ATI: Pediatrics

Normal infant bilirubin level:

0-5?

Toddler temp range

36.5°C to 37.5°C (97.8°F to 99.5°F) Same as infant

AST levels

8-20 U/L

Lead level for concern

Centers for Disease Control and Prevention (CDC) blood level of concern is 5 micrograms per deciliter of lead in blood for children

A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. "My child may take aspirin for his joint pain." B. "My child will need a blood transfusion prior to discharge." C. "I will need to wear a gown when I'm in my child's room." D. "I will apply lotion to my child's peeling hands."

Correct Answer: A. Children who have rheumatic fever may take salicylates (aspirin) to control the inflammatory process that occurs in the joints. Incorrect Answers: B. A child who has rheumatic fever does not require blood transfusions since there is no blood loss from this disorder. C. A child who has rheumatic fever only needs STANDARD isolation precautions. Rheumatic fever is an immune response that occurs after an infection with group A β-hemolytic streptococci. D. Kawasaki disease causes peeling hands, but rheumatic fever does not.

A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should consume 1,000 calories per day." B. "My child should have 4 oz of protein per day." C. "I should give my child 32 oz (4 cups) of milk per day." D. "I should feed my child 4 oz (1/2 cup) of vegetables per day."

Correct Answer: A. "My child should consume 1,000 calories per day." Toddlers who are 2 years old should consume 1,000 calories daily. Incorrect Answers: B. Toddlers who are 2 years old should have 2 oz of protein daily (NOT 4 oz). C. Toddlers who are 2 years old should have no more than 24 oz (3 cups) of milk per day. D. Toddlers who are 2 years old should consume 8 oz (1 cup) of vegetables per day.

A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing

Correct Answer: A. Abdominal distention A VP shunt allows excess CSF from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining CSF or a postop ileus. Incorrect Answers: B. This complication can occur following a cardiac catheterization. It is not associated with the insertion of a VP shunt. C. The inability of the shunt to drain due to a blockage will increase ICP. This can result in pressure on the oculomotor nerve, which causes DILATION of the pupils. D. Frontal bossing can be observed in infants with hydrocephalus. Open cranial sutures allow for excess CSF to cause head enlargement. Frontal bossing describes the protruding frontal skull bones that can occur in severe cases of hydrocephalus.

A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). Which of the following pieces of information should the nurse include in the teaching? A. Add fortified rice cereal to the infant's formula B. Alternate feedings between several family members C. Offer the infant juice between feedings D. Provide feedings on demand rather than on a schedule

Correct Answer: A. Add fortified rice cereal to the infant's formula The nurse should inform the guardians that adding fortified rice cereal or vegetable oil to the infant's formula helps promote weight gain. Incorrect Answers: B. The nurse should inform the guardians that caregiver consistency is recommended when providing feedings for the infant who has FTT. This consistency promotes the development of trust and attachment. C. The nurse should recommend restricting the infant's intake of juice until adequate weight is gained through prescribed sources of formula. D. The nurse should inform the guardians of the need to maintain a schedule for feeding times to promote weight gain and behavior modification.

A nurse is caring for a child who has electrical burns on the lower arms and hands. Which of the following findings indicate the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20/min D. Minimal pain

Correct Answer: A. Dark urine Dark urine can be an indication of myoglobinuria. It results from the elimination of waste products from muscle damage and can cause renal failure. Incorrect Answers: B. Radial pulses of +2 are within the expected reference range. They are a reflection of circulatory status, not burn complications. C. A respiratory rate of 20/min is within the expected reference range. It reflects respiratory status, not burn complications. D. Electrical injuries can cause major, full-thickness burns that destroy the nerve endings in the skin, thus reducing the amount of pain the client feels.

A nurse is developing a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include? A. Higher body fat content is associated with earlier onset of menarche B. Pubic hair is typically present prior to breast development C. Ovulation begins after sexual maturation is complete D. Menarche signals the beginning of puberty

Correct Answer: A. Higher body fat content is associated with earlier onset of menarche The nurse should inform the parents that the onset of menarche is expected to occur around 10.5 to 15.5 years of age. Females who have a higher body fat content have been shown to have an earlier onset of menarche. Incorrect Answers: B. The nurse should inform the parents that breast development usually begins around 8 - 12 years of age, followed 2 - 6 months later by the appearance of pubic hair. C. The nurse should inform the parents that ovulation is stimulated by the increasing amount of estrogen that develops after the onset of menarche. This increased level of estrogen promotes further sexual maturation. D. The nurse should inform the parents that menarche is an indication of late puberty. The onset of menstrual periods is preceded by an increase in height, breast development, and the appearance of pubic hair

A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include? A. Initiate protective-environment isolation for the child B. Apply pressure for 1-2 min at the puncture site following blood specimen collection C. Mix the child's ferrous sulfate elixir twice per day into a glass of milk for administration D. Check the child's blood glucose level every 4 hr

Correct Answer: A. Initiate protective-environment isolation for the child The nurse should suggest protective-environment isolation for the child, which consists of a private room with + air pressure and no live flowers; nurses must don a respirator mask, gloves, and gown prior to entering the child's room. A child who has aplastic anemia has decreased RBCs, platelets, and WBCs, causing immune suppression and increasing susceptibility to infection. Incorrect Answers: B. Aplastic anemia decreases the production of RBCs, WBCs, and platelets, which increases the child's risk for bleeding. The nurse should apply pressure to peripheral puncture sites for a MINIMUM of 5 MIN (not 2 min) to prevent bleeding following blood specimen collection. C. Ferrous sulfate is a required medication for a child who has iron-deficiency anemia, so it is not a necessary intervention for this client. The nurse should avoid mixing medications into liquids because if the child fails to drink the entire glass, the dosage received is not complete. D. Aplastic anemia does not affect the child's blood glucose level

A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse take? A. Provide thorough skin care B. Test for blood type and cross-match C. Allow ample hydrating fluids D. Maintain a low-carbohydrate diet

Correct Answer: A. Provide thorough skin care The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection. Incorrect Answers: B. This child is not likely to receive a blood transfusion, which would be indicated for significant blood loss. C. Fluid restriction might be necessary for a child who has nephrotic syndrome. D. The child's diet might require protein, sodium, and fat restrictions, but there is generally no indication for a low-carbohydrate diet

An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors? A. The infant's mother is likely HIV positive. B. The infant's ELISA test result is probably a false positive for HIV. C. Antiretroviral medications are inappropriate for infants and children who have HIV. D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations.

Correct Answer: A. The infant's mother is likely HIV positive. Transmission of HIV from a woman to her infant can occur during pregnancy, in delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants. Incorrect Answers: B. The ELISA test is unreliable for HIV testing in infants under 18 months of age because of false-positive results due to maternal antibodies. The results are reliable, however, for clients 18 months of age and older. C. While antiretroviral medications cannot cure HIV, they do slow the progress of the infection for clients of all ages. D. Infants who are HIV positive should receive immunization against childhood illnesses, including MMR and influenza.

A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg (4 lb) B. Heart rate of 125/min C. Soft, flat fontanel D. Systemic murmur

Correct Answer: A. Weight gain of 1.8 kg (4 lb) A 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider. Incorrect Answers: B. A heart rate of 125/min is an expected finding in a 2-month-old infant. C. A soft, flat fontanel is an expected finding in a 2-month-old infant. D. A systemic murmur is an expected finding in an infant who has a ventricular septal defect

A nurse is teaching the parents of a toddler who has enterobiasis about managing this parasitic disease. Which of the following pieces of information should the nurse include in the teaching? A. "You should encourage your child to take a tub bath daily." B. "You should keep your child's fingernails trimmed short." C. "You should dress your child in a 2-piece outfit at bedtime." D. "You should expect your child not to have a recurrence of the parasitic disease."

Correct Answer: B. "You should keep your child's fingernails trimmed short." The nurse should instruct the parents to keep their child's fingernails trimmed short to minimize the collection of ova under the nails. Incorrect Answers: A. The parents should encourage the toddler to take a shower instead of a tub bath. C. The parents should dress the child in a 1-piece sleeping outfit. D. Recurrence is common, and the disease should be managed and treated as it was previously

A nurse is providing teaching to the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include? A. Machine-wash clothing in cold water B. Dry clothing in a hot dryer for at least 20 min C. Soak combs and brushes for 5 min in boiling water D. Seal nonwashable items in a bag for 7 days

Correct Answer: B. Dry clothing in a hot dryer for at least 20 min The nurse should instruct the parent to dry the child's clothing in a hot dryer for at least 20 minutes. Incorrect Answers: A. The nurse should instruct the parent to machine-wash the child's clothing and bed linens in HOT water. C. The nurse should instruct the parent to soak the child's combs and brushes for 10 min (NOT 5 min) in boiling water. D. The nurse should instruct the parent to seal the child's nonwashable items in a bag for 14 days. (NOT 7)

A nurse is assessing a 12-year-old child during a well-child checkup. Which of the following physical findings should the nurse report to the provider? A. 5 cm (2 in) of growth in the past year B. Hyperopia C. Presence of pubic hair D. Weight gain of 3 kg (6.6 lb) in the last year

Correct Answer: B. Hyperopia The nurse should report hyperopia in a 12-year-old child to the provider. Hyperopia, or farsightedness, is an UNEXPECTED finding AFTER the age of 7. Incorrect Answers: A. 5 cm of growth per year is an expected finding for school-age children. C. The development of secondary sex characteristics, including the presence of pubic hair, can be an expected finding for a 12-year-old child. D. A weight gain of 2 to 3 kg (4.4 to 6.6 lb) per year is an expected finding for school-age children.

A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hours 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 escape and find the parent

Correct Answer: B. Inactivity and thumb sucking A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair. Incorrect Answers: A. Protest is the first stage of separation anxiety, which includes crying and screaming. C. Denial or detachment is the third stage of separation anxiety, in which the child appears happy and interacts with strangers. D. Protest is the first stage of separation anxiety, which includes attempting to escape the area to find a parent

A nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? A. Increased blood pressure B. Lanugo over the back C. Oily skin with acne D. Elevated body temperature

Correct Answer: B. Lanugo over the back The nurse should expect an adolescent who has anorexia nervosa to have lanugo present on the skin as a result of impaired metabolic activity. Other manifestations of anorexia nervosa include hypothermia, hypotension, and dry skin. Incorrect Answers: A. The nurse should expect an adolescent who has anorexia nervosa to have a decreased blood pressure. C. The nurse should expect an adolescent who has anorexia nervosa to have DRY skin. D. The nurse should expect an adolescent who has anorexia nervosa to have HYPOthermia

A nurse is planning care for a preschooler who is immediately postoperative following the placement of a ventriculoperitoneal shunt. Which of the following interventions should the nurse include in the plan? A. Monitor the preschooler's pupils every 8 hours B. Lay the preschooler on the nonoperative side C. Keep the head of the bed elevated to 30° D. Check bowel sounds once per day

Correct Answer: B. Lay the preschooler on the nonoperative side The preschooler should not be positioned on the shunt side postoperatively to avoid putting pressure on the shunt or surgical site. Incorrect Answers: A. The nurse should monitor the child's pupillary response every 15 to 30 minutes immediately following neurological surgery. Increased ICP can put pressure on the oculomotor nerve, causing unilateral pupil dilation. C. The nurse should maintain the preschooler in a flat position to avoid rapid draining of intracranial fluid through the shunt. D. The nurse should check the preschooler's BS frequently because peritonitis or an ileus can be postoperative complications.

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 into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster

Correct Answer: B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis (which affects the brain) and meningococcemia (which affects the blood). Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the CDC issued a recommendation that all incoming college students receive the meningococcal immunization. Incorrect Answers: A. The pneumococcal polysaccharide immunization is administered to children between the ages of 2-18 years who have a specific high-risk condition that places them at risk for an infection with Streptococcus pneumococci, a bacterium that causes meningitis, otitis media, and pneumonia. C. The final dose of the rotavirus immunization is administered prior to the age of 8 months. An additional booster dose is not recommended. D. The herpes zoster immunization is recommended for adults > 60 to prevent an episode of shingles.

A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? A. Bradycardia B. Muscle weakness C. Diarrhea D. Dry skin

Correct Answer: B. Muscle weakness Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea. Incorrect Answers: A. Bradycardia is not an adverse effect of baclofen. This medication can cause hypotension. C. Diarrhea is not an adverse effect of baclofen. This medication can cause constipation. D. Dry skin is not an adverse effect of baclofen. This medication can cause increased sweating.

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following actions should the nurse take? A. Place the infant in a lateral position B. Perform oropharyngeal suctioning C. Administer ranitidine orally D. Thicken the infant's formula

Correct Answer: B. Perform oropharyngeal suctioning When caring for an infant who has a tracheoesophageal fistula, the nurse should perform frequent oropharyngeal suctioning to decrease the infant's risk of aspiration. Incorrect Answers: A. When caring for an infant who has a tracheoesophageal fistula, the nurse should position the infant supine on an inclined plane with the head elevated to decrease the risk of aspiration. C. When caring for an infant who has a tracheoesophageal fistula, the nurse should maintain the infant on NPO status due to the risk of aspiration. D. When caring for an infant who has a tracheoesophageal fistula, the nurse should maintain the infant on NPO status due to the risk of aspiration.

A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hr B. Position the child on a cooling blanket and cover her with a sheet C. Place the child in a tub filled with water cooled to 26.7° to 29.4°C (80° to 85°F) D. Assess the child's temperature every 2 hr during the cooling process

Correct Answer: B. Position the child on a cooling blanket and cover her with a sheet A cooling blanket will lower the temperature of the blood circulating at the skin's surface. This cooler blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated to the skin and dispensed to the cooler outside surface. Incorrect Answers: A. Hyperthermia is caused by external conditions that create more heat than the body can eliminate. The body temperature exceeds the set point, which differs from the elevation of the body's actual set point associated with hyperpyrexia (fever). Because of this, antipyretics are not effective in treating hyperthermia. C. The child should be placed in a WARM bath. The nurse should gradually add cool water until the water temperature is 1°C (2°F) lower than the child's body temperature. Placing the child in water that is too cool will result in vasoconstriction of the BVs on the surface, which will not allow the visceral heat to dissipate to the cooler outside air. D. The nurse should assess the child's temperature every 30 - 60 minutes (NOT Q 2hrs) or continually during the cooling process to prevent hypothermia.

A nurse in an acute pediatric unit is caring for a 2-year-old child who has separation anxiety when her parents to leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. The child tries to bite the nurse. B. The child is withdrawn and refuses to talk. C. The child attempts to run away to find her parents. D. The child screams and cries loudly.

Correct Answer: B. The child is withdrawn and refuses to talk. Separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stage of despair. Incorrect Answers: A. Physical attacks are a manifestation of the stage of protest. C. Attempts to run away to find her parents is a manifestation of the stage of protest. D. Screaming and loud crying are manifestations of the stage of protest

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. The infant has lost 2.2 kg (1 lb) since the surgery. B. The infant has a total bilirubin level of 0.3 mg/dL. C. The infant has an aspartate aminotransferase (AST) level of 120 units/L. D. The infant's stools are gray in color.

Correct Answer: B. The infant has a total bilirubin level of 0.3 mg/dL. A bilirubin level of 0.3 mg/dL is within the expected reference range and indicates the surgery was successful. Incorrect Answers: A. Weight loss is an indication that the surgery was not successful. The infant should gain weight following the surgery due to improved intestinal absorption. C. An AST level of 120 units/L is above the expected reference range and indicates continued biliary obstruction. D. If the surgical correction was successful, the infant's stools should turn yellow and then brown in color. Gray stools indicate continued biliary obstruction.

A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL

Correct Answer: C A child who has sickle cell anemia must maintain adequate hydration because dehydration could cause sickle cell crisis that can occlude the child's circulation (1.005 to 1.030) Incorrect Answers: A. A child who has asthma should have a pulse oximetry reading of 90% or greater; therefore, this is not the nurse's priority finding. B. A child with nephrotic syndrome typically has moderate to large amounts of protein in the urine; therefore, this is not the nurse's priority finding. D. A blood glucose level of 110 mg/dL is within the expected reference range for this child; therefore, this is not the nurse's priority.

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 rates of maltreatment. B. In single-parent families, the parent's 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 across all socioeconomic groups.

Correct Answer: C. Children who were 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. Incorrect Answers: A. While child maltreatment occurs in all age groups, infants from birth to 1 year of age have the highest rate of maltreatment. B. In single-parent families, the parent is more often the abuser than the nonbiological partner. D. While child maltreatment does occur across all socioeconomic groups, the most cases occur in families of lower income and education level. These families often have a greater number of additional stressors and restricted access to available support systems.

A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in 1-piece outfits." B. "I need to buy diapers that are tighter than those my infant usually wears." C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet train my child."

Correct Answer: C. "I need to apply paste to the back of the wafer on my child's appliance." The parent should apply stoma paste to the back of the wafer on the appliance and around the stoma. This paste will act as a sealant to prevent skin breakdown. Incorrect Answers: A. The parent SHOULD dress the infant in 1-piece outfits to restrict the infant's hands from reaching the pouch. B. The parent should use diapers that are LARGER than the ones the child usually wears to go over the stoma and facilitate drainage. D. A child who has a colostomy will need bladder training when developmentally ready because the urinary system is still intact.

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

Correct Answer: C. Administer IV fluid replacement The greatest risk to this child is an injury from hypovolemic shock; therefore, the first action the nurse should take after ensuring the child has a patent airway is to administer IV fluid replacement therapy. Incorrect Answers: A. The nurse should administer IV morphine to reduce and control the child's pain and level of anxiety; however, there is another action the nurse should take first. B. The nurse should administer topical antimicrobials to the burn wounds to reduce the child's risk of infection; however, there is another action the nurse should take first. D. The nurse should administer tetanus prophylaxis to reduce the child's risk of tetanus infection; however, there is another action the nurse should take first.

A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the nurse administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen

Correct Answer: C. Amoxicillin A child who has acute otitis media should take an antibiotic to help alleviate the infection. Incorrect Answers: A. Diphenhydramine is an antihistamine used for allergic reactions. B. Furosemide is a diuretic used to decrease edema. D. Children who are <6 months old should not take ibuprofen. Acetaminophen is the preferred choice for children of this age.

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? A. Temperature 37.5°C (99.5°F) B. Apical pulse rate 140/min C. BP 86/40 mmHg D. Respiratory rate 32/min

Correct Answer: C. BP 86/40 mmHg A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider. (72-104/37-56) Incorrect Answers: A. 36.5-37.5 B. 90-160 D. 30-60

A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortions C. Barking cough D. Projectile vomiting

Correct Answer: C. Barking cough Infants who have tracheomalacia have a weakened trachea, which can lead to collapse. Clinical manifestations of tracheomalacia include a barking cough, stridor, wheezing, cyanosis, and apnea. Incorrect Answers: A. Tracheoesophageal fistula is an upper GI disorder; therefore, bowel sounds would not be absent in this condition. B. Neck contortions are an expected finding in an infant who has a hiatal hernia. D. Projectile vomiting is an expected finding in an infant who has hypertrophic pyloric stenosis

A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? A. Avoid laying the infant on his abdomen B. Avoid tucking the appliance into the infant's diaper C. Check the bag for stool every 4 hours D. Replace the appliance every 3 days

Correct Answer: C. Check the bag for stool every 4 hours The nurse should check the bag for stool every 4 hours or less to prevent the bag from overfilling and leaking. Stool from an ileostomy is acidic and can cause excoriation of the skin. Incorrect Answers: A. The nurse should allow the infant to lie on his abdomen because the ostomy has no nerves. Therefore, laying on the ostomy will not cause pain. B. The nurse should tuck the ostomy appliance INTO the infant's diaper to prevent accidental removal. D. The nurse should plan to replace the appliance 1/WEEK. Frequently changing the appliance increases the risk of injury to the skin surrounding the stoma.

A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the provider? A. BUN 8 mg/dL B. Uric acid 3.0 mg/dL C. Creatinine 0.9 mg/dL D. Urine specific gravity 1.010

Correct Answer: C. Creatinine 0.9 mg/dL The expected reference range for a toddler is a creatinine level of 0.3 to 0.7 mg/dL. This child's level is above the expected reference range and should be reported to the provider. Incorrect Answers: A. The expected reference range for a toddler is BUN 5 to 18 mg/dL. B. The expected reference range for a toddler is a uric acid level of 2.0 to 5.5 mg/dL. D. The expected reference range for a toddler is a urine specific gravity of 1.001 to 1.030

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

Correct Answer: C. Deep, rapid respirations This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia. Incorrect Answers: A. This finding indicates mild dehydration. A toddler experiencing severe dehydration would exhibit intense thirst. B. This finding indicates mild to moderate dehydration. A toddler experiencing severe dehydration would exhibit a capillary refill of 4 seconds or greater and skin tenting. D. This finding indicates moderate dehydration. A toddler experiencing severe dehydration would exhibit an absence of tears and sunken eyeballs.

A nurse is planning care for a school-aged child who has juvenile idiopathic arthritis (JIA). Which of the following actions should the nurse include in the plan? A. Encourage the child to sleep for 1 hour each afternoon B. Apply cold compresses to the child's affected joints each morning C. Encourage the child to participate in physical activities D. Limit the child's intake of foods that are high in uric acid

Correct Answer: C. Encourage the child to participate in physical activities The nurse should encourage the child to remain physically active to promote mobility and joint function. Incorrect Answers: A. The nurse should discourage the child from sleeping during the daytime. Children who have JIA have interrupted sleep patterns. Therefore, the nurse should encourage 30 to 60 minutes of quiet play instead of napping to improve nighttime sleep. B. The nurse should apply moist heat compresses to the child's affected joints or provide a long bath each morning to alleviate stiffness and pain. D. The nurse does not need to limit any specific foods for a child who has JIA. The child should maintain a healthy weight to decrease pressure on joints.

A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP

Correct Answer: C. FLACC The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. Incorrect Answers: A. The nurse should identify that the FACES pain scale is used for children aged 3 years and older. B. The nurse should identify that the CRIES pain scale is used for PRETERM newborns. CRIES is an acronym for crying, requires increased oxygen, increased vital signs, expression, and sleeplessness. D. The nurse should identify that the Premature Infant Pain Profile (PIPP) is used for PRETERM newborns

A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client? A. Less extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism

Correct Answer: C. Longer intestinal tract Compared to adults or older children, infants have a longer intestinal tract. This results in greater fluid losses, especially through diarrhea. Incorrect Answers: A. Compared to adults or older children, infants have a LARGER amount of extracellular fluid. This results in a larger fluid volume and more rapid water loss in this age group. B. Compared to adults or older children, infants have a larger body surface area. This results in greater fluid losses through insensible means. D. Compared to adults or older children, infants have an increased rate of metabolism. This results in the production of more metabolic waste, which must be excreted by the kidneys.

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities B. Administer meperidine every 4 hr until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for 8 hr

Correct Answer: C. Maintain the child on bed rest The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs. Incorrect Answers: A. Cold compresses are contraindicated because they enhance sickling and vasoconstriction. B. Meperidine is not recommended because this CNS stimulant can produce anxiety, tremors, and generalized seizures. D. A child who has sickle cell anemia and is in a vaso-occlusive crisis requires increased fluid intake to prevent sickling.

A nurse is caring for a preschooler who is immediately postoperative following the removal of a brainstem tumor. Which of the following actions should the nurse take? A. Have the child deep-breathe and cough every hour B. Offer the child clear liquids 4 hours after the procedure C. Monitor the child's temperature every 30 minutes D. Place the child in Trendelenburg position

Correct Answer: C. Monitor the child's temperature Q 30 min The nurse should monitor the child's temperature every 15 to 30 minutes. Surgery on the brainstem (serves a critical role in regulating certain involuntary actions of the body) can cause hyperthermia. Incorrect Answers: A. The nurse should have the child avoid coughing because this can increase ICP. B. The nurse should NOT offer the child clear liquids for at least 24 hours following the procedure. The gag and swallow reflexes are frequently depressed, increasing the risk of aspiration. D. The nurse should not place the child in the Trendelenburg position because it increases ICP and raises the risk of postoperative hemorrhage.

A nurse in an emergency department is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report as an indication of impending airway obstruction? A. Bradycardia B. Respiratory depression C. Nasal flaring D. Barking cough

Correct Answer: C. Nasal flaring Acute laryngotracheobronchitis (croup) causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increasing restlessness, flaring nares, and intercostal retractions. Incorrect Answers: A. Tachycardia, not bradycardia, is an indication of impending airway obstruction. B. Tachypnea, not bradypnea, is an indication of impending airway obstruction. D. A barking cough is a classic manifestation of acute laryngotracheobronchitis; however, it is NOT an indication of impending airway obstruction.

A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

Correct Answer: C. Palpate the abdomen for bladder distension A neurogenic bladder (nerves that carry messages back-and-forth between the bladder and the spinal cord and brain don't work the way they should) is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess for bladder distension due to the possibility of incomplete emptying of the bladder. Incorrect Answers: A. The nurse should not place a diaper on the infant until after the defect has been repaired and healed due to the risk of tearing the sac. The nurse should place padding under the infant to absorb urine and stool and provide frequent skin care. B. Povidone-iodine is neurotoxic and should not come into contact with the spinal malformation. D. The nurse should keep the meningocele sac from drying by applying sterile nonadherent dressings moistened with 0.9% sodium chloride every 2 to 4 hours. A dry dressing might stick to the sac and cause tearing.

A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take? A. Administer tolmetin prior to the procedure B. Apply a eutectic mixture of local anesthetics (EMLA) cream to the newborn's heel after the procedure C. Prepare concentrated sucrose for oral administration D. Place the newborn in an extended position

Correct Answer: C. Prepare concentrated sucrose for oral administration The nurse should provide the newborn with oral sucrose 2 minutes PRIOR to performing the heel puncture. This practice, along with non-nutritive sucking, has been shown to decrease the pain the newborn experiences during the heel puncture. Incorrect Answers: A. Tolmetin is an oral analgesic medication for clients 2 years of age and older. Therefore, the nurse should not administer this medication to the newborn. B. The nurse should apply EMLA cream to the puncture site about 1 hour prior to the procedure. This allows time for the EMLA cream to decrease the pain the newborn experiences during the heel puncture. D. If skin-to-skin contact with a parent is not possible, the nurse should swaddle and rock or hold the infant to decrease the pain that the newborn experiences during the heel puncture. Swaddling the newborn can reduce pain associated with procedures because it mimics the feeling of being in the womb, whereas being placed in an EXTENDED position would be UNCOMFORTABLE for the newborn and would likely increase PAIN because it is not a natural position at this age.

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 5 mg/dL B. Creatinine 0.2 mg/dL C. Sodium 125 mEq/L D. Potassium 4.2 mEq/L

Correct Answer: 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. Incorrect Answers: A. The nurse should expect an infant with acute renal failure to have an elevated BUN level. A BUN level of 5 mg/dL is within the expected reference range for an infant. B. The nurse should expect an infant with acute renal failure to have an elevated creatinine level. A creatinine level of 0.2 mg/dL is within the expected reference range for an infant. D. The nurse should expect an infant with acute renal failure to have hyperkalemia. A potassium level of 4.2 mEq/L is within the expected reference range for an infant

A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short

Correct Answer: D. Children who have ASD have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible. Incorrect Answers: A. Children who have ASD have difficulty adjusting to new situations. The nurse should assign this child to a private room with decreased auditory and visual stimulation to assist the child's adaptation. B. Children who have ASD prefer minimal physical contact. The nurse should refrain from holding or restraining the child and should reduce eye contact as much as possible to prevent outbursts. C. Children who have ASD have difficulty redirecting their focus and changing activities. The nurse should clearly state expectations and instructions at the appropriate developmental level and should not provide choices about scheduling planned care.

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

Correct Answer: D. Hematuria can be detected visually in clients who have acute post-streptococcal glomerulonephritis. Incorrect Answers: A. Elevated BP is a manifestation of acute post-streptococcal glomerulonephritis. B. Serum lipid levels are not elevated for clients who have acute post-streptococcal glomerulonephritis. The levels are within the expected reference range. C. Serum potassium levels are within the normal expected reference range or elevated for clients who have acute post-streptococcal glomerulonephritis.

A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I will breathe in through the mouthpiece, hold my breath for 5 sec, and then exhale." B. "If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10 sec interval." D. "I will record the highest reading of three attempts."

Correct Answer: D. "I will record the highest reading of three attempts." After establishing a personal best, the client should routinely check the PEFM by performing 3 attempts and recording the highest reading of the 3. Incorrect Answers: A. The nurse should instruct the adolescent to take a deep breath, place the lips around the mouthpiece, and then blow into the mouthpiece as hard and fast as possible. B. Values in the green zone represent 80% to 100% of the child's personal best; therefore, this does not warrant calling the provider. C. Slowly exhaling over a 10-second interval is an incorrect method of using the PEFM.

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."

Correct Answer: 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. Incorrect Answers: A. Constipation is not the cause of the toddler's protruding abdomen. B. Toddlers are NOT growing as rapidly as they did in infancy, and weight gain does NOT cause a protruding abdomen. C. A spinal deformity is not generally the cause of a toddler's protruding abdomen

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 parent 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."

Correct Answer: D. "You will be able to participate in physical exercises." Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided. Incorrect Answers: A. Passive ROM exercises are NOT done after a bleeding episode because rebleeding can occur. Active motion is best to allow activity to be tailored to the child's pain level. B. A manifestation of hemophilia A is hemarthrosis (bleeding into a joint capsule). This can result in numbness, tingling, or pain, along with discoloration, warmth, and swelling of the affected joint. The nurse should instruct the child to rest the joint, elevate it above the level of the heart, and apply ice to decrease the rate of bleeding into the joint capsule. C. Intracranial hemorrhage is a leading cause of death in clients who have hemophilia A. The nurse should instruct the child to avoid the use of aspirin because it has antiplatelet properties that can increase bleeding

A nurse is 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 4 oz of juice to drink each day." B. "I will offer my baby dry cereal and chilled banana slices as snacks." 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."

Correct Answer: D. (1qt = 32oz) As the infant transitions into toddlerhood, whole milk intake should average 24-30 oz per day. Too much milk can affect the child's intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids, which are needed for growth and development. Incorrect Answers: A. Children should not exceed 4 - 6 oz of juice per day between the ages of 1 and 6 years. Infants who are under 4-6 months of age should not be given juice. B. At 12 months of age, infants should be offered finger foods. Finger foods stimulate the pincer grasp, which aids fine motor development. Cereal is small but dissolves in the infant's saliva and would not cause an airway obstruction. Chilled banana slices are an appropriate food choice and help relieve teething. C. Introducing infants to foods prepared for the rest of the family is appropriate and helps them feel included. Home-cooked foods also provide infants with the nutrients they need. At 12 months of age, infants are able to eat soft table foods such as mashed potatoes, green beans, bread, and finely chopped meat.

A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hr B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the skin before attaching the sensor D. Cover the oximetry sensor with clothing

Correct Answer: D. Cover the oximetry sensor with clothing The nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading. Incorrect Answers: A. The nurse should move the sensor to a new site every 4-8 hours. The pulse oximetry sensor should not remain in a single location for an extended period of time because of the risk of tissue necrosis. B. The pulse ox sensor should be placed around the infant's hand or foot to obtain an accurate reading. C. The pulse ox uses a sensor to measure oxygen in the infant's hemoglobin. Conduction gel would interfere with the reading because it would not allow the sensor to attach to the skin.

A nurse is planning care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. Airborne precautions B. Contact precautions C. Protective environment D. Droplet precautions

Correct Answer: D. Droplet precautions The nurse should maintain droplet precautions for a client who has meningococcal meningitis for 24 - 72 hours after the initiation of antibiotic therapy. Disease transmission can occur through large-droplet particles when the client is talking. There is no drainage of infected body fluids with meningitis, so contact precautions are not necessary. Incorrect Answers: A. This type of isolation would be appropriate for diseases such as rubeola, in which transmission can occur via inhalation but there is no chance of transmission through infected body fluids. B. This type of isolation would be appropriate for diseases such as varicella-zoster, smallpox, and tuberculosis, in which there is a potential for transmission by both inhalation and contact with infected body fluids. C. This type of isolation precaution would be appropriate for a client who underwent an allogeneic hematopoietic stem cell transplant.

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints B. Massage the child's pressure areas C. Increase the child's fluid intake D. Encourage the child to use an incentive spirometer

Correct Answer: D. Encourage the child to use an incentive spirometer Encouraging the child to use an incentive spirometer will promote adequate oxygenation and is the priority nursing action Incorrect Answers: A. The nurse should perform passive range of motion for unaffected joints; however, a different action is the nurse's priority. B. The nurse should massage the child's pressure areas; however, a different action is the nurse's priority. C. The nurse should increase the child's fluid intake; however, a different action is the nurse's priority.

A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero B. Administer a folic acid supplement to the child each day C. Give pancreatic enzymes to the child with meals and snacks D. Ensure the child's dietary intake of calcium and iron is adequate

Correct Answer: D. Ensure the child's dietary intake of calcium and iron is adequate A child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption of and effects from the lead. Dietary recommendations should include milk as a good source of calcium. Incorrect Answers: A. Vitamin C does not influence absorption or excretion of lead, and intake does not need to be reduced for a child who has a blood lead level of 3 mcg/dL. Over time, a reduced intake can result in a vitamin C deficiency. B. A 3-year-old child does not need a folic acid supplement. This will not influence absorption or excretion of lead. C. Pancreatic enzymes are administered to children who have CF, not an elevated blood lead level

A nurse is planning preoperative teaching for a 5-year-old child. Which of the following interventions should the nurse include? A. Explain the long-term benefits of the procedure. B. Provide diagrams and pictures while explaining the procedure. C. Use correct medical terminology during the teaching session. D. Explain the procedure in terms of what the child will feel, see, hear, and taste.

Correct Answer: D. Explain the procedure in terms of what the child will feel, see, hear, and taste. Teaching for a preschooler should focus on the child's sensory experience. The teaching can also include what the child can do during the procedure. Incorrect Answers: A. Preschoolers are unable to think abstractly or understand concepts that will occur far in the future. B. The nurse should use dolls or stuffed animals to explain the procedure and allow the child to handle the equipment if possible. C. Teaching for a preschooler should be done using simple, familiar terms.

A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A. Restrict the child's potassium intake B. Administer acetaminophen to the child twice daily C. Weigh the child once each week D. Keep the child away from people who have an infection

Correct Answer: D. Keep the child away from people who have an infection Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections. Incorrect Answers: A. The nurse should instruct the parents to restrict the child's sodium (NOT Potassium) intake and, in severe cases, restrict fluids. A child who has acute glomerulonephritis should have a restricted potassium intake. B. Corticosteroids are the first-line treatment for children who have nephrotic syndrome. C. A child who has nephrotic syndrome should be weighed at home daily (NOT weekly) to determine the effectiveness of the therapy.

A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? A. Assess for edema of the extremities B. Apply warm compresses to the neck area C. Initiate airborne precautions D. Maintain a cardiorespiratory monitor

Correct Answer: D. Maintain a cardiorespiratory monitor Infants with pertussis typically present with APNEA in response to coughing spasms and mucus plugs. Humidified oxygen and suction equipment should be used as needed. Incorrect Answers: A. Pertussis causes paroxysms of coughing with frequent VOMITING. Therefore, infants who have pertussis are at risk of fluid volume deficit. B. The nurse should take this action when caring for a child who has a mumps infection, which causes enlarged, painful parotid glands. C. The nurse should initiate standard and droplet precautions when providing care for a client who has pertussis.

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

Correct Answer: D. Oxygen saturation When (ABC) approach to client care, the nurse should identify that checking the adolescent's oxygen saturation level is the priority. By monitoring the adolescent's oxygen saturation level and respiratory status, the nurse can identify if the client has developed opioid-induced respiratory depression. Incorrect Answers: A. The nurse should assess the adolescent's skin around the catheter site to monitor for bleeding, leakage, or infection. However, there is another assessment the nurse should perform first. B. The nurse should assess the adolescent's blood pressure to monitor for hypotension from the fentanyl and epidural catheter. However, there is another assessment the nurse should perform first. C. The nurse should assess the adolescent's pain level to evaluate effectiveness of the fentanyl. However, there is another assessment the nurse should perform first.

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 140 mEq/L B. Calcium 10.2 mg/dL C. Chloride 100 mEq/L D. Potassium 3.2 mEq/L

Correct Answer: D. Potassium 3.2 mEq/L The nurse should identify that a potassium level of 3.2 mEq/L is below the expected reference range of 4.1 to 5.3 mEq/L for an infant. Therefore, the nurse should report this finding to the provider. Incorrect Answers: A. The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L for an infant. B. The nurse should identify that a calcium level of 10.2 mg/dL is within the expected reference range of 8.8 to 10.8 mg/dL for an infant. C. The nurse should identify that a chloride level of 100 mEq/L is within the expected reference range of 90 to 110 mEq/L for an infant

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. Pruritus

Correct Answer: D. Pruritus Pruritus is an adverse effect of opioids. Constipation, respiratory depression, NV, agitation, orthostatic hypotension, and hallucinations are also adverse effects of opioids. Incorrect Answers: A. Dilated pupils are manifestations of withdrawal from opioids. B. Tremors are manifestations of withdrawal from opioids. C. Yawning is a manifestation of withdrawal from opioids

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 nonpharmacological 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

Correct Answer: D. Repeat memorized facts about the painful event Having the adolescent repeat memorized facts about the painful event is an example of the nonpharmacological pain management strategy of thought-stopping. Thoughts such as "the pain will be gone soon" or "I'll be home by this time tomorrow" 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. Incorrect Answers: A. Having the adolescent put together a puzzle is an example of the nonpharmacological pain management strategy of DISTRACTION. B. Having the adolescent discuss a recent pleasurable event is an example of the nonpharmacological pain management strategy of GUIDED IMAGERY. C. Having the adolescent tighten and then relax each body part is an example of the nonpharmacological pain management strategy of RELAXATION.

A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? A. Ask the child to hold a breath and blow it out slowly B. Ask the child to describe a pleasurable event C. Bounce the child gently while holding him upright D. Rock the child using long, rhythmic movements

Correct Answer: D. Rock the child using long, rhythmic movements The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest and rocking or swaying back and forth in long, wide movements. Incorrect Answers: A. This is an example of a distraction strategy. B. This is an example of guided imagery. C. Evidence-based practice indicates that bouncing is NOT an appropriate action.

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelets 120,000/mm^3 B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL

Correct Answer: D. Serum cholesterol 700 mg/dL A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids. Incorrect Answers: A. A platelet count of 120,000/mm^3 is below the expected reference range. Children with nephrotic syndrome have an increased platelet count because of hemoconcentration. B. A serum sodium level of 160 mEq/L is above the expected reference range. Children who have nephrotic syndrome have a serum sodium level that is lower than expected because of hemoconcentration. C. A hemoglobin level of 9 g/dL is below the expected reference range. Children who have nephrotic syndrome will have hemoglobin levels that are within the expected reference range or elevated.

A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying B. Semi-recumbent C. Flexed sitting D. Supine

Correct Answer: D. Supine The client should be placed in the supine position, with the legs in a frog position. Incorrect Answers: A. The side-lying position may be used during a lumbar puncture. B. A semi-recumbent position is used when performing a gavage feeding. The client's head and chest should be elevated. C. The flexed sitting position may be used during a lumbar puncture

A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? (Select all that apply.) A. "My child will likely be irritable for the next few weeks." B. "I will notify my child's doctor if the skin on her hands or feet begins to peel." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." E. "My child will have joint stiffness primarily at the end of the day."

Correct Answers: A. "My child will likely be irritable for the next few weeks." A child who is diagnosed with Kawasaki disease will likely be irritable for up to 2 months. C. "I will ensure my child does not receive any live vaccines for at least 18 months." A child who has Kawasaki disease receives high doses of gamma globulin (donated antibodies) during the initial phase, which might result in the inability to produce adequate antibodies in response to a live vaccine; therefore, these vaccines should be delayed for 11 months. D. "I will keep a record of my child's temperature until she has no fever for several days." Also, the temperature of this child who has Kawasaki disease should be recorded until she has been Afebrile for several days. Incorrect Answers: B. Peeling of the skin of the hands and feet is expected for a child who has Kawasaki disease. The peeling does not cause any pain and usually occurs between the 2nd and 3rd week. There is no need to report this manifestation to the child's provider. E. A child who has Kawasaki disease will likely have joint stiffness and arthritis-related symptoms for several weeks. The joint stiffness is typically worse during COLD weather and in the MORNING

A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment

Correct Answers: A. Enlarged heart B. Enuresis C. Leg ulcers E. Retinal detachment Chronic vaso-occlusive phenomena result from the obstruction of organs by red blood cells, leading to stasis and enlargement of the organs, infarction due to ischemia, and scarring. An enlarged heart, enuresis, leg ulcers, and retinal detachment are manifestations of chronic vaso-occlusive phenomena. Incorrect Answer: D. INTRAhepatic cholestasis is a manifestation of chronic vaso-occlusive phenomena. EXTRAhepatic cholestasis is caused by the blockage of bile flow from the liver due to a source outside of the liver, usually stones in the common bile duct. Intrahepatic cholestasis is caused by the blockage of bile flow from the liver due to a source outside of the liver such as scarring.

A nurse is teaching a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods increase the risk of choking in toddlers? (Select all that apply.) A. Hot dogs B. Grapes C. Bagels D. Marshmallows E. Graham crackers

Correct Answers: A. Hot dogs B. Grapes C. Bagels D. Marshmallows Foods that are shaped like a tube, such as hot dogs and grapes, place toddlers at risk for choking because they can completely block the throat when swallowed whole due to their shape and solidity. Foods that are hard to chew, such as bagels and marshmallows, place toddlers at risk for choking; if swallowed before they are adequately chewed, they can block the airway. Incorrect Answer: E. All foods and fluids can potentially cause choking. However, graham crackers become soft quickly when mixed with saliva. Their consistency when wet is more like cooked cereal or soft cookies soaked in milk. Therefore, graham crackers do not pose an increased choking hazard for toddlers.

A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to the body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.

Correct Answers: A. The child views death as similar to sleep. Preschool-age children may think of death like sleep. D. The child believes his thoughts can cause death. Preschool-age children also believe that their thoughts and wishes can make things happen since they are egocentric. This is part of why the death of a family member can be difficult for a child at this age. E. The child thinks death is a punishment. Finally, preschool-age children sometimes believe that death is the result of guilt or a punishment for something they did, said, or thought. Incorrect Answers: B. A school-age child will be interested in post-death services and what happens to the body after death due to an improved ability to comprehend what is happening. C. Preschool-age children have difficulty understanding the concept of time and are therefore not likely to believe that death is permanent. Instead, they perceive death as reversible

A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (Select all that apply.) A. "I should eat extra food on busy days when I am more active." B. "I should wait for 2 hr after eating before going swimming with my friends." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." E. "I should have a 16 oz sports drink if I start feeling weak or shaky."

Correct Answers: A. The nurse should instruct the adolescent to increase the intake of allowable foods when the level of activity is increased. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. C. Additionally, the nurse should instruct the adolescent to increase the intake of sugar-free fluids when sick because fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids such as water, broth, and tea. The adolescent should continue with the usual intake at mealtimes and follow the recommended meal plan as much as possible. D. Finally, the nurse should instruct the adolescent to eat a recommended snack 30 minutes prior to a planned activity such as playing in a baseball game. If the game is prolonged, a snack should be consumed every 45 minutes to 1 hour. If, for some reason, the extra food cannot be tolerated, the next intervention is to decrease the adolescent's insulin dose before baseball games. Incorrect Answers: B. The adolescent should exercise within 2 hours of eating because exercise requires more carbohydrates in the system. Waiting for 2 hours after eating before exercise increases the likelihood of a hypoglycemic episode. A carbohydrate snack will most likely be needed during and a few hours following prolonged activity or exercise. E. The adolescent should consume 8 oz of a sports drink when feeling hypoglycemic. Manifestations of hypoglycemia include dizziness, a headache, irritability, weakness, shakiness, and confusion. An 8 oz sports drink contains 15 g of carbohydrates. NOT 16 oz, it would contain a minimum of 30 g of ca

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 meet the nutritional needs of the infant? (Select all that apply.) A. Offer the infant a feeding every 2 hr 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 respiratory rate exceeds 80/min

Correct Answers: B. Allow 30 min to complete each feeding The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. C. Gradually increase the caloric density of the formula The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea. D. Position the infant semi-upright during feedings The nurse should plan to hold the infant in a semi-upright position during feedings to promote maximum chest expansion and decrease the risk of respiratory distress. E. Provide gavage feeding if respiratory rate exceeds 80/min The nurse should plan to withhold oral feedings and provide gavage feedings if the infant shows indications of stress or fatigue. An infant who has a respiratory rate of 80/min to 100/min has tachypnea, which is an indicator of infant stress. (30-60 normal) Incorrect Answer: A. The nurse should plan to provide the infant with feedings q 3 hours. This frequency allows the infant to get adequate rest between feedings while keeping the volume of feeding at a tolerable level

A nurse is caring for an infant who has biliary atresia. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Yellow sclerae B. Rapid weight gain C. Tar-colored stools D. Abdominal distention E. Dark urine

Correct Answers: Biliary atresia is a progressive process that leads to the destruction of the biliary tree. A. Yellow sclerae Yellow sclerae are an early manifestation of biliary atresia caused by obstruction of the biliary tree, resulting in cholestasis (condition where bile cannot flow from the liver to the duodenum). D. Abdominal distention Abdominal distention is a clinical manifestation of biliary atresia due to hepatomegaly. E. Dark urine Dark urine is a clinical manifestation of biliary atresia due to conjugated bilirubin escaping from the liver and being excreted in the urine. Incorrect Answers: B. Infants who have biliary atresia have difficulty metabolizing fat, leading to poor weight gain. C. Acholic or gray stools are a clinical manifestation of biliary atresia. Pale, putty-colored stools are due to the lack of bilirubin in the intestinal tract. (NOT tar-colored)

A nurse is teaching the parent of an infant about home safety. Which of the following pieces of information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker. B. Place soft pillows around the edge of the infant's crib. C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49°C (120°F).

Correct Answers: C. Position the car seat so it is rear-facing. Infants and children should remain in the rear-facing position in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines. D. Secure a safety gate at the top and bottom of the stairs. As the infant begins to crawl and becomes more mobile, the risk of falls increases E. Maintain the water heater temperature at 49°C (120°F). To prevent a burn injury, the temperature of the water heater NTE 49°C (120°F). Incorrect Answers: A. A stationary infant walker is recommended. Wheeled infant walkers can quickly move across uneven surfaces and result in injury. B. Soft pillows and cushions should not be used in cribs due to the increased risk of suffocation

A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child's parent about the illness? (Select all that apply.) A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water C. Administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area

Correct Answers: A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water E. Wash hands before and after contact with the affected area Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on teaching the child's parents about topical application of an antibacterial ointment. The parents should wash their hands before and after contact with the affected area and wash the child's bed linens daily in hot water to decrease the risk of reinfection or transmission. Incorrect Answers: C. The nurse should teach the child's parents about administering antibacterial medications. Acyclovir is an antiviral medication used for the treatment of viral skin infections. D. The nurse should plan on teaching the child's parents to wash the crusts each day with water and soap to promote healing.

How to calculate the client's BMI (formula)? Example: 12-year-old client who weighs 41 kg (90 lb) and has a height of 1.5 m (60 in).

Kg/m^squared To calculate the client's BMI, the nurse should divide the client's weight in kilograms by the square of the client's height in meters. 41 kg / square of 1.5 m = BMI of 18.2.

Nephrotic syndrome

Loss of large amounts of plasma protein, usually albumin, through urine due to an increased permeability of the glomerular membrane

Play Therapy vs. Therapeutic Play

Play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging the child to touch the equipment, the nurse is helping decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people Play therapy differs from therapeutic play and allows a specially trained therapist to interpret the emotions of children who have mental health issues

A nurse is caring for a 12-month-old infant following the surgical repair of a cleft palate. The nurse should plan to feed the infant using what instrument for how long?

The infant should be fed clear liquids using a CUP for 7-10 days following a cleft palate repair to prevent trauma and injury to the suture line Spoon, straw, and firm nipple use is contraindicated following a cleft palate repair because placing objects in the mouth could rub or disturb the suture line.

Purpose of massaging the anterior area of the infant's ear following ear drop administration

The nurse should instruct the parents to massage the anterior area of the ear following the administration of eardrops to facilitate instillation of the medication.

Hiatal hernia

The protrusion of an organ, typically the stomach, through the esophageal opening in the diaphragm

Tolmetin

Tolmetin is an oral analgesic medication for clients 2 years of age and older