.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening.
When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline?
A. Parental control should be consistent.
B. Children as young as 4 years rarely need reprimand or punishment.
C. Withdrawal of approval is effective.
D. Parents should enforce rigid rules to be followed without question.
A. Parental control should be consistent.
Which action by the nurse is most helpful in communicating with a preschool-aged child?
A. Speak clearly and directly to the child.
B. Use a doll to play and communicate.
C. Approach when a parent is not present.
D. Play a board game with the child.
B. Use a doll to play and communicate.
The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?
A. Engage the child through drawing pictures.
B. Suggest that the parent read a book to the child.
C. Provide paper and pencil for the child to keep a diary.
D. Ask the parent if the child is always uncommunicative.
A. Engage the child through drawing pictures.
A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?
A. Slowly pour hydrogen peroxide over the open wound.
B. Apply ice to the area before rinsing with cold water.
C. Wash the wound gently with mild soap and water.
D. Gently cleanse with a sterile pad using povidone-iodine.
C. Wash the wound gently with mild soap and water.
A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child’s adjustment to hospitalization?
A. Explain hospital schedules to the child, such as mealtimes.
B. Use terms, such as “honey” and “dear,” to show a caring attitude.
C. Provide a list of rules that limits visitation of siblings in the hospital.
D. Orient the parents to the hospital unit and refreshment areas.
A. Explain hospital schedules to the child, such as mealtimes.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent’s last tetanus toxoid booster was received eight years ago. What action should the nurse take?
A. Dispense a tetanus antitoxin.
B. Prepare human tetanus immune globulin.
C. Administer tetanus toxoid booster.
D. Delay the tetanus toxoid booster until due.
C. Administer tetanus toxoid booster.
A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?
A. Diarrhea.
B. Rhinorrhea.
C. Galactorrhea.
D. Steatorrhea.
D. Steatorrhea.
The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain?
A. Type of reaction to loud noises.
B. Any surgeries on the ears since birth.
C. Drainage from the infant’s ears.
D. Number of ear infections since birth.
A. Type of reaction to loud noises.
The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child’s cooperation?
A. Use a colorful straw.
B. Mix the medication in water.
C. Administer the medication using an oral syringe.
D. Ask the pharmacy to provide an enteric tablet.
A. Use a colorful straw.
The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching?
A. “I will give this antibiotic to my child until it is finished.”
B. “Using a teaspoon will help me measure this correctly.”
C. “I will call the clinic if my child develops a rash or itching.”
D. “My baby should begin to feel better within a few days.”
B. “Using a teaspoon will help me measure this correctly.”
Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant?
A. A lower sensitivity reactions to skin irritants.
B. A thin stratum corneum that increases topical absorption.
C. A smaller percentage of muscle mass.
D. A greater body surface area that requires larger dosages.
B. A thin stratum corneum that increases topical absorption.
A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?
A. Minimize interactive play with other children to lessen chances for injury.
B. Give low-dose children’s chewable aspirin in orange flavor for joint discomfort.
C. Use a firm and dry toothbrush to clean teeth at least twice per day.
D. Apply pressure and ice for bleeding while elevating and resting the extremity.
D. Apply pressure and ice for bleeding while elevating and resting the extremity.
A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child’s care?
A. Daily iron supplements should be given.
B. Plenty of fluids should be consumed daily.
C. Immunizations should be delayed for a few years.
D. Protective equipment should be worn for contact sports.
B. Plenty of fluids should be consumed daily.
The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?
A. Risk for infection.
B. Risk for hemorrhage.
C. Altered skin integrity.
D. Disturbance in body image.
A. Risk for infection.
During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?
A. Start another IV of dextrose solution and stay with the child.
B. Continue the transfusion and monitor the child’s vital signs.
C. Stop the infusion immediately and notify the healthcare provider.
D. Slow the transfusion and assess for cessation of symptoms.
C. Stop the infusion immediately and notify the healthcare provider.
The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand?
A. “Perform postural drainage before starting the aerosol therapy.”
B. “Give respiratory treatments when the child is coughing a lot.”
C. “Administer aerosol therapy followed by postural drainage before meals.”
D. “Ensure respiratory therapy is done daily during any respiratory infection.”
C. “Administer aerosol therapy followed by postural drainage before meals.”
The nurse is assessing the neurovascular status of a child in Russell’s traction. Which finding should the nurse report to the healthcare provider?
A. Pale bluish coloration of the toes.
B. Skin is warm and dry to the touch.
C. Toes are wiggled upon command.
D. Capillary refill less than 3 seconds.
A. Pale bluish coloration of the toes.
A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?
A. Insert an indwelling urinary catheter.
B. Administer IV pain medication.
C. Collect blood specimen for laboratory studies.
D. Assess the child’s respiratory status.
D. Assess the child’s respiratory status.
The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling’s repeated hospitalizations. Which is the best response that the nurse should offer?
A. Inform the parent that the child is too young to visit the hospital.
B. Suggest that the child visit a grandmother until the sibling returns home.
C. Ask the mother if the child asks when the sibling will be discharged.
D. Encourage the mother to have the children visit the hospitalized sibling.
D. Encourage the mother to have the children visit the hospitalized sibling.
Which finding in a 19-year-old female client should trigger further assessment by the nurse?
A. Menstruation has not occurred.
B. Reports no tetanus immunization since childhood.
C. Denies having any wisdom teeth.
D. History of painful, inward growth on bottom of foot.
A. Menstruation has not occurred.
A 15-year-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?
A. Refer the adolescent to the healthcare provider for a pregnancy screen.
B. Schedule a conference with her parents to recommend hormone therapy.
C. Explain that menarche varies and occurs between the ages of 12 and 18 years.
D. Suggest that she use diversions to help her not worry about delayed menarche.
C. Explain that menarche varies and occurs between the ages of 12 and 18 years.
Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.)
A. Child’s height and weight.
B. Adult dosage of medication.
C. Body surface area of child.
D. Average adult’s body surface area.
E. Average pediatric dosage of medication.
F. Nomogram determined mathematical constant.
A. Child’s height and weight.
C. Body surface area of child.
F. Nomogram determined mathematical consant