EXIT K 7
The nurse is giving nutritional counseling to the parents of an 8-month-old infant. Which statement does the nurse include in the counseling?
"Avoid peanuts and eggs in your baby's diet."
. The mother of an adolescent asks the nurse, "What's the best way to remove a tick from the skin?" What is the best response by the nurse?
"Remove the tick carefully with tweezers."
How many teeth does a 10-month-old infant usually have? Record your answer using a whole number.
10 − 6 = 4
A nurse is teaching a 12-year-old child with type 1 diabetes about the effects of Novolin N insulin. If the child receives this insulin at 7:30 am, at what time of day is an insulin reaction likely to occur?
2:30 pm
One minute after birth a neonate's heart rate is 106 beats/min; acrocyanosis and muscle tone with flexion are observed; flicking the sole triggers crying; and the cry is strong. What is the neonate's Apgar score? Record your answer using a whole number.
9
The nurse is assisting in sports physicals of junior high students. Which finding would prompt the nurse to ask whether a student has a history of diabetes?
A velvety darkening of the skin around the neck
When assessing a neonate and mother after a vaginal delivery, the nurse finds that the neonate's blood group is B positive and mother's is AB negative. The nurse also finds that the mother is negative to Coombs' test. What is the appropriate intervention in this situation?
Administer RhoGAM intramuscularly to the mother within 72 hours of delivery.
A nurse is caring for an infant whose vomiting is intractable. Which complication is most likely to occur?
Alkalosis
A nurse is interviewing an adolescent who is to start a chemotherapeutic drug regimen that includes vincristine. Which side effect is it most important for the nurse to prepare the adolescent to expect?
Alopecia
Which stage of Freud's psychosexual development theory does the nurse observe in a 3-year-old child?
Anal stage
The nurse assesses a patient and determines that she has achieved thelarche. What clinical finding prompted the nurse's report?
Appearance of breast buds
An adolescent experiencing a vaso-occlusive crisis reports right knee pain. What is the most appropriate nursing intervention?
Applying a warm soak to the knee
The nurse is teaching the parents of an infant who will have frequent cast changes about cast care. What suggestion should be included in the teaching?
Assess the skin at the edges of the cast.
What is the priority of nursing care for an infant with a newly applied spica cast?
Assessing the child's peripheral circulation
How can a nurse best accomplish therapeutic communication with an adolescent
By establishing a relationship over time
A nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How should the nurse test cranial nerve XI?
By telling the adolescent to shrug the shoulders
When planning long-term care for a 2-year-old child with cerebral palsy (CP), it is important for the nurse to consider that:
CP is not progressively degenerative
Which finding indicates that a newborn has vernix caseosa
Cheese-like substance on the skin
When assessing the typical characteristics of an infant with Down syndrome, for which other congenital anomaly should the nurse be alert?
Congenital heart defect
What is nurse's priority action when caring for a child with acute laryngotracheobronchitis?
Continually assessing the respiratory status
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most appropriate action by the nurse?
Continuing to observe the seizure
he parent of a child who has received all of the primary immunizations asks the nurse which ones the child should receive before starting kindergarten. The nurse tells the parent that her child should receive:
DTaP, IPV, MMR.
A nurse reviews the diet with the parents of a toddler with recently diagnosed celiac disease. What foods selected by the parents indicate that further teaching is needed?
Frankfurters and baked beans
A 3-month-old infant who has a 3-day history of diarrhea is admitted to the pediatric unit. The nurse obtains the infant's vital signs, performs a physical assessment, and reviews the infant's arterial blood gas results. Which acid-base imbalance does the nurse suspect?
Metabolic acidosis
A nurse is caring for an adolescent in the postanesthesia care unit. What action should the nurse take to ensure accuracy of a pulse oximeter reading?
Placing the probe on a finger or earlobe
A nurse is caring for a 13-year-old child who has an external fixation device on her leg. What is the nurse's priority goal when providing pin care?
Preventing infection
A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth?
Putting the naked newborn on the mother's skin and covering the infant with a blanket
A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease (congenital aganglionic megacolon). What procedure does the nurse expect to be used to confirm the diagnosis?
Rectal biopsy
Surgery to correct hypertrophic pyloric stenosis is performed on a 3-week-old infant who has been fed formula. Which postoperative feeding regimen is most appropriate?
Regular formula feeding within 24 hours of the surgery
An infant is receiving intermittent nasogastric tube feedings. In what position should the nurse place the infant?
Semi-Fowler
A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?
Tachycardia
The nurse manager of a home health care agency is teaching a group of nursing assistants about pica. Which age group is most likely to engage in this practice?
Toddlers
If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already?
Two doses of diphtheria, tetanus, and pertussis vaccine
A 17-year-old adolescent was recently found to have type 2 diabetes mellitus. What information will the nurse include when providing education to the family?
"The most important interventions are good nutrition and portion control.
At 5 minutes after birth a neonate's heart rate is 120 beats/min, the cry is weak, the body color is pink, the extremities are flexed with brisk movement, and the neonate grimaces when stimulated. What is the neonate's Apgar score? Record your answer using a whole number.
8
The nurse prepares to discharge a newborn from the hospital. Which action taken by the father indicates an understanding of the nurse's education regarding car seat safety? The father places the infant in the:
Back seat, facing backward
After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our son have to have restraints?" How should the nurse respond?
Because we're keeping the arms straight your baby won't be able to touch his mouth."
During assessment, the nurse asks a patient about developmental milestones such as the age at which thelarche and menarche occurred. The nurse determines that the patient experienced pubertal delay. Which finding in the patient support
Breast development occurred by 15 years of age.
Which of the following combinations of foods should the nurse encourage a child with glomerulonephritis to choose for a meal?
Corn, roast chicken, peach
An infant is born with exstrophy of the bladder. The parents are concerned and confused when they are told that their infant will need surgery. What nursing intervention will best help the infant's parents?
Demonstrating the same manner of care for the infant as for other infants on the unit
An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply.
Difficulty swallowing Loss of bladder control
The parents of an 11-year-old child with a terminal illness appear overwhelmed and anxious. What is the best response by the nurse?
Encouraging the parents to express their feelings.
Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly?
Encouraging them to express their concerns
While caring for a pregnant patient with body mass index of 32 during labor, the nurse observes that the second stage of labor lasts for about 11 minutes. The nurse also finds that the expected birth weight of the fetus is around 4200 g. Which complication does the nurse anticipate in the neonate after birth?
Erb palsy
An infant who underwent revision of a ventriculoperitoneal shunt is found to have meningitis, the result of an infected shunt. What clinical manifestations support this conclusion? Select all that apply.
Fever Lethargy Stiff neck Poor feeding
A nurse explains to the parents of a newborn with developmental dysplasia of the hip (DDH) that the infant most likely will be:
Fitted with a Pavlik harness
An 11-year-old child who recently returned from a camping trip reports chills, fever, and a headache and is taken to the clinic by the parents. What is most important for the nurse to assess initially during the child's history and physical examination? Select all that apply
History of allergies/ Duration of clinical findings.
A neonate is returned to the pediatric surgical unit after repair of a myelomeningocele. What priority assessments should be performed in the immediate postoperative period for this infant? Select all that apply.
Incision, for signs of CSF leak Urinary bladder, for distention Vital signs, for signs of infection Head circumference, for increase
A nurse is assessing the oral cavity of a 6-month-old infant. The parent asks which teeth will erupt first. What is the nurse's response?
Incisors
A school nurse teaches a 13-year-old child with hay fever that the prescribed phenylephrine (Neo-Synephrine) nasal spray must be used exactly as directed. What complication may occur if the nasal spray is used incorrectly?
Increased nasal congestion
A teenager with allergies is using oxymetazoline (Afrin) nasal spray. What effect should the nurse assess the client for if more than the recommended dose is taken?
Increased nasal congestion
.A nurse is assessing an adolescent child with the diagnosis of hemophilia. In what part of the body does the nurse expect bleeding to occur?
Joints
A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care?
Maintain standard and contact precautions
What is the most appropriate play activity for a preschooler whose hand is immobilized during IV therapy?
Manipulating jigsaw puzzles
An infant with hydrocephalus has a ventriculoperitoneal shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure?
Monitoring the infant for increasing intracranial pressure
An adolescent arrives at the clinic reporting buzzing in the ears. What assessment data are essential for the nurse to obtain?
Music preferences
A nurse in the family planning clinic reviews the health history of a sexually active 16-year-old girl whose chief concern is a thick, burning vaginal discharge accompanied by low abdominal pain. After her examination, the girl is informed that she may have a sexually transmitted infection (STI) that requires treatment. The adolescent is concerned that her parents will discover that she is sexually active. She asks the nurse whether her parents will be contacted. The nurse explains that her parents will:
Not be contacted, because treatment at the clinic is confidential
A 4-month-old infant is on nothing-by-mouth status in preparation for surgery. What should the nurse do when the infant starts crying?
Offer a pacifier.
An infant is admitted to the hospital with gastroenteritis. The infant vomits shortly after admission. Under standard precautions, what protective equipment should the nurse wear when cleaning the infant after the vomiting episode?
Pair of gloves
What is most important for a nurse to teach the parents of a child with Duchenne muscular dystrophy to do for their school-aged child?
Perform range-of-motion exercises.
A nurse is assessing the condition of a school-aged child with acute glomerulonephritis. What clinical finding does the nurse anticipate?
Periorbital edema
ministering vincristine to a school-aged child with leukemia. For which toxic effect should the nurse assess the child as long as the medication is being administered?
Peripheral neuropathy.
A 4-year-old child is receiving prednisone. Which immunizations are safe for the child to receive? Select all that apply.
Pertussis Inactivated poliovirus Tetanus immune globulin
Which fine motor skill will be seen in a 10-month-old infant?
Picking up finger foods
-Which fine motor skill will be seen in a 10-month-old infant?
Picking up finger foods.
What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure?
Providing small, frequent feedings
During a vaccination drive at a well-child clinic, a nurse notes that a recently hired nurse is not wearing gloves while vaccinating an infant. What should the nurse advise the newly hired nurse to do?
Put on gloves because standard precautions are required
Which screening report will help the nurse determine skeletal growth in a child?
Radiographs of the hand and wrist
A nurse is assessing a school-age child with cystic fibrosis. What complication of frequent stools and tenacious mucus does the nurse anticipate?
Rectal prolapse.
A nurse is assessing an adolescent after the administration of epinephrine. What side effect is most important for the nurse to identify?
Tachycardia
An adolescent is admitted to the hospital in respiratory distress, and the health care provider orders oxygen at 40% by way of a Venturi mask. The instructions for the Venturi mask indicate that delivery of 4 L/min equals 24% to 28% oxygen, delivery of 8 L/min equals 35% to 40% oxygen, and 12 L/min equals 50% to 60% oxygen. Mark where the ball of the flow meter should be raised to deliver the percentage of oxygen ordered by the health care provider.
The ball of the oxygen flowmeter should be set at 8 L/min to deliver 40% oxygen through the Venturi mask.
Which behavior of a 3-year-old child indicates delayed development? Select all that apply.
The child is unable to feed himself. The child is unable to climb the stairs
When assessing the reflexes of a 4-month-old infant, the nurse observes that the infant is extending an arm to the side while the head is turned. Which reflex does the nurse observe?
Tonic neck reflex
A child who has been undergoing prolonged steroid therapy takes on a cushingoid appearance. What will the nursing assessment probably reveal? Select all that apply.
Truncal obesity Thin extremities
In which muscle should a nurse administer an intramuscular injection to a 2-month-old infant?
Vastus lateralis
A nurse in the pediatric clinic is taking the health history of a toddler with an exacerbation of eczema. What are the nurse's priority assessments of the child? Select all that apply.
Wearing cotton clothes Tolerance of new foods
A nurse in the pediatric intensive care unit is assessing a 6-month-old infant with bronchiolitis. What physiological responses to this lower respiratory tract infection does the nurse expect? Select all that apply.
Wheezing Sternal retractions Nasal flaring Prolonged expiratory phase
A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse identify as the greatest risk for this infant?
greatest
An infant is admitted to the neonatal intensive care unit with exstrophy of the bladder. What covering should the nurse use to protect the exposed area?
Moist sterile dressing
A nurse in the clinic is obtaining a health history of a 16-year-old boy with a complaint of a thick urethral discharge. What is the most appropriate nursing action to help confirm a tentative diagnosis of gonorrhea?
Obtaining a urethral specimen for a culture
A 4-year-old child who weighs 44 lb is prescribed prednisone. The recommended dosage for children is 2 mg/kg/day given in four divided doses. What should the child receive in each dose? Express your answer as a whole number. ______ mg
10
An adolescent is hospitalized with multiple internal injuries after an automobile collision. The adolescent is being kept NPO and is receiving an IV infusion at 125 mL/hr and an antibiotic reconstituted in 10 mL of normal saline every 6 hours (6 am, 12 pm, 6 pm, 12 am). What is the intake from 7 am to 3 pm? Record your answer as a whole number with no punctuation. ___ mL
1010 mL.
A nurse in the pediatric clinic determines that the pancreatic enzyme replacement being taken by a child with cystic fibrosis is inadequate. What clinical finding supports this conclusion?
Abdominal cramping.
An adolescent child who has sustained full-thickness burns is to undergo skin grafting. The nurse explains to the child's parents that for permanent grafts the child must have:
Autografts
An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do?
Breathe into cupped hands
Two hours after a 1-year-old child with acute laryngitis is admitted to the hospital, the nurse observes increases in the child's respiratory and cardiac rates, increased restlessness, and substernal and intercostal retractions. What action should the nurse take immediately?
Calling the health care provider to report the child's respiratory status
A nurse is assessing the development of an 8-month-old infant. Which behaviors are expected at this stage of development? Select all that apply.
Creeping purposefully Displaying a pincer grasp
After assessing a neonate who was delivered using forceps immediately after birth, the nurse confirms facial paralysis. Which information does the nurse provide to the mother? (picture)
Don't panic; it will resolve within a few days.
After a tonsillectomy, which finding alerts the nurse to suspect the initial stage of hemorrhage?
Frequent swallowing
Which is an inborn error of metabolism that affects growth and development?
Hunter syndrome
An unconscious 16-year-old adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL. What finding does the nurse expect during the initial assessment?
Hyperpnea
A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child?
Hyperpnea.
The parent of a 3-month-old infant asks the nurse about selecting toys for the infant. Which toy should the nurse tell the parent is most appropriate at this age?
Metallic mirror
While assessing an infant, the nurse finds the presence of white, adherent patches on the tongue, palate, and inner aspects of the cheeks. The mother also states that the infant is refusing to suck the milk. Which medication does the nurse expect to be prescribed?
Nystatin (Mycostatin
Discharge planning for a toddler with newly diagnosed celiac disease includes instructions regarding dietary restrictions. What foods should the nurse recommend? Select all that apply.
Oatmeal Ice cream Rice cakes Corn crisps
The nurse is assessing the development of a child and observes family photographs of the child. The nurse finds that the child participates in play as seen in the image. Which type of play interaction does the child participate in as depicted in the image?
Parallel play
A 15-year-old with cystic fibrosis is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barreled-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention?
Performing postural drainage
What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?
Placing a tracheotomy set at the bedside
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?
Placing the child in a private room, restricting ill visitors, and using strict handwashing techniques
The nurse accompanies a 3-year-old child to the playroom. The toddler seems afraid to select a toy or activity. What age-appropriate play materials should the nurse offer? Select all that apply.
Plastic tea set Mold and clay Play telephone
A 7-year-old child with juvenile idiopathic arthritis has difficulty getting ready for school in the morning because of joint pain and stiffness. Which recommendation should the nurse make to the family?
Provide warm, moist heat to the affected joints before arising.
After returning from surgery an infant suddenly becomes cyanotic. What is the nurse's priority intervention?
Suctioning the nasopharynx
A nurse is counseling the family of a child with AIDS. What is the most important concern that the nurse should discuss with the parents?
Susceptibility to infection.
A nurse is assessing a 3-week-old infant who has been admitted to the pediatric unit with hydrocephalus. What finding denotes a complication requiring immediate attention?
Tense anterior fontanel
The parents inform the nurse that their child is often seen daydreaming. What does the nurse inform the parents?
The child is exhibiting normal behavior seen in children.
Why does the nurse recommend that parents give their child food rich in vitamin A
To help the child improve visual acuity
According to Erikson's theory of psychosocial development, which attribute plays an important role in the development of a healthy personality from birth to 1 year of age?
Trust versus mistrust
A school nurse is teaching the parents of school-age children about the importance of immunizations for the childhood communicable diseases. What preventable disease may have the complication of encephalitis?
Varicella.
Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit?
pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L
The nurse is conducting a physical examination of a 2-year-old child and records the child's height as 90 cm. What would be the estimated height of the child as an adult? Record your answer using a whole number. ______ cm
180 cm.
A nurse knows that play is an integral part of a child's social development. Place in order the types of play children engage in as they get older.
Solitary play Parallel play Dramatic play Peer group team play Competitive team play
Which formula is most preferable for a child who has lactose intolerance?
Soy-based formula
A nurse is caring for an infant with bilateral cryptorchidism. While clarifying the need for surgery with the parents, what information does the nurse communicate regarding the child's prognosis if the problem is not corrected?
Sterility upon maturity
The mother of a 5-month-old infant tells the nurse that she has started to feed her baby fortified cereal mixed with formula. She asks in which order she should introduce new foods. What foods should be selected first?
vegetables and noncitrus fruits
During a follow-up visit, the mother of a 10-month-old infant says, "My child lifts one foot to take a step, stands by holding the furniture, but does not attempt to stand alone without support, and walks while holding onto a hand." What is the accurate nursing response in this situation?
"Your child should be able to stand alone in another 2 months.
A 16-year-old adolescent with recently diagnosed type 1 diabetes will receive NPH (Novolin N) insulin subcutaneously. The nurse teaches the adolescent about peak action of the drug and the risk for hypoglycemia. How many hours after the drug does the NPH peak?
4 to 12 hours.
After assessing a newborn infant, the nurse finds that the infant has a heart rate of 90 beats/minute, irregular respirations with a weak cry, limp extremities, sneezing reflex, and a completely pink body. What would be the Apgar score of the child? Record your answer using a whole number. ______
6
The nurse is assessing a newborn immediately after birth. Which finding indicates normal development in a newborn?
A body weight of 3500 g
When teaching an adolescent with type 1 diabetes about dietary management, what instruction should the nurse include?
A ready source of glucose should be available.
What is the priority nursing intervention for a school-aged child with lead poisoning who is undergoing chelation therapy?
Careful monitoring of intake and output.
The nurse is teaching the parents of an 8-month-old infant about oral hygiene in infants. Which action by the parents indicates the need for further teaching?
Giving honey-coated pacifiers to the child
A nurse is reviewing the laboratory report of a 13-year-old child with type 1 diabetes. What test is considered the most accurate in the evaluation of the effectiveness of diet and insulin therapy over time?
Glycosylated hemoglobin
The nurse epidemiologist of a large urban hospital is called to the pediatric unit to provide information about an outbreak of diarrhea caused by Salmonella. Which common foods does the nurse suspect as the cause of the outbreak? Select all that apply.
Hamburgers Soft-boiled eggs
A 5-year-old child who is HIV positive is taken to the health department for immunizations before the start of school. The CD4 count shows severe immunosuppression. What immunizations can the child be given safely at this time? Select all that apply.
Hepatitis A/ Polio vaccine (IPV)/ Diphtheria, tetanus, pertussis (DTaP).
A 15-year-old adolescent who has type 1 diabetes mellitus is admitted to the pediatric intensive care unit in ketoacidosis with a blood glucose level of 170 mg/dL. The adolescent has a history of fluctuating blood glucose readings and difficulty adhering to the therapeutic regimen. A continuous insulin infusion is started. What reaction to the infusion is most important for the nurse to monitor?
Hypokalemia
A teenager has a prescription for oral solution levofloxacin (Levaquin) to treat a sinus infection, and the nurse explains when the medication should be taken. The nurse concludes that the teaching has been effective when the teenager says:
I should take the medication 1 hour before a meal."
What should the nurse suggest when parents ask what to do about their preschooler's stuttering?
Ignore the hesitancy and try to prevent situations that increase stuttering.
A nurse is discussing areas of potential concern, such as anemia, with several parents of 6-month-old infants. What should the nurse tell them is the most common cause of anemia in 1-year-olds?
Iron deficiency
Spinal fusion is performed in an adolescent with scoliosis. What postoperative nursing intervention is specifically related to surgery for scoliosis?
Log-rolling every 2 hours
What clinical findings should lead a nurse to suspect that a toddler with a rash has rubella? Select all that apply.
Low-grade fever Lymphadenopathy
The site of choice for administration of an intramuscular (IM) medication to an infant is
Vastus laterali
The nurse is teaching health promotion tips to the mother of a 2-year-old child. During the follow-up visit, the nurse observes that the child has diarrhea and dental caries. Which action made by the parent is responsible for this condition?
"I give my child 8 ounces of fruit juice daily.
A nurse notes that a child is exhibiting signs of cerebral palsy. At what age are these signs usually first noticeable?
12 months
A 6-month-old infant is admitted to the pediatric unit with a diagnosis of failure to thrive. The birthweight was 7 lb. Judging from growth and development charts, how many pounds does the nurse conclude that the infant should weigh?
14
The nurse administers a second dose of inactivated polio vaccine (IPV) to a 4-month-old child. When does the child receive the third dose of IPV?
14 to 18 months of age
A 10-year-old child has sustained partial-thickness burns of the anterior surfaces of both arms and hands and the upper half of the chest. Using the grading system of the American Burn Association, the nurse estimates the total body surface area (TBSA) involved. What is the approximate TBSA affected? Record your answer as a whole number.
17%
An 8-year-old child with a history of asthma is brought to the emergency department because of respiratory distress. The nurse immediately places the child in bed with the head of the bed elevated and administers oxygen with a facemask. The health care provider performs a physical assessment, writes prescriptions, and admits the child to the pediatric unit. What is the nurse's priority intervention?
Administer the prescribed nebulizer treatment.
A 13-year-old child with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis). The nurse assesses the child, obtains the child's vital signs, and reviews the child's laboratory test results. What is the priority nursing intervention?
Administering an analgesic
A nurse is reviewing the health history and laboratory report of a child with lead poisoning. What complications does the nurse expect in relation to lead toxicity? Select all that apply.
Anemia, Proteinuria Encephalopathy
A health care provider diagnoses acute nonlymphoid leukemia in a 2½-year-old child and the child is admitted to the hospital. What clinical manifestations of the disease should the nurse expect when assessing the child? Select all that apply.
Anorexia Petechiae Irritability Skin pallor Listlessness
A nurse is assessing a 10-year-old child admitted to the pediatric unit with acute poststreptococcal glomerulonephritis (APSGN). What specific signs and symptoms does the nurse expect? Select all that apply.
Anorexia/ Periorbital edema/ Increased creatinine level.
The nurse is educating the mother of an 8-year-old female about the sequences of maturational changes. Which response by the mother indicates effective learning?
Appearance of breast buds is an initial indication of puberty.
While assessing the development of a child, the nurse finds that the child is imitating the actions of her elders. Which stage, according to Erickson's developmental theory, does the nurse expect the child is in?
Autonomy versus shame and doubt
An infant is admitted to the pediatric unit with gastroenteritis and dehydration. The nurse determines that the parents understand the teaching about contact precautions when they note that after washing their hands they need to:
Change their gloves each time they change the baby's diaper.
A cardiac catheterization is performed on an infant. After the procedure, the leg used for the catheter insertion site becomes mottled. What is the best action by the nurse?
Checking the pulse in the extremity
A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and got a positive result. She confides that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl whether she has told anyone else, she replies, "Yes, but my mother doesn't believe me." Legally, who should the nurse notify?
Child protective services for immediate intervention
A nurse is conducting a health class for adolescents. What modifiable risk factor, most closely associated with the development of coronary heart disease (CHD) in both men and women, should the nurse discuss?
Cigarette smoking
What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for an infant with this diagnosis?
Clubbing of fingers
ccimer (Chemet) is being administered to a school-aged child who is being treated for lead poisoning. Which of the child's laboratory values is most important for the nurse to assess?
Creatinine clearance.
A 6-month-old infant is admitted to the pediatric unit with severe diarrhea. What nursing assessment is most indicative of dehydration?
Decreased urine output
A nurse is caring for a 3-week-old infant with hypertrophic pyloric stenosis who is severely dehydrated. What finding does the nurse expect when assessing the infant?
Depressed anterior fontanel
Which clinical findings should cause the nurse to suspect that an adolescent child with type 1 diabetes is hypoglycemic?
Difficulty concentrating, hunger, and diaphoresis
A 4-year-old child is admitted to the pediatric unit with a diagnosis of Wilms tumor. Considering the unique needs of a child with this diagnosis, the nurse should place a sign on the child's bed that states:
Do not palpate the abdomen.
For how long should a nurse maintain isolation of a child with bacterial meningitis?
For 48 hours after antibiotic therapy begins
A nurse in the clinic is assessing a teenager with a tentative diagnosis of primary syphilis. What is an early sign of this infection?
Genital lesion
A child is admitted with a diagnosis of acute poststreptococcal glomerulonephritis. While performing a physical assessment and reviewing the child's laboratory reports, what clinical findings does the nurse expect? Select all that apply.
Hematuria/ Proteinuria/ Periorbital edema/ Increased specific gravity/ Slight increase in blood pressure.
A nurse in the clinic is taking the health history of a 16-year-old girl. When the nurse asks questions concerning sexual activity, the adolescent begins to perspire and hyperventilate. As her anxiety increases, she indicates that she feels dizzy and short of breath and that her heart is racing. What condition does the nurse identify?
Hyperventilation syndrome
The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching?
I'll use a straight razor when I start shaving.
Parents express concerns to the nurse that their 4-year-old child is spending a large amount of time playing with an imaginary friend. What is the best response by the nurse?
Imaginary playmates are an important part of a young child's life."
A 13-year-old-child with type 1 diabetes is receiving 15 units of Novolin R insulin and 20 units of Novolin N insulin at 7 am each day. At what time should the nurse anticipate a hypoglycemic reaction from the Novolin N to occur?
In the afternoon
A nurse is assessing the status of a school-aged child with leukemia who is receiving vincristine (Oncovin). Which laboratory value indicates that fluid intake needs to be increased?
Increased blood uric acid level.
The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that should be taken.
Institute respiratory isolation Insert an intravenous access device Assist with a lumbar puncture Administer the prescribed antibiotics Monitor for signs of increased ICP
An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should the nurse include in the teaching plan? Select all that apply.
Insulin therapy Blood glucose monitoring Adherence to the treatment regimen
A child with a diagnosis of tuberculosis is admitted to the pediatric unit. Which location should the nurse select as the best placement for the child?
Isolation room.
A parent of three young children has contracted tuberculosis. Which should the nurse expect the health care provider to prescribe for members of the family who have a positive reaction to the tuberculin skin test and are candidates for treatment?
Isoniazid
A 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. What are the purposes of administering pain medication by way of the intravenous route rather than the intramuscular route? Select all that apply.
It decreases the risk of tissue irritation. Severe pain is reduced more effectively. Impaired peripheral circulation is bypassed.
A nurse is caring for an infant with phenylketonuria. What diet should the nurse anticipate will be prescribed by the health care provider?
Low-phenylalanine
A nurse in the pediatric clinic is caring for a child with lead poisoning (plumbism). For which associated complications should the nurse assess the child? Select all that apply.
Marked anemia/ Kidney damage/ Encephalopathy
While providing nursing care for an adolescent undergoing chemotherapy for leukemia, a nurse notes blood on the child's pillowcase, as well as several bloody tissues. Which of the child's laboratory test results should the nurse review?
Platelet count
A toddler receives a gastrostomy tube feeding every 4 hours. What is the priority nursing intervention for this child?
Positioning the child on the right side after the feeding
On return to the pediatric unit after a tonsillectomy, a nurse notes that a 4-year-old child is swallowing frequently. What is the probable cause of this response?
Postoperative bleeding
A school nurse is screening children for scoliosis. In what age group is it usually identified?
Preadolescence
After an above-the-knee amputation for bone cancer, an adolescent boy is returned to his room. He is monitored closely because of the potential for hemorrhage from the residual limb. What should the nurse plan to keep at the bedside?
Pressure dressing
In addition to standard precautions, what protective equipment or precautions should the nurse use when caring for a 4-year-old child admitted with pertussis?
Private room
Before surgery to relieve an intestinal obstruction, a 3-month-old infant is kept on nothing-by-mouth status and has a nasogastric tube in place. Which nursing intervention will help calm the infant and meet developmental needs?
Providing a pacifier for the infant to suck
A 13-year-old female adolescent comes to the pediatric clinic, and her body mass index (BMI) is found to be 21. Compare the adolescent's BMI to the body mass index-for-age percentiles for girls ages 2 to 20 years and determine what percentile this adolescent falls under. Record your answer using a whole number. ___th percentile (graph)
R..75 PERCENTIL
A 6-year-old child comes to the school nurse reporting a sore throat, and the nurse verifies that the child has a fever and a red, inflamed throat. When a parent of the child arrives at school to take the child home, the nurse urges the parent to seek treatment. If the sore throat is not treated, what illness is of most concern to the nurse?
Rheumatic fever.
An infant is admitted to the pediatric unit with bronchiolitis caused by the respiratory syncytial virus (RSV). What medication does the nurse anticipate that the practitioner will prescribe?
Ribavirin
A nurse in the pediatric clinic receives a call from the mother of a 12-month-old infant who has had a fever, runny nose, cough, and white spots in the mouth for 3 days. A rash started on the face and has now spread to the entire body. Which communicable infection does the nurse suspect?
Rubeola
When assessing the growth and development of children, the nurse uses a specific sequence of gross motor milestones. Place these milestones in order, from the one first performed at the youngest age to the one that is performed last, at the oldest age.
Running Jumping Balancing on one foot Hopping Skipping
When assessing a toddler with autism, what characteristic findings or behaviors should the nurse expect? Select all that apply.
Sad, blank facial expression Inability to maintain eye contact
The nurse finds that an adolescent has a tattoo on the neck and piercings on the ear and eyebrow. During the next visit, the nurse finds that the adolescent has an additional tattoo on right upper arm and another piercing on the nose. What are the priority nursing interventions in this situation? Select all that apply.
Screen the adolescent for human immunodeficiency virus (HIV). Schedule an appointment for administering the hepatitis vaccine.
According to Piaget's cognitive development, what are the different stages of reasoning seen in a child? Select all that apply.
Sensorimotor Preoperationa Formal operational Concrete operational
3-year-old child is admitted to the burn unit with partial- and full-thickness burns over 30% of the body. For what complication should the nurse assess the child during the first 48 hours?
Shock
What toys should a nurse suggest to the mother of a 4-month-old infant to help promote the child's growth and development?
Soft squeeze toys
The nurse notes that an infant has asymmetric gluteal folds. Which focused assessment is most important for the nurse to perform?
Testing for developmental dysplasia of the hip
A 16-year-old adolescent sustains an ankle injury while playing soccer. Crutches and no weight-bearing are prescribed by the practitioner. What must the nurse ensure when adjusting the crutches?
That they extend to 6 inches from the side of each foot
he American parents of an adopted Spanish preschooler inform the nurse that the child often stutters while speaking. Upon assessment, the nurse finds that there is no hearing impairment, brain injuries, or developmental disorders in the child. What does the nurse suspect is the cause for the stuttering?
The change in language exposure has caused stuttering.
While assessing a 2-month-old infant, the nurse makes a loud sound and observes that the child forms a "C" shape with thumb and index finger while flexing the extremities. What does the nurse interpret from these findings?
The child is exhibiting the Moro reflex
After receiving levothyroxine (Synthroid) for 3 months for congenital hypothyroidism an infant is brought to the pediatric clinic for a checkup. What does the mother tell the nurse about her baby that indicates that the drug is effective?
The infant's stools are soft
A 6-month-old infant has a congenital right-to-left shunt defect of the heart. What clinical findings are expected when the nurse completes a history and physical assessment and reviews the child's laboratory reports? Select all that apply.
Tissue hypoxia Increased hematocrit
A 25-day-old infant is admitted to the hospital after 3 days of vomiting, and pyloric stenosis is diagnosed. What are the most important nursing assessments at the time of admission? Select all that apply.
Tissue turgor Neurologic status Amount of last voiding
A 14-year-old adolescent with diabetes has been self-administering insulin twice a day.. This morning the parents found their child lethargic and confused. After the adolescent's admission to the emergency department, laboratory testing reveals a hemoglobin A1c level of 10% and a blood glucose level of 200 mg/dL. What does the nurse suspect as the most likely cause of this client's condition?
Uncontrolled blood glucose level
In the well-child clinic a nurse teaches a group of parents about guidelines that may prevent Reye syndrome in their preschool-aged children. What should the nurse tell the parents?
Use a medication other than aspirin when your child has a fever.
A nurse is reviewing medication instructions with the parents of an infant who is receiving digoxin (Lanoxin) and spironolactone (Aldactone). What parental response concerning their infant's care indicates that the instructions have been understood?
Vomiting should be reported to the health care provider
A nurse is preparing an infant for insertion of a nasogastric tube. List the steps of the procedure in the order that they should be performed.
Wash hands before opening the package. Use the tube to measure from ear to nose to stomach Insert the tube. Aspirate stomach contents.
After 3 months of supplemental oral iron therapy, there is no significant increase in a female adolescent's hemoglobin level. Iron dextran (Imferon) is ordered. What is the best way for the nurse to administer this medication?
With the use of the Z-track method
While performing preoperative teaching a nurse explores a young adolescent's concern about changes in appearance after surgery to correct scoliosis. What is the most appropriate statement by the nurse?
You're concerned about how you'll look after surgery."
According to Freud, which aspect of one's life helps in the development of our personality?
The need for sensual pleasure
The nurse in the pediatric clinic is reviewing the health history of a 10-year-old girl with a diagnosis of juvenile idiopathic arthritis (JIA). Currently the child is experiencing recurrent pain and swelling of the joints, particularly her knees and ankles. What organ is commonly affected in children with this disorder?
Eyes.