Exam 4 pedi
A newborn female is discovered to have congenital adrenogenital hyperplasia. What will the nurse most likely observe when assessing this patient? A) Enlarged clitoris B) Divergent vision C) Small for gestational age D) Abnormal facial features
A
A toddler is diagnosed with a functional heart murmur. What should the nurse explain to the child's parents about this murmur? A) This type of murmur is innocent. B) Mild activity restrictions are indicated. C) More frequent health appraisals are indicated. D) Corrective surgery may be required later in life.
A
An 8-year-old child is being treated for tonic-clonic seizures. What should the nurse emphasize when teaching the parents about this disorder? A) The child should maintain an active lifestyle. B) Immediately provide medication if a seizure begins. C) Have the child carry a padded tongue blade with her at all times. D) Ensure quiet time late in the day, when seizure activity is most likely to occur.
A
During the assessment of a preschool-age child, the nurse notes that the child's tongue is tender and there are cracks in the corners of the child's mouth. Which vitamin deficiency does the nurse suspect this child is experiencing? A) Vitamin A B) Vitamin B1 C) Vitamin C D) Vitamin D
A
The nurse is assessing a school-age child with sickle-cell anemia. Which assessment finding is consistent with this patient's diagnosis? A) Slightly yellow sclera B) Enlarged mandibular growth C) Increased growth of long bones D) Depigmented areas on the abdomen
A
The nurse is caring for a child who has just received a cast for a broken wrist. Why should the nurse elevate the limb onto a pillow? A) To prevent edema B) To promote healing C) To discourage infection D) To ensure proper bone alignment
A
The nurse is caring for a school-age child newly diagnosed with juvenile arthritis. Which diagnosis would be a priority for this patient? A) Knowledge deficit related to care needs B) Risk for inefficient peripheral tissue perfusion C) Ineffective coping related to physical limitations D) Imbalanced nutrition: less than body requirements
A
The nurse is caring for a school-age child newly diagnosed with type 1 diabetes mellitus. Which nursing action supports the 2020 National Health Goals to reduce the long-term complications from this disease process? A) Schedule the child and parents to attend diabetes education classes. B) Explain how the child's physical abilities will be affected during school. C) Recommend homeschooling so the mother can provide the needed medications. D) Discuss admission to a rehabilitation facility to learn self-care with this disease process.
A
The nurse is caring for an 8-month-old baby diagnosed with spastic cerebral palsy. Which assessment finding supports this medical diagnosis? A) The child has a strong Moro reflex when startled. B) The child bears weight on both feet when held upright. C) The child cries when held in a ventral suspension position. D) The child holds the back very straight when in a sitting position.
A
The nurse is completing the health history of a 6-month-old baby with retinoblastoma with the child's parents. Which symptom should the nurse expect that the parents have observed? A) One pupil appears white. B) The infant tugs and pulls at one ear. C) The infant's eye appears to be protruding. D) The infant always keeps her eyes tightly closed.
A
The nurse is evaluating teaching provided to the mother of a child with celiac disease. Which type of breakfast indicates that instruction has been effective? A) Eggs and orange juice B) Oat cereal and skim milk C) Wheat toast and grape jelly D) Rye toast and peanut butter
A
The nurse is planning care for a school-age child diagnosed with growth hormone deficiency. Which diagnosis should the nurse select to help the patient with this health problem? A) Risk for situational low self-esteem related to short stature B) Ineffective tissue perfusion related to infantile blood vessels C) Impaired skin integrity related to overproduction of melanin D) Risk for self-directed violence related to oversecretion of epinephrine
A
The nurse is preparing an educational session for community members that focuses on the 2020 National Health Goals. Which information should the nurse include to ensure a healthy musculoskeletal system? A) Importance of daily exercise B) Early diagnosis of painful joints C) Need for at least 8 hours of sleep D) Ensure an adequate intake of calcium
A
The nurse is preparing teaching materials for a family whose child is prescribed somatropin (Humatrope) for a growth hormone deficiency. What should the nurse instruct the parents about the administration of this medication? A) This medication must be given by injection. B) This medication must be given in the morning before school. C) Hip or knee pain is an expected adverse effect of this medication. D) This medication does not interact with any other types of medication.
A
The nurse is preparing to administer activated charcoal to a 4-year-old child who accidentally ingested a family member's heart medication. What should the nurse do to reduce the discomfort from this treatment? A) Insert a nasogastric tube. B) Mix the charcoal in milk. C) Obtain an order for an indwelling urinary catheter. D) Bring an intravenous infusion for fluid replacement.
A
The nurse is preparing to post a sign above the crib of an infant with a Wilms tumor. Which statement should the nurse post immediately? A) "Do not palpate abdomen." B) "No intramuscular injections." C) "No milk or milk products allowed." D) "No blood sampling in lower extremities."
A
The nurse is working with a school district to ensure students do not develop food-borne illnesses. Which intervention should the nurse emphasize that supports the 2020 National Health Goals regarding food preparation? A) Refrigerate foods promptly. B) Provide fresh fruits and vegetables. C) Ensure all students are appropriately immunized. D) Examine the number of students who contract food-borne illnesses.
A
What should the nurse teach the parents of a child with tetralogy of Fallot to do if the child suddenly becomes cyanotic and dyspneic? A) Place in a knee-chest position. B) Lie prone and maintain the airway. C) Lie supine with the head turned to one side. D) Place in a semi-Fowler's position in an infant seat.
A
While receiving a transfusion of packed red blood cells, a school-age child begins to experience itchy skin, hives, and wheezes. What should the nurse do first for this child? A) Stop the transfusion. B) Obtain a blood culture. C) Slow the transfusion rate. D) Provide a diuretic as prescribed.
A
A toddler weighing 22 lb with hemophilia A fell down several steps and sustained a knee injury. The parents have been instructed to provide the child with an infusion of factor VIII concentrate, one bag per 5 kg of body weight. How many bags of the concentrate will the parents infuse into the child? (Calculate to the nearest tenth decimal point.)
2 bags
A preadolescent weighing 99 lb is prescribed carbamazepine (Tegretol) 10 mg/kg per 24 hours in two divided doses. How much medication will the nurse provide the patient for one dose? (Enter numeric response only.)
225 mg
A child with leukemia is prescribed to receive ondansetron hydrochloride (Zofran) 0.15 mg/kg intravenously prior to receiving the first dose of chemotherapy. The child weighs 55 lb. How many milligrams of the medication should the nurse provide to the child? (Numeric value only. Calculate to the nearest tenth decimal point.)
3.8 mg
The nurse is caring for a child with a closed head injury. The child's blood pressure is 120/58 mmHg, and intracranial pressure is 16 mmHg. What is this child's cerebral perfusion pressure? (Enter numeric value only. Calculate to the nearing hundredth decimal point.)
84.67 MAP would be calculated as being (120 - 58) / 3 + 80 = 100.67. 100.67 - 16 = 84.67
A 2-month-old infant experiencing severe diarrhea is prescribed intravenous fluid replacement. Before adding potassium to this solution, which assessment should the nurse make? A) Is voiding B) Is sleeping C) Is crying with tears D) Hands are restrained
A
A child with leukemia is receiving methotrexate for therapy. Which nursing diagnosis should the nurse use to best guide this patient's care at this time? A) Impaired oral mucous membrane related to effects of chemotherapy B) Risk for impaired mobility related to depressant effects of methotrexate C) Excess fluid volume related to effect of methotrexate on aldosterone secretion D) Risk for self-directed violence related to effect of methotrexate on central nervous system
A
A female patient asks the nurse why she is always asked if she is pregnant before having an X-ray. What should the nurse explain to the patient? A) "Radiation to a fetus can cause a malignancy." B) "It is just something that we are expected to do." C) "It identifies how much radiation your body can stand." D) "It determines how long you can be in the radiation room."
A
The nurse is explaining to the parents of a school-age child with type 1 diabetes mellitus how the health care provider determines the daily insulin dose. The child is prescribed to receive 0.5 units/kg of body weight of intermediate-acting and short-acting insulin at the ratio of 2:1. Because the child weighs 66 lb, how many units of the short-acting insulin will the health care provider prescribe? (Enter numeric value only.)
5 units
A school-age child weighing 55 lb is prescribed to receive 15 ml/kg of packed red blood cells. If the child is to receive 10 ml/kg/hr, how many hours will it take to infuse the prescribed amount of blood for this patient? (Calculate to the nearest 10th decimal point.)
1.5 hours
The nurse is caring for a school-age child recovering from an allogeneic stem cell transplant. What should the nurse do to ensure the child does not develop an infection after the transplant? (Select all that apply.) A) Restrict all visits from other children. B) Provide sterilized age-appropriate play materials. C) Send for total body irradiation immediately after the transplant. D) Make arrangements for schoolwork to be delivered to the hospital. E) Encourage eating raw vegetables for each meal after the procedure.
A,B
The nurse is caring for a preschool-age child who survived near drowning. Which interventions should the nurse plan to promote optimum respiratory functioning for this patient? (Select all that apply.) A) Turn and reposition every 2 hours. B) Administer antibiotics as prescribed. C) Auscultate lung sounds every 2 to 4 hours. D) Monitor cardiac rhythm and blood pressure. E) Encourage deep breathing and incentive spirometry every hour.
A,B,C,E
The mother of a 3-month-old infant is distraught because the child vomits after every feeding. After an assessment, the nurse determines that the infant is experiencing regurgitation and not vomiting. What did the nurse assess in the infant? (Select all that apply.) A) Slight sour smell B) Occurs after a feeding C) Accompanied by prolonged crying D) Runs out of the mouth with no force E) Volume amount similar to entire stomach contents
A,B,D
The nurse has been asked to participate in a community health teaching session. Which interventions should the nurse include to help achieve the 2020 National Health Goals to reduce the incidence of anemias? (Select all that apply.) A) Explain the importance of healthy eating for adolescent participants. B) Instruct pregnant women to take iron supplementation as prescribed. C) Emphasize ways to reduce unintentional injuries at home, work, and play. D) Review foods that are rich in iron that should be a part of school-age children's diets. E) Examine strategies for elderly community members to improve the quality of life.
A,B,D
A child being treated for leukemia is diagnosed with neutropenia. What should the nurse instruct the parents and child to prevent infections? (Select all that apply.) A) Avoid large crowds. B) Inspect the skin daily for scratches or scrapes. C) Increase the intake of fresh fruits and vegetables. D) Remove house plants, flowers, and goldfish from the home environment. E) Stay away from people who have obvious colds, rashes, or other infections
A,B,D,E
The nurse is instructing the mother of a school-age child with a leg cast about cast care at home. What should the nurse include in this teaching? (Select all that apply.) A) Cover the cast with a plastic bag to bathe. B) Remind that nothing is to be put down the cast. C) Recommend using magic markers for autographs. D) Use the cool setting on a hair dryer to ease itchy skin. E) Encourage usual activities but restrict strenuous actions.
A,B,D,E
The nurse is planning a program for community family members that focuses on the 2020 National Health Goals to improve cardiovascular health. Which content should the nurse include in this program? (Select all that apply.) A) Measures to reduce obesity B) Importance of daily exercise C) Starting reduced-fat diets upon birth D) Engaging in stress-reduction activities E) Following a diet that supports heart function
A,B,E
A mother caring for a school-age child with type 1 diabetes mellitus is frantic because the child self-administered 15 units of regular insulin instead of the prescribed 5 units before breakfast this morning. What should the nurse instruct the mother to do at this time? (Select all that apply.) A) Observe for nervousness, weakness, dizziness, or sweating. B) Determine if the child is experiencing extreme hunger and thirst. C) Determine if the child is irritable or demonstrating stubbornness. D) Provide the child with a half-glass of orange juice or regular soda. E) Rub a small amount of honey on the child's gums and inside of the cheek.
A,C,D,E
An 18-month-old child is diagnosed with insufficient platelets. What should the nurse instruct the parents to reduce the risk of the child bleeding when at home? (Select all that apply.) A) Check that all toys have soft corners. B) Engage in limited amounts of rough play each day. C) Ensure mouth care is performed with a soft toothbrush. D) Do not apply Band-Aids or adhesive tape onto the skin. E) Pad the side and crib rails on the bed at home to prevent bruising.
A,C,D,E
The nurse is completing the health history for the parents of school-age child admitted with a ruptured spleen. For which activity should the nurse assess as the possible cause for this child's injury? A) Shooting pool B) Skateboarding C) Playing baseball D) Playing basketball
B
The nurse is evaluating the effectiveness of teaching provided to the parents of a school-age child prescribed liquid ferrous sulfate (Feosol) for iron-deficiency anemia. Which observations indicate that teaching has been effective? (Select all that apply.) A) Mother places medication in orange juice. B) Mother provides medication with a glass of milk. C) Child observed consuming fresh raw fruit and drinking water. D) Mother provides liquid-prepared medication to the child with a straw. E) Child goes to the bathroom to brush teeth immediately after taking the medication
A,C,D,E
The nurse suspects that an infant is experiencing intussusception. What did the nurse assess in this infant? (Select all that apply.) A) Crying as if in severe pain B) Pulse rate of 78 beats/min and irregular C) Sudden drawing up of the legs D) Vomit that looks like currant jelly E) Leg drawing up and crying repeats every 15 minutes
A,C,D,E
The nurses caring for children on an oncology unit are planning an open-house presentation on cancer prevention actions to support the 2020 National Health Goals. Which topics should the nurses include in their presentation? (Select all that apply.) A) Teaching testicular self-examination B) The need to take vitamin supplements every day C) The importance of getting adequate rest and daily exercise D) Explaining the reasons to avoid excessive sun exposure E) The importance of frequent health assessments to identify the symptoms of leukemia
A,D,E
A baby is born with ambiguous genitalia. What should the nurse emphasize when discussing this with the parents? A) Ambiguous genitalia result from hypothalamus stimulation. B) The child's true sex can be determined by a genetic karyotype. C) Ambiguous genitalia will develop fully with estrogen therapy. D) All children with ambiguous genitalia are chromosomally female.
B
A child with extensive burns is permitted to eat. Which nutrient should the nurse ensure is of a high amount when the child's meals are being prepared? A) Fats B) Protein C) Minerals D) Carbohydrates
B
A preadolescent girl with scoliosis is prescribed a body brace. What should the nurse teach the child about the purpose of the brace? A) Prevents torticollis B) Improves spinal stability C) Corrects spinal curvature D) Prevents herniation of a spinal disk
B
A school-age girl is diagnosed as having Cushing syndrome from long-term therapy with oral prednisone. What assessment finding is consistent with this patient's diagnosis and treatment? A) Child appears pale and fatigued. B) There are purple striae on the abdomen. C) The child is excessively tall for chronologic age. D) The child is demonstrating signs of hypoglycemia.
B
A toddler is diagnosed with osteomyelitis. What should the nurse anticipate as a priority intervention when planning this child's care? A) Assisting the child with crutch walking B) Maintaining intravenous antibiotic therapy C) Keeping the child quiet while in skeletal traction D) Restricting fluid to encourage red cell production
B
An infant is prescribed digoxin. What should the nurse explain to the parents regarding the action of this medication? A) Increases the heart rate B) Slows and strengthens the heartbeat C) Thickens the walls of the myocardium D) Prevents subacute bacterial endocarditis
B
Before discharging a school-age child being treated for a snake bite, the nurse instruct ways to prevent additional bites in the future. Which statement indicates that teaching provided to this child has been effective? A) "I should wear long pants when out of doors." B) "I should look at rocks before touching them." C) "I should poke a snake with a stick before touching it." D) "I should spray a snake with water before picking it up."
B
The nurse is assessing pupil size and reaction to light in a child with a cervical neck injury. Which cranial nerve is the nurse assessing in this patient? A) II (optic) B) III (oculomotor) C) IV (trochlear) D) VI (abducens)
B
The nurse is planning care for a preschool-age child diagnosed with meningitis. What should the nurse identify as a priority goal for this patient's care? A) Inspect the teeth for obvious caries. B) Reduce the pain related to nuchal rigidity. C) Provide an opportunity for therapeutic play. D) Increase stimulation opportunities to prevent coma.
B
The nurse is planning care for a preschool-age child with spastic cerebral palsy. Which nursing diagnosis should the nurse identify to guide care for this patient's musculoskeletal status? A) Risk for self-care deficit related to impaired mobility B) Risk for disuse syndrome related to spasticity of muscle groups C) Impaired verbal communication related to neurologic impairment D) Risk for delayed growth and development related to activity restriction
B
The nurse is planning teaching for the parents of a child with Legg-Calvé-Perthes disease. On what should the nurse emphasize when conducting this teaching? A) Surgery is needed with supporting rods. B) The child will have a non-weight-bearing period. C) The child will need passive range-of-motion exercises three times a day. D) The child will need to exercise to increase muscle strength of the knee joint.
B
The nurse is preparing to send a child with cancer for a radiation treatment. Which medication should the nurse provide to premedicate the child for this procedure? A) Analgesic B) Antiemetic C) Antipyretic D) Antineoplastic
B
The nurse notes that a child with a burn injury is prescribed daily debridement. What should the nurse instruct the child and parents about the purpose of this treatment? A) Relieves pain B) Prevents infection C) Maintains mobility of extremities D) Decreases the need for skin grafts
B
The parents of a child having a cardiac catheterization are waiting to see the child after the procedure. What should the nurse instruct the parents to expect when seeing the child for the first time? A) The child will be sleeping for at least 8 hours. B) A bulky pressure dressing will be present over the insertion site. C) The child will have bruising over the upper and lower extremities. D) The child will be on seizure precautions and have padded side rails.
B
Which health teaching concept should the nurse emphasize when instructing the parents of a child with polycythemia caused by a congenital heart disorder? A) Prepare for seizures. B) Prevent dehydration. C) Expect the skin to turn yellow. D) Encourage progressive activity.
B
The school nurse is planning a presentation to be given during the next parent/teacher conference to include the 2020 National Health Goals to prevent unintentional injuries in children. What should the nurse include in this presentation? (Select all that apply.) A) Legal aspects of child abuse B) Recognize signs of self-injury C) Provide information on home safety D) Ways to determine intentional injuries E) Emphasize safety with sports activities
B,C,D,E
The nurse is instructing a female adolescent about the medication leuprolide acetate (Lupron Depot-Ped), which has been prescribed to reduce the level of testosterone. What should the nurse include when teaching the patient about this medication? (Select all that apply.) A) Inject in the same region every month. B) Ensure effective birth control if sexually active. C) Transfer the medication into another syringe before injecting. D) Mark on a calendar when the injections are needed every 3 months. E) Notify the health care provider if nausea and vomiting occurs after taking the medication.
B,D
The nurse is planning a program for a community that focuses on the 2020 National Health Goals for neurologic health. Which topics should the nurse include in this presentation? (Select all that apply.) A) Ensuring a diet adequate in vitamins and protein B) Use of helmets for bicycle and motorcycle safety C) Learning the signs and symptoms of inflammatory disorders D) Practicing good hand washing technique and infection control E) Importance of proper emergency care to protect the head and neck
B,D,E
A 1-month-old infant is diagnosed with gastroesophageal reflux. Which intervention should the nurse teach the mother to help with the symptoms of this disorder? A) Hold in a horizontal position while feeding. B) Place on the back immediately after feeding. C) Feed with formula thickened with rice cereal. D) Administer prescribed medications before each feeding.
C
A 14-year-old child is brought into the emergency room with manifestations consistent with a ruptured appendix. What is the first action that the nurse should take in the care of this child? A) Apply oxygen. B) Position flat in bed. C) Place in the semi-Fowler's position. D) Insert an indwelling urinary catheter.
C
A 2-year-old child is diagnosed with lead poisoning caused by eating paint chips from a windowsill. What measure should the nurse instruct the parents to prevent this from occurring in the future? A) Teaching their daughter that paint is not an edible substance B) Not allowing their daughter any milk products during daylight hours C) Covering the windowsills with paneling to prevent her from reaching them D) Administering ipecac syrup the next time they see her eat a paint chip
C
A child with a head injury is demonstrating signs of cognitive deficits. The parents are concerned about how well the child will recover. Which nursing diagnosis should the nurse identify as the most appropriate for the family at this time? A) Anxiety related to extent of required hospitalization B) Risk for long-term learning deficits related to head injury C) Parental fear related to outcome after head injury in child D) Ineffective coping related to care of a child with a head injury
C
A newborn is diagnosed with coarctation of the aorta. Which assessment should the nurse make when caring for this infant? A) Observing for excessive crying B) Auscultating for a cardiac murmur C) Assessing for the presence of femoral pulses D) Recording an upper extremity blood pressure
C
A preschool-age child has been experiencing severe vomiting for over 24 hours. The child's respiratory rate is currently 10 breaths/min. On which health problem will the nurse focus when caring for this child? A) Overhydration B) Metabolic acidosis C) Metabolic alkalosis D) Hypertonic dehydration
C
An 18-month-old child is admitted with signs of increased intracranial pressure. What should the nurse observe when assessing this patient? A) Numbness of fingers and decreased temperature B) Increased pulse rate and decreased blood pressure C) Increased temperature and decreased respiratory rate D) Decreased level of consciousness and increased respiratory rate
C
An 8-year-old female child has been diagnosed with precocious puberty. When teaching the parents about this diagnosis, what should the nurse include as a priority? A) "The child will be unable to have children." B) "The child will need psychological counseling." C) "The child is physically able to become pregnant." D) "The child will not need medication to suppress further development."
C
An adolescent female is experiencing dysmenorrhea. What should the nurse teach the patient to help with this disorder? A) Take acetaminophen (Tylenol). B) Restrict fluid when having pain. C) Take over-the-counter ibuprofen. D) Use ice to help in reducing inflammation and pain.
C
An infant is brought to the emergency department with acetaminophen poisoning. Which medication should the nurse expect to administer to this child? A) Iron B) Deferoxamine C) Acetylcysteine D) Dexamethasone
C
The mother of a high school football player diagnosed with osteosarcoma of the femur is angry because she did not want him to play football. Which health teaching point should the nurse include in the teaching plan for the patient and mother? A) Tumor growth is more related to a dislike of milk. B) Osteosarcoma often follows trauma, such as a football injury. C) Football injuries do not contribute to the development of a tumor. D) The patient can expect some discoloration of his leg following chemotherapy.
C
The nurse is assessing the heart rate of a child with a congenital heart defect. What should the nurse document when a pulse of one strong beat and one weak beat is assessed? A) Dicrotic pulse B) Thready pulse C) Pulsus alternans D) Water hammer pulse
C
The nurse is caring for a 4-year-old child with acute lymphocytic leukemia (ALL). Why should the nurse assess this child's temperature using the axillary route instead of a rectal temperature? A) The child has anemia. B) The child is prone to diarrhea. C) The child has a low platelet count. D) The child has a low white blood cell count.
C
The nurse is caring for a child with chest tubes inserted after heart surgery that are attached to an underwater-seal drainage system. For which reason should the nurse prepare to clamp the chest tubes? A) The child is coughing. B) A clot obstructs the tubing. C) A tube becomes disconnected. D) Red-stained drainage appears in a tube.
C
The nurse is caring for a newborn diagnosed with patent ductus arteriosus. Which finding will the nurse assess that is consistent with this diagnosis? A) Slow heart rate B) Expiratory grunt C) Wide pulse pressure D) Absent femoral pulses
C
The nurse is instructing the parents of a child with sickle-cell anemia on safety precautions. What should the nurse emphasize during this teaching? A) Suggest the child participate in sports activities without restriction. B) Treat upper respiratory infections with over-the-counter medication. C) Ensure a consistent and daily intake of adequate fluids to prevent dehydration. D) Remind to avoid immunizations to prevent the introduction of bacteria into the body.
C
The nursing is planning care for a child recovering from neck surgery for rhabdomyosarcoma. Which outcome suggests the best long-term prognosis for this patient? A) The child tolerates chemotherapy to treat the tumor and on the neck and lungs. B) The child tolerates radiation for neck tumor and tumor found in the colon and liver. C) The child tolerates chemotherapy provided after complete removal of the neck tumor. D) The child tolerates chemotherapy every 4 weeks for 24 months to eradicate inoperable tumor
C
A mother, distressed to learn that her school-age child is diagnosed with type 2 diabetes mellitus, asks the nurse how this could happen because no one in the family has diabetes. What should the nurse explain to the mother? A) "This is caused by the pancreas not making enough insulin." B) "This disorder usually occurs when inadequate calories are ingested on a regular basis." C) "Because this disorder is genetic, someone in the family will eventually develop the illness." D) "This disorder is associated with overweight and eating a diet high in fats and carbohydrates."
D
A school-age child is scheduled for a bone marrow aspiration to confirm the diagnosis of aplastic anemia. What should the nurse instruct the child about this procedure? A) Leg pain will occur after the procedure. B) It will be done under general anesthesia. C) A narrow needle is used so there is no pain. D) The patient will have to lie on the stomach for the procedure.
D
A school-age child with pauciarticular juvenile arthritis has extreme pain upon waking in the morning. Which intervention should the nurse suggest the parents try to help the child with the pain? A) Encourage bed rest until the pain is gone. B) Perform isotonic exercises until the pain is gone. C) Provide 325 mg of aspirin immediately on arising. D) Encourage a warm bath each morning before school.
D
It is determined that a preschool-age child developed anemia after exposure to an insecticide. What should the nurse teach the parents before the child is discharged from the hospital? A) Schedule weekly chelating treatments. B) Provide the child with a high-protein diet. C) Schedule hospital visits to desensitize the child to the insecticide. D) Ensure that the child has no further exposure exposed to the insecticide.
D
The cardiac monitor of a child recovering from heart surgery alarms, and the nurse finds the child without a heartbeat. What should the nurse do first? A) Apply oxygen. B) Establish an airway. C) Begin rescue breathing. D) Begin cardiac compressions
D
The nurse instructs a preadolescent child with type 1 diabetes mellitus how to self-administer an injection of short-acting and long-acting insulin. Which observation indicates to the nurse that teaching has been successful? A) Administers the insulin intramuscularly B) Wipes off the needle with an alcohol swab C) Administers the insulin at a 30-degree angle D) Draws up the short-acting insulin into the syringe first
D
The nurse instructs the parents of a child with a congenital heart disorder on the administration of digoxin at home. Which observation indicates that teaching has been effective? A) The father provides a dose of the medication after the baby spits it up. B) The father provides a dose of the medication at the conclusion of a feeding. C) The mother feels for a radial pulse before giving the baby the next scheduled dose. D) The mother provides a dose of the medication 1 hour before the next scheduled feeding.
D
The nurse is advising a group of new parents on how to care for their infant at home if the baby develops mild diarrhea. Which statement indicates that teaching has been effective? A) "I should offer milk after each episode of diarrhea." B) "I should take the baby's temperature and call my physician." C) "I could give Kaopectate as long as I follow the directions on the bottle." D) "I should offer Pedialyte after 1 hour and frequently thereafter to prevent dehydration."
D
The nurse is caring for a preschool-age child recovering from a lumbar puncture. What should the nurse do to ensure the patient does not develop a spinal headache? A) Measure temperature every hour. B) Restrict fluids for 2 hours after the procedure. C) Elevate the head of the bed to a 30-degree angle. D) Take the pillow away and have the patient lie flat in bed
D
The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which nursing diagnosis should the nurse use to guide care during the immediate postoperative period? A) Anxiety related to new feeding method used postoperatively B) Ineffective tissue perfusion related to pressure on heart chambers C) Excess fluid volume related to increased fluid intake prescribed postoperatively D) Risk for infection of incision line, related to disruption of skin barrier during surgery
D
The nurse is concerned that a school-age child has iron-deficiency anemia. What did the nurse assess in this patient? A) Shyness B) Thumb-sucking C) Asks many questions D) Craving for ice cubes
D
The nurse is planning care for a 12-year-old child diagnosed with hyperthyroidism. Which issue should the nurse anticipate that this child will experience while attending school? A) Inability to fit legs under a school desk B) Noncomprehension of written material C) Increase in sleepiness by the end of the day D) Inability to submit neat handwriting assignments
D
The nurse is planning care for a school-age child recovering from being hit by a motor vehicle while riding a bicycle home from school. For what will the nurse assess to determine the onset of disseminated intravascular coagulation in this child? A) Blurred vision B) Nausea and vomiting C) Sudden onset of knee pain D) Bleeding from intravenous sites
D
The nurse is planning care for an 8-month-old infant with a ventricular septal defect. Which nursing diagnosis should the nurse use to help guide the care for this patient? A) Impaired gas exchange related to a right-to-left shunt B) Impaired skin integrity related to poor peripheral circulation C) Ineffective airway clearance related to altered pulmonary status D) Ineffective tissue perfusion related to inefficiency of the heart as a pump
D
The nurse receives report from the admission department that a child with a slipped femoral epiphysis is en route to the care area. For which type of child should the nurse begin to plan care? A) Tall, thin female B) Preadolescent female C) Active school-age male D) Obese preadolescent male
D
Which action should the nurse implement for an infant who develops heart failure? A) Restricting daily milk intake B) Keeping in a supine position C) Planning ways to reduce salt intake D) Placing in a semi-Fowler's position
D
Which of the following nursing diagnoses would best apply to a child during the acute phase of rheumatic fever? A) Disturbed sleep pattern related to hyperexcitability B) Ineffective breathing pattern related to cardiomegaly C) Risk for self-directed violence related to development of cerebral anoxia D) Activity intolerance related to inability of heart to sustain extra workload
D
While assessing a school-age child with a brain tumor after morning report, the child has an episode of projectile vomiting. What should the nurse do to help the child? A) Hold the child's breakfast tray. B) Administer an antiemetic as prescribed. C) Provide a cool compress for the forehead. D) Provide a snack until the breakfast tray arrives.
D
