Chapter 72 - NCLEX 2
The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF? 1."Has the child complained of back pain?" 2."Has the child complained of headaches?" 3."Has the child had any nausea or vomiting?" 4."Has the child had a sore throat or a fever within the past 2 months?"
"Has the child had a sore throat or a fever within the past 2 months" - Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A ß-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child has had a sore throat or an unexplained fever within the past 2 months.
The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother?
"Have the child perform simple isometric exercises during this time."
The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching? 1."A balance of rest and exercise is important." 2."I can apply lotion or powder to the incision if it is itchy." 3."Activities during which the child could fall need to be avoided for 2 to 4 weeks." 4."Large crowds of people need to be avoided for at least 2 weeks after this surgery."
"I can apply lotion or powder to the incision if it is itchy."
The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching?
"I hear that the side effects of the medication that my child will be on can cause overeacting." - These medications will cause weight loss
The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching? 1."I know that my child will outgrow this problem, just give him time." 2."I know that I need to be alert for signs of heart failure with this defect until it is repaired." 3."The doctors tell me that my child has a heart murmur caused by the ductus not closing after birth." 4."As I understand it, my child may have to have his defect closed, either during a catheterization or by surgery."
"I know that my child will outgrow this problem, just give him time." - A patent ductus arteriosus (PDA) is caused by a failure of the ductus to close within the first weeks of life. The infant may be asymptomatic or show signs of heart failure. The defect may be closed during cardiac catheterization or may require surgery. A characteristic machine-like murmur is present with PDA.
The nurse provides information to the parents of a 2-week-old infant who was diagnosed with club-foot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder?
"I need to bring my child back to the clinic in 1 month for a new cast."
The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching?
"I understand that my child needs to wear this brace for 12 hours a day."
The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching?
"I will apply lotion under the brace to prevent skin breakdown."
The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching?
"I will not let my child play with other children who have the flu unless they are taking acetaminophen."
The nurse is reinforcing discharge instructions to the parent of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching? 1."I'll check his temperature." 2."I'll give him medication so he'll be comfortable." 3."I'll let him decide when to return to his play activities." 4."I'll check his voiding to be sure there are no problems."
"I'll let him decide when to return to his play activities"
The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching? 1."I will not mix the medication with food." 2."If more than one dose is missed, I will call the doctor." 3."I will take my child's pulse before administering the medication." 4."If my child vomits after medication administration, I will repeat the dose."
"If my child vomits after medication administration, I will repeat the dose."
The parents of a newborn have been told that their child was born with bladder exstrophy and the parents ask the nurse about this condition. Which response should the nurse give to the parents about bladder exstrophy? 1."It is a hereditary disorder that occurs in every other generation." 2."It is caused by the use of medications taken by the mother during pregnancy." 3."It is a condition in which the urinary bladder is abnormally located in the pelvic cavity." 4."It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."
"It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."
The mother of a child with Marfan syndrome asks the nurse what can be done to help her child. Which are the best responses by the nurse? Select all that apply (5)
1. "You may need to consider surgery in the future." 2."You will need to make regular pediatric appointments for your child." 3. "You will need to make regular eye examination appointments for your child." 4. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." 5. "You will need to let the dentist know that antibiotics should be given before any procedure."
A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply. (4) A.A.P.P. 1.Ascites 2.Anorexia 3.Weight loss 4.Proteinuria 5.Decreased serum lipids 6.Periorbital and facial edema
1. Ascites 2. Anorexia 3. Proteinuria 4. Periorbital and facial edema
A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? (Select all that apply) (2) C.A.
1. Contact 2. Airborne
A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? Select all that apply. (3)
1. Elevate the right arm 2. Check the neurovascular status of the right extremity 3. Determine the level of pain using a pediatric pain assessment tool
Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply (3)
1. Frequent hand washing is important 2. The child should avoid exposure to other illnesses 3. Clean up body fluid spills with bleach solution (10:1 ration of water to bleach)
The nurse assists to create a nursing care plan for the child with an arm cast and should include which interventions in the plan? Select all that apply. (4)
1. Instruct parents to keep the cast clean and dry 2. Monitor the extremity for circulatory impairment 3. Instruct the child not to stick objects down the cast 4. Notify the regiested nurse (RN) immediately if circulatory impairment occurs
The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? Select all that apply. (3) 1.Cough 2.Irritability 3.Scalp diaphoresis 4.Tachypnea, tachycardia 5.Slow and shallow breathing
1. Irritability 2. Scalp diaphoresis (sweating) 3. Tachypnea, tachycardia - The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign.
The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply. 1.Provide adequate nutrition. 2.Restrict fluids, as prescribed. 3.Institute measures to prevent infection. 4.Monitor the arteriovenous (AV) fistula. 5.Administer blood products to treat severe anemia. 6.Anticipate the child will have central nervous system involvement.
1. Provide adequate nutrition 2. Restriction of fluids, as prescribed 3. Institute measures to prevent infection 4. Administer blood products to treat severe anemia 5. Anticipate the child will have central nervous system involvement
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?
A chronic disability characterized by impaired muscle movement and posture.
The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse? 1.Bradypnea 2.Diaphoresis 3.Decreased blood pressure (BP) 4.A weight gain of 1 lb in 1 day
A weight gain of 1 lb in 1 day - A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation.
A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?
Apply an ice pack to the injection site.
An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home? 1.Leave diapers off to allow the site to heal. 2.Avoid tub baths until the stent has been removed. 3.Encourage toilet training to ensure that the flow of urine is normal. 4.Restrict the fluid intake to reduce urinary output for the first few days.
Avoid tub baths until the stent has been removed
The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding? 1.Hematuria 2.Bacteriuria 3.Glucosuria 4.Proteinuria
Bacteriuria
Which laboratory result would verify the diagnosis of bacterial menigitis?
Cloudy cerebrospinal fluid with high protein and low glucose levels
The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted? 1.Cracked lips 2.A normal appearance 3.Conjunctival hyperemia 4.Desquamation of the skin
Conjunctival hyperemia - During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.
The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate? 1.Pallor 2.Hyperactivity 3.Exercise intolerance 4.Gastrointestinal disturbances
Exercise intolerance - The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign.
The nurse is assisting with gathering admission assessment data on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome? 1.Hypotension 2.Generalized edema 3.Increased urinary output 4.Frank, bright red blood in the urine
Generalized edema - Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, and edema. The urine is dark, foamy, and frothy, but microscopic hematuria may be present. Frank, bright red blood in the urine does not occur. Urine output is decreased and the blood pressure is normal or slightly decreased
A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox?
Macular rash on the trunk and scalp
A child is diagnosed with infectious mononucleosis. The nurse reinforces homecare instructions to the parents about the care of the child. Which instruction should the nurse provide to the parents?
Notify the pediatrician if the child develops abdominal or left shoulder pain.
The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should the nurse take?
Notify the registered nurse (RN)
A parent with a 6-year-old child diagnosed with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates a need for further teaching? 1."I make sure that my child goes potty before going to bed." 2."I have my child help with changing the wet sheets in the morning." 3."I take away privileges such as TV time when the bed is wet in the morning." 4."I make sure that my child does not have anything to drink 2 hours before bedtime."
"I take away privileges such as TV time when the bed is wet in the morning." -Providing a reward system appropriate for the child is more effective than a punitive system to treat enuresis. - Nighttime loss of bladder control, or bed-wetting, usually in children.
The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis? Select all that apply (3) 1.Headache 2.Hypotension 3.Red-brown urine 4.Periorbital edema 5.Increased urine output 6.A low blood urea nitrogen (BUN) level
1. Headache 2. Red-brown urine 3. Periorbital edema
The nurse is revieiwng the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question?
Keep the head of the bed elevated 45 degrees
A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?
Pastia's sign
The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first? 1.Assist to administer morphine sulfate 2.Place the child in a knee-chest position. 3.Administer 100% oxygen by face mask. 4.Prepare to administer intravenous fluids.
Place the child in a knee-chest position - The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot. - If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?
Placing the bed linens on the traction ropes
The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease?
Respiratory disease caused by a virus involving the parotid gland
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing?
Rigid extension and pronation of the arms and legs (Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.)
A child has a basilar skull fracture. Which primary health care provider's prescription should the nurse question?
Suction via the nasotracheal route as needed
The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data should the nurse expect to note during the examinations?
The dislocated femoral head pops back into the acetabulum
A healthcare provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child? 1.When the child is sleeping 2.When changing the child's diapers 3.When the mother is holding the child 4.When drawing blood for electrolyte levels
When drawing blood for electrolyte levels - Oxygen administration may be prescribed for the infant with HF for stressful periods, especially during bouts of crying or invasive procedures. - Drawing blood is an invasive procedure that would likely cause the child to cry.
The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching?
"I will have my child wear dark colored clothing so the tick will not be attracted to the colors."
The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching?
"I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."
The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching?
"I will need to give antiseizure medications when my child has a seizure"
A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and should include which intervention in the plan?
Provide a quiet atmosphere with dimmed lighting
The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which priority care measure? 1.Measuring intake and output 2.Administering anticholinergics 3.Preventing infection at the surgical site 4.Applying cold, wet compresses to the surgical site
Preventing infection at the surgical site - The most common complications associated with orchiopexy are bleeding and infection. - Orchiopexy (or orchidopexy) is a surgery to move an undescended (cryptorchid) testicle into the scrotum and permanently fix it there
The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching?
"I understand this whooping cough is viral and I have to let it run its course." - 1. Pertussis is caused by the bacteria Bordetella pertussis and treatment requires antimicrobial therapy. - 2. Symptoms of pertussis consist of a respiratory infection followed by increased severity of cough with a loud whooping on inspiration. - 3. The child may experience respiratory distress, and the parents should be instructed on reducing environmental factors that cause coughing spasms, such as dust, smoke, and sudden changes in temperature.
