ATI RN Nursing Care of Children Practice B

A nurse is teaching the guardian of a 6 month old infant about teething. Which of the following statements should the nurse make?

"Your baby might pull at their ears when they are teething." The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness.

A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply.)

-Increased temperature -Xerophthalmia -Cervical lymphadenopathy

A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.)

-vomiting -lethargy

A nurse is assessing the pain level of a 3 year old toddler. Which of the following pain assessment scales should the nurse use?

FACES The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management.

A nurse in an emergency department is caring for a school age child who has epiglottitis. Which of the following actions should the nurse take?

Monitor the childs oxygen saturation The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment.

A nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective?

Decreased edema A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema.

A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority?

Disease process The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration.

A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?

For 24 hr following initiation of antimicrobial therapy The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.

A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take?

Have the adolescent sign a consent form for treatment. The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent.

A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus?

Sodium 155 mEq/L as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L.

A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?

Sunken anterior fontanel The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid.

A nurse is creating a plan of care for a preschooler who has Wilma' tumor and is scheduled for surgery. Which of the following interventions should the nurse include?

Avoid palpating the abdomen when bathing the child before surgery. The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site.

A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching?

Brush the child's teeth after giving the medication The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste.

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron?

½ cup raisins The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron.

A nurse in an emergency department is caring for a school age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take?

Apply an antimicrobial ointment to the affected area. The nurse should apply an antimicrobial ointment to the burned area to prevent infection.

A nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain?

Allow the mother to breastfeed while the sample is being obtained. The nurse should allow the mother to breastfeed the infant prior to or during the procedure. Evidence-based practice indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants.

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?

An infant who is 8 months old and is not yet making babbling sounds. The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing.

A nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make?

When your child's lesions are crusted, usually 6 days after they appear The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.

A nurse is providing discharge teaching to the parents of a 6 month old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching?

"Allow the stent to drain into your infants diaper." The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow.

A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching?

"Award your child with a sticker when they sit on the potty chair." A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair.

A nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include?

"Wait 3 days before taking a tub bath." The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water.

A nurse is providing dietary teaching to the guardian of a school age child who has cystic fibrosis. Which of the following statements should the nurse make?

"You should offer your child high-protein meals and snacks throughout the day." The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection.

A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following findings to the provider?

Restricted ability to move the toes. The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours.

A nurse is preparing to administer ibuprofen 5 mg/kg every 6hr PRN for a temperature above 38.0° C (100.5° F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100mg/5 mL. How many mL should the nurse administer to the infant per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 mL PO per dose

A nurse is assessing a school age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the biceps reflex.

A is correct. The nurse should identify that this is the location to tap to elicit the biceps reflex.

A school nurse is caring for a child following tonic-clonic seizure. Which of the following actions should the nurse take first?

Check the childs respiratory rate. When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths.

A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?

Increase fat content in the childs diet to 40% of total calories. A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.

A nurse is assessing an 8 year old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next?

Initiate IV access After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume.

A nurse is creating a plan of care for a child who has varicella. Which of the following interventions should the nurse include?

Initiate airborne precautions for the child. The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear.

A nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?

Palpate the dorsum of the childs feet The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema.

A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take?

Place the infant in a knee-chest position The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.

A community health nurse is assessing an 18 month old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect?

Poor personal hygiene A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision.

A nurse is caring for a preschooler who has congestive heart failure. The nurse observed wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider?

Potassium Chloride The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia.

A nurse is assessing a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider?

Presence of strabismus Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider.

A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?

"Choose a waterproof sunscreen with a minimum SPF of 15." The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn.

A nurse is providing teaching to the family of a school age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching?

"Encourage the child to perform independent self-care." The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem.

A nurse is providing discharge teaching to the parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include?

"Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days." The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.

A nurse is receiving change of shift report for four children. Which of the following children should the nurse assess first?

A toddler who has a concussion and an episode of forceful vomiting When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.

A nurse is caring for a school age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?

Deep respirations of 32/min The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis.

A nurse is assessing a school age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Difficulty concentrating The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem.

A nurse is caring for a toddler who has acute otitis media and a temperature of 40° C (104° F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature?

Dress the toddler in minimal clothing The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature.

A nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe?

Recombinant growth hormone Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment.

A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following?

Wheezes The nurse should identify the sound during auscultation as wheezes, which are high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways.

A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?

"I should wear sandals as much as possible." Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection.

A nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?

"I will monitor my childs number of wet diapers." The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status.

A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will notify the doctor if I notice that my child is swallowing frequently." The nurse should instruct the parent that frequent swallowing is an indication of bleeding and, if it is observed, to notify the provider immediately.

A school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching?

"I will teach challenging academic subjects to students who have ADHD in the morning." Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective.

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding of the teaching?

"Mononucleosis is caused by an infection with the Epstein-Barr virus." The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus.

A nurse is planning care for a newly admitted school age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include?

Ensure the oxygen source is functioning in the childs room The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure.

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant?

Great toe The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for pulses, temperature, and color.

A nurse is assessing an adolescent who received polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?

Serum potassium level 4.1 mEq/L The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication.

A nurse is planning an educational program for school age children and their parents about bicycle safety. Which of the following information should the nurse plan to include?

The child should be able to stand on the balls of their feet when sitting on the bike To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar.

A nurse is planning care for a school age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan?

Use a semipermeable transparent dressing to cover the site. The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.

A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include?

"Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly.

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?

Nasal flaring When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress.

A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include?

Expressed likes and dislikes The nurse should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions.

A nurse is admitting a 4 month old infant who has heart failure. Which of the following findings is the nurse's priority? (Case study question)

Episodes of vomiting When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding.

A nurse is reviewing the laboratory results of a school age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication?

Erythrocyte sedimentation rate 18 mm/hr The nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis.

A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first?

Explore the parents' feelings and wishes regarding organ donation The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family.

A nurse is planning developmental activities for a newly admitted 10 year old child who has neutropenia. Which of the following actions should the nurse plan to take?

Provide the child with a book about adventure. The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read.