ssessment A

A nurse is contributing to the plan of care for a school-age child who has acute poststreptococcal glomerulonephritis (APSGN) and is mildly hypertensive. Which of the following actions should the nurse include in the plan of care?

A. Restrict the child’s sodium intake
B. Weigh the child every other day
C. Monitor the child’s blood pressure every 12 hour
D. Place the child on bed rest
Restrict the child’s sodium intake

A nurse is collecting data from a toddler at a well-child visit. Which of the following findings should the nurse identify as a possible indication of child maltreatment?

A. diaper dermatitis
B. bruise on the front of the lower leg
C. inflamed unilateral conjunctiva
D. laceration on the side of the torso
laceration on the side of the torso

A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parents asks the nurse why it is necessary to check the child’s urine for protein. Which of the following explanations should the nurse offer?

A. “A decrease in urine protein indicates that treatment is effective.”
B. “Protein in the urine indicates your child’s protein intake is adequate.”
C. “Protein in the urine indicates a need to begin dialysis.”
D. “An increase in urine protein indicates your child has a secondary infection.”
“A decrease in urine protein indicates that treatment is effective.”

A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the following parent statements indicates an understanding of the teaching?

A. “We will keep our child out of the sun between 3 p.m. and 5 p.m.”
B. “We will transition our child to a toddler bed when he is 2 feet tall.”
C. “We will purchase a toy storage box with a lightweight lid.”
D. “We will provide a healthy snack of peanuts.”
“We will purchase a toy storage box with a lightweight lid.”

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to include in the plan?

A. promote oxygen utilization
B. Administer antibiotics
C. encourage fluid intake
D. apply a warm compress to the joints
promote oxygen utilization

A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea. Which of the following findings should the nurse identify as a risk factor for this disorder? (select all that apply)

A. hypothyroidism
B. obesity
C. cannabis use
D. oral contraceptive use
E. emotional stress

1. hypothyroidism
2. cannabis use
3. oral contraceptive use
4. emotional stress

A nurse is reviewing the laboratory report of a preschooler who has Wilms’ tumor and is scheduled to begin treatment with an antineoplastic medication regimen. Which of the following laboratory results should the nurse report to the provider?

A. BUN 16 mg/dL
B. WBC count 5,500/mm3
C. serum glucose 98 mg/dL
D. Platelet count 70,000
Platelet count 70,000

A nurse is collecting data from an infant who is receiving IV therapy for fluid replacement. Which of the following findings indicates the infant’s status is improving?

A. WBC count 19,000/mm3
B. Sodium level 145 mEq/L
C. Capillary refill greater than 3 seconds
D. Dry mucous membranes
Sodium level 145 mEq/L

A nurse is collecting data from a 12 month old infant during a well-child visit. The nurse should identify which of the following findings as a deviation from expected growth and development?

A. vocabulary of three words
B. negative Babinski reflex
C. birth weight doubled
D. unable to build a two-block tower
birth weight doubled

A nurse is assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding?

A. Walks backwards with heel to toe
B. Stands on one foot for several seconds
C. Uses scissors to cut out shapes
D. Prints letters with a pencil
Stands on one foot for several seconds

A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child’s oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 z of gelatin, and drank 7 oz of water. What is the child’s oral intake for this shift in milliliters? (round to the nearest whole number)
690 ml

of oz x 30=mL

A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who is recovering from acute glomerulonephritis. Which of the following food choices by the parents indicates an understanding of the teaching?

A. pretzels
B. apples
C. canned corn
D. peanut butter
apples

A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect?

A. capillary refill of 2 seconds
B. flushed skin
C. weight loss of 10%
D. bulging anterior fonanel
weight loss of 10%

A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile idiopathic arthritis (JIA). Which of the following statements by the guardian indicates an understanding of the teaching?

A. “I will have my child sleep in knee, wrist, and hand splints.”
B. “I will encourage my child to take an afternoon nap.”
C. “I will apply topical hydrocortisone to my child’s joints as needed.”
D. “I will administer opioids to my child for the next several months to control the pain.”
“I will have my child sleep in knee, wrist, and hand splints.”

A nurse is caring for a preschooler who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the parent to administer for an acute asthma attack?

A. Levalbuterol
B. Fluticasone
C. Omalizumab
D. Montelukast
Levalbuterol

A nurse is reinforcing teaching with an adolescent female client who has acne vulgaris and a new prescription for isotretinoin. Which of the following information should the nurse include?

A. “You should apply this medication to the affected skin twice daily.”
B. “You will need to have two negative pregnancy tests prior to starting this medication.”
C. “Your provider will monitor your kidney function while you are taking this medication.”
D. “Your provider will prescribe a vitamin A supplement to take with each dose of this medication.”
“You will need to have two negative pregnancy tests prior to starting this medication.”

A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which of the following actions should the nurse take?

A. Place the infant in semi-Fowler’s position for 1 hr after the feeding
B. Flush the tube with 30 mL of normal saline before the feeding
C. Warm the feeding in the microwave immediately prior to administration
D. Auscultate over the infant’s epigastric area to ensure proper tube placement
Place the infant in semi-Fowler’s position for 1 hr after the feeding

A nurse is collecting data about a 4 year old preschooler’s gross motor skills. The nurse should expect the preschooler to be able to perform which of the following activities?

A. Hopping on one foot
B. Skipping on alternate feet
C. Jumping rope
D. Roller skating
hopping on one foot

A nurse is reinforcing teaching with the parents of a child who has cystic fibrosis and is taking pancrelipase as a pancreatic enzyme replacement. The nurse should plan to inform the child’s parents that the therapeutic effects of this medication can be evaluated by which of the following?

A. Blood glucose levels
B. amount and consistency of stools
C. chloride sweat tests
D. BUN and creatinine clearance tests
amount and consistency of stools

A nurse is auscultating heart sounds on an infant. The nurse should identify this sounds as which of the following?

A. Sinus rhythm
B. ventricular septal defect
C. pulmonic stenosis
D. atrial septal defect
sinus rhythm

A nurse is caring for an adolescent client who is experiencing sickle cell crisis. Which of the following laboratory values should the nurse report to the provider?

A. total bilirubin 0.5 mg/dL
B. reticulocyte count 1%
C. WBC count 8,000/mm3
D. Hgb 6 g/dL
Hgb 6 g/dL

A nurse is preparing to administer ophthalmic drops to a child. Which of the following action should the nurse take?

A. Position the child with hs head flexed while administering the medication
B. Apply pressure to the lacrimal punctum for 1 min following administration
C. Hold the dropper 5 cm (2 in) above the eye to administer the medication
D. Wipe the excess medication toward the inner canthus with a cotton swab
Apply pressure to the lacrimal punctum for 1 min following administration

A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following actions should the nurse take?

A. Ensure the availability of soft extremity restraints
B. Place a padded tongue blade at the bedside
C. Have a suction canister and tubing available in the room
D. Keep the child’s bed in the highest position
Have a suction canister and tubing available in the room

A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of the following actions should the nurse take first?

A. Open the sterile dressing tray
B. Administer pain medication to the client
C. Assist the client into the lateral position
D. Remove the previous dressing to inspect the wound
Administer pain medication to the client

A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM antibiotic to a child 5 min ago. Which of the following manifestations should the nurse expect to observe first?

A. wheezing
B. angioedema
C. hives
D. hypotension
hives

A nurse is collecting data from a toddler who has gastroesophageal reflux disease (GERD). Which of the following findings should hte nurse expect?

A. abdominal distension
B. constipation
C. chronic cough
D. decreased bowel sounds
chronic cough

A nurse is collecting data from a child who has iron deficiency anemia. Which of the following data signifies that adherence to ferrous sulfate therapy has occurred?

A. occasional vomiting and nausea
B. green, tarry stools
C. tolerates milk
D. weight gain
green, tarry stools

A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death?

A. “Your child will likely exhibit fear of the impending death with verbal uncooperativeness.”
B. “At this age, your child will understand that death is irreversible.”
C. “Your child will likely be curious about what happens to the body after death.”
D. “At this age, your child likely believes his thoughts can cause another person’s death.”
“At this age, your child likely believes his thoughts can cause another person’s death.”

A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The nurse should identify which of the following as an indication that the preschooler experienced an allergic reaction to the contrast dye?

A. jaundice
B. hematuria
C. urticaria
D. petechiae
urticaria

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has acute lymphocytic leukemia and an absolute neutrophil count of 450/mm3. Which of the following instructions should the nurse include?

A. “Allow your child to receive the varicella immunization.”
B. “Take your child’s rectal temperature twice per day.”
C. “Increase your child’s intake of fresh fruits and vegetables.”
D. “Keep your child away from crowded areas.”
“Keep your child away from crowded areas.”

A nurse is collecting data from a 6 month old child who is experiencing a sickle cell crisis. Which of the following areas should the nurse observe when monitoring for manifestation of splenic sequestration?

A
B
C
B

*splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood. LUQ

A nurse is reinforcing teaching with the parents of a toddler who has strabismus. Which of the following treatments should the nurse plan to include in the teaching?

A. corrective biconcave lenses
B. laser surgery
C. eye patch
D. artificial tears
eye patch

A nurse is assisting with the care of a school-age child who has congestive heart failure and is receiving digoxin. Which of the following manifestations should the nurse report to the provider?

A. potassium 3 mEq/L
B. decreased edema
C. heart rate 90/min
D. peripheral pulses 3+
potassium 3 mEq/L

A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following parent statements indicates an understanding of the teaching?

A. “I will keep my hearing aid batteries in my bedside table.”
B. “I will place a screen in front of the fireplace.”
C. “I will keep my medication in my purse.”
D. “I will use a steam vaporizer when my child has a cold.”
“I will place a screen in front of the fireplace.”

A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone. Which of the following laboratory results should the nurse report to the provider?

A. Fasting blood glucose 74 mg/dL
B. Sodium 150 mEq/L
C. Potassium 4.2 mEq/L
D. WBC count 9,400/mm3
Sodium 150 mEq/L

A nurse is caring for a child who has a fractured tibia and is in Buck’s traction. Which of the following actions should the nurse take?

A. ensure the weights are hanging freely
B. allow the child to change positions frequently
C. use palms of hands when handling the traction boot
D. check the pin site every 8 hr
ensure the weights are hanging freely

A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following instructions should the nurse include to decrease the child’s risk of an upper respiratory infection?

A. rinse the infant’s mouth with water before feeding
B. limit the infant’s fluid intake
C. use a cool mist vaporizer in the infant’s room
D. avoid applying lip balm to the infant’s lips
use a cool mist vaporizer in the infant’s room

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has a new prescription for home oxygen therapy. Which of the following statements by the guardian indicates an understanding of the teaching?

A. “I will restrict the length of the oxygen tubing to no longer than 3 feet.”
B. “I will place the extra oxygen tanks in a horizontal position for storage.”
C. “I will check the oxygen delivery equipment once every week.”
D. “I will make sure that electrical devices in the house are grounded.”
“I will make sure that electrical devices in the house are grounded.”

A nurse is collecting data from a 12 month old infant during a well child visit. Which of the following findings should the nurse report to the provider?

A. heart rate 130/min
B. respiratory rate 30/min
C. BP 155/70 mm Hg
D. temperature 37.5 C (99.5 F)
BP 155/70 mm Hg

A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin. Which of the following manifestations should the nurse identify as an indication of digoxin toxicity and report to the provider?

A. irritability
B. diaphoresis
C. vomiting
D. tachycardia
vomiting

A nurse has just received change-of-shift report for four children in a pediatric unit. Which of the following children should the nurse collect data from first?

A. A child who is 2 days postoperative following an appendectomy and reports incisional pain
B. A child who has a new diagnosis of diabetes mellitus and HbA1c level of 7.5%
C. A child who has a fever and nuchal rigidity
D. A child who experienced a seizure 1 hr ago and is resting
A child who has a fever and nuchal rigidity

A nurse is caring for an adolescent client who is practicing Jehovah’s Witness and is scheduled for surgery for a ruptured appendix. The adolescent tells the nurse that based on their religious beliefs, they cannot receive a blood transfusion. Which of the following responses should the nurse make?

A. “Why do members of your faith believe this?”
B. “You’ll only receive blood during the procedure if you need it.”
C. “I will let the surgical team know your wishes.”
D. “Let’s discuss the possible need for a transfusion with your parents.”
“Let’s discuss the possible need for a transfusion with your parents.”

A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg to repair a femur fracture. Which of the following findings is the priority for the nurse to report to the provider?

A. report of tingling in the right foot
B. pain rating of 7 on a scale of 0 to 10
C. decrease in food intake
D. increase in crusting at pin sites
report of tingling in the right foot

A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse plan to administer?

A. Haemophilus influenza type b (Hib)
B. Rotavirus (RV)
C. Polio (IPV)
D. Tetanus, diphtheria toxoids, and acellular pertussis (Tdap)
Tetanus, diphtheria toxoids, and acellular pertussis (Tdap)

A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

A. “Press the platform of the lancet firmly against your child’s finger.”
B. “Obtain the blood sample from the center of your child’s finger pad.”
C. “Put your child’s finger under warm, running water prior to collecting blood.”
D. “Steady the finger against a hard surface while puncturing the skin.”
“Put your child’s finger under warm, running water prior to collecting blood.”

A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening?

A. Clasping hands while arms are raised above the head
B. Bending forward with back parallel to the floor
C. Standing with feet shoulder-width apart
D. Bending knees while placing on hips
Bending forward with back parallel to the floor

A nurse is collecting data about the dietary habits of an adolescent female client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits?

A. The client chooses to eat more vegetables than fruits
B. The client consumes approximately 2,000 calories a day
C. The client fasts twice a week to manage dietary intake
D. The client increases their dietary intake during track season
The client fasts twice a week to manage dietary intake

A nurse is monitoring a child who is receiving a transfusion of packed RBCs. Which of the following responses by the child is an indication of a transfusion reaction?

A. “My nose is runny. Can I have a tissue?”
B. “I am hungry. Can I get a snack?”
C. “I am sleepy. I might take a nap after this.”
D. “I am cold. Can I have an extra blanket.”
“I am cold. Can I have an extra blanket.”

A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the following should the nurse recognize as an early manifestation of increased intracranial pressure?

A. fixed and dilated pupils
B. increased irritability
C. decorticate posturing
D. cheyne-stokes respirations
increased irritability

A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of actions the nurse should recommend to the parent.

A. identify the medication and dosage strength
B. Determine if the child is breathing
C. Empty the child’s mouth of remaining pills and residue
D. Call a poison control center

1. Determine if the child is breathing
2. Empty the child’s mouth of remaining pills and residue
3. identify the medication and dosage strength
4. Call a poison control center

A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory results should the nurse report to the provider?

A. Potassium 4.2 mEq/L
B. Lead 14 mcg/dL
C. Fasting blood glucose 75 mg/dL
D. Hematocrit 40%
Lead 14 mcg/dL

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of enterobiasis. The nurse should advise the guardian to take which of the following actions to prevent infection?

A. Dress the child in two-piece sleeping outfits
B. Trim the child’s fingernails short
C. Have the child take a tub bath daily
D. Repeat treatment in 4 weeks
Trim the child’s fingernails short

A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child’s diet?

A. white rice
B. whole wheat bread
C. Graham crackers
D. French fries
white rice

A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis?

A. Dry cough
B. Abdominal pain
C. Muscle stiffness
D. Swollen eyelids
dry cough

A nurse is reinforcing teaching with the guardians of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child?

A. Exaggerate the pronunciation of each word
B. Keep hands still when speaking
C. Stand away from child when speaking
D. Use facial expressions when speaking
Use facial expressions when speaking

A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a nasogastric tube. Which of the following actions should the nurse take?

A. Administer 20 mL/min formula by gravity
B. Refrigerate the formula for 30 min prior to administration
C. Confirm that the pH of the stomach contents is 5 or less
D. Flush the tube with 5 to 15 mL of 0.9% sodium chloride
Confirm that the pH of the stomach contents is 5 or less

A nurse is collecting data from an adolescent who has manifestations of physical abuse. Which of the following actions should the nurse take?

A. Conduct the admission process with the adolescent’s parent at bedside
B. Report the suspected abuse to the authorities
C. Use closed-ended questioning when speaking with the adolescent
D. Encourage the adolescent to enroll in family psychotherapy
Report the suspected abuse to the authorities

A nurse is reinforcing teaching with the parents of a 7 year old female child about behavioral expectations. Which of the following behaviors should the nurse include in the teaching?

A. Spends a lot of time by herself
B. Exhibits a decline in self-esteem
C. Selectively chooses a best friend
D. Shows a competitive nature with others
Spends a lot of time by herself

A nurse is caring for a school-age girl who is being treated for a frequent, severe urinary tract infections (UTIs). The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTIs?

A. “My daughter has bowel movements every 4 to 5 days.”
B. “I taught her to wipe from front to back after going to the bathroom.”
C. “She urinates every 2 to 3 hours during the day.”
D. “I don’t let her wear nylon underwar.”
“My daughter has bowel movements every 4 to 5 days.”

A nurse is contributing to the plan of care for an adolescent client who has human immunodeficiency virus (HIV). Based on the adolescent’s diagnosis, which of the following actions should be included in the plan of care?

A. Instruct visitors to wear gowns and masks when entering the client’s room
B. Contact the dietary department to request that foods be delivered on disposable dishes
C. Prepare a negative-pressure airflow room for the client
D. Inform the client regarding routes of transmission
Inform the client regarding routes of transmission

Assessment B

A nurse is caring for a toddler following a tonsillectomy. Which of the following is the priority finding that the nurse should report to the provider?

A. Drowsiness
B. Throat pain
C. Continuous swelling
D. Dark brown emesis
continuous swelling

A nurse is caring for a 1 month old infant who has a nasogastric tube in place for intermittent feedings. Which of the following actions should the nurse take?

A. Position the head of the crib at a 30 angle between feedings
B. Place the infant on the left side after a feeding
C. Administer feedings over 5 min
D. Flush the tube with 30 mL of tap water
Position the head of the crib at a 30 angle between feedings

A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22 lb). The prescription reads phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer with each dose? (Round to the nearest hundredth)
6.25

A nurse is assisting with the care of an adolescent following a cardiac catheterization. Which of the following is the priority finding the nurse should report to the provider?

A. Reports of pain 4 out of 10 on the pain scale
B. Heart rate 104/min
C. Distal pulse 1+
D. Bleeding noted on the dressing
Bleeding noted on the dressing

A nurse is reinforcing teaching about home care with the guardian of a 14 month old toddler who has spastic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching?

A. “I will perform daily stretching exercises to my toddler’s affected muscles.”
B. “I will ensure my toddler avoids activities that involve repetitive joint movements.”
C. “I will place my toddler on his stomach to nap after meals.”
D. “I will give my toddler pain medication just after he performs strenuous activities.”
“I will perform daily stretching exercises to my toddler’s affected muscles.”

A nurse is contributing to the plan of care for an infant who has bronchiolitis and is tachypneic. Which of the following actions should the nurse include in the plan of care?

A. Provide high flow oxygen via facemask
B. Implement chest percussion every 2 hr
C. Suction nasal passages with a bulb syringe
D. Initiate airborne precautions
Suction nasal passages with a bulb syringe

A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child’s parent tells the nurse, “I’m a bad parent, and I can’t deal with this.” Which of the following responses should the nurse make?

A. “I’m not sure I follow you. Can you explain?”
B. “I understand. Other parents say the same thing.”
C. “Let’s talk about home care for your child.”
D. “I disagree. You’re a great parent.”
“I’m not sure I follow you. Can you explain?”

A nurse is reinforcing dietary teaching with the parent of a child who has phenylketonuria. Which of the following foods should the nurse include the best recommendation for a low phenylalanine diet?

A. Banana
B. Boiled egg
C. Yogurt
D. Hamburger
Banana

A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance. Which of the following supplements should the nurse instruct the patient to include in the child’s diet?

A. Zinc
B. Vitamin D
C. Thiamine
D. Folic acid
Vitamin D

A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate?

A. Protective environment
B. Contact precautions
C. Airborne precautions
D. Droplet precautions
droplet precautions

A nurse is collecting data from an 18 month old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further?

A. Respiratory rate 25/min
B. Blood pressure 120/80
C. Heart rate 110/min
D. Rectal temperature 37.4 C (99.3 F)
Blood pressure 120/80

A nurse is reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetamide. Which of the following instructions should the nurse include?

A. Remove dried drainage with a cold washcloth
B. Instill medication immediately after cleansing the eye
C. Apply an occlusive gauze over the child’s eye
D. Cleanse the eye by wiping gently from the outer aspect of the eye inward toward the nose
Instill medication immediately after cleansing the eye

A nurse is preparing to assist a provider with a lumbar puncture for a school-aged child. Which of the following actions is the nurse’s priority?

A. Labeling collected specimens
B. Providing reassurance to the child
C. Maintaining the child’s position
D. Monitoring the child’s vital signs
Maintaining the child’s position

A nurse is collecting data from a 10 month old infant. Which of the following findings should the nurse report to the provider?

A. Pulls self to standing position
B. Moves by creeping on hands and knees
C. Takes intentional steps when standing
D. Sits with support by leaning on hands
Sits with support by leaning on hands

A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For which of the following adverse effects should the nurse monitor?

A. Hypersalivation
B. Depression
C. Bradycardia
D. Hyperreflexia
depression

A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats in a motor vehicle. Which of the following instructions should the nurse include in the teaching?

A. Ensure the shoulder-lap portion of the seat belt fits across the child’s abdomen when sitting in the booster seat
B. Use a no-back, belt positioning booster seat if the motor vehicle does not have head rests
C. Discontinue using a booster seat when the child is 135 cm (4 feet 5 in) in height
D. Secure the child in the booster seat using the motor vehicle’s shoulder-lap seat belt
Secure the child in the booster seat using the motor vehicle’s shoulder-lap seat belt

A nurse is reinforcing teaching about interventions for mild hypoglycemia with the parent of a child who has diabetes mellitus. Which of the following statements by the parent indicates that the teaching has been effective?

A. “I should administer a glucagon injection to my child.”
B. “I should give my child 5 grams of a simple carbohydrate.”
C. “I should give my child 4 ounces of orange juice followed by cheese and crackers.”
D. “I should give my child a snack that is 10 percent of his daily caloric intake.”
“I should give my child 4 ounces of orange juice followed by cheese and crackers.”

A nurse in a provider’s office is caring for a preschooler who has findings of croup. Which of the following statements by the parent requires immediate intervention by the nurse?

A. “My child has refused to drink any fluid for the past hours.”
B. “My child has been coughing throughout the night.”
C. “My child is very hoarse and has a fever by 100.4 degrees Fahrenheit.”
D. “My child recently had the flu.”
“My child has refused to drink any fluid for the past hours.”

A nurse is collecting data from a school-age child. The nurse should identify that which of the following findings is a manifestation of physical abuse?

A. Multiple dental caries
B. Malnutrition
C. Recurrent urinary tract infections
D. Bruises at various stages of healing
Bruises at various stages of healing

A nurse is caring for a school aged child who has hemophilia A. Which of the following finding should the nurse recognize as a manifestation of this disaster?

A. joint pain and stiffness
B. concave fingernails
C. prominent frontal bossing
D. increased risk if infection
joint pain and stiffness

A nurse is reinforcing teaching to the guardian of a toddler who is receiving chemotherapy and has developed stomatitis. Which of the following instructions should the nurse include in the teaching?

A. Administer viscous lidocaine before feedings
B. Brush teeth using a firm toothbrush
C. Frequently rinse the mouth with chlorhexidine mouthwash
D. Increase vitamin C intake by offering orange juices
Frequently rinse the mouth with chlorhexidine mouthwash

A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints?

A. mummy restraint
B. jacket restraint
C. elbow restraints
D. wrist restraints
mummy restraint

A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1 month old infant. Which of the following statements by the parents indicates an understanding of the teaching?

A. “I will let my baby sleep with me in bed at night.”
B. “I will allow my baby to have a pacifier while sleeping.”
C. “I will place my baby on a soft mattress to sleep.”
D. “I will cover my baby with a quilt while he is sleeping.”
“I will allow my baby to have a pacifier while sleeping.”

A nurse is assisting with the care of a child who is receiving a blood transfusion. Which of the following findings indicates the child is having a hemolytic reaction?

A. Chills and flank pain
B. Pruritus and flushing
C. Rales and cyanosis
D. Bradycardia and diarrhea
chills and flank pain

A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend?

A. Graham crackers
B. Rye bread
C. Whole wheat spaghetti
D. Yellow corn
Yellow corn

A nurse is contributing to the plan of care for a child who has type 1 diabetes mellitus and is experiencing an acute illness. Which of the following actions should the nurse include in the plan of care?

A. Monitor blood glucose levels every 6 hr
B. Withhold insulin until the illness has passed
C. Encourage an increased fluid intake
D. Administer glucagon every 3 hr
Encourage an increased fluid intake

A nurse is preparing to leave the room after performing nasal suctioning for an infant who has respiratory syncytial virus (RSV). Identify the sequence in which the nurse should remove the following personal protective equipment (PPE).

A. Mask
B. Gloves
C. Gown
D. Goggles

1. gloves
2. goggles
3. gown
4. mask

A nurse is collecting data for an adolescent who has asthma and has received an albuterol nebulizer treatment. Which of the following findings indicates an improvement in the adolescent’s condition?

A. Temperature 38.1 C (100.5 F)
B. Respiratory rate 20/min
C. SaO2 91%
D. Bilateral wheezing
Respiratory rate 20/A nursemin

A nurse is assisting in the care of a male client who has acute post-streptococcal glomerulonephritis (APSGN). For which of the following manifestations should the nurse monitor?

A. Hypotension
B. Oliguria
C. Epispadias
D. Chordee
oliguria

A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant’s heart rate?

A. Apical
B. Radial
C. Carotid
D. Femoral
Apical

A nurse is preparing to obtain a peak expiratory flow rate from an adolescent. Which of the following actions should the nurse take?

A. Document the average of the client’s three attempts
B. Instruct the client to exhale slowly over 5 seconds into the meter
C. Determine the zone according to the client’s age
D. Have the client stand during the procedure
Have the client stand during the procedure

A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler?

A. Ask the child to state their name
B. Ask the pharmacy for the child’s room number
C. Ask the child to state their birthday
D. Ask the guardian to verify the child’s name
Ask the guardian to verify the child’s name

A nurse is assisting with the care of a 4 year old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure (select all that apply)

A. Discuss benefits of the procedure
B. Provide the child with a detailed explanation of the procedure
C. Implement interactive sessions of 30 min
D. Give the child needless IV supplies to play with
E. Allow the child to perform the procedure with a doll

1. Discuss benefits of the procedure
2. Give the child needless IV supplies to play with
3. Allow the child to perform the procedure with a doll

A nurse is reinforcing teaching about liquid oral supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching?

A. “I will give my child a double dose of this medication if she misses a dose.”
B. “I will give this medication to my child with a cup of skim milk.”
C. “This medication will turn my child’s stools white.”
D. “I will give this medication to my child with a straw.”
“I will give this medication to my child with a straw.”

A nurse is reinforcing discharge teaching with the guardians of a 6 month old infant following a surgical procedure to repair a hypospadias. Which of the following instructions should the nurse include?

A. Wait 1 week before giving the infant a tub bath
B. Apply antifungal ointment to the infant’s penis
C. Avoid giving the infant fruit juice
D. Apply dry gauze dressing to the infant’s penis twice daily
Wait 1 week before giving the infant a tub bath

A nurse is screening a group of school-age children for abuse. The nurse should identify that which of the following conditions places a child at risk for physical abuse?

A. A child who has ADHD
B. Recurrent otitis media
C. Obesity
D. Assertiveness
A child who has ADHD

A nurse is providing care to parents immediately following their child’s unexpected death. Which of the following actions should the nurse take?

A. Limit the amount of time the parents spend with the child’s body
B. Inform the parents that siblings should not view the body
C. Offer the parents the opportunity to bathe and dress the child’s body
D. Avoid touching the parents when expressing sympathy
Offer the parents the opportunity to bathe and dress the child’s body

During a well child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep a night. Which of the following recommendations should the nurse make?

A. Vary the time the toddler goes to bed each night
B. Allow the toddler to watch television before bedtime
C. Provide the toddler with a favorite toy at bedtime
D. Increase the toddler’s activity prior to bedtime
Provide the toddler with a favorite toy at bedtime

A nurse in a pediatric clinic is caring for an infant who has hear failure and a prescription for digoxin. Which of the following statements by the parent indicates the desired therapeutic effect of the medication?

A. “My baby is breathing easier than she use to.”
B. “My baby is taking longer naps.”
C. “My baby is having fewer wet diapers.”
D. “My baby’s heart rate is faster than it used to be.”
“My baby is breathing easier than she use to.”

A nurse is caring for a 3 year old female child who is prescribed an indwelling catheter. Which of the following actions should the nurse take when performing this procedure?

A. Place a nonsterile drape under the buttocks
B. Use a catheter that is 12 French in size
C. Insert the catheter another 10 cm (3.9 in) after urine returns
D. Apply 2% lidocaine lubricant into the urethral meatus
Apply 2% lidocaine lubricant into the urethral meatus

A nurse is contributing to the plan of care for a child who is in Buck’s traction. Which of the following interventions should the nurse include in the plan?

A. Remove the weights when changing the bed linens
B. Maintain the leg in an extended position
C. Monitor the halo device every 4 hr
D. Provide pin care as prescribed.
Maintain the leg in an extended position

A nurse is reinforcing teaching with the parent of an infant who has a new diagnosis of human immunodeficiency virus (HIV). Which of the following statements made by the parent indicates an understanding of the teaching

A. “The antiretroviral medication will stop the progression of the disease.”
B. “It won’t be possible for my child to attend daycare.”
C. “I should bring my child in for immunizations on schedule.”
D. “My child’s nutritional needs will not change.”
“I should bring my child in for immunizations on schedule.”

A nurse is assisting with the development of a health promotion program for the guardians of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program?

A. The sleep patterns of adolescents are well established
B. The percentage of adolescents that consider suicide is higher for males than for females
C. The leading cause of death in adolescents is physical injury
D. The caloric intake needs of adolescence are less than that of school-age children
The leading cause of death in adolescents is physical injury

A nurse in a pediatric is talking on the telephone with the parent of a 6 month who has a urinary tract infection and started taking an oral antibiotic the day before. Listen to the audio clip and determine which of the following responses the nurse should make.

A. “Mix the medicine with 1/4 cup of juice before giving it to your baby.”
B. “Mix the medicine with 1 teaspoon of honey before giving it to your baby.”
C. “Mix the medicine with 1/4 cup of formula before giving it to your baby.”
D. “Mix the medicine with 1 teaspoon of applesauce before giving it to your baby.”
“Mix the medicine with 1 teaspoon of applesauce before giving it to your baby.”

A nurse is contributing to the plan of care for a 10 month old infant who is postoperative following a cleft palate repair. Which of the following actions should the nurse include in the plan of care?

A. Place the infant in side-lying position
B. Offer the infant liquids with a straw
C. Prohibit the guardian from holding the infant for 8 hr
D. Cleanse the suture line with a lemon glycerin swab
Place the infant in side-lying position

A nurse is reinforcing teaching with the parents of a 2 year old toddler at a well child visit. Which of the following should the nurse recommend as an age-appropriate activity for the toddler?

A. Creating a rock collection
B. Learning the alphabet with flash cards
C. Putting together a large piece puzzle
D. Riding a tricycle
Putting together a large piece puzzle

A nurse is caring for a school age child who has hypoglycemia. Which of the following manifestations should the nurse expect?

A. Oliguria
B. Hypotension
C. Paralytic ileus
D. Flushed skin
hypotension

A nurse is reinforcing teaching regarding the immunization schedule with the parent of a 6 month old infant during a well baby visit. Which of the following statements by the parent indicates an understanding of the teaching?

A. “My baby will receive his third DTaP vaccine today.”
B. “My baby is old enough to receive the varicella vaccine today.”
C. “My baby will receive his final polio vaccine today.”
D. “My baby will receive his first hepatitis B vaccine today.”
“My baby will receive his third DTaP vaccine today.”

A nurse is reinforcing teaching with a guardian whose child was exposed to poison ivy. Which of the following instructions should the nurse provide?

A. Flush the child’s skin within 15 min with cold, running water
B. Apply miconazole topical ointment to the area daily for 1 week
C. Wash the child’s clothes in cool, detergent free water
D. Encourage the guardian to keep the child away from other children for a week
Flush the child’s skin within 15 min with cold, running water

A nurse is collecting physical data from a 4 year old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child’s skin turgor?

A. The child’s sacral area
B. The top of the child’s hand
C. The child’s sternal area
D. The child’s abdomen
The child’s abdomen

A nurse is assisting with planning dietary needs for a toddler. Which of the following interventions should the nurse include in the plan of care?

A. Give the toddler 1/2 cup (113 g) of fruit daily
B. Encourage the toddler to drink 8 oz (236.6 mL) of juice daily
C. Give the child 40 oz (1.2 L) of milk daily
D. Provide 1 Tbsp (15 g) of solid food for each year of age
Provide 1 Tbsp (15 g) of solid food for each year of age

A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect?

A. Hgb 9 g/dL
B. Hct 37%
C. Iron 100 mcg/dL
D. Total iron binding capacity 325 mcg/dL
Hgb 9 g/dL

A nurse is collecting data from an 18 month old toddler. Which of the following is a deviation from expected growth and development that the nurse should report to the provider?

A. The toddler is unable to recognize familiar objects by name
B. The toddler is unable to dress himself in simple clothing
C. The toddler is unable to talk in complete sentences
D. The toddler is unable to draw a circle
The toddler is unable to recognize familiar objects by name

A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when the child will no longer be contagious. Which of the following responses should the nurse make?

A. “When your child no longer has a fever.”
B. “Three days after the rash started.”
C. “Six days after lesions appear if they are crusted.”
D. “When your child’s lesions disappear.”
“Six days after lesions appear if they are crusted.”

A nurse is caring for a child who has type 1 diabetes mellitus and has been receiving insulin via subcutaneous infusion pump. Which of the following laboratory tests would verify the average blood glucose level over the past 2 months?

A. Postprandial blood glucose
B. Fasting blood glucose
C. Glycosylated hemoglobin
D. Mean corpuscular hemoglobin
Glycosylated hemoglobin

A nurse is a care provider’s office is preparing to administer scheduled vaccines to an infant. The infant’s parent refuses to allow the nurse to administer the vaccines. Which of the following actions should the nurse take?

A. Ask the parent why they do not want the vaccines to be administered
B. Provide the parent with a vaccine information sheet (VIS)
C. Question the parent if their other children are vaccinated
D. Tell the parent that the vaccines must be completed at the next visit
Provide the parent with a vaccine information sheet (VIS)

A nurse is caring for a group of children in an acute care setting. The nurse should identify that which of the following children is at risk for impaired elimination?

A. A child who has hyperglycemia
B. A child who has enuresis
C. A child who has hypothyroidism
D. A child who has juvenile idiopathic arthritis
A child who has hyperglycemia

A nurse is preparing to administer an intramuscular injection to an 11 month old infant. In which of the following areas should the nurse administer the injection?

A
B
C
B

the vastus lateralis muscle

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching?

A. “I should not give my child aspiring for pain or fever.”
B. “My child will take antibiotics for 6 months.”
C. “My child might have a period of irregular movement of the extremities.”
D. “I should expect there to be blood in my child’s urine.”
“My child might have a period of irregular movement of the extremities.”

A nurse is reviewing the laboratory findings of a school-age child who reports feeling tired and being easily bruised. Which of the following laboratory values should the nurse report to the provider?

A. Platelets 85,000/mm3
B. Hematocrit 39%
C. Hemoglobin 14.2 g/dL
D. RBC count 5 million/mm3
Platelets 85,000/mm3

INTEGUMENTARY SYSTEM

A nurse is collecting date from an infant who has scabies. Which of the following findings should the nurse expect? (select all that apply)

A. Presence of nits on the hair shaft
B. Pencil-like marks on hands
C. Blisters on the soles of the feet
D. Small, red bumps on the scalp
E. Pimples on the trunk

1. Pencil-like marks on hands
2. Blisters on the soles of the feet
3. Pimples on the trunk

A nurse is reinforcing teaching with a group of parents about preventing insect bites. Which of the following information should the nurse include? (select all that apply)

A. Wear perfumes when outside
B. Avoid areas of tall grass
C. Wear bright-colored clothing
D. Wear insect repellent
E. Check house pets frequently

1. Avoid areas of tall grass
2. Wear insect repellent
3. Check house pets frequently

A nurse is reinforcing teaching with the guardian of a child who has pediculosis capitis. Which of the following instructions should the nurse include?

A. Apply mayonnaise to the affected area at night
B. Treat all household pets
C. Use an over the counter medication containing 1% permethrin
D. Discard the child’s stuffed animals
Use an over the counter medication containing 1% permethrin

A nurse is caring for a child who has cellulitis on the hand. Which of the following actions should the nurse take?

A. Administer oral antibiotics to the child
B. Cleanse area using Burrow solution
C. Prepare the child for cryotherapy
D. Apply a topical antifungal medication
Administer oral antibiotics to the child

A nurse is contributing to the plan of care for a child who has tinea capitis. Which of the following interventions should the nurse include? (select all that apply)

A. Treat infected house pets
B. Use selenium sulfide shampoo
C. Cleanse area with Burrow solution
D. Administer antiviral medication
E. Use moist, warm compresses

1. Treat infected house pets
2. Use selenium sulfide shampoo

A nurse is reinforcing teaching with the guardian of an infant who has seborrheic dermatitis of the scalp. Which of the following instructions should the nurse include?

A. “You can use petrolatum to help soften and remove patches from your infant’s scalp.”
B. “When patches are present, you should keep your infant away from others.”
C. “You should avoid washing your infant’s hair while patches are present on the scalp.”
D. “When patches are present, it indicates that your infant has a systemic infection.”
“You can use petrolatum to help soften and remove patches from your infant’s scalp.”

A nurse is caring for a child who has contact dermatitis due to poison ivy exposure. Which of the following actions should the nurse take? (select all that apply)

A. Remove the clothing over the rash
B. Initiate contact isolation precautions while the rash is present
C. Expose the rash to a heat lamp for 15 min
D. Cleanse the affected areas with hydrogen peroxide solution
E. Apply calamine lotion to the skin

1. Remove the clothing over the rash
2. Apply calamine lotion to the skin

A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. Which of the following laboratory findings should the nurse plan to monitor?

A. Cholesterol and triglycerides
B. BUN and creatinine
C. Blood potassium
D. Blood sodium
Cholesterol and triglycerides

A nurse is contributing to the plan of care for an infant who has diaper dermatitis. Which of the following interventions should the nurse include? (select all that apply)

A. Apply talcum powder with every diaper change
B. Allow the buttocks to air dry
C. Use commercial baby wipes to cleanse the area
D. Use cloth diapers until the rash is gone
E. Apply zinc oxide ointment to the affected area

1. Allow the buttocks to air dry
   2 Apply zinc oxide ointment to the affected area

A nurse is collecting data from an infant who has eczema. Which of the following findings should the nurse expect? (select all that apply)

A. Generalized distribution of lesions
B. Papules
C. Ecchymosis in flexural areas
D. Crusting lesions
E. Keratosis pilaris
1A. Generalized distribution of lesions

2. Papules
3. Crusting lesions

A nurse is caring for a client who has a superficial partial-thickness burn. Which of the following actions should the nurse take?

A. Monitor IV infusion of 0.9% sodium chloride
B. Apply cool, wet compresses to the affected area
C. Clean the affected area using a soft-bristle brush
D. Administer morphine sulfate
Clean the affected area using a soft-bristle brush

A nurse is collecting data from a client who has major burns and suspected septic shock. Which of the following findings should the nurse expect? (select all that apply)

A. Increased body temperature
B. Altered sensorium
C. Decreased capillary refill time
D. Decreased urine output
E. Increased bowel sounds

1. Increased body temperature
2. Altered sensorium
3. Decreased urine output

A nurse is assisting with the care of a client who has a major burn and is experiencing severe pain. Which of the following actions should the nurse take?

A. Monitor morphine sulfate IV
B. Monitor meperidine IM
C. Administer acetaminophen PO
D. Administer hydrocodone PO
Monitor morphine sulfate IV

A nurse is caring for a client who has a skin graft. Which of the following findings indicate infection? (select all that apply)

A. Pink color to subcutaneous fat
B. Unstable body temperature
C. Generation of granulation tissue
D. Subeschar hemorrhage
E. Change in skin color around the affected area.

1. Unstable body temperature
2. Subeschar hemorrhage
3. Change in skin color around the affected area.

A nurse is caring for a client who has a moderate burn. Which of the following actions should the nurse take?

A. Maintain immobilization of the affected area
B. Expose affected area to the air
C. Initiate a high-protein, high-calorie diet
D. Implement contact isolation
Initiate a high-protein, high-calorie diet

ENDOCRINE DISORDERS

A nurse is reinforcing teaching about sick-day management with a parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include? (select all that apply)

A. Monitor blood glucose levels every 3 hr
B. Discontinue taking insulin until feeling better
C. Drink 8 oz of fruit juice every hour
D. Test urine for ketones
E. Call the provider if blood glucose is greater than 240 mg/dL

1. Monitor blood glucose levels every 3 hr
2. Test urine for ketones
3. Call the provider if blood glucose is greater than 240 mg/dL

A nurse is reinforcing teaching with a child who has type 1 diabetes mellitus about self-care. Which of the following statements by the child indicates understanding of the teaching?

A. “I should skip breakfast when I am not hungry.”
B. “I should increase my insulin with exercise.”
C. “I should drink a glass of milk when I am feeling irritable.”
D. “I should draw up the NPH insulin into the syringe before the regular insulin.”
“I should drink a glass of milk when I am feeling irritable.”

A nurse is collecting data from a child who has type 1 diabetes mellitus. Which of the following manifestations indicate of diabetic ketoacidosis? (select all that apply)

A. Blood glucose 58 mg/dL
B. Weight gain
C. Dehydration
D. Mental confusion
E. Fruity breath

1. Dehydration
2. Mental confusion
3. Fruity breath

A nurse is reinforcing teaching with a school-age child who has diabetes mellitus about insulin administration. Which of the following instructions should the nurse include?

A. “You should inject the needle at a 30 degree angle.”
B. “You should combine our glargine and regular insulin in the same syringe.”
C. “You should aspirate for blood before injecting the insulin.”
D. “You should give four to six injections in one area before switching sites.”
“You should give four to six injections in one area before switching sites.”

A nurse is reinforcing teaching with an adolescent who has diabetes mellitus about manifestations of hypoglycemia. Which of the following findings should the nurse include? (select all that apply)

A. Increased urination
B. Hunger
C. Poor skin turgor
D. Irritability
E. Sweating and pallor
F. Kussmaul respirations

1. Hunger
2. Irritability
3. Sweating and pallor

A nurse is caring for a child who has short stature. Which of the following diagnostic tests should the nurse expect to confirm a growth hormone (GH) deficiency? (select all that apply)

A. CT scan of the head
B. Skeletal x-rays
C. GH Stimulation test
D. Blood IGF-1
E. DNA testing

1. CT scan of the head
2. Skeletal x-rays
3. GH Stimulation test
4. Blood IGF-1

A nurse is reinforcing teaching with the guardian of a child who has growth hormone deficiency. Which of the following complications of untreated growth hormone deficiency should the nurse include? (select all that apply)

A. Delayed sexual development
B. Premature aging
C. Advanced bone age
D. Short stature
E. Increased epiphyseal closure

1. Delayed sexual development
2. Premature aging
3. Short stature

A parent of a school-age child who has GH deficiency asks the nurse how long the child will need to take injections for growth delay. Which of the following responses should the nurse make?

A. “Injections are usually continued until age 10 for girls and age 12 for boys.”
B. “Injections continue until your child reaches the fifth percentile on the growth chart.”
C. “Injections might be stopped once your child grows less than 1 inch/year.”
D. “The injections will need to be administered throughout your child’s entire life.”
“Injections might be stopped once your child grows less than 1 inch/year.”

A nurse is collecting data from a child who has short stature. Which of the following findings would indicate a growth hormone deficiency?

A. Proportional height to weight
B. Height proportionally greater than weight
C. Oversized jaw
D. Early-onset puberty
Proportional height to weight

IMMUNE & INFECTIOUS DISORDERS

A nurse is preparing to administer immunizations to a 4 month old infant. Which of the following actions should the nurse take to provide atraumatic care?

A. Administer 81 mg of aspirin
B. Use the Z-track method when injecting
C. Ask the guardians to leave the room during the injection
D. Provide sucrose solution on the pacifier
Provide sucrose solution on the pacifier

A nurse is planning to administer recommended immunizations to a 2 month old infant. Which of the following vaccines should the nurse plan to give? (select all that apply)

A. Rotavirus (RV)
B. Diphtheria, tetanus, and acellular pertussis (DTaP)
C. Haemophilus influenzae type b (Hib)
D. Hepatitis A (HepA)
E. Pneumococcal conjugate (PCV13)
F. Inactivated poliovirus (IPV)

1. Rotavirus (RV)
2. Diphtheria, tetanus, and acellular pertussis (DTaP)
3. Haemophilus influenzae type b (Hib)
4. Pneumococcal conjugate (PCV13)
5. Inactivated poliovirus (IPV)

A nurse is planning to administer recommended immunizations to a 4 year old child. Which of the following vaccines should the nurse plan to give? (select all that apply)

A. Inactivated poliovirus (IPV)
B. Haemophilus influenzae type b (Hib)
C. Measles, mumps, rubella (MMR)
D. Varicella (VAR)
E. Hepatitis B (HeB)
F. Diphtheria, tetanus, and acellular pertussis (DTaP)

1. Inactivated poliovirus (IPV)
2. Measles, mumps, rubella (MMR)
3. Varicella (VAR)
4. Diphtheria, tetanus, and acellular pertussis (DTaP)

A nurse is preparing to administer the varicella vaccine to an adolescent. Which of the following questions should the nurse ask to determine whether there is a contraindication to administering the vaccine?

A. “Do you have an allergy to eggs?”
B. “Have you ever had encephalopathy following immunizations?”
C. “Are you currently taking corticosteroid medication?”
D. “Have you ever had an anaphylactic reaction to yeast?”
Are you currently taking corticosteroid medication?”

A nurse is caring for a 15 month old child in a clinic. Which of the following actions should the nurse take?

CHART:
HepB: 1 month, 2 months, 12 months
Rotavirus: 2 months, 4 months, 6 months
DTaP: 2 months, 4 months, 6 months
Hib: 2 months, 4 months, 12 months
IPV: 2 months, 4 months, 6 months
MMR: 12 months
Varicella: 12 months
HepA: 12 months

A. Administer DTaP vaccine
B. Administer rotavirus vaccine
C. Hold immunizations until fever subsides
D. Administer hepatitis A vaccine
Administer DTaP vaccine

A nurse is reinforcing teaching with a group of family members about complications of communicable diseases. Which of the following communicable diseases can lead to pneumonia? (select all that apply)

A. Rubella (German measles)
B. Rubeola (measles)
C. Pertussis (whooping cough)
D. Varicella (chicken pox)
E. Mumps

1. Rubeola (measles)
2. Pertussis (whooping cough)
3. Varicella (chicken pox)

nurse is caring for a client who has rubeola. The nurse should monitor for which of the following complications? (select all that apply)

A. Otitis media
B. Constipation
C. Laryngitis
D. Arthralgia
E. Syncope

1. Otitis media
2. Laryngitis

A nurse is collecting data from a client who has pertussis. Which of the following findings should the nurse expect? (select all that apply)

A. Runny nose
B. mild fever
C. Cough with whooping sound
D. Swollen salivary glands
E. red rash

1. Runny nose
2. mild fever
3. Cough with whooping sound

A nurse is reinforcing teaching with a group of family members about communicable diseases. The nurse should include that which of the following is the best method to prevent a communicable disease?

A. Hand washing
B. Avoiding persons who have active disease
C. Covering your cough
D. Obtaining immunizations
Obtaining immunizations

A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority for the nurse to take?

A. Provide emotional support to the family
B. Reinforce teaching with the family on care of the child
C. Provide a diversional activity for toddler
D. Administer analgesics to the toddler
Administer analgesics to the toddler

A nurse is caring for an infant who has manifestations of acute otitis media (AOM). The nurse should identify that which of the following factors places the infant at risk for otitis media? (select all that apply)

A. breastfeeds without formula supplementation
B. Attends day care 4 days per week
C. Immunizations are up to date
D. History of a cleft palate repair
E. Parents smoke cigarettes outside

1. Attends day care 4 days per week
2. History of a cleft palate repair
3. Parents smoke cigarettes outside

A nurse is caring for a toddler who has had rhinitis, cough, and diarrhea for 2 days. The tympanic membrane has an orange discoloration and decreased movement. Which of the following statements should the nurse make?

A. “Your child has an ear infection that requires antibiotics.”
B. “Your child could experience transient hearing loss.”
C. “Your child will need to be on a decongestant until this clears.”
D. “Your child will need to have to have a myringotomy.”
“Your child could experience transient hearing loss.”

A nurse is caring for a toddler who has had three ear infections in the past 5 months. The nurse should identify that this places the toddler at risk for developing which of the following long-term complications?

A. Balance difficulties
B. Rash
C. Speech delays
D. Mastoiditis
Speech delays

A nurse is collecting data from an infant who has acute otitis media. Which of the following findings should the nurse expect? (select all that apply)

A. Decreased pain in the supine position
B. Rolling head side to side
C. Loss of appetite
D. Increased sensitivity to sound
E. Crying

1. Rolling head side to side
2. Loss of appetite
3. Crying

A nurse is reinforcing teaching with the guardian of a child who has HIV. Which of the following information should the nurse include? (select all that apply)

A. Obtain yearly influenza vaccination
B. Monitor a fever for 24 hr before seeking medical care
C. Avoid individuals who have colds
D. Provide nutritional supplements
E. Administer aspirin for pain

1. Obtain yearly influenza vaccination
2. Avoid individuals who have colds
3. Provide nutritional supplements

A nurse is caring for a child who has AIDS. Which of the following isolation precautions should the nurse initiate?

A. Contact
B. Airborne
C. Droplet
D. Standard
Standard

A nurse is assisting with the admission of a child who has HIV. The nurse should identify which of the following findings as an indication that the child is in the mildly symptomatic category of the infection? (select all that apply)

A. Herpes zoster
B. Anemia
C. Oral candidiasis
D. Hepatomegaly
E. Lympadenopathy

1. Oral candidiasis
2. Hepatomegaly
3. Lympadenopathy

A nurse in a community center is reinforcing teaching with a group of adolescents about HIV/AIDS. Which of the following statements should the nurse include in the teaching?

A. “You can contract HIV through casual kissing.”
B. “HIV is transmitted through IV substance use.”
C. “HIV is now curable if caught in the early stages.”
D. “Medications inhibit inhibit transmission of the HIV virus.”
“HIV is transmitted through IV substance use.”

A nurse is caring for a child who has severely symptomatic HIV. Which of the following findings should the nurse expect? (select all that apply)

A. Kaposi’s sarcoma
B. Hepatitis
C. Wasting syndrome
D. Pulmonary candidiasis
E. Cardiomyopathy

1. Kaposi’s sarcoma
2. Wasting syndrome
3. Pulmonary candidiasis

NEOPLASTIC DISORDERS

A nurse is assisting with the care for a toddler who has a Wilms’ tumor. Which of the following actions should the nurse take?

A. Palpate the child’s abdomen to identify the size of the tumor
B. Assist with preparing the child for surgery
C. Reinforce teaching with the guardians about dialysis
D. Obtain a 24 hr urine specimen from the child
Assist with preparing the child for surgery

A nurse is collecting data from a child who has leukemia. Which of the following are early manifestations of leukemia? (select all that apply)

A. Hematuria
B. Anorexia
C. Petechiae
D. Ulcerations in the mouth
E. Unsteady gait

1. Anorexia
2. Petechiae
3. Unsteady gait

A nurse is assisting with the care for a child who has thrombocytopenia following chemotherapy. Which of the following actions should the nurse take? (select all that apply)

A. Monitor for manifestations of bleeding
B. Administer routine immunizations
C. Obtain rectal temperatures
D. Avoid peripheral venipunctures
E. Limit visitors

1. Monitor for manifestations of bleeding
2. Avoid peripheral venipunctures

A nurse is assisting with the care for a child who has oral mucositis. Which of the following actions should the nurse take? (select all that apply)

A. Swab the mucosa with lemon glycerin swabs
B. Apply viscous lidocaine
C. Offer soft foods
D. Use a soft, disposable toothbrush for oral care
E. Encourage gargling with a warm saline mouthwash

1. Offer soft foods
2. Use a soft, disposable toothbrush for oral care
3. Encourage gargling with a warm saline mouthwash

A nurse is collecting data from a child who has rhabdomyosarcoma of the nasopharynx. Which of the following are manifestations of rhabdomyosarcoma? (select all that apply)

A. Enlarged neck lymph nodes
B. Pain
C. Vomiting
D. Epistaxis
E. Diplopia

1. Enlarged neck lymph nodes
2. Pain
3. Epistaxis

GASTROINTESTINAL DISORDERS

A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an action for the nurse to take?

A. Offer chicken broth
B. Assist with initiating oral rehydration therapy
C. Assist with starting an infusion of a hypertonic IV solution
D. Keep NPO until the diarrhea subsides
Assist with initiating oral rehydration therapy

A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take?

A. perform a tape test
B. Collect stool specimen for culture
C. Test the stool for occult blood
D. Assist with initiating an infusion of IV fluids
perform a tape test

A nurse is collecting date from a child who has a rotavirus infection. Which of the following are expected findings? (Select all that apply)

A. Fever
B. Vomiting
C. Water stools
D. Bloody stools
E. Confusion

1. Fever
2. Vomiting
3. Water stools

A nurse is reinforcing teaching with a group of parents about Salmonella. Which of the following information should the nurse include? (Select all that apply)

A. Incubation period is nonspecific
B. It is a bacterial infection
C. Bloody diarrhea is common
D. Transmission can be from house pets
E. Antibiotics are used for treatment

1. It is a bacterial infection
2. Bloody diarrhea is common
3. Transmission can be from house pets

A nurse is reinforcing teaching a group of caregivers about E. coli. Which of the following information should the nurse include? (select all that apply)

A. Severe abdominal cramping occurs
B. Watery diarrhea is present for more than 5 days
C. It can lead to hemolytic uremic syndrome
D. It is a foodborne pathogen
E. Antibiotics are given for treatment

1. Severe abdominal cramping occurs
2. It can lead to hemolytic uremic syndrome
3. It is a foodborne pathogen

A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? (select all that apply)

A. Projectile vomiting
B. Dry mucus membranes
C. Currant jelly stools
D. Sausage-shaped abdominal mass
E. Constant hunger

1. Projectile vomiting
2. Dry mucus membranes
3. Constant hunger

A nurse is caring for a child who has Hirschsprung’s disease. Which o the following actions should the nurse take?

A. Encourage a high-fiber, low-protein, low-calorie diet
B. Prepare the family for surgery
C. Place an NG tube for decompression
D. Initiate bed rest
Prepare the family for surgery

A nurse is assisting with the care of an infant who has just returned from PACU following cleft lip and palate repair. Which of the following actions should the nurse take?

A. Remove the packing in the mouth
B. Place the infant in an upright position
C. Offer a pacifier with sucrose
D. Observe the mouth with a tongue blade
Place the infant in an upright position

A nurse is collecting data from a child who has Meckel’s diverticulum. Which of the following manifestations should the nurse expect? (select all that apply)

A. Abdominal pain
B. Fever
C. Mucus and blood in stools
D. Vomiting
E. Rapid, shallow breathing

1. Abdominal pain
2. Mucus and blood in stools

A nurse is reinforcing teaching with the guardian of an infant about gastrointestinal reflux disease. Which of the following instructions should the nurse include? (select all that apply)

A. Offer frequent feedings
B. Thicken formula with rice cereal
C. Use a bottle with a one way valve
D. Position baby upright after feedings
E. Use a wide-based nipple for feedings

1. Offer frequent feedings
2. Thicken formula with rice cereal
3. Position baby upright after feedings

GENITOURINARY & REPRODUCTIVE DISORDERS

A nurse is reinforcing teaching with the guardian of a child who has a urinary tract infection. Which of the following instructions should the nurse include? (select all that apply)

A. Wear nylon underpants
B. Avoid bubble baths
C. Empty bladder completely with each void
D. Watch for manifestations of infection
E. Wipe perineal area back to front

1. Avoid bubble baths
2. Empty bladder completely with each void
3. Watch for manifestations of infection

A nurse is contributing to the plan of care for a child who has a urinary tract infection. Which of the following interventions should the nurse include?

A. Administer an antidiuretic
B. Restrict fluids
C. Evaluate the child’s self-esteem
D. Encourage frequent voiding
Encourage frequent voiding

A nurse is caring for a child who has enuresis. The nurse should identify that which of the following conditions is a complication of enuresis?

A. urinary tract infections
B. Emotional problems
C. Urosepsis
D. Progressive kidney disease
Emotional problems

A nurse is collecting data from an infant who has a suspected urinary tract infection. Which of the following findings should the nurse expect? (select all that apply)

A. Increase in hunger
B. Irritability
C. Decrease in urination
D. Vomiting
E. Fever

1. Irritability
2. Vomiting
3. Fever

A nurse is collecting data from a child who has a urinary tract infection. Which of the following findings should the nurse expect? (select all that apply)

A. night sweats
B. swelling of the face
C. pallor
D. pale-colored urine
C. fatigue

1. swelling of the face
2. pallor
3. fatigue

A nurse is caring for an infant who has a hydrocele. Which of the following actions should the nurse take?

A. Prepare the infant for surgery
B. Explain to the guardians that the issue generally self-resolves
C. Retract the foreskin and cleanse several times daily
D. Refer the family for genetic counseling
Explain to the guardians that the issue generally self-resolves

A nurse is caring for a male infant who has an epispadias. Which of the following findings should the nurse expect? (select all that apply)

A. bladder exstrophy
B. Inability to retract foreskin
C. widened pubic symphysis
D. Urethral opening on the dorsal side of the penis
E. Pain

1. bladder exstrophy
2. widened pubic symphysis
3. Urethral opening on the dorsal side of the penis

A nurse is caring for an infant who has ambiguous genitalia. Which of the following actions should the nurse take? (select all that apply)

A. Prepare the infant for surgery
B. Test the infant’s adrenal function
C. Cover the genitals with a sterile dressing
D. Refer to the family for genetic counseling
E. Explain the need for a chromosomal analysis

1. Prepare the infant for surgery
2. Test the infant’s adrenal function
3. Refer to the family for genetic counseling
4. Explain the need for a chromosomal analysis

A nurse is caring for an infant who has obstructive uropathy. Which of the following findings should the nurse expect? (select all that apply)

A. Decreased urine flow
B. Urinary tract infection
C. History of maternal polyhydramnios
D. Concentrated urine
E. Hydronephrosis

1. Urinary tract infection
2. Hydronephrosis

A nurse is collecting data from a child who has nephrotic syndrome. Which of the following findings should the nurse expect? (select all that apply)

A. Urine dipstick +2 protein
B. Edema in the ankles
C. Hyperlipidemia
D. Polyuria
E. Anorexia

1. Urine dipstick +2 protein
2. Edema in the ankles
3. Hyperlipidemia
4. Anorexia

A nurse is caring for a school-age child who has acute glomerulonephritis. Which of the following findings should the nurse report to the provider?

A. BUN 8 mg/dL
B. Blood creatinine 1.3 mg/dL
C. Blood pressure 100/74 mm Hg
D. Urine output 550 mL 24 hr
Blood creatinine 1.3 mg/dL

A nurse is caring for a preschooler who has nephrotic syndrome. Which of the following findings should the nurse report to the provider?

A. Blood protein 5.0 g/dL
B. Hgb 14.5 g/dL
C. Hct 40%
D. Platelet 200,000 mm3
Blood protein 5.0 g/dL

A nurse is collecting data from a child who has chronic kidney disease. Which of the following findings should the nurse expect?

A. Flushed face
B. Hyperactivity
C. Weight gain
D. Delayed growth
Delayed growth

A nurse is collecting data from a child who has acute post-streptococcal glomerulonephritis (APSGN). Which of the following manifestations should the nurse expect? (select all that apply)

A. pale urine
B. periorbital edema
C. ill appearance
D. decreased creatinine
E. hypertension

1. periorbital edema
2. ill appearance
3. hypertension

MUSCULOSKELETAL DISORDERS

A nurse is caring for a child who is in a plaster spica cast. Which of the following actions should the nurse take?

A. Use a heat lamp to facilitate drying
B. Avoid turning the child until the cast is dry
C. Assist the client with crutch walking after the cast is dry
D. Apply moleskin to the edges of the cast
Apply moleskin to the edges of the cast

A nurse is reinforcing teaching with a group of caregivers about fractures. Which of the following information should the nurse include?

A. “Children need longer time to heal from a fracture than an adult.”
B. “Epiphyseal plate injuries can result in altered bone growth.”
C. “A greenstick fracture is a complete break in the bone.”
D. “Bones are unable to bend, so they break.”
“Epiphyseal plate injuries can result in altered bone growth.”

A nurse is caring for a child who sustained a fracture. Which of the following actions should the nurse take? (select all that apply)

A. Place a heat pack on the site of injury
B. Elevate the affected limb
C. Check neurovascular status frequently
D. Encourage ROM of the affected limb
E. Stabilize the injury

1. Elevate the affected limb
2. Check neurovascular status frequently
3. Stabilize the injury

A nurse is caring for a child who has a fracture. Which of the following findings should the nurse expect? (Select all that apply)

A. Crepitus
B. Edema
C. Pain
D. Fever
E. Ecchymosis

1. Crepitus
2. Edema
3. Pain
4. Ecchymosis

A nurse is caring for a child who is in skeletal traction. Which of the following actions should the nurse take? (select all that apply)

A. Remove the weights to reposition the client
B. Check the child’s position every 4 hr
C. Monitor pin sites every 4 hr
D. Ensure the weights are hanging freely
E. Ensure the rope’s knot he is in contact with the pulley

1. Check the child’s position every 4 hr
2. Monitor pin sites every 4 hr
3. Ensure the weights are hanging freely

A nurse is caring for a toddler who has a hip dysplasia and has been placed in a hip spica cast. The child’s guardian asks the nurse why a PPavlik harness is not being used. Which of the following responses should the nurse make?

A. “The Pavlik harness is used for children with scoliosis, not hip dysplasia.”
B. “The Pavlik harness is used for school-age children.”
C. “The Pavlik harness cannot be used for your child because their condition is too severe.”
D. “The Pavlik harness is used for infants less than 6 months of age.”
“The Pavlik harness is used for infants less than 6 months of age.”

A nurse is reinforcing preoperative teaching with an adolescent client who is scheduled to receive spinal instrumentation for scoliosis. Which of the following information should the nurse include?

A. “You will go home the same day of surgery.”
B. “You will have minimal pain.”
C. “You will need to receive blood.”
D. “You will not be able to eat until the day after surgery.”
“You will need to receive blood.”

A nurse is caring for a child who is suspected of having Legg-Calve-Perthes disease. The nurse should prepare the child for which of the following diagnostic procedures?

A. Bone biopsy
B. Genetic testing
C. CT scan
D. Radiographs
Radiographs

A nurse is collecting data from a child who has Legg-Calve-Perthes disease. Which of the following findings should the nurse expect? (Select all that apply)

A. Longer affected leg
B. hip stiffness
C. back pain
D. limited ROM
E. limp with walking

1. hip stiffness
2. back pain
3. limited ROM
4. limp with walking

A nurse is caring for an infant and notices an audible click in their left hip. Which of the following diagnostic test should the nurse expect the provider to perform? (select all that apply)

A. Barlow test
B. Babinski reflex
C. Manipulation of foot and ankle
D. Ortolani test
E. Ponseti method

1. Barlow test
2. Ortolani test

A nurse is caring for a child who has cerebral palsy and is experiencing muscle spams. Which of the following medications should the nurse expect the provider to prescribe? (select all that apply)

A. Baclofen
B. Diazepam
C. Oxybutynin
D. Methotrexate
E. Prednisone

1. Baclofen
2. Diazepam

A nurse is contributing to the plan of care for a toddler who has cerebral palsy. Which of the following interventions should the nurse include?

A. Structure interventions according to the toddler’s chronological age.
B. Determine the toddler’s need for an evaluation of hearing ability
C. Monitor the toddler’s pain level routinely using a numeric rating scale
D. Provide total care for daily hygiene activities
Determine the toddler’s need for an evaluation of hearing ability

A nurse is reinforcing discharge teaching with the guardians of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include? (select all that apply)

A. Provide extra time for completion of ADLs
B. Use cold compresses for joint pain
C. Take ibuprofen on an empty stomach
D. Remain home during periods of exacerbation
E. Perform range-of-motion exercises

1. Provide extra time for completion of ADLs
2. Perform range-of-motion exercises

A nurse is collecting data from a child who has muscular dystrophy. Which of the following findings should the nurse expect? (Select all that apply)

A. Purposeless, involuntary, abnormal movements
B. Spinal defect and saclike protrusion
C. Muscular weakness in lower extremities
D. Unsteady, wide-based or waddling gait
E. upward slant to the eyes

1. Muscular weakness in lower extremities
2. Unsteady, wide-based or waddling gait

A nurse is assisting with the care of an infant who has a myelomeningocele. Which of the following actions should the nurse take?

A. Encourage the guardian to cuddle the infant
B. Monitor the infant’s temperature rectally
C. Maintain the infant in a supine position
D. Apply a sterile, moist dressing on the sac
Apply a sterile, moist dressing on the sac

NEUROLOGIC DISORDERS

A nurse is assisting with the care of a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take?

A. Place the client on NPO status
B. Prepare the client for a liver biopsy
C. Position the client dorsal recumbent
D. Put the client in a protective environment
Place the client on NPO status

A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (Select all that apply)

A. Negative Gram stain
B. Normal glucose content
C. Turbid and cloudy color
D. Decreased WBC count
E. Normal protein content

1. Negative Gram stain
2. Normal glucose content
3. Normal protein content

A nurse is collecting data from a 4 month old infant who has meningitis. Which of the following manifestations should the nurse expect?

A. Depressed anterior fontanel
B. Constipation
C. Presence of the rooting reflex
D. High-pitched cry
High-pitched cry

A nurse is reviewing the medical record of a client who has Reye syndrome. Which of the following findings should the nurse identify as a risk factor for Reye syndrome?

A. Recent history of infectious cystitis caused by Candida
B. Recent history of bacterial otitis media
C. Recent episode of gastroenteritis
D. Recent episode of Haemophilus influenzae meningitis
Recent episode of gastroenteritis

A nurse is assisting with the development of an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (select all that apply)

A. Inactivated polio vaccine (IPV)
B. Pneumococcal conjugate vaccine (PCV)
C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
D. Haemophilus influenzae type B (Hib) vaccine
E. Inactivated influenza vaccine (IIV)

1. Pneumococcal conjugate vaccine (PCV)
2. Haemophilus influenzae type B (Hib) vaccine

A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (select all that apply)

A. Loss of consciousness
B. Appearance of daydreaming
C. Dropping help objects
D. Falling to the floor
E. Having a piercing cry

1. Loss of consciousness
2. Appearance of daydreaming
3. Dropping help objects

A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take?

A. Position the child in a side-lying position
B. Try and determine the seizure trigger
C. Reorient the child to the environment
D. Note the time of the postictal period
Position the child in a side-lying position

A nurse is reinforcing teaching to the guardians of a child who is to have an electroencephalogram (EEG). Which of the following statements by a guardian indicates teaching was effective?

A. “My child should remain quiet and still during this procedure.”
B. “I cannot wash my child’s hair prior to the procedure.”
C. “I should not give my child anything to eat prior to the procedure.”
D. “This procedure will be very painful for my child.”
“My child should remain quiet and still during this procedure.”

A nurse is reinforcing teaching with a group of caregivers about the risk factors for seizures. Which of the following factors should the nurse include? (select all that apply)

A. Febrile episodes
B. Hypoglycemia
C. Sodium imbalances
D. Low blood lead levels
E. Presence of diphtheria

1. Febrile episodes
2. Hypoglycemia
3. Sodium imbalances

A nurse is preparing to reinforce treatment options with the guardian of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? (select all that apply)

A. Vagal nerve stimulator
B. Additional antiepileptic medications
C. Corpus callosotomy
D. Focal resection
E. Radiation therapy

1. Vagal nerve stimulator
2. Additional antiepileptic medications
3. Corpus callosotomy
4. Focal resection

A nurse is assisting with performing a peripheral vision test on a child. Which of the following actions should the nurse take?

A. Place the child 10 feet away from a Snellen chart
B. Show a set of cards to the child one at a time
C. Cover the child’s eye while performing the test on the other eye
D. Have the child focus on an object while performing the test
Have the child focus on an object while performing the test

A nurse is reinforcing teaching with a group of caregivers about possible manifestations of Down syndrome. Which of the following findings should the nurse include? (Select all that apply)

A. A large head with bulging fontanels
B. Larger ears that are set back
C. Protruding abdomen
D. Broad, short feet and hands
E. Hypotonia

1. Protruding abdomen
2. Broad, short feet and hands
3. Hypotonia

A nurse is collecting data from a child who has myopia. Which of the following findings should the nurse expect? (Select all that apply)

A. Headaches
B. Photophobia
C. Difficulty reading
D. Difficult focusing on close objects
E. Poor school performance

1. Headaches
2. Difficulty reading
3. Poor school performance

A nurse is collecting screening data from a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? (select all that apply)

A. Uses monotone speech
B. Speaks loudly
C. Repeats sentences
D. Appears shy
E. Is overly attentive to the surroundings

1. Uses monotone speech
2. Speaks loudly
3. Appears shy

A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following statements by the guardian indicates an understanding of the teaching?

A. “I should expect him to have frequent diarrhea.”
B. “I should place a cool mist humidifier in his room.”
C. “I should avoid the use of lotion on his skin.”
D. “I should expect him to grow faster in length than other infants.”
“I should place a cool mist humidifier in his room.”

RESPIRATORY DISORDERS

A nurse is reinforcing teaching with an adolescent to self-administer a corticosteroid medication using a metered-dose inhaler (MDI). Which of the following instructions should the nurse include (select all that apply)

A. Shake the device prior to use
B. Rinse and expectorate after administration
C. Inhale slowly with medication administration
D. Exhale quickly after medication administration
E. Wait 30 seconds between puffs

1. Shake the device prior to use
2. Rinse and expectorate after administration
3. Inhale slowly with medication administration

A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first?

A. Increase the oxygen flow rate
B. Encourage the child to take deep breaths
C. Ensure proper placement of the sensor probe
D. Place the child in the Fowler’s position
Ensure proper placement of the sensor probe

A nurse is collecting data from an infant who has a respiratory infection. Which of the following findings is an early indication of acute hypoxemia?

A. Nonproductive cough
B. Hypoventilation
C. Tachypnea
D. Nasal stuffiness
Tachypnea

A nurse is caring for a child who is receiving oxygen. Which of the following findings indicates oxygen toxicity?

A. Increased blood pressure
B. Hyperventilation
C. Decreased PaCo2
D. Unconsciousness
Unconsciousness

A nurse is caring for a child who is receiving a bronchodilator medication by nebulized aerosol therapy. Which of the following actions should the nurse take? (select all that apply)

A. Instruct the child that the treatment will last 30 min
B. Obtain vital signs prior to the procedure
C. tell the child to take slow deep breaths
D. Determine if the child should use a mask
E. Attach the device to an air source

1. Obtain vital signs prior to the procedure
2. tell the child to take slow deep breaths
3. Determine if the child should use a mask
4. Attach the device to an air source

A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take?

A. Administer oral prednisone
B. Initiate chest percussion and postural drainage
C. Administer humidified oxygen
D. Suction the nasopharynx as needed
E. Administer oral penicillin

1. Administer humidified oxygen
2. Suction the nasopharynx as needed

A nurse is reinforcing teachings with a group of guardians about influenza. Which of the following information should the nurse include?

A. “Amantadine will prevent the illness.”
B. “The influenza vaccine is recommended for children 4 months and older.”
C. Zanamivir can be given to children 1 year and older.”
D. “Oseltamivir should be given within 48 hours of onset of manifestations.”
“Oseltamivir should be given within 48 hours of onset of manifestations.”

A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding?

A. Hgb 11.6 and Hct 37%
B. Inflamed and reddened throat
C. Frequent swallowing and clearing of the throat
D. Blood-tinged mucus
Frequent swallowing and clearing of the throat

A nurse is assisting with the care of a child in the postoperative period following a tonsillectomy. Which of the actions should the nurse take?

A. Encourage the child to blow their nose gently
B. Administer analgesic on a schedule
C. Offer orange juice
D. Position the child supine
Administer analgesic on a schedule

A nurse is collecting data from a child who has epiglottis. Which of the following findings should the nurse expect? (select all that apply)

A. Hoarseness
B. Difficulty swallowing
C. Low-grade fever
D. Drooling
E. Dry, barking cough
F. Stridor

1. Difficulty swallowing
2. Drooling
3. Stridor

A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child’s respiratory status? (select all that apply)

A. Oxygen saturation 95%
B. Wheezing
C. Retraction of sternal muscles
D. Warm extremities
E. Nasal flaring

1. Wheezing
2. Retraction of sternal muscles
3. Nasal flaring

A nurse is reinforcing teaching to an adolescent about the appropriate use of their asthma medications. Which of the following medications should the nurse instruct t he client to use as needed before exercise?

A. Fluticasone/salmeterol
B. Montelukast
C. Prednisone
D. Albuterol
Albuterol

A nurse is contributing to the plan of care for a child who has asthma. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)

A. Perform chest percussion
B. Place the child in an upright position
C. Monitor oxygen saturation
D. Administer bronchodilators
E. Administer dornase alfa daily

1. Place the child in an upright position
2. Monitor oxygen saturation
3. Administer bronchodilators

A nurse is reinforcing teaching with a child who has asthma about how to use a peak flow meter. Which of the following information should the nurse include in the teaching? (select all that apply)

A. Zero the meter before each use
B. Record the average of the attempts
C. Perform three attempts
D. Deliver a long, slow breath into the meter
E. Sit in a chair with feet on the floor

1. Zero the meter before each use
2. Perform three attempts

A nurse is preparing to assist the charge nurse with discussing risk factors for asthma with a group newly licensed nurses. Which of the following conditions should the nurse include in the teaching?

A. Family history of asthma
B. Family history of allergies
C. Exposure to smoke
D. Low birth weight
E. Being underweight

1. Family history of asthma
2. Family history of allergies
3. Exposure to smoke
4. Low birth weight

A nurse is reviewing the diagnostic findings for a preschool age child who is suspected of having cystic fibrosis. Which of the following findings should the nurse identify as an indication of cystic fibrosis?

A. Sweat chloride content 85 mEq/L
B. Increased blood levels of fat-soluble vitamins
C. 72 hr stool analysis sample indicating hard, packed stools
D. Chest x-ray negative for atelectasis
Sweat chloride content 85 mEq/L

A nurse is assisting with the admission of a child who has cystic fibrosis. Which of the following medications should the nurse expect the provider to prescribe? (select all that apply)

A. Tobramycin
B. Loperamide
C. Fat-soluble vitamins
D. Albuterol
E. Dornase alfa

1. Tobramycin
2. Fat-soluble vitamins
3. Albuterol
4. Dornase alfa

A nurse is collecting data from a child who has a cystic fibrosis. Which of the following findings should the nurse expect? (select all that apply)

A. Wheezing
B. Clubbing of fingers and toes
C. Barrel-shaped chest
D. Thin, water mucus
E. Rapid growth spurts

1. Wheezing
2. Clubbing of fingers and toes
3. Barrel-shaped chest

A nurse is reinforcing discharge teaching for a child who has cystic fibrosis. Which of the following instructions should the nurse include?

A. Provide a low-calorie, low protein diet
B. Administer pancreatic enzymes with meals and snacks
C. Implement a fluid restriction during times of infection
D. Restrict physical activity
Administer pancreatic enzymes with meals and snacks

CARDIOVASCULAR DISORDERS

A nurse is collecting data from an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? (select all that apply)

A. Weak femoral pulses
B. Cool skin of lower extremities
C. Severe cyanosis
D. Clubbing of the fingers
E. Low blood pressure

1. Weak femoral pulses
2. Cool skin of lower extremities
3. Low blood pressure

A nurse is collecting data from an infant who has heart failure. Which of the following findings should the nurse expect? (select all that apply)

A. Bradycardia
B. Cool extremities
C. Peripheral edema
D. Increased urinary output
E. Nasal flaring

1. Cool extremities
2. Peripheral edema
3. Nasal flaring

A nurse is reinforcing teaching with the caregiver of an infant who has a prescription for digoxin. Which of the following statements should the nurse make?

A. “Do not offer your baby fluids after giving the medication.”
B. “Digoxin increased your baby’s heart rate.”
C. “Give the correct dose of medication at regularly scheduled times.”
D. “If your baby vomits a dose, you should repeat the dose to ensure that the correct amount is received.”
“Give the correct dose of medication at regularly scheduled times.”

A nurse is assisting with the care of a 2 year old child who has a heart defect and is scheduled for cardiac catherization. Which of the following actions should the nurse take?

A. Place on NPO status for 12 hr prior to the procedure
B. Check for iodine or shellfish allergies prior to the procedure
C. Elevate the affected extremity following the procedure
D. Limit fluid intake following the procedure
Check for iodine or shellfish allergies prior to the procedure

A nurse is collecting data from a child who has rheumatic fever. Which of the following findings should the nurse expect? (select all that apply)

A. Erythema marginatum (rash)
B. Continuous joint pain of the digits
C. Tender, subcutaneous nodules
D. Decreased erythrocyte sedimentation rate
E. Elevated C-reactive protein

1. Erythema marginatum (rash)
2. Elevated C-reactive protein

HEMATOLOGIC DISORDERS

A nurse is reinforcing teaching about the management of epistaxis to an adolescent. Which of the following positions should the nurse instruct the adolescent to take when experiencing a nosebleed?

A. Sit up and lean forward
B. Sit up and tilt the head up
C. Lie in a supine position
D. Lie in a prone position
Sit up and lean forward

A nurse is providing reinforcement teaching about epistaxis to the parent of a school-age child. Which of the following should the nurse include as an action to take when managing an episode of epistaxis? (select all that apply)

A. Press the nares together for at least 10 min
B. Breathe through the nose until the bleeding stops
C. Pack cotton or tissue into the naris that is bleeding
D. Apply a cold cloth across the bridge of the nose
E. Insert petroleum into the naris after the bleeding stops

1. Press the nares together for at least 10 min
2. Apply a cold cloth across the bridge of the nose

A nurse is reinforcing teaching to the parent of a child who has a new prescription for liquid oral iron supplements. Which of the following statements by the parent indicates an understanding?

A. “I should take my child to the emergency department if his stools become dark.”
B. “My child should avoid eating citrus fruits while taking the supplements.”
C. “I should give the iron with milk to help prevent an upset stomach.”
D. “My child should take the supplement through a straw.”
“My child should take the supplement through a straw.”

A nurse is preparing to administer iron dextran IM to a school-age child who has iron deficiency anemia. Which of the following actions by the nurse is appropriate?

A. Administer the dose in the deltoid muscle
B. Use the Z-track method when administering the dose
C. Avoid injecting more than 2 mL with each dose
D. Massage the injection site for 1 min after administering the dose
Use the Z-track method when administering the dose

A nurse is caring for an infant whose screening test reveals a potential diagnosis of sickle cell disease. Which of the following tests should be performed to distinguish if the infant has the trait or the disease?

A. Sickle solubility test
B. Hemoglobin electrophoresis
C. Complete blood count
D. Transcranial Doppler
Hemoglobin electrophoresis

A nurse is planning to administer the influenza vaccine to a toddler. Which of the following actions should the nurse take?

A. Administer subcutaneously in the abdomen
B. Use a 20 gauge needle
C. Divide the medication into two injections
D. Place the child in the supine position
Place the child in the supine position

A nurse is preparing to administer an intramuscular (IM injection to a child. Which of the following muscle groups is contraindicated?

A. Deltoid
B. Ventrogluteal
C. Vastus lateralis
D. Dorsogluteal
Dorsogluteal

A nurse is reinforcing teaching with the guardian of an infant about administration of oral medications. Which of the following should the nurse include in the teaching? (Select all that apply)

A. Use a universal dropper for medication administration
B. Ask the pharmacy to add flavoring to the medication
C. Add the medication to a formula bottle before feeding
D. Use the nipple of a bottle to administer the medication
E. Hold the infant in an semi-reclining position

1. Ask the pharmacy to add flavoring to the medication
2. Use the nipple of a bottle to administer the medication
3. Hold the infant in an semi-reclining position

A nurse is preparing to administer medication to a toddler. Which of the following actions should the nurse take? (select all that apply)

A. Identify the toddler by asking the caregiver
B. Tell the caregiver to administer the medication
C. Calculate the safe dosage
D. Ask the toddler to pick a toy to hold during administration
E. Offer juice after medication

1. Calculate the safe dosage
2. Ask the toddler to pick a toy to hold during administration
3. Offer juice after medication

A nurse is caring for an infant who needs otic medication. Which of the following is an appropriate action for the nurse to take?

A. Hold the infant in an upright position
B. Pull the pinna downward and straight back
C. Hyperextend the infant’s neck
D. Ensure that the medication is cool
Pull the pinna downward and straight back

A nurse is collecting data from an infant about pain. Which of the following pain scales should the nurse use?

A. FACES
B. FLACC
C. Oucher
D. Numeric scale
FLACC

A nurse is contributing to the plan of care for a child following a surgical procedure. Which of the following interventions should the nurse include in the plan of care?

A. Administer NSAIDs for pain greater than 7 on a scale of 0 to 10
B. Administer intranasal analgesics for pain
C. Administer IM analgesics for pain
D. Administer IV analgesics on a schedule
Administer IV analgesics on a schedule

A nurse is collecting data from an infant. Which of the following are findings of pain in an infant? (Select all that apply)

A. Pursed lips
B. Loud cry
C. Lowered eyebrows
D. Rigid body
E. Pushes away stimulus

1. Loud cry
2. Lowered eyebrows
3. Rigid body

A nurse is contributing to the plan of care for an infant who is experiencing pain. Which of the following interventions should the nurse include in the plan of care? (select all that apply)

A. Offer a pacifier
B. Use guided imagery
C. Use swaddling
D. Initiate a behavioral contact
E. Encourage kangaroo care

1. Offer a pacifier
2. Use swaddling
3. Initiate a behavioral contact

A nurse is assisting with preparing a toddler for an intravenous catheter insertion using atraumatic care. Which of the following actions should the nurse take (select all that apply)

A. Reinforce the procedure using the child’s favorite toy
B. Ask the guardians to leave during the procedure
C. Assist with performing the procedure with the child in his bed
D. Allow the child to make one choice regarding the procedure
E. Apply lidocaine and prilocaine cream to three potential insertion sites

1. Reinforce the procedure using the child’s favorite toy
2. Allow the child to make one choice regarding the procedure
3. Apply lidocaine and prilocaine cream to three potential insertion sites

A nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool-age child?

A. Describing manifestations of illness
B. Relating fears to magical thinking
C. Understanding cause of illness
D. Awareness of body functioning
Relating fears to magical thinking

A nurse on a pediatric unit is caring for a toddler. Which of the following behaviors is an effect of hospitalization? (select all that apply)

A. Believes the experience is a punishment
B. Experiences separation anxiety
C. Displays intense emotions
D. Exhibits regressive behaviors
E. Manifests disturbance in body image

1. Experiences separation anxiety
2. Displays intense emotions
3. Exhibits regressive behaviors

A nurse is reinforcing teaching with a guardian about parallel play in children. Which of the following statements should the nurse include?

A. “Children sit and observe other playing.”
B. “Children exhibit organized play when in a group.”
C. “The child plays alone.”
D. “The child plays independently when in a group.”
“The child plays independently when in a group.”

A nurse is reinforcing teaching with a group of caregivers about separation anxiety. Which of the following information should the nurse include?

A. It is often observed in the school-age child
B. Detachment is the stage exhibited in the hospital
C. It results in prolonged issues of adaptability
D. Kicking a stranger is an example
Kicking a stranger is an example

A nurse is caring for a child who is dying. Which of the following are findings of impending death? select all that apply)

A. Heightened sense of hearing
B. Tachycardia
C. Difficulty swallowing
D. Sensation of being cold
E. Cheyne-Stokes respirations

1. Difficulty swallowing
   2 Cheyne-Stokes respirations

A nurse is reinforcing teaching with a guardian about complicated grief. Which of the following statements should the nurse make?

A. “Complicated grief occurs when little time is spent thinking about the loss.”
B. “Personal activities are rarely affected when experiencing complicated grief.”
C. “Guardians will experience complicated grief together.”
D. “Counseling can be helpful in resolving complicated grief.”
“Counseling can be helpful in resolving complicated grief.”

A nurse is reinforcing teaching with a caregiver of a preschool child about factors that affect the child’s perception of death. Which of the following factors should the nurse include?

A. Preschool children have no concept of death
B. Preschool children perceive death as temporary
C. Preschool children often regress to an earlier stage of behavior
D. Preschool children experience fear related to the disease process
Preschool children perceive death as temporary

A nurse often cares for children who are dying. Which of the following are actions for the nurse to take to maintain professional effectiveness? select all that apply)

A. Remain in contact with the family after their loss
B. Develop a professional support system
C. Take time off from work
D. Suggest that a hospital representative attend the funeral
E. Demonstrate feelings of sympathy toward the family.

1. Remain in contact with the family after their loss
2. Develop a professional support system
3. Take time off from work

A nurse is caring for a child who has a terminal illness and reviews palliative care with an assistive personnel (AP). Which of the following statements by the AP indicates understanding of this review?

A. “I’m sure the family is hopeful that the new medication will stop the illness.”
B. “I’ll miss working with this client now that only nurses will be caring for the child.”
C. “I will get all the client’s personal objects out of the room.”
D. “I will listen and respond as the family talks about their child’s life.”
“I will listen and respond as the family talks about their child’s life.”

A nurse on a pediatric unit is assisting the manager with preparing an education program on working with families for a group of newly hired nurses. Which of the following should the nurse include when discussing the developmental theory?

A. Describes that stress is inevitable
B. Emphasizes that change with one member affects the entire family
C. Provides guidance to assist families adapting to stress
D. Defines consistencies in how families change
Defines consistencies in how families change

A nurse is assisting a group of guardians of adolescents to develop skills that will improve communication within the family. The nurse hears one guardian state, “My son knows he better do what I say.” Which of the following parenting styles is the parent exhibiting?

A. Authoritarian
B. Permissive
C. Authoritative
D. Passive

A nurse is assisting with performing family data collection. Which of the following should the nurse include?

A. Medical history
B. Parents’ education level
C. Child’s physical growth
D. Support systems
E. Stressors

1. Medical history
2. Parents’ education level
3. Support systems
4. Stressors

A nurse is preparing to examine a preschooler during a well-child visit. Which of the following actions should the nurse take to prepare the child?

A. Allow the child to role-play using miniature equipment
B. Use medical terminology to describe what will happen
C. Separate the child from the caregiver during the examination
D. Keep medical equipment visible to the child
Allow the child to role-play using miniature equipment

A nurse is checking the vital signs of a 3-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider?

A. Temperature 37.2 C (99.0 F)
B. Heart rate 106/min
C. Respirations 35/min
D. Blood pressure 88/54 mm Hg
Respirations 35/min

A nurse is using an otoscope to examine a child’s ears. Which of the following findings should the nurse expect?

A. Light reflex is located at the 2 o-clock position
B. Tympanic membrane is red in color
C. Bony landmarks are not visible
D. Cerumen is present bilaterally
Cerumen is present bilaterally

A nurse is collecting data from a 6 month old infant. Which of the following reflexes should the nurse expect the infant to exhibit?

A. Moro
B. Plantar grasp
C. Stepping
D. Tonic neck
Plantar grasp

A nurse is checking the trigeminal nerve of an adolescent client. Which of the following responses should the expect? (select all that apply)

A. Clenching teeth together tightly
B. Recognizing sour tastes on the back of the tongue
C. Identifying smells through each nostril
D. Detecting facial touches with eyes closed
E. Looking down and in with the eyes

1. Clenching teeth together tightly
2. Detecting facial touches with eyes closed

A nurse is assisting with collecting data from 12 month old infant during a well child visit. Which of the following findings should the nurse report to the provider?

A. Closed anterior fontanel
B. Eruption of six teeth
C. Birth weight doubled
D. Birth length increased by 50%
Birth weight doubled

A nurse is collecting data during a developmental screening on a 10 month old infant. Which of the fine motor skills should the nurse expect the infant to perform? (select all that apply)

A. Grasp the rattle by the handle
B. Try building a two block tower
C. Use a crude pincer grasp
D. Place objects into a container
E. Walks with one hand held

1. Grasp the rattle by the handle
2. Use a crude pincer grasp

A nurse is collecting data during a well-baby visit with a 4 month old infant. Which of the following immunizations should the nurse plan to administer to the infant? (select all that apply)

A. Measles, mumps, rubella (MMR)
B. Polio (IPV)
C. Pneumococcal vaccine (PCV)
D. Varicella
E. Rotavirus vaccine (RV)

1. Polio (IPV)
2. Pneumococcal vaccine (PCV)
3. Rotavirus vaccine (RV)

A nurse is reinforcing teaching about when introducing new foods to the guardians of a 4 month old infant. The nurse should recommend that the caregiver introduce which of the following foods first?

A. Strained yellow vegetables
B. Iron fortified cereals
C. Pureed fruits
D. Whole milk
Iron fortified cereals

A nurse is reinforcing teaching about dental care and teething to the caregiver of a 9 month old infant. Which of the following statements by the caregiver suggests an understanding of the teaching?

A. “I can give my baby a warm teething ring to relieve discomfort.”
B. “I should clean my baby’s teeth with a cool, wet wash cloth.”
C. “I can give Advil for up to 5 days while my baby is teething.”
D. “I should place diluted juice in the bottle my baby drinks while falling asleep.”
“I should clean my baby’s teeth with a cool, wet wash cloth.”

A nurse is collecting data from a 2 1/2 year old toddler at a well child visit. Which of the following findings should the nurse report to the provider?

A. Height increased by 7.5 cm (3 in) in the past year
B. Head circumference exceeds chest circumference
C. Anterior and posterior fontanels are closed
D. Current weight equals four times the birth weight
Head circumference exceeds chest circumference

A nurse is assisting with a development screening on an 18 month old. Which of the following skills should the toddler be able to perform? (Select all that apply)

A. Build a tower with six blocks
B. Throw a ball overhand
C. Walk up and down stairs
D. Stand on one foot for a few seconds
E. Use a spoon without rotation

1. Throw a ball overhand
2. Use a spoon without rotation

A nurse is reinforcing teaching about growth and development characteristics to the guardian on a 2 year old toddler. Which of the following statements by the guardian indicates an understanding of the teaching?

A. “My child should be able to turn the pages of a book one a time.”
B. “My child should be able to walk on their tiptoes for several steps.”
C. “My child should be able to cut out an outline using scissors.”
D. “My child should be able to put the toys away after using them.”
“My child should be able to turn the pages of a book one a time.”

A nurse providing anticipatory guidance to the adoptive parents of a toddler. Which of the following information should the nurse include? (Select all that apply)

A. Develop food habits that will prevent dental caries
B. Meeting caloric needs results in an increased appetite
C. Expression of bedtime fears is common
D. Expect behaviors associated with negativism and ritualism
E. Annual screenings for phenylketonuria are important

1. Develop food habits that will prevent dental caries
2. Expression of bedtime fears is common
3. Expect behaviors associated with negativism and ritualism

A nurse is reinforcing teaching to the guardian of a preschooler about methods to promote sleep. Which of the following statements by the guardian indicates an understanding of the teaching?

A. “I will sleep in the bed with my child if she wakes up during the night.”
B. “I will let my child stay up an additional 2 hours on weekend nights.”
C. “I will let my child watch television for 3 minutes just before bedtime each night.”
D. “I will keep a dim light on in my child’s room during the night.”
“I will keep a dim light on in my child’s room during the night.”

A nurse is conducting a well-child visit with a 5 year old child who is up to date with current immunizations. Which of the following immunizations should the nurse plan to administer to the child? (select all that apply)

A. Diphtheria, tetanus, pertussis (DTaP)
B. Inactivated poliovirus (IPV)
C. Measles, mumps, rubella (MMR)
D. Pneumococcal (PCV)
E. Haemophilus influenzae type B (Hib)

1. Diphtheria, tetanus, pertussis (DTaP)
2. Inactivated poliovirus (IPV)
3. Measles, mumps, rubella (MMR)

A nurse is assisting an education program for a group of caregivers of preschooler about promoting optimum nutrition. Which of the following information should the nurse include in the program?

A. Saturated fats should equal 20% of total daily caloric intake
B. Average calorie intake should be 1,800 calories per day
C. Daily intake of fruits and vegetables should total 2 servings
D. Healthy diets include a total of 8 g protein each day
Average calorie intake should be 1,800 calories per day

A nurse is collecting data from a 3 year old child during a well child visit. Which of the following gross motor skills should the nurse expect the child to perform?

A. Ride a tricycle
B. Hop on one foot
C. Jump rope
D. throw a ball overhead
Ride a tricycle

A nurse is caring for a preschooler who expresses the need to leave because their doll is scared to be at home alone. Which of the following characteristics of preoperational though is the child exhibiting?

A. Egocentrism
B. Centration
C. Animism
D. Magical thinking
Animism

A nurse is participating in a discussion about prepubescence and preadolescence with a group of guardians of school-age children. Which of he following information should the nurse include in the discussion?

A. Initial physiologic changes appear during early childhood
B. Changes in height and weight occur slowly during this period
C. Growth differences between boys and girls become evident
D. Sexual maturation becomes highly visible in boys
Growth differences between boys and girls become evident

A nurse is assisting with conducting a well child visit with a child who is scheduled to receive the recommended immunizations for 11-12 year olds. Which of the following immunizations should the nurse administer? (select all that apply)

A. Inactivated influenza (IIV)
B. Pneumococcal (PCV)
C. Meningococcal (MenB-4C)
D. Tetanus and diphtheria toxoids and pertussis (Tdap)
E. Rotavirus (RV)

1. Inactivated influenza (IIV)
2. Meningococcal (MenB-4C)
3. Tetanus and diphtheria toxoids and pertussis (Tdap)

A nurse is assisting with providing education about age appropriate activities for the caregivers of a 6 year old child. Which of the following activities should the nurse include in teaching?

A. Jumping rope
B. Playing table games
C. Solving jigsaw puzzles
D. Joining competitive sports
Jumping rope

A nurse is assisting with teaching a course about safety during the school age. Which of the following information should the nurse include in the course? (Select all that apply)

A. Gating stairs at the top and bottom
B. Wearing helmets when riding bicycles or skateboarding
C. Riding safely in bed of pickup trucks
D. Implementing firearm safety
E. Wearing seat belts

1. Wearing helmets when riding bicycles or skateboarding
2. Implementing firearm safety
3. Wearing seat belts

A nurse is reinforcing teaching about expected changes during puberty to a group of guardians of early adolescent girls. Which of the following statements by one of the guardians indicates an understanding of the information?

A. “Girls usually stop growing about 2 years after menarche.”
B. “Girls are expected to gain about 65 pounds during puberty.”
C. “Girls experience menstruation prior to breast development.”
D. “Girls typically grow more than 10 inches during puberty.”
“Girls usually stop growing about 2 years after menarche.”

A nurse is assisting with providing anticipatory guidance to the caregiver of a 13 year old adolescent. Which of the following screenings should the nurse recommend for the adolescent? (select all that apply)

A. Body mass index
B. Blood lead level
C. 24 hr dietary recall
D. Weight
E. Scoliosis

1. Body mass index
2. Weight
3. Scoliosis

A nurse is caring for an adolescent whose guardian expresses concerns about the child sleeping such long hours. Which of the following conditions should the nurse inform the guardian as requiring additional sleep during adolescence?

A. Sleep terrors
B. Rapid growth
C Elevated zinc levels
D. Slowed metabolism
Rapid growth

A nurse is assisting teaching a class about puberty in boys. Which of the following should the nurse include as the first manifestation of sexual maturation?

A. pubic hair growth
B. Vocal changes
C. Testicular enlargement
D. Facial hair growth
Testicular enlargement

A nurse is assisting a group of guardians of adolescents to develop skills that will improve communication within the family. The nurse hears one guardian state, “My son knows he better do what I say.” Which of the following parenting styles is the parent exhibiting?

A. Authoritarian
B. Permissive
C. Authoritative
D. Passive

A nurse is assisting a group of guardians of adolescents to develop skills that will improve communication within the family. The nurse hears one guardian state, “My son knows he better do what I say.” Which of the following parenting styles is the parent exhibiting?

A. Authoritarian
B. Permissive
C. Authoritative
D. Passive
Authoritarian

A nurse is reviewing the medical record of a newborn who has necrotizing enterocolitis (NEC). The nurse should identify that which of the following findings is a risk factor for NEC?

a. Macrosomia
b. Transient tachypnea of the newborn (TTN)
c. Maternal gestational hypertension
d. Gestational age 36 weeks
Gestational age 36 weeks

A nurse is collecting data from a newborn who has congenital hypothyroidism. Which of the following findings should the nurse expect? (select all that apply)

a. Hypertonicity
b. Cool extremities
c. Short neck
d. Tachycardia
e. Hyperreflexia

1. cool extremities
2. short neck

A nurse is reinforcing teaching with the parent of a newborn who has plagiocephaly. Which of the following statements by the parent indicates an understanding of the instructions?

a. “I should put my baby to sleep on the belly during her afternoon nap.”
b. “I should ensure my baby’s head is in the same position whenever sleeping.”
c. “I should have my baby wear the prescribed helmet 23 hours a day.”
d. “I should allow my baby to sleep in an infant swing.”
“I should have my baby wear the prescribed helmet 23 hours a day.”

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and is scheduled to receive phototherapy. Which of the following interventions should the nurse include?

a. Reposition the newborn every 4 hr
b. Lotion the newborn’s skin twice per day
c. Check the newborn’s temperature every 8 hr
d. Remove the newborn’s eye mask during feedings
Remove the newborn’s eye mask during feedings

A nurse is reinforcing preconception teaching with a client whonhas phenylketonuria (PKU). Which of the following information should the nurse include?

a. Follow a low-phenylalanine diet once pregnancy is confirmed
b. Testing of phenylalanine levels will be required one to two times per week throughout pregnancy
c. Increase intake of dietary proteins prior to conception
d. Cesarean birth will be required due to the likelihood of having a fetus with macrosomia
Testing of phenylalanine levels will be required one to two times per week throughout pregnancy

A nurse is caring for a child who is experiencing respiratory distress. Which of the following findings are early manifestations of respiratory distress? (select all that apply)

a. Bradypnea
b. Peripheral cyanosis
c. Tachycardia
d. Diaphoresis
e. Restlessness

1. Tachycardia
2. Diaphoresis
3. Restlessness

A nurse in an urgent in an urgent care clinic is caring for a child whose guardian reports that the child has swallowed paint thinner. The child is lethargic, gagging, and cyanotic. Which of the following actions should the nurse anticipate assisting with?

a. Induce vomiting with syrup of ipecac
b. Insert a nasogastric tube, and administer activated charcoal
c. Prepare for intubation with a cuffed endotracheal tube
d. Administer chelation therapy using deferoxamine mesylate
Prepare for intubation with a cuffed endotracheal tube

A nurse in an urgent care clinic is admitting an infant who experienced a life threatening event. Which of the following prescriptions by the provider should the nurse anticipate? (select all that apply)

a. Electroencephalogram
b. Electrocardiogram
c. Urine culture
d. Arterial blood gases
e. Blood culture

1. Electroencephalogram
2. Electrocardiogram
3. Blood culture

A nurse is reinforcing teaching with a caregiver about acetaminophen poisoning. Which of the following information should the nurse include?

a. Nausea begins 24 hr after ingestion
b. Pallor can appear as early as 2 hr after ingestion
c. Jaundice will appear in 12 hr if the child is toxic
d. Children can have 4 g/day of acetaminophen
Pallor can appear as early as 2 hr after ingestion

A nurse in a community center is assisting with an in-service to a group of guardians on management of airway obstructions in toddlers. Which of the following responses by one of the caregivers indicates an understanding of the information? (select all that apply)

a. “I will push on my child’s abdomen.”
b. “I will hyperextend my child’s head to open the airway.”
c. “I will use my finger to check my child’s mouth for objects.”
d. “I will use my finger to check my child’s mouth for objects.”
e. “I will place my child in my car and take them to the closest emergency facility.”

1. “I will push on my child’s abdomen.”
2. “I will place my child in my car and take them to the closest emergency facility.”

A nurse is reinforcing teaching with a group of guardians about characteristics of infants who have failure to thrive. Which of the following characteristics should the nurse include?

a. intense fear of strangers
b. Increased risk for childhood obesityc. c. inability to form close relationships with siblings
d. developmental delays
developmental delays

A nurse is reinforcing teaching with the teacher of a child who has attention-deficit/hyperactivity disorder (ADHD). Which of the following classroom strategies should the nurse include? (select all that apply)

a. Eliminate testing
b. Allow for regular breaks
c. Combine verbal instruction with visual cues
d. Establish consistent classroom rules
e. Increase stimulu in the environment

1. Allow for regular breaks
2. Combine verbal instruction with visual cues
3. Establish consistent classroom rules

A nurse is reinforcing teaching with a guardian about posttraumatic stress disorder (PTSD). Which of the following information should the nurse include? (select all that apply)

a. Children who have PTSD can benefit from psychotherapy
b. A manifestation of PTSD is phobias
c. Personality disorders are a complication of PTSD
d. PTSD develops following a traumatic event
e. There are six stages of PTSD

1. Children who have PTSD can benefit from psychotherapy
2. A manifestation of PTSD is phobias
3. Personality disorder are a complication of PTSD

A. urse ks reinforcing teaching with the guardian of a child about risk factors for attention-deficit/hyperactivity disorder (ADHD). Which of the following risk factors should the nurse include?

a. formula-feeding as an infant
b. history of head trauma
c. history of postterm birth
d. child of a single guardian
history of head trauma

A nurse is caring for a child who has a depressive disorder. which of the following findings should the nurse expect? (select all that apply)

a. prefers being with peers
b. weight loss or gain
c. reports low self-esteem
d. sleeps more than usual
e. hyperactivity

1. weight loss of gain
2. reports low self-esteem
3. sleeps more than usual
4. Assessing the Care Environment for a Client Who is Experiencing Suicidal Ideations
5. -search the client’s belonging with the client present. Remove all glass, metal silverware, electrical cords, vases, belts, shoelaces, metal nail files, tweezers, matches, razors, perfume, shampoo, plastic bags, and other potentially harmful items from the client’s room and vicinity
6. -allow the client to use only plastic eating utensils. Count utensils when brought into and out of the client’s room
7. -check the environment for possible hazards (windows that open, overhead pipes that are easily accessible, non-breakaway shower rods, non-recessed shower nozzles)
8. -ensure that the client’s hands are always visible, even when sleeping
9. Caring for a Client Who Has Immunosuppression
10. monitor skin and mucous membranes for infection (breakdown, fissures, and abscess)
11. Developing an Emergency Preparedness Plan
12. The Hospital Incident Command System (HICS) for disaster management offers a clear structure for disaster management at the facility level
13. Identifying Reportable Diseases
14. -Nurses are also mandated to report to the proper agency (local health department, state health department) when a client is diagnosed with a communicable disease
15. -a complete list of reportable diseases and a description of the reporting system are available through the Centers for Disease Control and Prevent Web site. Each state mandates which diseases must be reported in that state. There are more than 60 communicable diseases that must be reported to public health departments to allow officials to do the following: ensure appropriate medical treatment of diseases (tuberculosis), monitor for common-source outbreaks (foodborne: hepatitis A), plan and evaluate control and prevention plans (immunizations for preventable diseases), identify outbreaks and epidemics, determine public health priorities based on trends, educate the community on prevention and treatment of these diseases
16. Nationally notifiable diseases: identified at the CDC website and include the following
17. -anthrax, botulism, cholera, congenital rubella syndrome (CRS), diphtheria, giardiasis, gonorrhea, hepatitis A, B, C, HIV, influenza-associated pediatric mortality, legionellosis/legionnaires’ disease, lyme disease, malaria, meningococcal disease, mumps, pertussis (whooping cough), poliomyelitis, paralytic, poliovirus infection, nonparalytic, rabies (human or animal), rubella (german measles), salmonellosis, severe acute respiratory syndrome-associated coronavirus disease (SARS-CoV), shigellosis, smallpox, syphilis, tetanus/C. tetani, toxic shock syndrome (TSS) (other than streptococcal), tuberculosis (TB), typhoid fever, vancomycin-intermediate and vancomycin-resistant, viral hemorrhagic fever, staphylococcus aureus (VISA/VRSA)
18. Identifying a Prescription to Clarify With the Provider
19. -caused by damage to sensory nerve fibers resulting in numbness and pain
20. **peripheral neuropathy includes focal neuropathies, caused by acute ischemic damage or diffuse neuropathies, which are more widespread and involve slow, progressive loss. This can lead to complications (foot deformities, ulcers).
21. **autonomic neuropathy can affect nerve conduction of the heart (exercise intolerance, painless myocardial infarction, altered left ventricular function, syncope), gastrointestinal system (gastroparesis, reflux, early satiety), and urinary tract (decreased bladder sensation, urinary retention). It affects the autonomic nervous system, which minimizes manifestations of hypoglycemia (diaphoresis, tremors, palpitations), which can be dangerous for the client
22. -clients who have impaired sensory perception might not feel numbness, pain, or burning
23. managing adverse effects of risperidone
24. orthostatic hypotension
25. -nursing actions: monitor blood pressure and heart rate for orthostatic changes
26. -client education: change position slowly
27. placing a client in side-lying position
28. -position clients, especially those who are unable to move themselves, so that they maintain good body alignment. Frequent position changes prevent discomfort, contractures, pressure on tissues, and nerve and circulatory damage, and they stimulate postural reflexes and muscle tone
29. -use pillows, bath blankets, hand rolls, boots, splints, trochanter rolls, ankle support devices, and other aids to maintain proper body alignment
30. preparing for a sterile dressing change
31. do not turn your back on a sterile field
32. teaching care seat safety
33. motor vehicle injury
34. -place infants and toddlers in a rear-facing car seat until 2 years of age or until they exceed the height and weight limit of the car seat. They can then sit in a forward-facing car seat
35. -use a car seat with a five-point harness for infants and children
36. -all car seats should be federally approved and be placed in the back seat, which is the safest place in the vehicle
37. -infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height recommended by manufacturer
38. -toddlers over the age of 2 years, or who exceed the height recommendations for rear-facing car seats, should use a forward-facing car seat until they reach the height and weight requirements for a booster seat
39. -newborn infants should be placed in a federally approved car seat at a 45 degree angle to prevent slumping and airway obstruction. The car seat is placed rear facing in the rear seat of the vehicle and secured using the safety belt. The shoulder harnesses are placed in the slots at or below the level of the infant’s shoulders. The harness should be snug and the retainer clip placed at the level of the intant’s armpits
40. Educating staff nurses about organ donation
41. -recognize that requests for tissue and organ donations must be made by specifically trained personnel
42. -provide support and education to family members as decisions are being made. Use private areas for any family discussions concerning donation
43. -be sensitive to cultural and religious influences
44. -maintain ventilatory and cardiovascular support for vital organ retrieval
45. evaluating staff performance
46. -have one or more staff members assist with positioning clients. moving them up in bed is a significant cause of back pain and injury
47. -keep your head and neck in a straight line with your pelvis to avoid neck flexion and hunched shoulders, which can cause impingement of nerves in your neck
48. -use smooth movements when lifting and moving clients to prevent injury from sudden or jerky muscle movements
49. -when standing for long periods of time, flex your hips and knees by using a footrest. when sitting for long periods of time, keep your knees slightly higher than your hips
50. -avoid repetitive movements of the hands, wrists, and shoulders. take a break every 15 to 20 min to flex and stretch joints and muscles whenever possible
51. -avoid twisting your spine or bending at the waist (flexion) to minimize the risk for injury
52. evaluating the need for a chest compression vest
53. high-frequency chest compression uses a mechanical chest device combined with nebulization therapy
54. identifying resources to improve health care for migrant farmworkers
55. agency for healthcare research and quality (AHRQ): conducts research to improve the quality, affordability, and safety of healthcare services. uses research data to publish clinical guidelines and recommendations for a variety of health conditions
56. information to include in a change of shift report
57. nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients
58. -formats include face-to-face, audiotaping, or presentation during walking rounds in each client’s room (unless the client has a roommate or visitors are present)
59. -an effective report should: include significant objective information about the client’s health problems, proceed in a logical sequence, include no gossip or personal opinion, relate recent changes in medications, treatment, procedures, and the discharge plan
60. hand-off or change-of-shift report
61. -performed with the nurse who is assuming responsibility for the client’s care
62. -describes the current health status of the client
63. -informs the next shift of pertinent client care information
64. -provides the oncoming nurse the opportunity to ask questions and clarify the plan of care
65. -should be given in a private area (a conference room or at the bedside) to protect client confidentiality
66. priority steps in the time management process
67. time initially spent developing a plan will save time later and help to avoid management by crisis
68. client teaching about basal body temperature method of contraception
69. BBT is the temperature of the body at rest. prior to ovulation, the temperature drops slightly and rises during ovulation. identifying the time of ovulation is a symptom-based method that can be used to facilitate or avoid conception
70. evaluating guardians’ understanding of child safety measures
71. avoid sun exposure between 1000 and 1400, wear protective clothing, and apply sunscreen to prevent sunburn
72. sequence of performing an abdominal assessment
73. for most body systems, follow the sequence of first inspecting, then palpating, followed by percussion, and finally auscultation
74. the exception is the abdomen; inspect, auscultate, percuss, and palpate in that order to avoid altering bowel sounds
75. expected findings of autism spectrum disorder
76. -delays in at least one of the following: social interaction, social communication, imaginative play prior to age 3 years
77. -distress when routines are changed
78. -unusual attachments to objects
79. -inability to start or continue conversation
80. -using gestures instead of words
81. -delayed or absent language development
82. -grunting or humming
83. -inability to adjust gaze too look at something else
84. -not referring to self correctly
85. -withdrawn, labile mood
86. -lack of empathy
87. -decreased pain sensation
88. -spending time along rather than playing with others
89. -avoiding eye contact
90. -withdrawal from physical contact
91. -heightened or lowered senses
92. -not imitating actions of others
93. -minimal pretend play
94. -short attention span
95. -intense temper tantrums
96. -showing aggression
97. -exhibiting repetitive movements
98. -typical IQ less than 70
99. dietary modification for a client who has crohn’s disease
100. educate the client to eat high-protein, high-calorie, low-fiber foods
101. planning care for a client who has rheumatoid arthritis
102. encourage foods high in vitamins, protein, and iron
103. evaluating the effectiveness of chlorpromazine
104. -treatment of acute and chronic psychotic disorders
105. -schizophrenia spectrum disorders
106. -bipolar disorder: primarily the manic phase
107. -tourette disorder
108. -agitation
109. -prevention of nausea/vomiting through blocking of dopamine in the chemoreceptor trigger zone of the medulla
110. intervention for lorazepam overdose
111. -administer flumazenil for benzodiazepine toxicity to counteract sedation and reverse adverse effects
112. -IV: administer flumazenil to counteract sedation and reverse adverse effects
113. priority action for insulin administration
114. measure doses accurately, and double-check dosages of high-alert medications (insulin and heparin) with a colleague. check the medication’s expiration date
115. teaching about estradiol
116. estrogen either suppresses blood coagulation or promotes it; the effect depends on genetic influences. monitor for embolic event (MI, pulmonary embolism, DVT, stroke)
117. teaching about manifestations of digoxin toxicity
118. monitor for indications of anorexia, nausea, vomiting, visual disturbances, dysrhythmias
119. vitamin k administration following birth
120. administered to prevent hemorrhagic disorders. vitamin K is not produced in the gastrointestinal tract of the newborn until around day 7. vitamin K is produced in the colon by bacteria once formula or breast milk is introduced
121. expected laboratory values in a toddler who has hemophilia A
122. prolonged partial thromboplastin time (aPTT)
123. laboratory values to report to the provider following hemodialysis
124. excessive sodium retention: kidney failure, Cushing’s syndrome, aldosteronism, some medications (glucocorticosteroids)
125. manifestations of multiple sclerosis
126. nystagmus
127. manifestations of vaso-occlusive crisis
128. hematuria
129. reportable findings for a newborn
130. normal temperature range is 36.5C to 37.5C (97.7F to 99.5F), with 37C (98.6) being average. the newborn is at risk for hypothermia and hyperthermia until thermoregulation (ability to produce heat and maintain normal body temperature) stabilizes. if the newborn becomes chilled (cold stress), oxygen demands can increase and acidosis can occur
131. assessing oxygen toxicity
132. nonproductive cough, substernal pain, nausea, vomiting, fatigue, dyspnea, restlessness, paresthesias
133. creating plan of care for a child
134. antibiotics
135. -administer through IV or aerosol
136. -specific to treat the pulmonary infection. common medications include tobramycin, ticarcillin, or gentamicin
137. -nursing actions: assess for allergies, high doses may be prescribed. collect blood specimens before and after some IV antibiotics to maintain therapeutic levels
138. expected findings of the acute phase of kawasaki disease
139. onset of high fever, lasting 5 days to 2 weeks, that is unresponsive to antipyretics
140. -irritability, red eyes without drainage, bright red, chapped lips, strawberry tongue with white coating or red bumps on the posterior aspect, red oral mucous membranes with inflammation including the pharynx, swelling of hand and feet with red palms and soles, nonblistering rash, bilateral joint pain, enlarged lymph nodes, desquamation of the perineum, cervical lymphadenopathy, cardiac manifestations: myocarditis, decreased left ventricular function, pericardial effusion, and mitral regurgitation
141. home wound care teaching
142. -in most instances, the surgeon will perform the first dressing change. subsequent dressing changes can be performed by the nurse using surgical aseptic technique
143. -preventing infection by using aseptic technique when performing dressing changes
144. identifying visual changes due to cataracts
145. opacity in the lens of an eye that impairs vision
146. period of communicability for varicella
147. 1 to 2 days before lesions appear until all lesions have formed crusts
148. priority action to promote ambulation
149. noted pain experts agree that pain is whatever the person experiencing it says it is, and it exists whenever the person says it does. the client’s report of pain is the most reliable diagnostic measure of pain
150. teaching about manifestations of ovarian cancer
151. abdominal pain or swelling/abdominal discomfort
152. actions for a client who is experiencing excessive postpartum bleeding
153. -assess bladder for distention. insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output
154. -caring attitude: show concern and facilitate an emotional connection and support among nurses and clients, families, and significant others
155. -firmly massage the uterine fundus
156. -perineal pad saturation in 15 min or less
157. -constant oozing, trickling, or frank flow of bright red blood from vagina
158. -provide oxygen at 10 to 12 L/min via nonrebreather facemask, and monitor oxygen saturation
159. therapeutic intent: controls postpartum hemorrhage
160. actions to take for a preschooler experiencing an anaphylactic reaction
161. -cardiovascular manifestations include weak, thready pulse, tachycardia, and hypotension
162. -hypotension is a blood pressure below the expected reference range (systolic less than 90 mm Hg) and can be a result of fluid depletion, heart failure, or vasodilation
163. -if indications of allergy appear (urticaria, rash, hypotension, dyspnea), stop the cephalosporin immediately, and notify the provider
164. -monitor hemodynamic status. the client usually experiences extensive vasodilation and capillary leak (tachycardia, weak pulse)
165. -Provide rapid intervention including epinephrine ddministration for severe allergic reaction to prevent death. notify the rapid response team of anaphylaxis is suspected
166. actions to take to maintain client safety
167. -assess client’s suicide plan
168. -ensure client swallow all medications
169. -initiate one-on-one constant supervision
170. -search client’s belongings with the client present
171. anticipating provider prescriptions for postoperative complications
172. -compression. of nerves, blood vessels, and muscle inside a confined place, resulting in neuromuscular ischemia; most commonly occurring in relation to tibial fractures or fractures involving the forearm
173. -loosen the dressing or open and bivalve the cast
174. -prepare the client for fasciotomy
175. assessing risk for a client who is postpartum and has preeclampsia
176. -increased plasma uric acid
177. -seizures
178. -preeclampsia is GH with the addition of proteinuria of greater than or equal to 1+. report of transient headaches might occur along with episodes of irritability. edema can be present
179. assessment and management of postoperative complications
180. -administer IV fluid and electrolyte replacement
181. -dehydration
182. -high-pitched bowel sounds above site of obstruction
183. -place in semi-fowler’s position
184. caring for a client who has schizophrenia
185. -hyperactivity such as pacing, restlessness
186. -low risk of EPS
187. -tardive dyskinesia (TD): manifestations include involuntary movements of the tongue and face, such as lip-smacking which cause speech and/or eating disturbances, can also include involuntary movements of arms, legs, or trunk
188. caring for a client who has a psychobiological disorder
189. Nursing care
190. -accept somatic manifestations as being real to the client
191. -assess for suicidal ideation and thoughts of self-harm
192. -identify the cultural impacts of the client’s view of health and illness
193. -identify secondary gains from somatic manifestations attention distraction from personal obligations or problems
194. -report new physical manifestations to the provider
195. -limit the amount of time allowed to discuss somatic manifestations
196. -encourage independence and self care
197. -encourage verbalization of feelings
198. -educate the client on alternative coping mechanisms
199. -educate the client on assertiveness techniques
200. -encourage daily physical exercise
201. Patient Health questionnaire 15 (PHQ-15): Used to identify the presence of the 15 most commonly reported somatic manifestations
202. -Abdominal pain, back pain, pain in the extremities/joints, menstrual problems or cramps, headaches, chest pain, dizziness, fainting, heart pounding or racing, dyspnea, problems or pain with sexual intercourse, problems with bowel elimination (constipation/diarrhea), nausea, indigestion or gas, lethargy, problem sleeping
203. somatic symptom disorder: somatization is the expression of psychological stress through physical manifestations
204. evaluating outcomes for an adolescent who is postoperative
205. -capillary refill
206. -increased ain unrelieved with elevation or by pain medication, or elevation
207. -paresthesia or numbness (early finding)
208. -pulselessness distal to the fracture (late finding)
209. -skin temperature
210. identifying complications during transfusion of packed red blood cells
211. chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom
212. identifying complications of bulimia nervosa
213. -cardiac dysrhythmias, severe bradycardia, and hypotension
214. -hyponatremia
215. identifying findings of attention deficit hyperactivity disorder and intellectual disability
216. -blurting out responses before questions are asked
217. -decreased response to social cues
218. -decreasing stimuli in the environment
219. -evidence of social or academic impairment
220. -inattention
221. -language difficulties
222. identifying manifestations of inflammatory bowel diseases
223. -abdominal pain/cramping: often right-lower quadrant pain
224. -albumin: decreased
225. -anorexia and weight loss
226. -crohn’s disease
227. -diarrhea: five loose stools/day with mucous or pus
228. -fever
229. -tachycardia
230. -WBC: increased
231. identifying risks for a child who has a gastrostomy tube
232. 2 to 11 days after injury or surgery
233. -purulent drainage, pain, redness, edema (in and around the wound), fever, chills, odor, increased pulse respiratory rate, increase in WBC count
234. skin irritation around the tubing site
235. -provide a skin barrier for any drainage at the site, monitor the tube’s placement
236. nursing actions to promote venous circulation
237. -client often report muscle cramping and aches, pain after sitting, and pruritus
238. -elastic (antiembolic) stockings cause external pressure on the muscles of the lower extremities to promote blood return to the heart
239. -varicose veins are enlarged, twisted, and superficial veins that can occur in any part of the body; however, they are commonly observed in the lower extremities and in the esophagus
240. -when suspecting poor venous return or possible thrombus, notify the provider, elevate the leg, and do not apply pressure or massage the thrombus to avoid dislodging it