ATI Learning systems 3.0 Nursing Care of Children dynamic Quiz full
A nurse is caring for a preschool-age child who has a mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take? A. Place viscous lidocaine on the child's oral legions B. Instruct the child to use a soft-sponge toothbrush when brushing her teeth C. Encourage the child to rinse her mouth with hydrogen peroxide every 2-4hr D. Give the child lemon glycerin swabs to use after each meal
B. Instruct the child to use a soft-sponge toothbrush when brushing her teeth The child should use this because a regular toothbrush may cause further irritation to the mucosal ulcers.
A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7mg/dL C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375mg/dL D. A client who has leukemia and a hematocrit of 32%
C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375mg/dL The initial goal of therapy for DKS is a blood glucose <240mg/dL. To accomplish this, the client should receive regular insulin via continuous IV fusion, and the nurse should monitor the blood glucose level hourly. The nurse should report this result so that the provider can adjust the clients insulin dosage.
A nurse is admitting a child who has a Wilms' tumor. Which of the following actions should the nurse take? A. Initiate precautions for the child B. Explain to the Childs parents that chemotherapy will start 3 months after surgery C. put a "no abdominal palpation" sign over the Childs bed D. Prepare the child for a spinal tap
C. put a "no abdominal palpation" sign over the Childs bed The nurse should place a sign over the child's bed stating "no abdominal palpation" because palpation is not necessary to confirm diagnosis and could prompt metastasis.
A nurse is assessing a toddler who has AIDS. Which of the following findings is an indication of an opportunistic infection? A. Koplik spots B. Peripheral neuropathy C. Chancre D. Candidiasis
D. Candidiasis Candidiasis (oral thrush) results from the overgrowth of Candida albicans, which is an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems.
A nurse is assessing a 10-month-old infant at a well-infant checkup. Which of the following assessment findings should the nurse report to the provider? A. The infant is unable to walk independently B. The infant's Moro reflex is absent C. The infant's anterior fontanel is open D. The infant needs assistance to sit up
D. The infant needs assistance to sit up The infant is expected to have the ability to sit up unsupported around 8 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is assessing a 6-month-old infant. The guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infant's visual acuity? A. Shine a penlight briefly into the left eye and then the right eye B. Move a brightly colored toy from side to side in front of the infant's face C. Ask the guardian to sit in front of the infant and nod his head up and down D. Observe the infant's ability to grasp the feet and pull them to the mouth
B. Move a brightly colored toy from side to side in front of the infant's face The nurse can observe the infant's ability to fixate on the toy and track its movement. The nurse can also perform this assessment using the human face as a visual target.
A nurse is teaching the guardian of a school age child who has DM how to recognize DKA. Which of the following findings should the nurse identify as a manifestation of this complication? A. Slow heart rate B. Protruding eyeballs C. Deep, rapid respirations D. Decreased urinary output
C. Deep, rapid respirations Deep and rapid respirations are also known as Kussmaul respirations, which is a manifestation of DKA.
A nurse is teaching a group of parents and guardians about otitis media. Which of the following should the nurse identify as a risk factor for this illness A. Summer months B. Breastfeeding C. ages 7 tp 10 years D. Passive smoking
D. Passive smoking The nurse should identify passive smoking as a risk factor for otitis media. Exposure to the secondhand smoke promotes the attachment of pathogens to the middle ear, extends the inflammatory response, and impaired drainage through the Eustachian tube. Each of these effects increases the risk for development of otitis media.
A nurse is reviewing the morning laboratory results of an infant who is receiving digoxin and furosemide for the treatment of heart failure. Which of the following findings should the nurse report to the provider? A. Sodium 140mEq/L B. Calcium 10.2mg/dL C. Chloride 100mEq/L D. Potassium 3.2mEq/L
D. Potassium 3.2mEq/L The nurse should identify the potassium below the expected reference range of 4.1-5.3mEq/L for the infant.
A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot
D. Standing on 1 foot The nurse should expect a 3-year-old child to have the gross motor availability to stand on 1 foot for a few seconds.
A nurse is planning care for a preschool - age child who has autism and is being admitted to the facility . Which of the following actions should the nurse plan to take ? A. Encourage the parents to bring the child's stuffed animal B. Give the child choices when planning daily activities C. Administer phenytoin 3 times per day D. Provide a shared room with another child his age
A. Encourage the parents to bring the child's stuffed animal Encouraging parents to bring in a Childs favorite stuffed animal may lessen the disruptiveness of hospitalization.
A nurse is planning care for a toddler who has acute gastroenteritis and was recently admitted. Which of the following should the nurse plan to provide for the child? A. Oral rehydration solution B. Bananas or applesauce C. Chicken or beef broth D. Hypertonic IV solution
A. Oral rehydration solution The nurse should plan to provide an oral rehydration solution (ORS) to this child who has acute gastroenteritis. ORS promotes the body's reabsorption of water and the sodium and is more effective and less traumatic than administration of IV fluids for the treatment of dehydration due to diarrhea and emesis.
A nurse is caring for a 4-month-old infant who has tetralogy of Fallot and experiences a hyper cyanotic spell. Which of the following actions should the nurse take? A. Place the infant in knee-chest position B. Begin CPR C. Prepare to intubate the infant D. Administer IV adenosine
A. Place the infant in knee-chest position The nurse should identify that a hyper cyanotic spell occurs when a vascular spasm reduces pulmonary blood flow and forces a R-L shunt in the ventricles. The knee-chest position increases systemic vascular resistance, which forces more blood through the pulmonary artery.
A nurse is assessing a 6-year-old client at a well-child visit. Which of the following findings requires further assessment by the nurse? A. Presence of space, fine pubic hair B. Decreased head circumference compared to full height C. Increased leg length in relation to height D. Presence of a loose central incisor
A. Presence of space, fine pubic hair The development of sexual characteristics prior to the age of 9 in boys and 8 in girls is an indication of precocious puberty and requires further evaluation.
A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parents lap during examination B. The child is interested in how the examination equipment works C. Th child asks specific questions about body function D. Th child questions how her development compares to other children at the same age.
A. The child prefers to sit on the parents lap during examination Toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the examination.
A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A. "Your child's immunizations today will be half-doses." B. "Th pneumococcal and influenza vaccines are recommended for your child." C. "Immunizations will be delayed until your child tests HIV-negative." D. "You child will need to restart the immunization schedule once your child's laboratory values are within the reference range."
B. "Th pneumococcal and influenza vaccines are recommended for your child." Immunization against common childhood illnesses, including influenza and pneumococcal disease, is recommended for all children exposed to and infected with HIV.
A nurse is caring for a 4-week-old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful? A. Loss of 2.2 kg(1lb) since the surgery B. Total bilirubin of 0.3mg/dL C. Aspartate aminotransferase (AST) level of 120 units/L D. The infants stools are gray in color
B. Total bilirubin of 0.3mg/dL A bilirubin level of 0.3mg/dL is within the expected range and indicates the surgery was successful
A nurse is providing teaching to the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the teaching? A. "Donepezil might slow the progression of the disorder." B. "My child will prefer group therapy with other children." C. "We can help our child by structuring our daily routine." D. "Our child probably has this condition as a result of prematurity."
C. "We can help our child by structuring our daily routine." Children with autism benefit from a structured routine. The environment can minimize the anxiety the child might have.
A nurse is caring for an infant who is breasted and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take? A. Offer the infant water before feedings B. Discontinue amoxicillin C. Administer the anti fungal medication after feedings D. Give the infant formula instead of milk
C. Administer the anti fungal medication after feedings The nurse should administer an anti fungal medication to the infant after feedings to ensure adequate contact time with the oral mucosa and tongue to enhance treatment of the oral candidiasis.
A nurse is providing discharge teaching to the guardian of an infant following a hypospadias repair. Which of the following instructions should the nurse include? A. Clamp the infants catheter for 30 min each day B. Give the infant a tub bath once per day C. Apply antibacterial ointment to the penis once per day D. Decrease the infants fluid intake for 3 days
C. Apply antibacterial ointment to the penis once per day The nurse should instruct the guardian to apply an antibacterial ointment to the infant's penis once daily to prevent infection.
A nurse is providing anticipatory guidance about the accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the rarebits to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk B. Go to an emergency department C. Call the poison control center D. Induce vomiting
C. Call the poison control center According to evidence-based practice, the nurse should instruct the parents to call the poison control center, which will then identify what further actions the parents should take.
A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? A. Preschoolers have the highest rate of maltreatment B. In single-parent families, the parents non-biological partner is typically the abuser of the child. C. Children who were born prematurely are more likely to be maltreated. D. Child maltreatment occurs equally among all groups
C. Children who were born prematurely are more likely to be maltreated. Children born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often have increased care needs, which increases the risk of caregiver fatigue and can lead to an increased potential for maltreatment.
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production
C. Deep, rapid respirations This is a finding of severe dehydration, and can also include weight loss of 10% or more, parched mucus membranes, and tachycardia.
A nurse is caring for a 6-year-old child who is experiencing encopresis. Which of the following actions should the nurse take? A. Instruct the parent to limit stool softener use to no more than twice a week. B. Encourage the child to attempt to have a bowel movement 4 times per day. C. Determine if there are any recent stressors in the child's environment D. Urge the parent to provide negative consequences when the child has a bowel accident.
C. Determine if there are any recent stressors in the child's environment Encopresis can be caused by stress or changes in the environment.
A nurse is reviewing the laboratory values for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect? A. BUN 5mg/dL B. Creatinine 0.2 mg/dL C. Sodium 125 mEq/L D. Potassium 4.2 mEq/L
C. Sodium 125 mEq/L The nurse should expect an infant with acute renal failure to have hyponatremia. A sodium level of 125 mEq/L is below the expected reference range for an infant.
A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? A. Cover the child's wounds with a clean, dry cloth B. Establish IV access with a large-bore catheter C. Provide reassurance to the child's parents D. Determine the child's breathing pattern
D. Determine the child's breathing pattern Using the ABC framework, an open away, ability to breathe, and circulating oxygen to the body. An alteration in the can indicate a threat to life. Using this framework, airway must always be clear first, and breathing is the second priority. Hence, determining the child's breathing pattern in the first action that should be taken.
A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before the child can have corrective surgery. The nurse should explain the the parents should wait no longer than 6 to 12 months for surgery to prevent which of the following outcomes? A. Repeated ear infections B. Nutritional deficits C. Immune system deficits D. Difficulty with language acquisition
D. Difficulty with language acquisition Clients who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. Because of the cleft in the palate, these infants could develop poor speech habits.
A nurse is caring for a toddler who has a fever, high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take? A. Administer 81mg of aspirin B. Give the toddler a cold bath C. Place the toddler in supine position D. Pad the rails of the toddler's bed
D. Pad the rails of the toddler's bed When caring for a toddler with manifestations of bacterial meningitis, the nurse should implement seizure precautions, which includes padding of the side rails of the bed.
A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? A. Dilated pupils B. Tremors C. Yawning D. Pruritis
D. Pruritis Pruritis is an adverse effect of opioids. Constipation, respiratory depression, nausea, vomiting, agitation, orthostatic hypotension, and hallucinations are also adverse effects.
A nurse is creating a plan of care for a preschooler who was admitted for the treatment of measles. Which of the following activities should the nurse include in the client's care plan? A. Constructing a model airplane B. Playing a video game in the playroom C. Pulling a wagon with toys in the hallway D. Putting together a puzzle with large pieces.
D. Putting together a puzzle with large pieces. The nurse should recommend putting together a puzzle with large pieces for a hospitalized preschooler. Other recommended activities for preschoolers on airborne precautions include playing pretend and dress up, painting, and looking at illustrated books.
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100mL IV infused over 4 hr. The drip factor of the IV tubing is 60gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
25 100mL/240 min X 60gtt/min = 25
A nurse is providing teaching to the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicated an understanding of the teaching? A. "I should ignore the stuttering and not interrupt her." B. "I should finish my child's sentence if she is stuck on a word." C. "I should reward my child when she doesn't stutter." D. "I should tell my child to slow down when she starts stuttering."
A. "I should ignore the stuttering and not interrupt her." Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become prolonged.
A nurse is providing teaching to an adolescent who was recently diagnosed with T1DM. Which of the following insulin injection sites would the nurse recommend that the client use during basketball competitions? A. Hip B. Upper arm C. Thigh D. Lower leg
A. Hip Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. When participating in vigorous exercise that involves both arms and legs, the client should use a hip as the insulin injection site.
A nurse is preparing to administer routine immunizations to a 6 year old child. In addition to DTaP; the MMR; and VAR, which of the following immunizations should the nurse administer? A. IPV B. Hib C. PCV D. HBV
A. IPV The 4th dose of IPV should be given between 4-6 years age. The first 3 doses are given between 2-18mo.
A nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? A. Withhold the medication if the infant's heart rate is less than 110/min B. Mix the medication in 120 mL (4oz) of infant formula. C. Expect the infant to vomit frequently while taking this medication D. Double the dose if the infant has increased edema
A. Withhold the medication if the infant's heart rate is less than 110/min The parent should withhold the medication and notify the provider if the infant's heart rate is less than 110/min
A school nurse is providing care to a child who has a nosebleed. Which of the following actions should the nurse perform? SATA A. Place the child in a supine position B. Apply pressure to the child's nose using the thumb and forefinger C. Have the child tilt his head back D. Apply a warm cloth to the bridge of the child's nose E. Keep the child calm
B, E Applying pressure continuously for 10 min to the nose with thumb and finger helps control the bleeding. If bleeding persists, place ice or a cold cloth on the bridge of the nose and inserting cotton or tissue into the nostril. Keep the child calm to slow the bleeding as agitation can raise blood pressure, which will increase the bleeding.
A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicated an understanding of the teaching? A. "I can take my brac off to sleep every night at bedtime." B. "I can take off my brace for about an hour daily to shower." C. "I should loosen the straps on my brace if it is rubbing against my skin." D. "I should place the pads of the brace against my skin with a t-shirt over them."
B. "I can take off my brace for about an hour daily to shower." The nurse should instruct the child to wear the brac for 23 hours a day and only to move it of showering or participating in physical therapy.
A nurse is caring for a 10-year-old who should reduce his fat intake. Which of the following menu choices should the nurse suggest? A. A hot dog on a whole-wheat bun B. 3oz of baked chicken on a whole-wheat roll C. 1/2 cup diced potatoes with scrambled eggs D. Medium blueberry muffin
B. 3oz of baked chicken on a whole-wheat roll A baked chicken sandwich on a whole wheat bun has the lowest fat content at 6.2g
A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor? A. preeclampsia B. Alcohol consumption C. Placenta previa D. Late prenatal care
B. Alcohol consumption Alcohol consumption is a maternal risk factor for the development of congenital heart disease.
A nurse is assessing the visual acuity of a group of school-aged children. Which of the following actions should the nurse take? A. Position each child with their heels at a line that is 6m (20ft) away from the Snellen chart B. Allow each child to wear his or her glasses during the exam C. Start the screening by covering each child's right eye D. Begin by having each child read the largest line of letters at the top of the Snellen chart
B. Allow each child to wear his or her glasses during the exam The nurse should allow each child to wear his or her glasses during screening for visual acuity.
A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain B. Check for pulses in the affected leg every 4 hr C. Cleanse the pins every 12 hr D. Inform the parents to discourage visitors for the child
B. Check for pulses in the affected leg every 4 hr Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremities every 4 hours.
A nurse is providing immediate postoperative care for a preschooler who had a tonsillectomy. Which of the following actions should the nurse take? A. Offer ice cream or pudding when the child is fully awake B. Eliminate the use of a straw when offering fluids C. Apply a hating pad to the neck area D. Instruct the child to blow his nose to clear the bloody secretions.
B. Eliminate the use of a straw when offering fluids Straws can accidentally injure the surgical site and cause bleeding. Their use should be avoided in the immediate postoperative period.
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicate that the infant has a developmental delay? A. Creeping on hands and knees B. Inability to vocalize vowel sounds C. Using a crude pincer grasp D. Standing by holding onto a support
B. Inability to vocalize vowel sounds The infant should begin vocalizing bowl sounds at the age of 7 months. By the age of 10 months, the infant should be able to say at least 1 word.
A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hr ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb sucking C. Showing interest in nearby toys D. Attempting to find the parent
B. Inactivity and thumb sucking A child who is thumb sucking and refusing to eat or drink is displaying manifestations of the second stage of separations anxiety, which is despair
A nurse is providing teaching to a parent of a preschooler who has impetigo Which of the following statements by the parent indicates an understanding of the teaching ? A. " Impetigo is caused by a virus B. Impetigo is contagious for 48 hours after vesicles rupture C . I will wash my child's clothes hot water D. My child now has immunity against impetigo
C . I will wash my child's clothes hot water The parent should wash the childs clothes in hot water to kill bacteria. The parent should also keep the childs towels and washcloths separate from those of other members of the household.
A nurse is teaching a school-age child who has a new diagnosis of T1 DM. Which of the following statements should the nurse make? A. "If you take too much insulin, drink a sugar-free cola." B. "You will need to decrease your insulin dosage when you become a teenager." C. "You can use a vial of insulin up to 30 days." D. "Stop taking your insulin if you are vomiting."
C. "You can use a vial of insulin up to 30 days." The child can use an opened vial of insulin for 28-30 days stored at room temperature, or in the refrigerator.
A nurse is assessing an infant who was born at 32 weeks gestation and is now 8 months old. Which of the following developmental ages should the nurse expect the infant to demonstrate? A. 2 mo B. 4 mo C. 6 mo D. 8 mo
C. 6 mo Because the infant was born 8 weeks prematurely, the nurse should use this data to determine that the infants setback age is 6 months. Therefore, the nurse should expect the infant to have achieved the developmental milestones of a 6 month old infant.
A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? A. Pull the infants pinna up and back when examining the ears B. Palpate and count the infants radial pulse for 15 seconds C. Examination the infants throat at the end of the exam D. Check the infants blood pressure in both arms
C. Examination the infants throat at the end of the exam The nurse should perform noninvasive assessments first to avoid causing th infant to cry, which can make the remainder of the exam difficult.
A nurse us assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale B. color tool C. FACES pain rating scale D. Numeric scale
C. FACES pain rating scale The FACES scale includes various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent their pain level.
A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. HPV, Hep A B. MMR, TDap C. Hib, IPV d. VAR, LAIA
C. Hib, IPV These are administered a 2 months, 4 months, 6-18 months, and 4-6 years.
A nurse is providing teaching for a parent about pinworm testing. At which of the following times should the nurse advise the parent to perform the tape test? A. Immediately after a BM B. After being on clears for 24 hr C. Immediately after the child wakes up in the morning D. After soaking for 20 min in a warm bath
C. Immediately after the child wakes up in the morning before a BM as it could rid the eggs in the area.
A nurse us caring for a 6-month-old infant who has intussusception. Which of the following actions should the nurse take? A. Prepare to administer high-dose steroids B. Give the child magnesium hydroxide PO C. Prepare the child for a barium enema D. Inform the parents that the child will need a colostomy
C. Prepare the child for a barium enema The pressure created by a barium enema might force the bowel to resume a normal configuration. Some children with intussusception are treated with the barium enema and do not require surgical intervention.
A nurse is obtaining a urine sample from a 5-month-old infant by applying a urine collection bag. Which of the following actions should the nurse take first? A. Apply the collection bad to the skin at the area of the symphysis pubis B. Apply the collection bag to the skin at the area of the perineum C. Wash and dry the genitalia, perineum, and surrounding skin D. Stroke the muscles on other side of the infants spine
C. Wash and dry the genitalia, perineum, and surrounding skin The first action the nurse should take is to wash and dry the genitalia, perineum, and the skin area to which the urine collection bag will be secured.
A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? A. side-lying B. supine C. prone D. semi-fowlers
C. prone When providing preoperative care for an infant who has a myelomeningocele, the nurse should maintain the infant in a prone position. This position reduces pressure and the risk of trauma to the sac.
A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen B. Elevate the adolescents leg on pillows C. Place an ice pack in the cast D. Assess for manifestations of circulatory impairment
D. Assess for manifestations of circulatory impairment In the ABC framework, circulation is the third priority, but highest here. Circulation gets oxygen to the organs.
A nurse is teaching an adolescent about various strategies for chronic pain management. Which of the following activities should the nurse use as an example of the non pharmacological strategy of thought-stopping? A. Assemble a puzzle B. Discuss a recent pleasurable event C. Tighten and then relax each body part D. Repeat memorized facts about the painful event
D. Repeat memorized facts about the painful event Thought stopping is a pain management strategy that can help the adolescent control the pain. After listing the facts, the nurse should then have the adolescent condense and memorize the facts to repeat them whenever pain occurs.
A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following? A. Olfaction B. Visual acuity C. Speech patterns D. Hand-eye coordination
C. Speech patterns Chronic otitis media can result in hearing loss, which can affect speech development.
A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria
C. Tachypnea An infant who has moderate dehydration will have slight tachypnea.
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A. The child prefers playmates of the same sex B. The child is competitive when playing board games C. The child complains daily about going to school D. The child enjoys spending time alone
C. The child complains daily about going to school Complaining very day about going to school is an unexpected finding for a 7-year-old child. The child is in Erickson's psychosocial development stage of industry vs. inferiority. Children at this stage want to learn and master new concepts. If the child complains daily about going to school, further evaluation is warranted.
A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following replies should the nurse provide? A. "You should give your child a stool softener daily." B. "Toddlers gain weight at a rapid pace." C. "You should have your child assessed for a spinal deformity." D. "Toddlers do not have well-developed abdominal muscles."
D. "Toddlers do not have well-developed abdominal muscles." The abdominal muscles are immature and minimally developed at this stage. Therefore, many toddlers have a "potbellied" appearance.
A nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A. "Initial vaccines should be administered between birth and 2 weeks of age." B. "Your child will need to begin the vaccination series over again if subsequent doses in the series are missed." C. "An allergic reaction to a vaccine is due to the active ingredient of the vaccine." D. "A vaccination should be postponed if your child has a rectal temp of 99.5*F and head congestion."
A. "Initial vaccines should be administered between birth and 2 weeks of age." The first dose of hep B should be administered within the first 2 weeks after birth. The dose should be given before discharge from the hospital if the mother is Hep B negative.
A nurse is caring for a child who has sickle cell anemia and is experiencing a vast-occlusice crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints C. Withhold live virus immunizations
A. Administer ibuprofen The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic.
A nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include? A. Begin after the extrusion reflex has diminished B. Introduce solids between 2-3 mo age C. Wait until the infant's first tooth erupts D. Add a sweetener such as light corn syrup to bland foods
A. Begin after the extrusion reflex has diminished The extrusion reflex pushes the food out of the mouth instead of swallowing. The tongue extrusion reflex diminishes after 4 months of age
A nurse is conducting a health assessment for a 24-month-old toddle at the local health department. The nurse should expect which of the following findings? Select all that apply A. 8 deciduous teeth B. Ability to build a tower of 6 blocks C. Vocabulary of 10-20 words D. Slightly bowed or curved leg appearance E. Head circumference greater than the chest circumference
B. Ability to build a tower of 6 blocks D. Slightly bowed or curved leg appearance The nurse should expect a 24-month-old toddler to be able to stack a short tower of 6 or 7 blocks. Additionally, they will have a "pot-bellied" appearance; the legs should be slightly bowed to support the weight of the large trunk.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. Maintains the child on strict blood rest B. Check the child's blood pressure every 4 hr C. Administer albumin to the child every 8 hr D. Provide the child with a low-carbohydrate diet
B. Check the child's blood pressure every 4 hr The nurse should check the blood pressure every 4-6 hr to monitor for HTN
A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for a child? A. Jump rope B. Coloring book and crayons C. Checkers game D. jack-in-the-box
B. Coloring book and crayons Preschoolers have increasing fine motor control and imagination. They enjoy toys that allow creativity and self-expression
A nurse is assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? A. Grasping a small object with jus the thumb and index finger B. Dropping a cube when passing from 1 hand to the other C. Falling from a standing position to sitting D. Losing balance when leaning sideways while sitting
B. Dropping a cube when passing from 1 hand to the other
A nurse is caring of a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. Obtain a portable suction machine and suction tubing B. Ease the child to the floor in Sims' position C. Time the length of the seizure D. Notify the child's parents
B. Ease the child to the floor in Sims' position The greatest risk to the child is an injury resulting from a fall; therefore, the nurse should first gently ease the child to the floor to decrease the chance of injury and turn the child on the left side to prevent aspiration.
A nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? A. Administer IV morphine B. Administer topical antimicrobials C. Administer IV fluid replacement D. Administer tetanus prophylaxis
C. Administer IV fluid replacement The greatest rick to this child is an injury from hypovolemic shock; therefore, the first action the nurse should take after ensuring a patent airway is to administer IV fluid replacement therapy.
A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extraction of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions? A. Remove the IV line B. Elevate the extremity C. Notify the provider D. Stop the infusion
D, B, C, A After observing the extraversion, the nurse should first stop the infusion. Next, the eternity should be elevated, following which you call the doctor. Last should be to remove the line once the doctor has ordered it.
A nurse us teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. "I can give my baby 4ox of juice to drink each day." B. "I will offer my baby dry cereal and chilled bananas as a snack." C. "I am introducing my baby to the same foods the family eats." D. "My infant drinks at least 2 qt of skim milk each day
D. "My infant drinks at least 2 qt of skim milk each day
A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A. "Have your parents stretch and move your legs for you." B. "Apply heat to joints that become painful, stiff, and swollen." C. "Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."
D. "You will be able to participate in physical exercises." Physical exercises are a non-contact sport and can be done with protective equipment.
A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following directions should the nurse provide? A. "Your child will need to take estrogen daily when she reaches puberty." B. "Your child will need monthly blood coagulation studies." C. "Your child will need surgery to remove the diseased thyroid." D. "Your child will need to take thyroid hormone replacement for her entire life."
D. "Your child will need to take thyroid hormone replacement for her entire life."
A nurse is preparing to administer an enema to a 10-month-old infant. Which of the following actions should the nurse plan to take? A. Administer the enema using room-temperature tap water B. Insert the tubing 7.5cm (3in) into rectum C. Position the infant sitting upright on a bedpan while administering the enema D. Hold the infant's buttocks together after administering the fluid
D. Hold the infant's buttocks together after administering the fluid Because the infant is incontinent, the nurse should hold the buttocks together for a short time to maintain retention.
A nurse is assessing an adolescent who is receiving fentanyl via epidural. Which of the following assessments should the nurse identify as the priority? A. Skin around the catheter site B. Blood pressure C. Pain level D. Oxygen saturation
D. Oxygen saturation O2 sats are the priority, and monitoring it will identify if there is an opioid developed respiratory depression
A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry
A. Provide a high-fat diet for the toddler Children with CF have impaired intestinal absorption of fat. Therefore, the toddler will require an increased intake of fat.
A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse plant to take to help decrease the risk of a vast-occlusive crisis? A. Provide adequate fluid intake throughout the day B. Provide oxygen at 2L/min via nasal cannula C. Administer a blood transfusion D. Give ibuprofen to manage pain
A. Provide adequate fluid intake throughout the day Adequate hydration is an effective strategy to help prevent sickle cell crises. Maintaining adequate hydration can reduce the risk of sickle cell formation.
A nurse is caring for a toddler who is postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Restrain the toddler's arms at the elbow B. Feed the toddler with a spoon C. Monitor the toddler's oral temperature D. Weigh the toddler every 48 hours
A. Restrain the toddler's arms at the elbow When caring for a toddler who is postoperative following a cleft palate repair, the nurse should apply elbow restraints (unless prescribed otherwise) to prevent the toddler from rubbing or disrupting the sutured area.
A nurse is preparing to administer acetaminophen 240mg PO daily to a child with a temp of 38.9C (102F). The amount available is oral solution 160mg/5mL. How many mL should the nurse administer per dose?
7.5
A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A. Burp the infant at least 2-3 times during the feeding B. Remove the nipple from the infant's mouth if swallowing becomes audible C. Stop the feeding if formula appears in the nasal cavity D. Discourage the parents from participating in the feeding prior to the surgical repair.
A. Burp the infant at least 2-3 times during the feeding Infants with a cleft lip and palate will swallow an increased amount of air during a feeding d/t a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed.
A nurse is providing teaching about home care to the guardian of an adolescent who has hemophilia. Which of the following pieces of information should the nurse provide? A. Encourage the adolescent to participate in non-contact sports B. Provide the adolescent with a firm-bristled toothbrush C. Administer aspirin to the adolescent for episodes of pain D. Provide disposable razors to the adolescent for shaving
A. Encourage the adolescent to participate in non-contact sports The nurse should instruct the guardian the the adolescent should be allowed to participate in non-contact sports such as walking, bowling, and golf. Contact sports may be allowed if the adolescent wears protective gear and receives routing recombinant factor VIII infusions
A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Fractured rib
A. Tension pneumothorax The nurse should identify these manifestations as an indication the infant is developing a tension pneumothorax. The infant might also become cyanotic and show asymmetry of the thorax.
A nurse is performing a physical assessment on a 12-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant's current weight is double his birth weight B. The infant's posterior fontanel is closed C. The infant is unable to walk without support D. A total of 6 teeth are present
A. The infant's current weight is double his birth weight Th nurse should expect a 12 month old infant's weight to be triple his birth weight; therefore, the nurse should report this finding to a provider.
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should recommend which of the following immunizations prior to moving onto a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal Polysaccharide C. Rotavirus D. Herpes zoster
B. Meningococcal Polysaccharide This immunization prevents infection from a meningococcal bacterial. College freshmen, particularly those in dorms, are at an increased risk for meningococcal disease relative to their age.
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. Perform nasotracheal suctioning B. Test the nasal secretions for glucose C. Maintain direct lighting on the child D. Lower the head of the bed
B. Test the nasal secretions for glucose The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions and leakage of CSF. The leakage of CSF is positive for glucose and occurs if the child has a skull fracture
A nurse is caring for a school-aged child who has acute post-streptococcal glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypotension B. Elevated serum lipid levels C. Decreased serum potassium levels D.Hematuria
D.Hematuria Hematuria can be detected visually in clients who have acute post-streptococcal glomerulonephritis.
A nurse is assessing a 6-month-old infant who had a cardiac catheterization with right femoral entry to diagnose a possible congenital heart defect. Which of the following findings should the nurse report to the provider? A. Cool toes on the right foot B. Weak pedal pulses in both feet C. Positive Babinski reflex on both feed D. Erythema on the right foot
A. Cool toes on the right foot The nurse should monitor the temperature of the infant's right extremity and should report and indication of coolness distal to the entry site to the provider because this can indicate an obstruction of an artery.
A nurse is teaching the parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will give my child an iron tablet once each day at bedtime." B. "I will administer the iron tablet with orange juice." C. "I will encourage my child to take an antacid with the iron tablet." D. "I will crush the iron tablet prior to giving it to my child."
B. "I will administer the iron tablet with orange juice." Intake of citrus juice with the iron will increase the iron's absorption.
A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse provide to foster a rapport and encourage conversation? A. "Do you like school?" B. "Tell me about your favorite video game." C. "We have another child your age on the unit." D. "Would you like your friends to visit you?"
B. "Tell me about your favorite video game." The nurse should use therapeutic communication to encourage the child to respond with more than just the name of a game. This type of communication fosters a rapport and encourages communication.
A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to met the nutritional needs of the infant? Select all that apply A. Offer feeding every 2 hours B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if the RR >80
B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if the RR >80
A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A. "Children commonly begin having imaginary friends when they reach school age." B. "Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." D. " Set limits by not allowing your child to have the imaginary friend present during family meals."
C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions.
A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons." D. "I should ensure the crib slats are no more than 3 inches apart."
C. "I should make sure my baby's clothing does not have buttons." The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration.
A nurse is providing teaching to a school-aged child who just had fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hr? A. "Use a toothbrush to scratch under the cast if your skin itches." B. "Avoid moving your leg and the joints above and below the cast." C. "Keep the cast above the level of your heart." D. "Clean soil from the cast with soapy water."
C. "Keep the cast above the level of your heart." Immediately following the injury (and for at least the first 48 hours), the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return.
A nurse is talking with the parents of a 4-month-old infant about growth and development. Which of the following statements indicates that the parent needs further teaching? A. "I need to remind my older kids to keep small objects out of the baby's reach." B. "I let my baby play on her stomach when she is awake and I am watching." C. "My baby loves to play with the pillows in her crib." D. "I put my baby in a rear-facing car seat in the back seat of the car."
C. "My baby loves to play with the pillows in her crib." Parents should never place pillows in their infant's crib since they pose a suffocation hazard.
A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices due to the nigh protein content? A. Medium baked potato B. Wheat bagel with 1 tbsp apricot jam C. Large orange D. 1/2 cup of peanut butter with apple slices
D. 1/2 cup of peanut butter with apple slices
A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A. Small plastic doll with clothes and accessories B. Alphabet flash cards C. Handheld video game D. 10-piece wooden puzzle
D. 10-piece wooden puzzle Age appropriate toys for a toddler include puzzles, large crayons, picture books, push-pull toys finger paints, modeling clay, and musical toys.
A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer to the child? A. Zafirlukast B. Budesonide C. Montelukast D. Albuterol
D. Albuterol The nurse should plan to administer albuterol to a child with an acute exacerbation of asthma. It is considered a rescue medication.
A nurse is providing teaching to the guardians of a 4-month-old infant on how to play with them. Which of the following play activities should the nurse suggest? A. Show the infant a board book with large pictures B. Imitate the sounds of different farm animals for the infant C. Give the infant a large push-pull toy D. Allow the infant to splash in the bathtub
D. Allow the infant to splash in the bathtub Splashing is an appropriate activity for the developmental age of the infant and provides tactile stimulation. However, the nurse thud emphasize the importance of bath safety to prevent injury.
A nurse is providing anticipatory guidance for the caregivers of a 5-month-old infant. Which of the following points should the nurse include in the teaching? A. Switch the infant from formula to low-fat cow's milk at 6 months go age B. Heat fruit juice before offering it to the infant C. Introduce a new food every other day D. Allow the infant to try finger foods, such as crackers, after 6 months of age.
D. Allow the infant to try finger foods, such as crackers, after 6 months of age. The nurse should instruct the caregivers that infants will acquire the coordination to begin self-feeding finger foods at around 6 months of age
A nurse in the emergency department is assessing a preschooler for indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Frequent urinary tract infections D. Bruises at various stages of healing
D. Bruises at various stages of healing The nurse should recognize the the bruises at various stages of healing are a manifestation of physical abuse.
