NCLEX REVIEW 4000

Which sign is likely to indicate abuse in a 4-year-old child? 1. Conflicting stories about the accident or injury from the parents. 2. History consistent with the child's injuries 3. Disheveled parental appearance and low socioeconomic status 4. Appropriate emotional response by the caregiver

1. Conflicting stories about the accident or injury from the parents. RATIONALE: Conflicting stories about the accident or injury from the parents is a warning sign of abuse. A history consistent with the child's injuries, a disheveled appearance and low socioeconomic status, and an appropriate emotional response by the caregiver aren't indicators of expected or potential abuse.

A child, age 10, is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as ordered. The child's left leg is immobilized in a splint. What is an appropriate expected outcome for this child? 1. The child will change position with minimal discomfort. 2. The child will bear weight on the affected limb. 3. The child will ambulate with crutches. 4. The child will participate in age-appropriate activities.

1. The child will change position with minimal discomfort. RATIONALE: To prevent pressure ulcers, the child must turn and change positions periodically. However, during the acute phase of osteomyelitis, moving the affected leg may cause extreme pain and discomfort. Therefore, the nurse must support and handle the leg gently during turning and repositioning. Weight bearing is contraindicated because it may cause pathologic fractures. Ambulating with crutches is an inappropriate outcome because the child is restricted to bed rest and the affected leg is immobilized to limit the spread of infection. Participation in age-appropriate activities isn't a realistic outcome because an acutely ill child isn't likely to be interested in activities; this outcome would be suitable after the acute disease phase ends.

A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first? 1. heart rate, respiratory rate, and blood pressure 2. recent exposure to communicable diseases 3. number of immunizations 4. height and weight

1. heart rate, respiratory rate, and blood pressure RATIONALE: The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather data about disease exposure, immunizations, and height and weight later.

A 4-year-old child is ordered to receive 25 ml/hour of I.V. solution. The nurse is using a pediatric microdrip chamber to administer the medication. For how many drops per minute should the microdrip chamber be set? Record your answer using a whole number.

25 gtts/min v/mints x gtts= 25ml/60 mints x 60 gtts= 1500/60= 25 ml/min RATIONALE: When using a pediatric microdrip chamber, the number of milliliters per hour equals the number of drops per minute. If 25 ml/hour is ordered, the I.V. should infuse at 25 gtt/minute.

A mother complains to the nurse that her 4-year-old son often "lies." What is the nurse's best response? 1. let the child know that he'll be punished for lying. 2. ask him why he isn't telling the truth. 3. it's probable due to his vivid imagination and creativity. 4. acknowledge him by saying, "that's a pretend story."

4. acknowledge him by saying, "that's a pretend story." RATIONALE: It's important to acknowledge the child's imagination, while also letting him know in a nice way that what he has said isn't real. Punishment isn't appropriate for a 4-year-old child using his imagination, and accusing him of lying is a negative reinforcement. The child isn't truly lying in the adult sense. Although imagination and creativity need to be acknowledged by the mother, the nurse must respond to the mother's concern with appropriate interventions, not opinion on why the behavior is occurring.