nursing care of chillren
a nurse is providing teaching to an adolescent who has fiberglass arm cast. which of the following instructions should the nurse include in the teaching?
place a plastic bag over the cast when showering
a nurse is caring for a school-aged child who is having a tonic-clonic seizure. which of the following actions should the nurse perform first?
position the child on his side
a nurse is assessing a 6-year-old client at a well-child visit. which of the following findings requires further assessment by the nurse?
presence of sparse, fine pubic hair
a nurse is discussing play activities with a group of parents of toddlers. which of the following activities should the nurse recommend for this age group?
pushing a toy lawn mower
a nurse is caring for a 15-month-old client who requires droplet precautions. which of the following actions should the nurse take?
wear a mask when assisting the toddler with meals
a nurse is assessing a 2-month-old infant who has ventricular septal defect. which of the following findings should the nurse report to the provider?
weight gain of 4lbs
a nurse is caring for an infant who has biliary atresia. which of the following manifestations should the nurse expect? (SATA)
yellow sclerae abdominal distention dark urine
a nurse is assessing a school-aged child who is 30 minutes postoperative following a cardiac catheterization using the left femoral artery. which of the following findings should the nurse identify as the priority to report to the provider?
the pulse strength of the child's left popliteal artery site is decreased
a nurse is assessing a 6-month-old infant during a well-child visit. which of the following motor activities should the nurse expect the infant to have achieved?
turning from back to stomach
a nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. which of the following findings indicates a complication of this procedure?
abdominal distention
a nurse is caring for a child who is in the ER after ingesting a bottle of acetaminophen. which of the following medications should the nurse plan to administer?
acetylcysteine
a nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. which of the following actions should the nurse take?
administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion
a nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. an assessment of the mouth reveals whitish patches on the tongue that will not scrape off. which of the following actions should the nurse take?
administer an antifungal medication after feedings
a nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. which of the following actions should the nurse take?
administer ibuprofen
a nurse is reviewing lab findings of an adolescent who has acute renal failure. which of the following findings should the nurse expect?
metabolic acidosis
a nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. which of the following interventions should the nurse include in the plan?
monitor the child for increased temp
a nurse is caring for a toddler who is postop following a cleft palate repair. which of the following actions should the nurse take?
restrain the toddler's arms at the elbows
a nurse is preparing a school-age child for a tonsillectomy. which of the following actions should the nurse take?
schedule the child for a preoperative visit to the facility
a nurse is caring for a 6-week-old infant following a pyloromyotomy. which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure?
small, frequent bottle feedings of electrolyte solution
a nurse is providing teaching to the guardian of a school-age child who has hearing loss. which of the following techniques should the nurse recommend to facilitate communication with the child?
speak at the child's eye level
a nurse is assessing a 4-year-old child for growth and development milestones during a well-child visit. which of the following findings suggests a possible delay in development?
speaking using 2 or 3 word sentences
a nurse is caring for a 1-year-old infant who has chronic otitis media. the nurse should identify that which of the following areas is at risk of a delay in development?
speech patterns
a nurse is assessing the development of a 3-year-old child. which of the following gross motor skills should the nurse expect the child to be able to perform?
standing on 1 foot
a nurse is assessing a school-age child who has celiac disease. which of the following findings should the nurse expect?
streatorrhea
a nurse is admitting a child who has a history of tonic-clonic seizures. which of the following items is the priority to have in the child's room?
suction equipment
a nurse is assessing the fine motor skills of a 3-year-old preschooler. which of the following findings should the nurse expect?
the preschooler builds a tower of 9 cubes
a nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. which of the following interventions is the priority for the nurse to include?
monitor the child's O2 sat level
a nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. which of the following adverse effects should the nurse include?
muscle weakness
a nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. which of the following statements by the parent indicates an understanding?
my child should consume 1000 calories/day
a nurse is performing a neurological exam on a 15-month-old toddler. which of the following findings should the nurse expect?
negative Babinski reflex
a nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. the mother asks if this game has any developmental significance. the nurse should reply that peek-a-boo helps develop which of the following concepts in the child?
object permanence
a nurse is planning care for an infant with an unrepaired myelomeningocele. which of the following actions should the nurse take?
palpate the abdomen for bladder distention
a nurse is teaching a group of parent's and guardians about otitis media. which of the following should the nurse identify as a risk factor for the illness?
passive smoking
a nurse is caring for a 2-year-old child who has cystic fibrosis. the nurse is planning to take the child to the playroom. which of the following activities would be appropriate for the child?
building towers with blocks
a nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. the nurse should identify that which of the following is a cause of this complication?
bulky stools
a nurse is caring for a 12-month-old infant following the surgical repair of a cleft palate. the nurse should plan to feed the infant using which of the following instruments?
cup
a nurse is admitting a child who has Wilms' tumor. which of the following actions should the nurse take?
put a "no abdominal palpation" sign over the child's bed
a nurse is caring for an adolescent client who has a prescription for opioids. which of the following findings should the nurse recognize as an adverse effect of opioids?
pruritus
a nurse is caring for a child who has a possible intussusception. the parents of the child ask the nurse how the diagnosis is determined. which of the following responses should the nurse make?
"an abdominal ultrasound will confirm the pocket in the intestine"
a nurse is assessing a preschooler who has recurrent and persistent otitis media. when obtaining the child's history from her parent, which of the following questions should the nurse ask?
"does anyone smoke around or in the same house as your child?"
a nurse is providing education for the family of a 6-month-old infant about ways to stimulate language development. which of the following instructions should the nurse include?
"explain what you are doing to the infant while providing care"
a nurse is caring for a 16-year-old client who reports dysmenorrhea and asks about alternative therapies for treatment. which of the following statements should the nurse make?
"herbal medication can be effective but should be monitored by your provider"
a nurse is teaching the family of a child about hospice care. which of the following statements should the nurse include in the teaching?
"hospice staff members consider the family's needs to be just as important as those of the child"
a nurse is teaching a parent of an infant who has a colostomy. which of the following statements by the parent indicates an understanding of the teaching?
"i need to apply paste to the back of the wafer on my child's appliance"
a nurse is caring for a school-age child who has glomerulonephritis. the child has decreased urinary output and blood pressure of 160/78mmHg and is receiving hydralazine. which of the following lunch choices should the nurse recommend?
3oz grilled chicken, 1 cup of pear slices, and 120ml of apple juice
a nurse is assessing a newborn at birth to assign Apgar scores. at 1 min of age, the newborn is crying vigorously with limbs flexed and has a heart rate of 120/min. the newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. which of the following Apgar scores should the nurse assign this infant?
9
a nurse is assessing pain in a 3-year-old child following a tonsillectomy. which of the following rating scales should the nurse use to determine the child's pain level?
FACES rating scale
a nurse is caring for a child who has tetralogy of fallot. which of the following lab values should the nurse expect to find?
RBC 6.8milllion/uL
a nurse is admitting a child who has acute lymphocytic leukemia. which of the following lab values should the nurse expect?
RBCs 2.5million/uL
a nurse is assessing a 1-week-old infant at a well-child visit. the nurse should notify the provider about which of the following assessment findings?
a blue coloring of the sclera
a nurse on a pediatric unit has just received reports for 4 newly admitted clients. for which of the following children should the nurse plan to initiate droplet precautions?
a child who has pertussis
a nurse is conducting a heath assessment for a 24-month-old toddler at the local health department. the nurse should expect which of the following findings? (SATA)
ability to build a tower of 6 blocks slightly bowed or curved leg appearance
a nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. which of the following actions should the nurse take first?
administer IV fluid replacement
a nurse is caring for a toddler who has otitis media and a temp of 102.4F. which of the following actions should the nurse take first?
administer an antipyretic to the child
a nurse is assessing an infant who has acute gastroenteritis. which of the following findings should the nurse identify as the priority?
capillary refill 5 seconds
a charge nurse is providing education about child maltreatment to a group of newly licensed nurses. which of the following pieces of information should the charge nurse include in the teaching?
children who were born prematurely are more likely to be maltreated
a nurse is assessing a child who is postoperative and received unit of packed RBCs during a surgical procedure. which of the following findings indicates the child is experiencing a hemolytic transfusion reaction?
chills and flank pain
a nurse is providing discharge teaching to the guardian of an adolescent who is postoperative following a tonsillectomy. which of the following manifestations should the guardian report to the provider?
constant clearing of the throat
a nurse is assessing a toddler who has gastroenteritis. which of the following findings indicates the toddler is experiencing severe dehydration?
deep, rapid respirations
a nurse is caring for a 6-year-old child who is experiencing encopresis. which of the following actions should the nurse take?
determine if there are any recent stressors in the child's environment
a nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. which of the following findings should the nurse investigate further as an indication of child maltreatment? (SATA)
dislocated left shoulder revealed by x-ray thin, frail extremities
a nurse is planning care for a child who has meningococcal meningitis. which of the following isolation precautions should the nurse plan to implement?
droplet precautions
a nurse is assessing a 9-month-old infant. which of the following findings should the nurse to the provider as a possible developmental delay?
dropping a cube when passing from 1 hand to the other
a nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. which of the following findings should the nurse identify as indication the treatment is effective?
heart rate 118/min
a nurse is assessing a 12-year-old child during a well-child checkup. which of the following physical findings should the nurse report to the provider?
hyperopia
a nurse is caring for a 4-year-old child who has pneumonia. the child's mother left 2 hours ago, and he is currently experiencing the separation anxiety stage of despair. which of the following findings should the nurse expect?
inactivity and thumb sucking
a nurse is caring for a toddler who has gastroenteritis caused by Salmonella. which of the following is the priority action for the nurse?
initiate contact precautions
a home health nurse is developing a plan of care a toddler who has hemophilia. which of the following instructions for the parents should the nurse include in the plan?
inspect the toddler's toys for sharp edges
a nurse is caring for a preschool-age child who has mucosal ulceration after receiving chemotherapy. which of the following actions should the nurse take?
instruct the child to use a soft-sponge toothbrush when brushing her teeth
a nurse is caring for a 3-year-old child who has a cyanotic cardiac defect. the child cries when her parents leave the room, worsening her cyanosis and dyspnea. into which of the following positions should the nurse place the child to improve these manifestations?
knee-chest
a nurse is assessing a toddler who has measles (rubeola). which of the following findings should the nurse expect?
koplik spots
a nurse is providing teaching to a parent of a preschooler who has tinea capitis. which of the following instructions should the nurse include in the teaching?
leave the medicated shampoo on the scalp for 5 to 10 mins
a nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. the nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization?
male gender
a nurse is teaching the parents of an infant who has acute otitis media about how to administer antibiotic ear drops. which of the following instructions should the nurse include?
massage the anterior area of the infant's ear following administration
a nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. the nurse should recommend which of the following immunizations prior to moving into a campus dormitory?
meningococcal polysaccharide
a nurse is assessing a 3-year-old preschooler. which of the following developmental milestones should the nurse expect the preschooler to demonstrate?
stacking 10 blocks
a nurse is assessing the gross and fine motor behaviors of a toddler. which of the following behaviors should the nurse identify as an expected achievement for a 3-year-old child?
standing on 1 foot for several seconds
a nurse is providing teaching to an adolescent client who has juvenile idiopathic arthritis. which of the following instructions should the nurse include in the teaching?
"attend school regularly"
a nurse is teaching the guardian of a preschooler. the guardian states that the preschooler has had an imaginary playmate for about 3 months. which of the following pieces of information should the nurse give the guardian?
"have your child take responsibility for actions if he tries to blame the imaginary friend"
a nurse is providing education to the parent of a toddler who is about to receive her first dose of MMR immunization. which of the following statements by the parent indicates an understanding of the teaching?
"i can give my child acetaminophen for discomfort associated with the immunization"
a nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. which of the following responses by the adolescent indicates an understanding of the teaching?
"i can take my brace off for about an hour daily to shower"
a nurse is caring for a female adolescent who is being treated for frequent urinary tract infections (UTIs). which of the following statements by the adolescent indicates a possible cause of the UTIs?
"i have bowel movements every 4-5 days"
a nurse is teaching the parent of an infant about injury prevention. which of the following statements by the parent indicates an understanding of the teaching?
"i should make sure my baby'y clothing does not have buttons" (risk for aspiration)
a nurse is teaching the parents of a 10-year-old child who has iron-deficiency anemia. which of the following statements by a parent indicates an understanding of the teaching?
"i will administer the iron tablet with orange juice"
a nurse is providing teaching to the parent of an infant who has developmental hip dysplasia and a new prescription for a Pavlik harness. which of the following parent statements indicates understanding of the teaching?
"i will apply the harness over a t-shirt and knee socks" (helps irritation of skin)
a nurse is providing teaching about disease management to the parent of a preschooler who has a new diagnosis of asthma. which of the following parent statements indicates an understanding of the teaching?
"i will encourage my child to participate in sports"
a nurse is providing postop teaching to the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. which of the following statements by the parent indicates an understanding of the teaching?
"i will fold my baby's diaper away from the incision"
a nurse is teaching the parent of a preschool-aged child about the treatment for pinworms. which of the following statements by the parent indicates an understanding of the teaching?
"i will give my child a dose of albendazole today and again in 2 weeks"
a nurse is teaching the parent of toddler about home safety. which of the following statements by the parent indicates an understanding of the teaching?
"i will lock my medications in medicine cabinet"
a nurse is providing teaching to the parents of a school-aged child who has type 1 diabetes about managing hypoglycemia. which of the following responses by a parent indicates an understanding of the teaching?
"i will make sure my child drinks 240ml of milk as soon as possible"
a nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). which of the following responses by the adolescent indicates an understanding of the teaching?
"i will record the highest reading of 3 attempts"
a nurse on a pediatric unit is caring for a child who is not eating well. which of the following suggestions should the nurse offer to the parents to promote the child's food intake?
"let your child eat with others when possible"
a nurse is teaching the parents of a child who has rheumatic fever. which of the following statements by a parent indicates an understanding of the teaching?
"my child may take aspirin for his joint pain"
a nurse is teaching to a group of parents of adolescents about developmental needs. which of the following statements by a parent should the nurse investigate further?
"my child spends 4 hours per day using online chat rooms"
a nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has HIV. which of the following statements should the nurse include in the teaching?
"the pnuemococcal and flu vaccines are recommended for your child"
a nurse is preparing to obtain an ASO titer from a child who has acute glomerulonepritis. the child's parent asks the nurse to explain the purpose of the test. which of the following responses should the nurse provide?
"the test shows us if your child had a recent strep infection"
a nurse is providing teaching to the parent of a toddler who is undergoing insertion of tympanostomy tubes. which of the following statements should the nurse include?
"the tubes should stay in place until they fall out on their own"
a nurse is teaching the guardians of an infant who has mild gastroesophageal reflux (GER). which of the following instructions about feeding therapies should the nurse recommend?
"thicken feedings with rice cereal"
a nurse is teaching the parents of a toddler who has enerobiasis about managing this parasitic disease. which of the following pieces of information should the nurse include in the teaching?
"you should keep your child's fingernails cut short"
a nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. which of the following statements should the nurse include in the teaching?
"you will be able to participate in physical exercise"
a nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. which of the following statements should the nurse make?
"your baby can start the pneumococcal vaccine now"
a nurse is teaching the parents of a child who has cerebral palsy. which of the following statements should the nurse make?
"your child will need a a botulinum toxin A injection to reduce muscle spasicity"
a nurse is caring for a child who adheres to vegetarian diet and has sustained superficial partial-thickness burns. the nurse should recommend which of the following foods choices due to the high protein content?
1/2 cup of peanut butter with apple slices
a nurse is caring for a toddler. which of the following objects should the nurse select from the playroom for this child during hospitalization?
10-piece wooden puzzle
a nurse is performing a nutritional screening for a 12-year-old client who weighs 90lbs and has a height of 1.5meters. which of the following values is the client's BMI?
18.2 (divide clients weight in kg by the square of the clients height in meters)
a nurse is assessing an infant who was born at 32 weeks gestation and is now 8 months old. which of the following development ages should the nurse expect the infant to demonstrate?
6 months
a nurse on the pediatric unit is caring for a group of clients. which of the following findings should be the nurse's priority?
a child who has sickle cell anemia and a urine specific gravity of 1.030
a nurse is caring for a 4-month-old child who is hospitalized. which of the following toys should the nurse provide for the child?
a plastic mirror
a nurse is caring for an infant who is experiencing dehydration. which of the following assessments is the nurse's priority?
measure the client's weight daily
a nurse is assessing a 6-month-old infant following a cardiac catheterization. which of the following findings should the nurse report to the provider?
BP 86/40
a nurse at a clinic is preparing to administer immunizations to a 5-year-old child. which of the following immunizations should the nurse plan to give?
DTaP
a nurse is assessing the pain level of a 3-year-old child who is postop following abdominal surgery. which of the following pain scales should the nurse use?
FACES pain rating
a nurse is assessing an 18-month-old infant who is postop. which of the following pain scales should the nurse use?
FLACC (facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years)
a nurse is caring for a child who has an exacerbation of cystic fibrosis. which of the following lab finding should the nurse report to the provider immediately?
O2 sat 85%
a nurse is planning care for an infant who has heart failure. which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (SATA)
allow 30 mins to complete each feeding gradually increase the caloric density of the formula position the infant semi-upright during feedings provide gavage feeding if RR exceeds 80/min
a nurse is providing teaching to the guardians of a 4-month-old infant on how to play with the infant. which of the following play activities should the nurse suggest for this infant?
allow the infant to splash in the bathtub
a nurse in the ER is reviewing lab results for several children who have manifestations of influenza. which of the following children should the nurse report to the provider immediately?
an infant with a WBC count of 24,000
a nurse is caring for a child who has epistaxis. which of the following actions should the nurse perform?
apply continuous pressure to the child's nose for at least 10 mins
a nurse is caring for a child who has epistaxis. which of the following actions should the nurse take?
apply continuous pressure to the lower part of the child's nose
a nurse is facilitating a group discussion with preschool teachers about child abuse. which of the following examples should the nurse use to illustrate a suggestive finding?
arm cast for a spiral fracture of the forearm
a nurse is planning to assess an 8-year-old child who was brought to the clinic by a parent. the parent reports the child has missed school for 3 weeks and refuses to go back due to "not feeling well". which of the following actions should the nurse perform during the initial assessment?
ask the child to describe what things were like right before not wanting to go to school
a nurse is caring for a child who received penicillin IM 15mins ago. the child is now irritable and restless. which of the following actions should the nurse take first?
assess for laryngeal edema
a nurse is providing teaching to the parents of an infant who is breastfeeding. when should the nurse instruct the parents to introduce solid foods in the infant's diet?
at 4-6 months of age
a nurse is admitting a child who has a UTI and a hx of myelomeningocele. after completing the admission hx, which of the following actions should the nurse take?
attach a latex allergy ID band (clients w neural tube defects are at risk of latex allergy)
a nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophageal fistula repair as a newborn. which of the following findings should the nurse include in the teaching?
barking cough
a nurse in the ER is assessing a preschooler for indications of child maltreatment. the nurse should identify that which of the following findings is a manifestation of physical abuse?
bruises at various stages of healing
a nurse is assessing a toddler who has AIDS. which of the following findings is an indication of an opportunistic infection?
candidiasis
a nurse is assessing a preschooler who has HIV. which of the following manifestations should the nurse expect?
chronic diarrhea
a nurse is caring for a 3-yer-old child on a pediatric unit. the nurse should identify which of the following as an appropriate toy for the child?
coloring book and crayons
a nurse is assessing an infant who has untreated congenital hypothyroidism. which of the following manifestations should the nurse expect?
constipation
a nurse is providing dietary teaching to the parent of a toddler who has phenylketonuria. which of the following foods should the nurse recommend?
cooked carrots
a nurse is providing teaching to the parents of a 4-year-old child about fine motor development. which of the following tasks should the nurse include as an expected finding for this age group?
copying a circle
a nurse is teaching the parent of an infant about food allergens. which of the following is the most common food allergy in children?
cow's milk
a nurse is caring for a child who has electrical burns on the lower arms and hands. which of the following findings indicate the child is experiencing a complication of the injury?
dark urine (myoglobinuria)
a nurse is teaching a school-age child and his parents how to self-administer insulin. which of the following actions should the nurse take first?
demonstrate the injection technique on an orange
a nurse in an ER is caring for a 4-year-old child who has burns to the neck and face following a house fire. which of the following actions should the nurse take first?
determine the child's breathing pattern
a nurse is assessing a 4-year-old child's cognitive development during a well-child visit. which of the following should the nurse expect the child to display?
development of the superego
a nurse is caring for an infant who has a cleft palate. the parents ask the nurse how long they should wait before the child can have corrective surgery. the nurse should explain that the parents should wait no longer than 6-12 months for surgery to prevent which of the following outcomes?
difficulty with language
a nurse in an ER is caring for a toddler who is in acute respiratory distress. which of the following findings should alert the nurse to the possibility of epiglottitis?
drooling
a nurse is caring for an infant who is 6 months old and has moderate dehydration. which of the following findings should the nurse expect?
dry mucous membranes
a nurse is planning care for a 6-year-old child who is receiving chemotherapy. the child has a highlight platelet count of 20,000. based on this lab value, which of the following interventions should the nurse include in the plan of care?
encourage quiet play (lessen client's risk of injury/hemorrhage)
a nurse is caring for a toddler who has asthma. the parents are concerned about the toddler's reaction to the hospitalization. which of the following actions should the nurse take to decrease the child's anxiety?
encourage rooming-in
a nurse is planning preop teaching for a preschooler who is scheduled for a tonsillectomy. which of the following interventions should the nurse plan to include?
encourage the preschooler to bring a favorite toy to the hospital
a nurse is observing the behavior of a 2-year-old child. which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers?
engaging in play near other children
a nurse is preparing to assess an 11-month-old infant during a well-child examination. which of the following actions should the nurse take?
examine the infants throat at the end of the examination (least invasive to more invasive)
a nurse is assessing a 4-year-old child. the nurse should expect the child to be able to perform which of the following activities?
fastening buttons on a shirt
a nurse working on a maternal -newborn unit is teaching a group of newly licensed nurses about assisting new mothers with breastfeeding. the nurse should include which of the following infant conditions as a contraindication for breastfeeding?
galactosemia (cannot metabolize lactose)
a nurse is performing a visual acuity screening for school-aged child using the Snellen letter chart. which of the following actions should the nurse take?
have the child wear his glasses during vision screening
a nurse in a provider's office is assessing a client. the nurse determines the client's BMI is 21.2. this finding is classified as which of the following?
healthy weight (18.5-24.9)
a nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions?
hip
a nurse is preparing to administer an enema to a 10-month-old infant. which of the following actions should the nurse plan to take?
hold the infants buttocks together after administering the fluid
a nurse is assessing the gross motor skills of a 4-year-old preschooler. the nurse should expect the preschooler to perform which of the following activities?
hopping on 1 foot
a nurse is assessing a child who has bilateral pheochromocytoma. which of the following findings should the nurse expect?
hypertension
a nurse in an emergency department is assisting with the care of a 4-year-old child who ingested toilet bowl cleaner. the child has hempytosis, is crying, and states, "it burns". which of the following actions should the nurse perform? (SATA)
identify how much cleaner was in the bottle insert an IV for morphine administration apply pulse oximetry
a nurse is assessing a 9-month-old infant during a well-child visit. which of the following findings indicates that the infant has a developmental delay?
inability to vocalize vowel sounds
a nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. the nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development?
industry vs inferiority
a nurse is planning to teach a 9-year-old child who has a new diagnosis of diabetes. the nurse should identify that school-age children are attempting to master which of the following developmental tasks?
industry vs inferiority
a nurse is creating a plan of care for a child who has aplastic anemia. which of the following interventions should the nurse include?
initiate protective-environment isolation for the child
a nurse is planning care for a preschooler who is scheduled for a surgical procedure. the nurse should identify that the preschooler is in which of the following of Erikson's psychosocial stages of development?
initiative vs guilt
a nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. which of the following findings should the nurse expect?
lanugo over the back
a nurse is caring for an infant who has gastroenteritis and is dehydrated. which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client?
longer intestinal tract
a nurse is caring for an infant who has pertussis. which of the following actions should the nurse take?
maintain a cardiorespiratory monitor
a nurse is caring for the family of a preschooler who has a terminal illness. the nurse should teach the family to expect the preschooler to have which of the following concepts of death?
people can come back to life after they die
a nurse is caring for a school-aged child who has skeletal traction applied to repair a pelvic fracture. which of the following actions should the nurse take?
place the child on a pressure-reduction mattress
a nurse is teaching the parent of an infant about home safety. which of the following pieces of information should the nurse include? (SATA)
position the car sear so it is rear-facing secure a safety gate at the top and bottom of the stairs maintain the water heater temp at 120F
a nurse is planning care for a child who has hyperthermia. which of the following actions should the nurse take?
position the chid on a cooling blanket and cover her with a sheet
a nurse is reviewing the lab report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. which of the following findings should the nurse report to the provider?
potassium 2.5
a nurse is caring for a school-aged child who has sickle cell anemia. which of the following actions should the nurse plan to take to help decrease the risk of a vaso-occlusive crisis?
provide adequate fluid intake throughout the day
during a well-child visit, the guardian of a toddler reports that the toddler takes several hours to fall asleep at night. which of the following recommendations should the nurse take?
provide the toddler with a favorite stuffed animal at bedtime
a nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. to meet the nutritional needs of the child, which of the following actions should the nurse plan to take?
supplement the child's feedings with enteral feedings
a nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. which of the following findings indicates the infant has moderate dehydration?
tachypnea
a nurse is assessing a 3-year-old child during a well-child examination. which of the following findings should the nurse report to the provider?
the child cannot walk on tiptoe
a nurse is taking the history of and performing a physical on a school-age child who has ADHD. which of the following findings in the child's medical record should the nurse identify as a risk factor for ADHD?
the child had prenatal exposure to alcohol on a regular basis
a nurse is assessing the dynamics of a family in which child maltreatment is suspected. which of the following findings should the nurse report to the provider?
the child has several unexplained scars and bruises
a nurse in an acute pediatric unit is caring for a 2-year-old child who has separation anxiety when her parents to leave for work. the nurse should identify which of the following behaviors as a manifestation of the stage of despair?
the child is withdrawn and refuses to talk
a nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. which of the following findings should alert the nurse to a complication related to the casting?
the child reports tightness at the wrist
a nurse is assessing a 10-month-old infant checkup. which of the following assessment findings should the nurse report to the provider?
the infant needs assistance to sit up
a nurse in a provider's office enters an examination room to assess an 8-month-old infant for the first time. which of the following reactions by the infant should the nurse expect?
the infant turns away when the nurse approaches
a nurse is performing a physical assessment on a 12-month-old infant. which of the following findings should the nurse report to the provider?
the infant's current weight is double his birth weight
a nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. the nurse should include which of the following pieces of information about the function of cochlear implants?
they provide direct stimulation of auditory nerve fiber
a hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. which of the following pieces of information should the nurse include in the teaching?
toddlers will react to the parents' anxiety and sadness
a nurse is providing preoperative education for an 8-year-old child prior to cardiac surgery. which of the following actions should the nurse take?
use a doll with tubes and an incision to explain the surgery
a nurse is preparing to administer an oral medication to an 8-month-old infant. which of the following actions should the nurse take?
use an oral syringe to place the medication alongside the infant's tongue
a nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. which of the following interventions should the nurse include?
use manual jaw control when feeding the toddler
a nurse is planning preoperative teaching for a school-age child who is scheduled for cardiac surgery. which of the following actions should the nurse plan to take when teaching the child?
use photographs to help explain the procedure
a nurse is preparing to administer an IM injection to a 2-month-old infant. in which of the following sites should the nurse plan to administer the injection?
vastus lateralis
a nurse is planning to collect a specimen from a male infant using a urine collection bag. which of the following actions should the nurse take?
wash and dry the infant's genitalia and perineum thoroughly
a nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. which of the following pieces of information should the nurse include?
withhold the medication if the infant's HR is less than 110
a nurse is caring for an 8-year-old child who has sickle cell anemia. which of the following actions should the nurse take?
give the child flavored popsicles
a nurse is talking with the parent of a preschool-aged child who tells the nurse, "my child has suddenly become disinterested in certain foods." which of the following statements should the nurse make?
"keep a diary of the foods your child eats each day"
a nurse is providing teaching to a school-aged child who just had a fiberglass cast application following a lower-extremity fracture. which of the following instructions should the nurse give the child and his parents about care during the first 48hrs?
"keep the cast about the level of your heart"
a nurse is talking with the parent of a 4-month-old infant about growth and development. which of the following statements indicates that the parent needs further teaching?
"my baby loves to play with the pillows in her crib"
a nurse is providing teaching about poisoning prevention to a group of parents with toddlers. which of the following statements should the nurse make?
"put all cleaning supplies in a locked cabinet"
a nurse is providing teaching to the family of a child who has autism spectrum disorder. which of the following statements indicates that the family understands the teaching?
"we can help our child by structuring our daily routine"
a nurse is teaching the parents of a 3-year-old child who has persistent otitis media about prevention. which of the following statements by the parents indicates an understanding of the teaching?
"we should not smoke around our child"
a nurse is providing teaching about disease-management strategies to a 9-year-old who has cystic fibrosis. which of the following statements should the nurse include?
"you mucus is thick because cystic fibrosis interferes with how your glands work"
a nurse is performing a annual physical assessment of a preschooler. the parent expresses concern about the child's 4lb weight gain over the past year. which of the following responses should the nurse make?
"your child's weight change is expected for this age group"
a nurse is caring for a child who has paralytic poliomyelitis. which of the following actions should the nurse take?
administer oral analgesics prior to exercises
a nurse is providing teaching to the guardian of an adolescent. the guardian reports that the adolescent sleeps about 10hr on weekend nights. which of the following responses should the nurse provide?
adolescents need more sleep due to rapid growth
a nurse is assessing a child who is postoperative. which of the following findings should the nurse identify as an indication that naloxone should be administered?
respiratory depression
a nurse is assessing a child who is receiving IV chemotherapy. assessment findings include extravasation of the tissues surrounding the IV insertion site. in which order should the nurse take the following actions?
stop the infusion elevate the extremity notify the provider remove the IV line
a nurse is assisting a provider during a femoral venipuncture on a toddler. the nurse should place the child in which of the following positions?
supine
a nurse is assessing a 6-month-old infant at a well-child visit. which of the following findings indicates the need for further assessment?
the infants legs remain crossed and extended when supine
a nurse in the ER is caring for an unaccompanied infant following a motor-vehicle crash. during the assessment, the nurse notes that the infant's anterior fontanel is almost closed. she has 6 teeth, is able to sit unsupported, an can drink from a cup. the child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada". the nurse should make which of the following age assessments for this child?
12 months old
a nurse in an ER is caring for an 8-year-old who is up-to-date with current immunization recommendations and has a deep puncture injury. which of the following should the nurse anticipate adminsitering?
adult tetanus booster (Td)
a school nurse is caring for a child who is experiencing an acute asthma attack. which of the following medications should the nurse plan to administer to the child?
albuterol
a nurse is caring for a 4-month-old child who has acute otitis media and a fever of 101F. which of the medications should the nurse administer?
amoxicillin
a nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. which of the following instructions should the nurse include?
provide a high-fat diet for the toddler
a nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. which of the following actions should the nurse take?
rock the child using long, rhythmic movements
a nurse is caring for a preschooler who was brought to an outpatient clinic with a 2 day history of a vesicular, honey-colored region around the nose and mouth. if the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child's parent about the illness? (SATA)
apply a topical antibacterial ointment to the lesions wash the child's bed linens daily with hot water wash hands before and after contact with the affected area
a nurse is caring for a toddler. which of the following lab findings should the nurse report to the provider?
creatinine 0.9mg/dL (0.3-0.7 for a toddler)
a nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. which of the following techniques should the nurse plan to use?
encourage the child to focus on a recent pleasurable experience
a nurse is caring for an adolescent who has sickle cell anemia. which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (SATA)
enlarged heart enuresis leg ulcers retinal detachment
a nurse is assessing a child who has stage I Hodgkin disease. which of the following findings should the nurse expect?
enlarged lymph nodes
a nurse on a pediatric unit is caring for a child who has autism spectrum disorder. which of the following actions should the nurse take?
ensure that staff visits with the child are kept short
a nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3mcg/dL. when teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include?
ensure the child's dietary intake of calcium and iron is adequate
a nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. which of the following findings should the nurse report to the provider?
head lagging when the infant is pulled from a lying to sitting position
a nurse is providing discharge teaching for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. which of the following responses indicates an understanding of the teaching?
"i should lightly massage my baby underneath the straps once a day"
a nurse is assessing a 6-month-old infant who had a cardiac catheterization with right femoral entry to diagnose a possible congenital heart defect. which of the following findings should the nurse report to the provider?
cool toes on the right foot
a nurse is assessing a preschooler who has influenza and reports the new onset of sore throat and difficulty swallowing. which of the following findings is the priority for the nurse to report to the provider?
the child is drooling
a nurse is caring for a 4-week-old infant who is 2 weeks postoperative following surgical correction of biliary atresia. which of the following findings is an indication that the surgery was successful?
the infant has a total bilirubin level of 0.3mg/dL
a nurse is providing teaching to the parent of a 4-year-old child who stutters. which of the following statements by the parent indicates an understanding?`
"i should ignore the stuttering and not interrupt her"
a nurse is assessing the fine motor skill development of a 4-year-old child. the nurse should expect the child to be able to perform which of the following activities?
copying a square
a school nurse is assessing a child who has been stung by a bee. the child's hand is swelling, and the nurse notes that the child is allergic to insect stings. which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA)
nausea urticaria stridor
a nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). which of the following interventions should the nurse include in the plan of care? (SATA)
observe the parents' actions when feeding the child maintain a detailed record of food and fluid intake
a nurse is providing teaching to the parents of a child who has strabismus. which of the following instructions should the nurse include to prevent the development of amblyopia?
patch the unaffected eye
a nurse is caring for an infant who is postoperative for the treatment of an intact myelomeningocele sac. in which of the following positions should the nurse place the infant?
prone
a nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. which of the following actions should the nurse take first?
tell the guardian that a repeat dose of medication should not be given
a nurse is performing a well-child assessment on a 4-year-old child. which of the following findings should the nurse expect?
the child is able to hop on 1 foot
a nurse is providing teaching to a parent of a preschooler who has impetigo. which of the following statements by the parent indicates an understanding of the teaching?
"i will wash my child's clothes in hot water"
a nurse is providing discharge teaching to the parent of a school-aged child who has leukemia and is receiving chemotherapy. which of the following statements by the parent indicates an understanding of the teaching?
"i will inspect my child's mouth every day for sores"
a nurse is creating a plan of care for 6-month-old infant who requires continuous pulse oximetry monitoring. which of the following interventions should the nurse include?
cover the oximetry sensor with clothing
a nurse is caring for a school-aged child who begins to have tonic-clonic seizure when leaving the bathroom. which of the following actions should the nurse take first?
ease the child to the floor in Sims' position
