PEDIATRICS 40, 43, 44, 48

10) The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child? 1. 0.9% normal saline (NS) 2. D5 0.2% (¼) normal saline 3. D5W 4. Albumin

Answer: 1 Explanation: 1. 0.9% normal saline (NS) is an isotonic fluid and maintains Na and chloride at present levels. 2. D5 0.2% (¼) normal saline would not be used initially but later, as maintenance fluids. 3. D5W can lower sodium levels, and so it would not be used to replace fluids in severe isotonic dehydration. 4. Albumin is used to restore plasma proteins.

5) In the morning, a nurse receives change-of-shift report on four pediatric clients, each of whom has some form of fluid-volume excess. Which of the children should the nurse see first? 1. The child with tachypnea and pulmonary congestion 2. The child with hepatomegaly and normal respiratory rate 3. The child with dependent and sacral edema and regular pulse 4. The child with periorbital edema and normal respiratory rate

Answer: 1 Explanation: 1. A child with respiratory distress should be the first client the nurse checks after receiving a report. 2. The child with hepatomegaly and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion. 3. The child with dependent and sacral edema and regular pulse is more stable than the child with tachypnea and pulmonary congestion. 4. The child with periorbital edema and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.

16) The nurse is providing care for the family of a child who is diagnosed with acquired immunodeficiency syndrome (AIDS). Which priority nursing diagnosis should the nurse include in the plan of care? 1. Anticipatory Grieving 2. Risk for Impaired Parenting 3. Compromised Family Coping 4. Parental Role Conflict

Answer: 1 Explanation: 1. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving. 2. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving. Risk for Impaired Parenting might be present, but further information is needed to anticipate this problem. 3. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving. Compromised Family Coping might be present, but further information is needed to anticipate this problem. 4. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving. Parental Role Conflict might be present, but further information is needed to anticipate this problem.

15) A 2-year-old child with a fever is prescribed amoxicillin clavulanate 250 mg/5 mL 3 times daily by mouth for 10 days for otitis media. Which is the priority teaching instruction for the parents of this child? 1. Giving the antibiotic for the full 10 days 2. Measuring the prescribed dose in a household teaspoon 3. Spreading the dose evenly during daylight hours 4. Stopping the antibiotic when the child is afebrile

Answer: 1 Explanation: 1. Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. 2. A household teaspoon could contain less than 5 mL, and the full dose must be given. 3. The antibiotic should be administered around the clock to maintain a blood level. 4. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.

2) A nurse is providing education to a group of new mothers regarding immunity and infection. Which information regarding the development of immunity should the nurse include in the teaching session? 1. Acquired through immunization or exposure to the natural disease 2. Acquired through exposure to diseases from family members 3. Acquired through diseases from other children 4. Newborns being born with diseases already in their systems

Answer: 1 Explanation: 1. As children grow, they develop immunity through immunization or exposure to the natural disease. As children mature and become more active, they interact more frequently with other children and adults and increase their exposure to infectious agents. 2. Children cannot acquire diseases from family members who have had the disease 3. Acquiring disease from other children would not give children immunity. 4. Newborns are not born with diseases in their systems.

12) A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give? 1. Furosemide (Lasix) 2. Hydrochlorothiazide (Aquazide) 3. Spironolactone (Aldactone) 4. Mannitol (Osmitrol)

Answer: 1 Explanation: 1. Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. 2. Thiazide diuretics (like hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. 3. Spironolactone (Aldactone) is a potassium-sparing diuretic. While there is a net increase in calcium in the urine, it is not as effective an option as furosemide. 4. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium.

8) A child is prescribed oral corticosteroid for a rash caused by graft-versus-host disease. Which should the nurse monitor the child for after administering the drug? 1. Hyperglycemia 2. Hepatic toxicity 3. Seizures 4. Renal toxicity

Answer: 1 Explanation: 1. Hyperglycemia is a side effect of steroid therapy. 2. Hepatic toxicity is not a side effect associated with steroid therapy. 3. Seizures are not a side effect associated with steroid therapy. 4. Renal toxicity is not a side effect associated with steroid therapy.

11) The pediatric nurse would expect that patient-controlled analgesia (PCA) would be most appropriate for which client? 1. 12-year-old client who is postoperative for spinal fusion for scoliosis 2. 10-year-old client who has a fractured femur and concussion from a bike accident 3. 5-year-old client who is postoperative for tonsillectomy 4. Developmentally delayed 16-year-old client who is postoperative for bone surgery.

Answer: 1 Explanation: 1. PCA is most appropriate in children 5 years old and older. Children must be able to press the button and understand that they will receive pain medicine by pushing the button. 2. Children who have suffered head trauma would not be candidates for PCA. 3. PCA generally is prescribed for clients who will be hospitalized for at least 48 hours. 4. Children who are developmentally delayed would not be candidates for PCA

11) A 6-year-old child is hypokalemic. Which menu choice should the nurse encourage for this child? 1. Pizza with a fruit plate 2. Chicken strips with chips 3. Fajita with rice 4. A hamburger with French fries

Answer: 1 Explanation: 1. Pizza with a fruit plate should be encouraged because fruits (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination. 2. Chicken strips and chips are not good sources of potassium. 3. The nurse is looking for potassium-rich foods that are attractive to children. This choice does not meet the requirement. 4. A hamburger and French fries do not provide potassium.

19) Which nursing action is most appropriate to decrease the risk of transmitting viral infections by clients and family members at a local clinic? 1. Sanitizing toys, telephones, and doorknobs to kill pathogens 2. Teaching parents safe food preparation and storage 3. Withholding immunizations for children with compromised immune systems 4. Allowing all children to congregate in the same waiting room

Answer: 1 Explanation: 1. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. 2. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but it is not related to the flu virus. 3. Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy. 4. Children should be separated in different waiting rooms when seeking care at a pediatric clinic.

6) The nurse is caring for a child on bed rest who has severe edema in a left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority? 1. Risk for Impaired Skin Integrity 2. Risk for Altered Body Image 3. Risk for Imbalanced Nutrition: Less Than Body Requirements 4. Risk for Activity Intolerance

Answer: 1 Explanation: 1. The highest priority problem is skin integrity. 2. Body image would not take priority over the integrity of the skin for this scenario. 3. Nutrition would not take priority over the integrity of the skin for this scenario. 4. Activity intolerance would not take priority over the integrity of the skin for this scenario.

1) A nurse is providing information to a group of new mothers. Which rationale, indicating increased susceptibility for infant infection, should the nurse include in the teaching session? 1. Low levels of antibodies 2. High levels of maternal antibodies to diseases to which the mother has been exposed 3. Passive transplacental immunity from maternal immunoglobulin G 4. Exposure to microorganisms during the birth process

Answer: 1 Explanation: 1. The infant's immune system is not fully developed at birth, and the infant has low levels of antibodies due to lack of exposure to antigens. 2. Newborns and young infants do have high levels of maternal antibodies, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. 3. Newborns and young infants do have passive transplacental immunity, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. 4. Newborns and young infants do have exposure to microorganisms during the birth process, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection.

10) The pediatric clinic has set a goal that 95% or more of the children attending the clinic will be fully immunized. Which should the clinic nurses teach the families to meet this goal? 1. The benefits of immunizations outweigh the risks of communicable diseases. 2. Immunizations should be completed by the time the child starts school. 3. Once a child receives a vaccination, that individual has lifelong immunity against that disease. 4. Vaccinations are 100% safe.

Answer: 1 Explanation: 1. The risks and benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. 2. The immunization schedule is not completed by the time the child starts school. Immunizations continue throughout the life of the individual. 3. It is important that the families realize that to be fully protected, many vaccinations will need to be repeated at specified times. 4. Vaccinations can cause illness or injury. No medication is 100% safe.

7) A nurse is providing care for a pediatric client in the intensive care unit (ICU) who has been on opioids for an extended period of time. Which assessment finding indicates to the nurse that the child is experiencing withdrawal symptoms related to the opioid weaning process? 1. Hyperactive deep tendon reflexes, vomiting, and abdominal cramps. 2. Bradycardia and pallor. 3. Decreased blood pressure and drowsiness. 4. Voracious appetite and hypotonicity.

Answer: 1 Explanation: 1. These are symptoms of withdrawal resulting from reducing the dose too quickly. 2. A child who is being withdrawn from opioids too quickly will be tachycardic and have hot flashes and sweating. 3. The child who is being withdrawn from opioids too quickly will be hypertensive and wakeful. 4. Nausea, abdominal pain, diarrhea, and hypertonicity would be symptoms of withdrawal.

11) Which is the priority nursing action when providing care to a pediatric client who has documented allergies to cow's milk, peanuts, and latex? 1. Evaluating the hospital room for equipment containing latex 2. Ordering an EpiPen for the child 3. Notifying dietary of the milk and peanut allergy 4. Placing a sign on the door which identifies all allergies

Answer: 1 Explanation: 1. This is appropriate as latex allergies can be life threatening. Many pieces of medical equipment may contain latex. 2. Nurses do not prescribe or dispense medication, so this is inappropriate. 3. This action should be taken but is not the priority. 4. Depending on hospital policy, there may be some sign to indicate allergies, but this is not the priority.

7) A child who has not had a tetanus immunization steps on a rusty nail. Which term should the nurse use to identify the tetanus immunization when teaching the parents about the vaccine? 1. Toxoid 2. Live virus 3. Killed virus 4. Recombinant

Answer: 1 Explanation: 1. Toxoids are chemicals normally associated with a disease that stimulate the production of immunity. A tetanus immunization is an example of a toxoid vaccine. 2. A live virus vaccine contains a microorganism that is live but attenuated, or in a weakened form. A varicella immunization is an example of a live virus vaccine. 3. A killed virus vaccine contains a microorganism that has been killed but is still capable of causing the human body to produce antibodies. This term is used to describe an inactivated poliovirus vaccine. 4. A recombinant vaccine used a genetically altered organism. A hepatitis B immunization is an example of this type vaccine.

12) Which should the nurse use when reconstituting vaccines? 1. The diluents provided 2. Normal saline 3. Any solution available 4. Sterile water

Answer: 1 Explanation: 1. When reconstituting vaccines, it is important to use the solution provided and follow the manufacturer's directions. 2. Not all medications are compatible with normal saline. 3. Only use what is suggested by the manufacturer. 4. Unless otherwise suggested, use what is suggested by the manufacturer. Page Ref: 1056-1059

25) Which complementary pain management interventions should the nurse include in the plan of care for a pediatric client who is experiencing chronic pain? Select all that apply. 1. Hypnosis 2. Guided imagery 3. Patient-controlled analgesia (PCA) 4. Fentanyl patch 5. EMLA cream

Answer: 1, 2 Explanation: 1. Hypnosis is a complementary intervention that is appropriate for the nurse to include in the plan of care for a pediatric client who is experiencing chronic pain. 2. Guided imagery is a complementary intervention that is appropriate for the nurse to include in the plan of care for a pediatric client who is experiencing chronic pain. 3. PCA is not a complementary pain management therapy. 4. Fentanyl patch is not a complementary pain management therapy. 5. EMLA cream is not a complementary pain management therapy.

14) The nurse is planning care for a preschool-age child who is intellectually disabled and is scheduled for surgery the next day. Which should the nurse consider when choosing a pain assessment tool? Select all that apply. 1. The child's language skills 2. The child's ability to understand the concept of more and less 3. The child's ability to sit for a 10-minute evaluation 4. The child's ability to perceive pain 5. The child's ability to understand pain

Answer: 1, 2 Explanation: 1. In order to report pain, the child needs adequate verbalization skills to communicate to the nurse. 2. The child who understands more or less can be given a three-option pain scale. The child who cannot understand more or less may need a behavioral pain scale. 3. The assessment does not require the child to sit still. 4. Children perceive pain. The issue is if the nurse can recognize the child's pain. 5. Children do not need to understand pain in order to feel pain.

21) The nurse is providing care to a pediatric client who is receiving sedation for a painful procedure. Which are the priority nursing actions? Select all that apply. 1. Monitoring respirations 2. Assessing for manifestations of deep sedation 3. Ensuring a crash cart is available 4. Administering the prescribed opioid 5. Administering the prescribed benzodiazepine

Answer: 1, 2, 3 Explanation: 1. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to monitor the child's respirations. 2. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to assess for manifestations associated with deep sedation. 3. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is ensuring a crash cart is available. 4. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to have an opioid antagonist available if respiratory depression occurs. 5. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to have a benzodiazepine antagonist available, if needed.

21) The nurse is assessing a pediatric client who is experiencing metabolic acidosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?"

Answer: 1, 2, 3 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis.

19) Which distraction techniques should the nurse to use for a school-age child during a painful procedure? Select all that apply. 1. Blowing bubbles 2. Music therapy 3. Guided imagery 4. Hypnosis 5. Sucrose solution

Answer: 1, 2, 3 Explanation: 1. Blowing bubbles or popping bubbles can be a distraction for a young school-age child. 2. Listening to music or singing can be used as distraction for this age group. 3. Guided imagery is a means of encouraging relaxation and mental images to manage pain. 4. Under hypnosis, the child is an altered state of awareness; this is not a form of distraction. 5. Sucrose solution is used for infants up to 12 months of age. This is a complementary therapy but not a method of distraction.

23) The nurse is providing care to a child who experienced an anaphylactic reaction to an unknown allergen. Which high-risk foods should the nurse question the family about regarding recent consumption? 1. Peanut butter 2. Shrimp 3. Eggs 4. Milk 5. Soda

Answer: 1, 2, 3 Explanation: 1. Peanut products, such as peanut butter, are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 2. Shellfish, such as shrimp, is considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 3. Egg whites are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 4. While milk allergies are common, they rarely cause anaphylaxis. 5. Soda is not a high risk for the nurse to include in the assessment process.

23) Which are discharge criteria the nurse includes in the plan of care for a client who has received sedation? Select all that apply. 1. Stable vital signs 2. Patent airway 3. Ability to sit up without assistance 4. Adequate fluid intake 5. Ability to urinate

Answer: 1, 2, 3 Explanation: 1. Stable vital signs are a criterion for discharge for a pediatric client who has received sedation. 2. A patent airway is one criterion for discharge for the pediatric client who has received sedation. 3. The ability to sit up without assistance is one criterion for discharge for the pediatric client who has received sedation. 4. Fluid intake is not essential as some sedation medications stimulate vomiting. 5. Ability to urinate is not an essential criterion for discharge for the pediatric client who has received sedation.

22) Which are the priority nursing assessments when providing care to a pediatric client who is receiving sedation? Select all that apply. 1. Respiratory effort 2. Chest wall movement 3. Skin color 4. Level of consciousness 5. Pain

Answer: 1, 2, 3, 4 Explanation: 1. A respiratory effort assessment is a nursing priority for the pediatric client who is receiving sedation. 2. Assessing chest wall movement is a nursing priority for the pediatric client who is receiving sedation. 3. Assessing skin color is a nursing priority for the pediatric client who is receiving sedation. 4. Assessing level of consciousness is a nursing priority for the pediatric client who is receiving sedation. 5. Assessing the client's pain is not a priority when providing care to a pediatric client who is receiving sedation.

24) Which pediatric diagnoses require the nurse to include interventions to treat chronic pediatric client pain in the plan of care? Select all that apply. 1. Juvenile idiopathic arthritis 2. Sickle cell disease 3. Attention deficit hyperactivity disorder (ADHD) 4. Cancer 5. Human immunodeficiency virus (HIV)

Answer: 1, 2, 4 Explanation: 1. Juvenile idiopathic arthritis is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 2. Sickle cell disease arthritis is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 3. ADHD is not a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 4. Cancer is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 5. HIV is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care.

20) The mother of an immunocompromised child expresses concern that her child will "catch" a disease from the scheduled vaccination. Which vaccines should be administered to this child as they carry no risk for acquiring the infection? 1. Toxoid 2. Killed virus vaccine 3. Live virus vaccine 4. Attenuated vaccine 5. Immunoglobulins

Answer: 1, 2, 5 Explanation: 1. A toxoid is not an organism but a chemical produced by the organism. The toxoid has been treated to weaken its toxic effect. 2. The immunization contains organisms that are dead and incapable of reproducing. 3. This immunization contains live but weakened organisms. These organisms can mutate and reproduce and may cause disease in a weakened immune system. 4. An attenuated vaccine is the same as a live virus vaccine. 5. Immunoglobulins are the antibodies produced by others against a disease. They do not contain the live or killed virus.

19) Which pediatric client diagnoses necessitate close monitoring for respiratory acidosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis

Answer: 1, 2, 5 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis.

28) Which communicable diseases, preventable through childhood immunization, should the nurse include in a presentation to families at a local community center wellness fair? (Select all that apply.) 1. Measles 2. Chickenpox 3. Fifth disease 4. Mononucleosis 5. Whooping cough

Answer: 1, 2, 5 Explanation: 1. Measles is a communicable disease that can be prevented through childhood immunization. 2. Chickenpox is a communicable disease that can be prevented through childhood immunization. 3. Fifth disease, while a communicable disease, is not preventable through childhood immunization. 4. Mononucleosis, while a communicable disease, is not preventable through childhood immunization. 5. Whooping cough, or pertussis, is a communicable disease that can be prevented through childhood immunization.

31) Which vaccines should the nurse prepare to administer to a 6-month-old infant during a scheduled well-child visit? Select all that apply. 1. DTaP vaccine 2. Hib vaccine 3. HPV4 vaccine 4. MMR vaccine 5. PCV13 vaccine

Answer: 1, 2, 5 Explanation: 1. The DTap vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit. 2. The Hib vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit. 3. The HPV4 vaccine is not appropriate to administer to a 6-month-old infant during a scheduled well-child visit. This vaccine is not administered until a child is 11 to 12 years of age. 4. The MMR vaccine is not appropriate to administer to a 6-month-old infant during a scheduled well-child visit. This vaccine is not administered until a child is 12 to 15 months of age. 5. The PCV13 vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit.

21) Which interventions should the nurse include in the plan of care for a hospitalized child who is diagnosed with rheumatoid arthritis (RA)? Select all that apply. 1. Performing passive range-of-motion (ROM) exercises with the child 2. Discouraging the child from completing activities of daily living (ADLs) 3. Encouraging periods of rest for the child 4. Placing cool compresses on the child's joints 5. Performing daily weights

Answer: 1, 3, 5 Explanation: 1. Active and passive ROM is encouraged as this decreases joint stiffness and inflammation. 2. The child should be encouraged, not discouraged, to be as independent as possible with ADLs. 3. Exacerbations of RA often cause fatigue; therefore, it is appropriate for the nurse to encourage rest periods. 4. Warm, not cool, compresses should be placed on the joints. 5. Daily weights are needed, as it is not uncommon for the child with RA to experience reduced activity and metabolic needs yet maintain the same diet, which places the child at risk for overweight and obesity.

22) The nurse is providing education to a family whose child experiences anaphylaxis when exposed to any amount of latex. Which items, often found in the home or school environment, should the nurse include in the teaching session? Select all that apply. 1. Art supplies 2. Toothpaste 3. Balloons 4. Perfumes 5. Chewing gum

Answer: 1, 3, 5 Explanation: 1. Art supplies often contain latex; therefore, the nurse should include this item in the teaching session. 2. Toothbrushes, not tooth paste, are known to contain latex. The nurse should not include this item in the teaching session. 3. Balloons often contain latex; therefore, the nurse should include this item in the teaching session. 4. Perfumes are not known to contain latex. The nurse should not include this item in the teaching session. 5. Chewing gum often contains latex; therefore, the nurse should include this item in the teaching session.

19) Which infection control measures should the nurse include in the discharge instructions for the family of a child who is immunodeficient? Select all that apply. 1. "It is important that your child does not share cups with other members of the family." 2. "You should avoid washing your child's utensils in the dishwasher." 3. "You should allow your child to eat fresh fruit with the skin intact." 4. "It is important that everyone practices hand hygiene before touching your child." 5. "You should use alcohol wipes to cleanse your child's diaper area."

Answer: 1, 4 Explanation: 1. Children who are immunodeficient should not share cups with other members of the family, as this increases the child's risk for developing an infection. 2. Utensils should be washed in warm water or placed in the dishwasher to ensure that contaminates are properly cleansed. 3. Fresh fruit should be washed and peeled prior to allowing the child who is immunocomprised to eat it. 4. Hand hygiene before handling the child, after changing diapers, and prior to feeding the child is essential to decrease the risk for infection. 5. The diaper area should be cleaned with mild soap and allowed to dry. The use of alcohol will increase the risk for skin breakdown and infection.

9) After a severe allergic reaction, an EpiPen is prescribed for the school-age child. Which instructions should the nurse provide to this child's parents based on the current data? Select all that apply. 1. "It is important that your child always has access to this medication." 2. "Your child is too young to self-administer this medication." 3. "If you are able to administer the medication, there is no need for follow-up care." 4. "It is important to check the expiration date on the medication and replace if expired." 5. "Your child should wear a Medic Alert bracelet at all times."

Answer: 1, 4, 5 Explanation: 1. This is appropriate care. 2. Both the child and family members should be taught administration of the EpiPen. 3. The EpiPen effect is good for approximately 20 minutes. The child should be transported to the hospital immediately after administering the EpiPen. 4. An expired EpiPen may have less than desired effects. 5. If the child is unable to speak due to anaphylaxis, it is important that rescuers have information about the child's allergies.

4) The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes. Which additional assessment data indicates to the nurse that the infant is experiencing an early to moderate stage of dehydration? 1. Bradycardia 2. Tachycardia 3. Increased blood pressure 4. Normal fontanels

Answer: 2 Explanation: 1. Bradycardia is not a sign of dehydration. 2. Tachycardia is a sign that indicates moderate dehydration. 3. In dehydration, the blood pressure is hypotensive. 4. Fontanels would be sunken in moderate dehydration.

2) A premature neonate is at greater risk for infection than a full-term newborn because of a reduced number of which immunoglobulin? 1. IgE 2. IgG 3. IgA 4. IgM

Answer: 2 Explanation: 1. IgE does not cross the placenta and is not present at birth in either preterm or full-term infants. 2. Maternal IgG crosses the placenta. Newborns' levels are similar to their mothers'. Premature infants have lower levels of IgG obtained from their mothers and are at greater risk for infection. 3. IgA does not cross the placenta and is not present at birth in either preterm or full-term infants. 4. IgM does not cross the placenta. The levels are low at birth in both preterm and full-term infants.

6) The nurse is teaching parents how to prevent the spread of infectious disease. Which is the priority health promotion strategy the nurse should recommend for all age groups of children? 1. Decreasing environmental exposure to pathogens 2. Performing hand hygiene 3. Ensuring all toys are clean and free from germs 4. Keeping child away from sick adults

Answer: 2 Explanation: 1. It is not possible to keep children free from colds. 2. Proper hand hygiene is one of the most important health promotion strategies for all age groups of children as well as child care providers. 3. Keeping all toys clean and free from germs is not possible. 4. It is not always possible to keep children away from sick adults.

15) A child with human immunodeficiency virus (HIV) is diagnosed with oral candidiasis. Which should the nurse include in the plan of care related to oral care based on this information? 1. Listerine 2. Normal saline 3. Viscous lidocaine 4. Scope

Answer: 2 Explanation: 1. Listerine is a commercial mouth rinse that can have an alcohol base and cause drying of the membranes. 2. The mouth care should be with a nonalcohol base. Normal saline can keep the child's lips and mouth moist. 3. Viscous lidocaine causes numbing, and could depress the gag reflex in a younger child. 4. Scope is a commercial mouth rinse that can have an alcohol base and cause drying of the membranes.

9) The nurse is preparing to perform a heel stick on a neonate. Which complementary therapy should the nurse implement to decrease pain during this quick but painful procedure? 1. Holding the newborn 2. Providing a sucrose pacifier to the newborn 3. Massaging the newborn 4. Swaddling the newborn

Answer: 2 Explanation: 1. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress. 2. Sucrose provides short-term, natural pain relief, and is most appropriate for use in neonates to decrease pain associated with a quick procedure. 3. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress. 4. Swaddling for a neonate undergoing a quick painful procedure will not decrease the pain.

4) Which common mode of infectious disease should the nurse include in a teaching session with parents within the community? 1. Playing with the same toy 2. Coughing without covering the mouth 3. Sitting together eating meals 4. Playing board games

Answer: 2 Explanation: 1. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. 2. The fecal-oral and respiratory routes are the most common sources of transmission in children. 3. Eating together will not transmit infectious disease. 4. Playing with board games will not transmit infectious disease.

18) The 17-month-old toddler, diagnosed with terminal cancer, is experiencing constant pain. Which prescription does the nurse anticipate from the healthcare provider for this toddler? 1. Patient-controlled analgesia (PCA) with the parents controlling the button that administers the dosage 2. Intravenously administered opioids on a scheduled basis 3. Intravenously administered opioids on a prn basis 4. Orally administered opioids on a prn basis

Answer: 2 Explanation: 1. PCA should always be controlled by the individual receiving the medication. It is inappropriate to have the parents control the medication administration. 2. This provides continuous blood levels of the opioid. 3. By waiting until symptoms are present, the child's blood level will drop, making it more difficult to control the pain. 4. Parenteral administration controls pain more effectively than oral medication as oral absorption may be modified by stomach activities. In addition, providing analgesics on a scheduled basis is preferred over prn.

17) The hospital has instructed its nurses that they must participate in disease surveillance associated with infectious agents. Which disease(s) are likely to be the weapons of terrorists? 1. Rocky Mountain spotted fever and Lyme disease 2. Plague, anthrax, and smallpox 3. Rubella, mumps, and chickenpox 4. Severe acute respiratory syndrome (SARS)

Answer: 2 Explanation: 1. Rocky Mountain spotted fever and Lyme disease are caused by ticks endemic to wooded areas. 2. Plague, anthrax, and smallpox are choices of terrorists because they are highly contagious, lethal diseases that can kill large numbers of people in a relatively short time. 3. Rubella, mumps, and chickenpox are childhood communicable diseases that are not usually fatal. 4. SARS is a rare infectious disease.

14) The nurse is providing care to a child who is diagnosed with Lyme disease. The mother wants to know how to protect her other children from contracting this disease from the infected child. Which should the nurse include in the teaching session regarding the transmission of this disease process? 1. Lyme disease is passed from person to person. 2. Lyme disease is passed from animals to person. 3. Lyme disease is passed from adults to children. 4. Lyme disease is passed from person to insects.

Answer: 2 Explanation: 1. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not communicable from person to person. 2. Zoonosis describes infectious diseases that are transmitted by animals and are not communicable from person to person. Lyme disease is an example of this type of infectious disease. 3. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not communicable from adults to children. 4. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not passed from people to insects.

4) A 5-year-old child is hospitalized with a fractured femur. Which tool should the nurse use to assess this child's pain? 1. CRIES Scale 2. Faces Pain Rating Scale 3. SUN Scale 4. PIPP Scale

Answer: 2 Explanation: 1. The CRIES Scale was developed for preterm and full-term neonates. 2. A 5-year-old child should be able to use the Faces Scale to choose which face best matches the child's pain level. 3. The SUN Scale was developed for use in newborns. 4. The PIPP Scale was developed for premature infants.

7) In which position should the nurse place a child who is experiencing an anaphylactic shock reaction? 1. Trendelenburg position 2. Flat, with legs slightly elevated 3. High Fowler position 4. Reverse Trendelenburg position

Answer: 2 Explanation: 1. The Trendelenburg position has the head of the bed lowered and is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. 2. Flat, with legs slightly elevated, is the position that is used for a client experiencing shock. This allows for the blood pressure to be maintained during this critical time. 3. The high Fowler position has the head of the bed elevated and will not be effective to maintain a blood pressure when shock is occurring. 4. The reverse Trendelenburg position has the head of the bed elevated and will not be effective to maintain a blood pressure when shock is occurring.

5) During the nurse's initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which nursing action is appropriate? 1. Reassess the child in 15 minutes to see if the pain rating has changed. 2. Administer the prescribed analgesic. 3. Do nothing, since the child appears to be resting. 4. Ask the child's parents if they think the child is hurting.

Answer: 2 Explanation: 1. There is no need to reassess, as the child needs pain medication now. 2. School-age children are old enough to report their pain level accurately. A pain score of 6 is an indication for prompt administration of pain medication. The child might be trying to be brave or might be lying still because movement is painful. 3. The child might be lying quietly because movement increases the pain. 4. School-age children can answer for themselves and do not need the parents to answer for them.

5) The nurse is teaching a preschool-age child and parents the importance of hand washing after using the toilet. Which rationale for this practice should the nurse include in the teaching session? 1. Children's immune systems are not fully developed. 2. It is the main way to limit the transmission of disease. 3. Not all bathrooms are clean. 4. Children do not like to have dirty hands.

Answer: 2 Explanation: 1. Underdeveloped immune systems will not transmit disease. 2. The fecal-oral and respiratory routes are the most common sources of transmission in children. 3. Children usually do not wash their hands after toileting unless they are closely supervised. 4. This is not a reason for washing hands after using the toilet.

16) Which is the priority nursing action when it is suspected that an infectious agent has been used as a weapon by terrorists? 1. Separating clients according to age 2. Initiating airborne and contacts precautions 3. Separating clients according to level of development 4. Disposing of blood-contaminated needles in the lead-lined container

Answer: 2 Explanation: 1. Separating clients according to age will do nothing to stop terrorism. 2. When clients present with the same type of infectious symptoms, the priority nursing action is to initiate airborne and contact precautions prior to diagnosis. 3. Separating clients according to level of development will do nothing to stop terrorism. 4. Proper disposal of blood-contaminated needles in the sharps container is appropriate nursing actions but does not relate to terrorism.

17) The nurse is providing discharge instructions to the family of a child who experienced an anaphylactic reaction. Which parental statements indicate accurate understanding of the action that histamine plays during this type of reaction? Select all that apply. 1. "Histamine releases IgE antibodies, which help to stop the reaction." 2. "Histamine causes smooth muscle contraction, which causes the wheezing." 3. "Histamine causes increased capillary permeability, which is what causes difficulty breathing." 4. "Histamine causes vasoconstriction leading to respiratory issues." 5. "Histamine causes the destruction of red blood cells, which is why we administer the EpiPen."

Answer: 2, 3 Explanation: 1. IgE antibodies cause the release of histamine, not the other way around. 2. Smooth muscle contraction causes the constriction of the bronchioles, which causes the wheezing and respiratory distress. 3. Increased capillary permeability causes the plasma to leak into surrounding tissues, including the lungs, leading to pulmonary edema. 4. Anaphylaxis causes vasodilation, not vasoconstriction. 5. Histamine does not cause red cell destruction.

21) Which nursing actions allow a child to acquire active immunity against a disease? 1. Administering a dose of immunoglobulins 2. Administering a killed virus vaccine 3. Administering a toxoid vaccine 4. Administering antibiotic therapy 5. Administering antiviral therapy

Answer: 2, 3 Explanation: 1. Immunoglobulins provide passive immunity. No active immunity is acquired. 2. This immunization will stimulate antibody production in the child which is active immunity. 3. This immunization will also stimulate antibody production in the child. 4. Antibiotic therapy provides no immunity. 5. Antiviral therapy provides no immunity.

23) Which age-appropriate techniques should the nurse implement in order to encourage a young child to participate in deep breathing exercises? Select all that apply. 1. Showing the child how to use the "blow bottle" 2. Using a pinwheel that the child plays with and asking the child to blow until it turns 3. Asking the child to blow bubbles in a glass of water using a straw 4. Having the child blow scraps of paper across the bedside table with a straw 5. Telling the child that a "shot" will be needed if the child does not follow the nurse's

Answer: 2, 3, 4 Explanation: 1. A blow bottle is appropriate for an older pediatric client, not a young child. 2. Asking the young child to blow on a pinwheel is an age-appropriate intervention to facilitate deep breathing. 3. Asking the child to blow bubbles into a glass of water is an age-appropriate intervention to facilitate deep breathing. 4. Having the child blow scraps of paper across the bedside table with a straw is an age-appropriate intervention to facilitate deep breathing. 5. Telling the child that an injection will be administered if the nurse's directions are not followed is not therapeutic nor age appropriate.

20) Which nonpharmacologic interventions are appropriate for the nurse to use when treating pediatric clients in pain? Select all that apply. 1. Regional nerve block 2. Cutaneous stimulation 3. Application of heat 4. Electroanalgesia 5. Use of EMLA cream

Answer: 2, 3, 4 Explanation: 1. A regional nerve block involves injecting medications in an area that controls pain for a region of the body. It does not provide nonpharmacologic relief. 2. Massage and rubbing of the skin as well as swaddling and kangaroo care are nonpharmacologic means of relieving pain. 3. The use of heat (and cold) may help reduce pain sensations and utilizes no pharmacologic agents. 4. Electrical stimulation to the skin uses the gate control theory to relieve pain. 5. EMLA cream is a mixture of lidocaine and prilocaine that is applied to the intact skin. It is a pharmacologic pain relief method.

25) The nurse administers the flu vaccine to a school-age child. Which should the nurse include in the documentation for the administration of this vaccine? Select all that apply. 1. The date of the last flu vaccine 2. The site of the vaccination 3. The lot and serial number of the vaccine 4. The date and time of administration. 5. Who assisted in restraining the child

Answer: 2, 3, 4 Explanation: 1. This information is not pertinent. 2. The site should be recorded. 3. This information should be recorded in case a problem develops. 4. This should be recorded. 5. This information is not pertinent.

20) Which interventions should the nurse include in the plan of care to address nutrition for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Encourage three large meals each day. 2. Eliminate unpleasant odors from the environment during meals. 3. Weigh the child each day, using the same scale. 4. Assess skin turgor every 4 hours. 5. Include favorite foods in the meal plan.

Answer: 2, 3, 5 Explanation: 1. Children diagnosed with AIDS who are experiencing impaired nutrition should be offered small frequent meals to meet nutritional needs. 2. Unpleasant stimuli and odors often decrease the desire for food. 3. Taking daily weights, using the same scale, is an appropriate intervention to monitor the child's nutritional status. 4. Skin turgor should be assessed each shift, not every 4 hours, in order to monitor hydration status. 5. Allowing children to eat their favorite foods encourages intake.

her child needed hospitalization since her school-age nephew had the same symptoms and was treated at home. Which should the nurse include in the explanation to the infant's mother? Select all that apply. 1. Infants have a lower proportion of their body weight as water. 2. The percentage of extracellular fluid is higher in the infant than the school-age child. 3. School-age children have a larger body surface area. 4. The school-age child's kidneys are more mature and better able to conserve water. 5. The metabolic rate of the school-age child is higher.

Answer: 2, 4 Explanation: 1. Infants have a higher percentage of body weight as water. 2. This statement is accurate. 3. Body surface area (BSA) is an assessment of skin surface. BSA compares the height and weight of the child and is greatest in infancy. 4. This statement is accurate. 5. Infants have a higher metabolic rate than a school-age child.

8) An analgesic is prescribed for a postsurgical pediatric client to be administered every 3 to 4 hours. Which can occur if the nurse is delayed in administering the prescribed analgesic? 1. Decrease in the chance of withdrawal symptoms 2. Decrease in the chance of addiction 3. Increase in the chance of breakthrough pain 4. Increase in the child's pain tolerance

Answer: 3 Explanation: 1. A delay in giving pain medication will not decrease the chance of withdrawal symptoms if the medication is stopped without weaning. 2. Delaying the pain medication will not decrease the chance of addiction. 3. Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain. 4. Delaying the pain medication will not increase the child's pain tolerance.

22) The nurse is preparing to administer a vaccine to a 14-month-old toddler. Which assessment factor would warrant a delay in the scheduled vaccination during the well-child visit? 1. The child is allergic to a substance in the vaccine. 2. The child has a low-grade fever and a runny nose. 3. The child received a dose of immune globulin 2 months ago. 4. The child is on antibiotics.

Answer: 3 Explanation: 1. A vaccine allergy contradicts the administration of the vaccine for life. This factor does not warrant a delay. The child should not receive the vaccine at the next well-child visit or at any other time. 2. A mild upper respiratory infection would not be a contraindication for vaccine administration. 3. The antibodies in the immune globulin will prevent the child from developing immunity to the vaccination. By the next well-child visit, the immune globulins will not prevent immunity from developing. 4. Antibiotic administration will not prevent the development of active immunity.

4) An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of the body changes that occur because of SLE? 1. Attends school but does not stay for after-school activities 2. Discusses the body changes with healthcare providers only 3. Discusses the body changes with her best friend 4. Only attends small parties at friends' homes

Answer: 3 Explanation: 1. Avoiding social activities does not show acceptance of body changes. 2. Discussing changes only with healthcare providers does not indicate the teen has adjusted to the body image changes. 3. Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the changes in her body image. 4. Avoiding social activities other than those involving immediate friends indicates the teen is still concerned with body image.

1) A 4-year-old child is admitted to the hospital secondary to dehydration. Laboratory tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. Which condition does the nurse suspect based on the current data? 1. Hypernatremia 2. Metabolic acidosis 3. Hypotonic dehydration 4. Isotonic dehydration

Answer: 3 Explanation: 1. Hypernatremia is a condition where the body fluids are too concentrated and there is an excess of sodium. 2. Metabolic acidosis refers to a condition where the pH of the blood is acidic. 3. This occurs when fluid loss is characterized by a proportionately greater loss of sodium than water. Serum sodium is below normal levels. Hemoglobin and hematocrit will be high due to the loss of serum water. 4. This occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion.

12) Which statement by the parent of a preschool-age child would indicate the need for further teaching regarding pain management? 1. "I will call the office tomorrow if the pain medicine is not relieving the pain." 2. "I can expect my child to have some pain for the next few days." 3. "Because my child just had surgery today, I can expect the pain level to be higher tomorrow." 4. "I will plan to give my child pain medicine around the clock for the next day or so."

Answer: 3 Explanation: 1. If prescribed medication is not relieving the pain to a satisfactory level, the healthcare provider should be notified. This statement indicates the parent understands and does not need additional teaching. 2. The child is expected to have some pain for a few days after surgery. This statement indicates the parent understands the teaching. 3. Increasing pain can be a sign of complication and should be reported to the healthcare provider; therefore, the nurse should clarify expectations for pain control. 4. The child should receive pain medication on a scheduled basis. This statement indicates the parent understands the teaching.

3) Which parental statement indicates correct understanding of preventive techniques for heat-related illnesses when children exercise? 1. "Wearing dark clothing during exercise is recommended." 2. "Water is the fluid of choice to replenish fluids." 3. "During activity, stop for fluids every 15 to 20 minutes." 4. "Hydration should occur at the end of an exercise session."

Answer: 3 Explanation: 1. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating. 2. A combination of water and sports drinks is best to replace fluids during exercise. 3. During activity, stopping for fluids every 15 to 20 minutes is recommended. 4. Hydration should occur before and during the activity, not just at the end.

12) Which is the rationale for ensuring the irrigation of blood products and ensuring that they are cytomegalovirus (CMV)-negative prior to administering a blood transfusion for a pediatric client diagnosed with severe combined immune deficiency (SCID)? 1. Transfusion reaction from lymphocytes and platelets in the donor blood. 2. Transfusion reaction and infection from lymphocytes in the donor blood. 3. Infection and graft-versus-host disease from lymphocytes in the donor blood. 4. Infection and graft-versus-host disease from erythrocytes in the donor blood.

Answer: 3 Explanation: 1. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. 2. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. 3. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. 4. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease.

18) Which parental action indicates accurate understanding of information presented by the nurse to treat a fever related to otitis media? 1. Putting the child in a tub of cold water to reduce the fever 2. Alternating acetaminophen with ibuprofen every 2 hours 3. Offering generous amounts of fluids frequently 4. Using aspirin every 4 hours to reduce the fever

Answer: 3 Explanation: 1. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature. 2. Alternating acetaminophen with ibuprofen every 2 hours could result in an overdose. 3. The body's need for fluids increases during a febrile illness. 4. Aspirin has been associated with Reye syndrome and should not be given to children with a febrile illness unless prescribed by the healthcare provider.

15) The nurse administers IV morphine to a 4-year-old postoperative client. Which assessment finding requires further evaluation by the nurse? 1. Pulse decreased from 136 to 104 2. Blood pressure dropped from 110/72 to 90/55 3. Respiratory rate went from 42 to 16 4. Child pulls away from nurse who wants to assess surgical site

Answer: 3 Explanation: 1. The normal pulse rate for children 2 to 5 years of age is between 70 and 120. 2. 90/55 is a normal finding for this age group. 3. This respiratory rate is on the low side for the age group and requires further evaluation to determine if the child's respirations are being depressed. 4. This is normal behavior for a 4-year-old child. Page Ref: 973

6) A hospitalized 3-year-old child needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which is an appropriate nursing diagnosis to address this situation? 1. Knowledge Deficit of the procedure 2. Fear related to the unfamiliar environment 3. Anxiety related to anticipated painful procedure 4. Ineffective Individual Coping related to an invasive procedure

Answer: 3 Explanation: 1. The scenario indicates that the child has been through this before, so Knowledge Deficit is not the most appropriate diagnosis. 2. The child's fear is related not to the unfamiliar environment but to the anticipated pain of the IV stick. 3. This child is not old enough to understand the need for an IV infusion. The scenario indicates that the child has been through this painful procedure before, and the child's reaction to entering the treatment room is based on anticipation of repeat discomfort. 4. The child's behavior is appropriate for coping in this age child.

11) A mother brings in her 4-month-old infant for a routine checkup and vaccinations. The mother reports that her child was exposed to the flu. Which nursing action is accurate based on the current data? 1. Withhold the DTaP vaccination but give the others as scheduled. 2. Give the infant the flu vaccination but withhold the others. 3. Give the vaccinations as scheduled. 4. Withhold the vaccinations.

Answer: 3 Explanation: 1. There is no reason to withhold any of the vaccinations due at this time. 2. The flu vaccination would not routinely be given to a 4-month-old infant. 3. Giving the vaccine as scheduled will keep the infant properly immunized. 4. Recent exposure to an infectious disease is not a reason to defer a vaccine.

24) Which vaccine reaction, noted by the mother during a telephone conversation with a nurse, would require activation of emergency medical services? 1. A few hives are noted around the injection site. 2. The child is running a slight temperature. 3. The child has swelling of the face. 4. Fever and joint pains occurring within hours of the vaccination.

Answer: 3 Explanation: 1. This is a mild allergic reaction and does not require calling 911. 2. A slight temperature does not require calling 911. 3. This could be the onset of anaphylaxis, and immediate response is essential to the survival of the child. The mother should call 911. 4. This is a common reaction to immunizations and does not indicate anaphylaxis. Page Ref: 1058

9) A child with croup has an increased PCO2, a decreased pH, and a normal HCO3 blood gas value. Which does the nurse report to the healthcare provider based on these data? 1. Uncompensated metabolic alkalosis 2. Uncompensated metabolic acidosis 3. Uncompensated respiratory acidosis 4. Uncompensated respiratory alkalosis

Answer: 3 Explanation: 1. Uncompensated metabolic alkalosis has an increased pH, normal PCO2, and increased HCO3. 2. Uncompensated metabolic acidosis has a decreased pH, normal PCO2, and normal HCO3. 3. If the pH is decreased and the PCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. 4. Uncompensated respiratory alkalosis has an increased pH, decreased PCO2, and normal HCO3.

20) Which pediatric client diagnoses necessitate close monitoring for respiratory alkalosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis

Answer: 3, 4 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis.

29) Which live virus vaccines should the nurse teach to parents as being used to decrease the risk of communicable diseases? Select all that apply. 1. Poliovirus 2. Tetanus 3. Measles 4. Varicella 5. Hepatitis B

Answer: 3, 4 Explanation: 1. Poliovirus is an example of a killed virus vaccine that is used to decrease the risk of communicable diseases. 2. Tetanus is an example of a toxoid vaccine that is used to decrease the risk of communicable diseases. 3. Measles is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 4. Varicella is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 5. Hepatitis B is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases.

26) There has been an outbreak of communicable diseases in the community. To reduce parental anxiety, the nurse presents information about disease at the school's Parent Teacher Association meeting. Which vectorborne diseases, not communicable from person to person, should the nurse include in the teaching session? Select all that apply. 1. Measles 2. Whooping cough 3. Rocky Mountain spotted fever 4. West Nile virus 5. Lyme disease

Answer: 3, 4, 5 Explanation: 1. Rubeola, or measles, is caused by a virus and is transmitted person to person. 2. Pertussis, or whooping cough, is caused by a gram-positive coccobacillus called Bordetella pertussis and is spread person to person. 3. Rocky mountain spotted fever is a vectorborne disease spread by a tick. 4. West Nile virus is transmitted by a mosquito, a vector, and is not transmitted person to person. 5. Lyme disease is also a vectorborne disease spread by a tick.

32) Which vaccines should the nurse prepare to administer to an 11-year-old child during a scheduled well-child visit? Select all that apply. 1. DTaP vaccine 2. Hib vaccine 3. HPV4 vaccine 4. MMR vaccine 5. MenACWY-D

Answer: 3, 5 Explanation: 1. The DTap vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 2. The Hib vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 3. The HPV4 vaccine is appropriate to administer to an 11-year-old child during a scheduled well-child visit. 4. The MMR vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 5. The MenACWY-D vaccine is appropriate to administer to an 11-year-old child during a scheduled well-child visit.

13) A nurse is planning care for a child with human immunodeficiency virus (HIV). Which is the priority nursing diagnosis for this child? 1. Ineffective Peripheral Tissue Perfusion 2. Ineffective Thermoregulation 3. Risk for Fluid Volume Deficit 4. Risk for Infection

Answer: 4 Explanation: 1. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Ineffective Tissue Perfusion, peripheral, would not be a priority problem with this disease process. 2. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Ineffective Thermoregulation would not be a priority problem with this disease process. 3. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid Volume Deficit would not be a priority problem with this disease process. 4. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Infection is the priority nursing diagnosis.

13) The nurse is caring for a child who has been sedated for a painful procedure. Which is the priority nursing action? 1. Placing the child on a cardiac monitor 2. Allowing parents to stay with the child 3. Monitoring pulse oximetry 4. Assessing the child's respiratory effort

Answer: 4 Explanation: 1. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. 2. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority. 3. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. 4. When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and the child's effort of breathing.

17) Which rationale will the seasoned nurse share with the novice nurse regarding why the specific gravity for infants is lower than for older children? 1. The infant has a greater body surface area. 2. The infant has a higher basal metabolic rate. 3. The infant has a greater percentage of body weight that is water. 4. The infant's kidneys are less able to concentrate urine.

Answer: 4 Explanation: 1. Although this is true, it does not explain the lower specific gravity. 2. This statement is true but does not explain the specific gravity differences. 3. Although the statement is true, it does not explain the specific gravity differences. 4. This statement is accurate and explains why the specific gravity of the infant's urine is closer to water than an older child's urine specific gravity.

1) . While making rounds, the nurse observes all of the following client behaviors. Which child should the nurse further evaluate for postoperative pain? 1. The 6-month-old in deep sleep. 2. The 2-year-old who is cooperative when the nurse takes vital signs. 3. The 4-year-old who is actively watching cartoons. 4. The 14-month-old who is thrashing his arms and legs.

Answer: 4 Explanation: 1. Children are unable to obtain deep sleep when experiencing acute pain. 2. When experiencing acute pain, children are less likely to cooperate with treatments. 3. It is difficult for children to concentrate when experiencing acute pain. 4. Young children in acute pain display a variety of behaviors, including loud crying, screaming, thrashing their arms and legs, lack of cooperation, clinging behavior, and restlessness and irritability.

13) A parent reports that her 5-year-old child, who has had all recommended immunizations, had a mild fever 1 week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which diagnosis does the nurse anticipate based on the current data? 1. Rubeola (measles) 2. German measles (rubella) 3. Chickenpox (varicella) 4. Fifth disease (erythema infectiosum)

Answer: 4 Explanation: 1. Children with rubeola have a high temperature and a blotchy maculopapular rash. Because there is a vaccination for rubeola, it is unlikely the child has it. 2. The rash of rubella is a pink, maculopapular rash that begins on the face and progresses downward to the trunk and extremities. The child is fully vaccinated, making this unlikely. 3. Varicella (chickenpox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. 4. Fifth disease manifests first with a flu-like illness, followed by a red "slapped-cheek" sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms.

8) The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. Which nursing action is accurate to safely administer this vaccine to the infant? 1. Administering the vaccine by ID (intradermal) injection 2. Administering the vaccine by SQ (subcutaneous) injection 3. Administering the vaccine by IM (intramuscular) injection 4. Administering the vaccine via a nasal spray

Answer: 4 Explanation: 1. DTaP is not administered by an ID injection. 2. DTaP is not administered by a SQ injection. 3. DTaP is administered by an IM injection. 4. DTaP is not administered via a nasal spray.

6) The nurse is caring for a child with rheumatoid arthritis. Which nonpharmacologic intervention should the nurse include in the plan of care for joint pain? 1. Elevation of the extremity 2. Immobilization 3. Massage 4. Application of moist heat

Answer: 4 Explanation: 1. Elevation of the extremity would not have an effect on reducing pain in rheumatoid arthritis. 2. Immobilization can lead to contractures. Range of motion to the involved joint should be maintained. 3. Massage of extremities should be avoided because of potential risk for emboli. 4. Moist heat can promote relief of pain and decrease joint stiffness.

8) A nurse is planning care for a child with hyperkalemia. Which manifestation associated with the documented hyperkalemia requires immediate intervention by the nurse? 1. Hyperthermia 2. Respiratory distress 3. Seizures 4. Cardiac arrhythmias

Answer: 4 Explanation: 1. Excessive potassium is unrelated to the body temperature. 2. Potassium is needed for contractility of heart and skeletal muscles but not for the muscles of respiration. 3. Seizures are not an adverse outcome of hyperkalemia. 4. A child with hyperkalemia is at risk for cardiac problems that can be life threatening, such as arrhythmias.

18) When teaching a pregnant client about antibodies that are passed from mother to newborn, which antibody should the nurse include? 1. IgM 2. IgA 3. IgD 4. IgG

Answer: 4 Explanation: 1. IgM is the first antibody produced with primary immune response. It does not cross the placenta. 2. IgA does not cross the placenta. 3. Although the function of IgD is not fully understood, it is not thought to cross the placenta. 4. IgG crosses the placenta and provides the newborn with passive immunity.

10) A 6-year-old postoperative client's IV infiltrates and has to be restarted immediately for medication. There is no time for placing local anesthetic cream on the skin. Which complementary therapy would be helpful when placing this IV? 1. Restraints 2. Moderate sedation 3. Anesthesia 4. Distraction

Answer: 4 Explanation: 1. Restraints are used only as a last resort and are not appropriate for an IV start. 2. Moderate sedation has its own side effects and possible complications and should not be used for quick procedures. 3. Drugs may not be used for quick procedures, such as a dressing change or an unexpected intravenous insertion, injection, or venipuncture. 4. Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure.

23) Which statement regarding what was found during the nurse's daily check of the vaccine refrigerator would cause concern about the potency of the vaccines? 1. The vaccine was frozen as labeled. 2. The vaccines have been stored in a refrigerator where the temperature has been maintained between 35 and 46° F. 3. The vaccine's expiration date expires within the next month. 4. The vaccine is stored in the door of the refrigerator.

Answer: 4 Explanation: 1. Some vaccines are stored in the freezer. 2. This is appropriate to maintain potency. 3. The vaccine is still effective until the expiration day. 4. The door will not maintain the temperature of the vaccine. Vaccines should be stored in the middle of the refrigerator.

3) The nurse is caring for a postoperative toddler-age child. Which pain assessment tool should the nurse use to assess this child's pain? 1. Poker Chip Tool 2. Oucher Scale 3. Faces Pain Rating Scale 4. FLACC Behavioral Pain Assessment Scale

Answer: 4 Explanation: 1. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 2. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 3. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 4. The FLACC scale is an appropriate tool for infants and young children who cannot report pain.

18) Which is the priority nursing assessment when providing care for an infant at risk for dehydration? 1. Urine output 2. Urine specific gravity 3. Vital signs 4. Daily weight

Answer: 4 Explanation: 1. The infant is unable to concentrate urine and will continue to void dilute urine. Therefore, this is not the priority nursing assessment for an infant at risk for dehydration. 2. The infant's kidney is immature and unable to concentrate urine. Therefore, this is not the priority nursing assessment for an infant at risk for dehydration. 3. Pulse will elevate and blood pressure may drop, but the other vital sign findings will remain unchanged. However, this is not the best assessment of dehydration. 4. Daily weights on an infant provide the most accurate assessment of fluid balance.

2) A nurse is taking care of four different pediatric clients. Which child is at greatest risk for dehydration? 1. 7-year-old child with migraine headaches 2. 4-year-old child with a broken arm 3. 2-year-old child with cellulitis of the left leg 4. 18-month-old child with tachypnea

Answer: 4 Explanation: 1. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system is at a lower risk than is a toddler with a condition that increases insensible water loss. 2. The pediatric client with an acute condition that does not directly affect electrolytes is at a lower risk than is a client with a condition that increases insensible water loss. 3. The pediatric client with an acute condition, such as a client with cellulitis that does not affect the GI or electrolyte system, is at a lower risk than is a toddler with a condition that increases insensible water loss. 4. The pediatric client with the greatest risk is under 2 years of age and with a condition that increases insensible fluid loss.

9) A mother refuses to have her child immunized with the measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which is an appropriate response by the nurse? 1. Telling the mother that by not immunizing the child she may be exposing pregnant women to the virus, which could cause fetal harm 2. Honoring the mother's request because she is the parent 3. Telling the mother that she is wrong and should have her child immunized 4. Explaining the potential complications of measles, mumps, and rubella infections

Answer: 4 Explanation: 1. This mother is not concerned about other women; she is concerned about what is best for her child. 2. Nurses are responsible for helping parents make informed decisions. It is important that the mother has all the facts before she makes a decision. 3. The mother has the right to make the decisions for her child. The nurse's role is not to tell the parents what to do but to give them the information they need to make decisions. 4. Explaining that if her child contracts measles, mumps, or rubella, the child could have very serious and permanent complications from these diseases is correct; measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness.

17) During shift report, the night nurse reports that a terminally ill child has developed tolerance to the prescribed morphine. Which concept should the nurse use when planning care for this child? 1. The child is physically dependent on morphine. 2. The child is addicted to morphine. 3. The child is showing physical signs of withdrawal. 4. The child will need more medication to achieve the same effect.

Answer: 4 Explanation: 1. While the child may be physically dependent, this is not the meaning of tolerance. 2. Addiction refers to a compulsive use of a substance despite harm. This is not the definition of tolerance. 3. Withdrawal occurs when the opioid is stopped suddenly. This is not the meaning of tolerance. 4. Tolerance occurs when the body has become accustomed to the presence of the drug in the system. When this happens, the child will need more of a drug or a stronger drug to get the same effect.

22) The nurse is assessing a pediatric client who is experiencing metabolic alkalosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?"

Answer: 4, 5 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis.

30) Which recombinant vaccines should the nurse teach to parents as being used to decrease the risk of communicable diseases? Select all that apply. 1. Poliovirus 2. Tetanus 3. Measles 4. Acellular pertussis 5. Hepatitis B

Answer: 4, 5 Explanation: 1. Poliovirus is an example of a killed virus vaccine that is used to decrease the risk of communicable diseases. 2. Tetanus is an example of a toxoid vaccine that is used to decrease the risk of communicable diseases. 3. Measles is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 4. Acellular pertussis is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases. 5. Hepatitis B is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases.

Following a motor vehicle accident and successful cardiopulmonary resuscitation, arterial blood gases are drawn from a 13-year-old client. What will the nurse identify as the result of this test? a. Acid-base balance b. Prognosis c. Capillary metabolic exchange d. Carbonic acid level

Answer: a. Acid-base balance Feedback: The test provides information about immediate status of the client's acid-base balance. It will not provide data that can predict future outcomes. Capillary blood gases are done on newborns and infants to decrease the amount of blood used, but that is not the test referred to in this question. Carbonic acid contributes to the acid-base balance, but is not measured specifically in this test as a percentage.

The nurse is discussing the risks and benefits of vaccines with a family and must secure signed, informed consent for the children to be immunized. The nurse emphasizes that which reaction to vaccines is very rare? a. Encephalopathy b. Maculopapular rash c. Urticaria around the injection site d. Fever of 100°F (37.8°C)

Answer: a. Encephalopathy Feedback: The risk of encephalopathy from complications of measles and varicella is much greater than the risk of encephalopathy from being immunized. Wheals and urticaria are local non-life-threatening allergic reactions that can occur within minutes of any immunization. A mild fever is a common reaction 24-48 hours after administration of the diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine. A rash may occur 7-10 days after the administration of the measles, mumps, and rubella (MMR) vaccine.

The child post-stem cell transfusion tells a nurse that she has a rash, diarrhea, and abdominal pain. Which condition does the nurse suspect? a. Graft-versus-host disease b. Severe combined immunodeficiency disease c. Anaphylaxis d. Systemic lupus erythematosus

Answer: a. Graft-versus-host disease Feedback: Symptoms of graft-versus-host disease include a pruritic or painful rash, diarrhea, and abdominal pain. Symptoms of severe combined immunodeficiency disease include respiratory infections, diarrhea, and recurrent oral candidiasis, failure to thrive, and skin infections. Anaphylaxis is a hypersensitivity reaction with symptoms of hypotension, wheezing, stridor, vomiting, urticarial edema, and diarrhea. The symptoms of systemic lupus erythematosus include rash, fatigue, malaise, weight loss, nephritis, vasculitis, and arthritis.

Which intervention by the nurse is most important when taking care of a child with severe dehydration? a. Monitor weight daily. b. Monitor for crackles in the lungs. c. Monitor level of consciousness. d. Monitor serum sodium levels.

Answer: a. Monitor weight daily. Feedback: When managing a child with severe dehydration, the nurse must weigh the child daily with the same scale and without clothing to compare past weights and calculate weight loss. A dehydrated child will not have crackles in the lungs. Level of consciousness and serum sodium levels will be monitored, but the priority is hydration.

For which reasons do nurses recognize that children are more vulnerable than adults during a bioterrorism attack? (Select all that apply.) a. Passively acquired maternal antibodies b. Immunization is not complete. c. Immature immune system and immature blood-brain barrier d. Slower respiratory rate e. Large blood volume

Answer: a. Passively acquired maternal antibodies; b. Immunization is not complete; c. Immature immune system and immature blood-brain barrier Feedback: Newborns and infants are especially vulnerable to infectious diseases because their immune systems are immature, their passively acquired maternal antibodies provide limited protection, and disease protection through immunization is not yet complete. Being closer to the ground and having a faster (not slower) respiratory rate increase inhalation of heavy chemical and biological aerosolized agents. Children have a smaller blood volume in proportion to adults.

A child is diagnosed with severe combined immunodeficiency deficiency syndrome. The nurse's priority interventions are directed toward which objective? a. Prevention of infection b. Maintenance of skin integrity c. Management of body image concerns d. Maintenance of cardiac function

Answer: a. Prevention of infection Feedback: Although all body systems are affected, prevention of infection is the key in immune disorders.

A mother refuses to have her child receive any immunizations, based on her religious beliefs. What is the priority nursing diagnosis when planning health teaching for this family? a. Risk for Infection related to incomplete immunization series b. Knowledge Deficit (parent) related to potential side effects of vaccines c. Acute Pain related to injection and associated anxiety d. Risk for Injury related to vaccine reaction

Answer: a. Risk for Infection related to incomplete immunization series Feedback: The child will be at risk for infection from childhood communicable diseases. None of the other nursing diagnoses relate to the mother's religious beliefs.

The nurse is monitoring a 6-year-old admitted to the emergency department with sixth disease. For which medical emergency does the nurse watch closely? a. Seizure activity b. Increased pain c. Excessive diarrhea d. Sore throat

Answer: a. Seizure activity Feedback: Febrile seizures are a complication of sixth disease and the nurse should watch the client closely. Pain, diarrhea, and sore throat are not symptoms or complications of sixth disease.

A 10-year-old child presents to the emergency department with decreased urinary output, lethargy, and confusion. The nurse suspects hypernatremia. About what condition is the nurse most concerned and how can the hypernatremia be treated? a. Seizures/hypotonic fluid b. Coma/hypertonic fluid c. Confusion/salt tablets d. Anuresis/tap water

Answer: a. Seizures/hypotonic fluid Feedback: Seizures can occur when hypernatremia occurs rapidly or is severe. Severe hypernatremia can be fatal. Hypernatremia is treated by intravenous administration of hypotonic fluid. A decreased level of consciousness manifested by confusion, lethargy, or coma can result from shrinking of the brain cells; anuresis may also occur, but the treatments associated with these conditions will be a hypotonic fluid.

The nurse concludes that a parent of an otherwise healthy child with varicella (chickenpox) has an accurate understanding of the disease. Which statement by the parents is appropriate following education about the disease process? a. "I will take my child to our primary healthcare provider to request antibiotics." b. "I will send my child back to school when all the lesions are dry and crusted over." c. "I will take my child to our primary healthcare provider to request acyclovir." d. "I will give my child acetaminophen 120 mg three times a day for the duration of the illness."

Answer: b. "I will send my child back to school when all the lesions are dry and crusted over." Feedback: Varicella is no longer contagious when all the lesions are dry. Acetaminophen should be used when the child has a fever, not three times per day, every day, during the illness. Antibiotics are not effective against viruses. Acyclovir is an antiviral but is recommended for immunocompromised children, not healthy children and adolescents.

The neonatal nurse explains to new parents that infants are at greater risk for fluid and electrolyte imbalance than older children are. Which parent comment would indicate that further education is needed? a. "Compared to an adult, an infant has little body water for reserve." b. "Infants maintain their temperature by losing heat through their heads." c. "Infants have a higher metabolic rate than older children do." d. "Infants lose water through their skin, and they have a larger proportion of skin surface area than older children do."

Answer: b. "Infants maintain their temperature by losing heat through their heads." Feedback: Incorrect answers indicate the parents understand the lesson taught, and do not require further education. A correct answer indicates the parents do not understand the lesson, and require further education. Losing heat through their heads will have minimal affect on fluid loss in infants. A parent who makes this comment will require further education.

The nurse assesses a 10-year-old male client with multiple fractures shortly after the child arrives on the unit from the emergency department. The nurse attempts to assess the child's pain using a number scale and then a FACES scale. The child responds, "I do not know, I just hurt bad!" What is the most appropriate action by the nurse? a. Explain the scale and tell the child that he needs to rate his pain. b. Administer the prescribed dose of intravenous morphine. c. Reassess the child in 30 minutes to see whether he will give a rating of his pain. d. Give the prescribed dose of oral acetaminophen with codeine.

Answer: b. Administer the prescribed dose of intravenous morphine. Feedback: The child is in severe pain and needs intravenous pain medication that will provide prompt relief. Although pain assessment is important, the nurse must rate the child's pain based on his actions and verbal statements instead of a FACES scale or numeric scale score. The child is not coping with the severe pain and therefore is unable to focus on scoring his pain. Explanations regarding pain rating scales are provided most effectively when the client is not in acute pain. Oral analgesics generally do not provide relief as effectively and promptly as intravenous medication does.

Which nursing diagnosis is most important for a teenager diagnosed with SLE? a. Alterations in Nutrition b. Body Image, Disturbed c. Activity Intolerance, Risk for d. Infection, Risk for

Answer: b. Body Image, Disturbed Feedback: Adolescents with SLE may have an altered body image because of rash, alopecia, arthritic changes in the joints, and chronic disease. Alterations in nutrition, activity intolerance, and infection are important and should be addressed, but are not the priority for the teenager.

A child is diagnosed with severe combined immunodeficiency. The nurse considers that dietary instruction to the parents is effective if which food is included in the child's diet? a. Grilled cheese b. Chicken fingers and milkshakes c. Tuna salad and whole wheat bread d. Hamburger and skim milk

Answer: b. Chicken fingers and milkshakes Feedback: Children with severe combined immunodeficiency should be given a diet high in protein and calories. Chicken fingers and milkshakes have both high calories and protein.

A 6-month-old infant is admitted with severe dehydration. Effectiveness of therapy is evaluated with which assessment measures? (Select all that apply.) a. Documenting abdominal girth every shift b. Documenting mucous membrane moisture every shift c. Daily weights each day on a rotating shift d. Recording intake and output accurately e. Evaluating level of consciousness continuously

Answer: b. Documenting mucous membrane moisture every shift; d. Recording intake and output accurately; e. Evaluating level of consciousness continuously Feedback: All of the choices represent assessment measures that evaluate the effectiveness of therapy except abdominal girth, which does not provide information regarding hydration status, and daily weights on a rotating schedule. Daily weights should be done, but they must be completed on the same scale at the same time each day while the infant is wearing no clothing.

A school nurse teaches a coaching staff about heat-related illnesses. Which action by a coach indicates to the nurse that teaching was effective? a. Sleep 2-3 hours in the middle of the day during all-day practice. b. Have cell phones or other mechanisms to call for emergency assistance. c. During activity, stop for fluids every 30 minutes. d. Allow 1-2 hours' rest during the middle of the day, with fluids and food provided.

Answer: b. Have cell phones or other mechanisms to call for emergency assistance. Feedback: Rest 2-3 hours during the day of all-day practice, but sleep is not required. Stop for fluids every 15-20 minutes. It is essential to have a means of communication in case of emergency.

The school nurse sees a 14-year-old child who presents with fatigue and a nagging cough of 3 weeks' duration that has become productive with thick mucus and is much worse at night. The school nurse suspects pertussis (whooping cough), because vaccine protection wanes in 5-10 years. What is the school nurse's first nursing action? a. Provide emotional support to the parents. b. Isolate the child and contact the parents. c. Encourage fluids to prevent dehydration. d. Report the case to the Centers for Disease Control and Prevention (CDC).

Answer: b. Isolate the child and contact the parents. Feedback: Isolation is necessary to prevent the disease from spreading to classmates by aerosolized droplet infection. The case is not reportable until a positive culture is returned. The remaining interventions are important but are not the first nursing action, because the entire school population might be at risk.

Which behavioral responses and verbal descriptions of pain are characteristic of a preschooler? (Select all that apply.) a. Holds body very still when talking to the nurse. b. Points to where the hurt is. c. Cries and screams, unable to describe the type of pain. d. Strikes out physically when painful procedures are performed. e. States, "I'll try to be brave."

Answer: b. Points to where the hurt is; d. Strikes out physically when painful procedures are performed. Feedback: The preschooler can point to where the pain is and can describe to some degree the type and intensity of the pain. A child this age will resist painful procedures by physically striking out. Holding the body very still to avoid pain and trying to be brave are characteristic of school-age children. Detailed description of pain is characteristic of adolescents.

The nurse assesses a 4-year-old who was adopted from Russia and has had no immunizations. The child does not appear ill but has a fine, pink, maculopapular rash that progressed from the face to the neck, chest, and back, then to the extremities within 3 days. Cervical and occipital lymph nodes are tender and enlarged. Which communicable disease would the nurse suspect? a. Scarlet fever b. Rubella (German measles) c. Meningococcus d. Hand, foot, and mouth disease

Answer: b. Rubella (German measles) Feedback: The child's pattern of rash eruption and lymphadenopathy is characteristic of rubella. The child with scarlet fever has a fine, red, sandpaper rash that spares the face and appears on the neck and trunk. The toes and fingers can peel, and a strawberry tongue is seen on day 4 or 5. Hand, foot, and mouth lesions are papulovesicular and last 7-10 days. The child with meningococcus is very ill and has a red-to-purple urticarial, maculopapular, or petechial rash that can progress to purpura.

An infant in the neonatal intensive care unit must undergo numerous painful procedures. Which complementary therapy to decrease pain during the procedures is most appropriate? a. Massage b. Sucrose pacifier c. Imagery d. Swaddling

Answer: b. Sucrose pacifier Feedback: Sucrose provides short-term, natural pain relief and is most appropriate for use in infants and neonates to decrease pain during the procedure. Imagery is not appropriate for an infant. Massage and swaddling are appropriate comfort measures following procedures and as adjuncts to pain medication. Swaddling might be appropriate as a means of restraint for specific procedures, but it does not relieve pain.

A child is diagnosed with lupus and is experiencing a skin exacerbation. What should the nurse encourage the parents to do when providing care in order to decrease the risk factors associated with exacerbation in skin? a. Provide oral rehydration products. b. Use sunscreen products of 30 SPF. c. Use antimicrobial soap. d. Provide a high-protein diet.

Answer: b. Use sunscreen products of 30 SPF. Feedback: Exposure to sunlight can increase the risk of exacerbation in lupus. Maintaining good hydration, hygiene, and nutrition would not prevent the exacerbation of lupus.

The nurse notes several changes in the past 24 hours in a child with heart failure. Which finding is the most significant in assessing the child for fluid volume overload? a. Presence of lung crackles b. Weight gain of .4 kg c. Bounding pulse d. Jugular venous distention

Answer: b. Weight gain of .4 kg Feedback: All are signs of fluid volume overload. However, an increase of weight is always the best indicator of an increase in fluid. The other options indicate heart failure as a result of the increase in fluid.

The nurse asks a 6-year-old male client to rate his pain using the FACES pain-rating scale. The child is 12 hours postoperative for an appendectomy. The child chooses the first face, indicating that he does not have any pain, but the child's mother reports that just before the nurse entered the room, the child stated that his stomach was hurting badly. What is the most appropriate initial action by the nurse? a. Ask the mother to report any more complaints of pain to the nurse. b. Ask the child why he told his mother he had pain but rates his pain as a 0 on the pain scale. c. Administer a dose of prescribed pain medication to the child. d. Reassess the child in 1 hour.

Answer: c. Administer a dose of prescribed pain medication to the child. Feedback: The male client might be trying to be brave in front of the nurse. He also might be concerned about the consequences of stating that he has pain (i.e., IM injection). Unrelieved pain delays healing. The nurse should expect this child to have pain, because he has recently had surgery. Prompt administration of pain medication is the most appropriate initial action by the nurse. She should reassess the child within 30 minutes of administering pain medication. Although asking the mother to report further complaints of pain is an appropriate action, it is not the most appropriate initial action. The nurse should not confront the child about his pain rating.

A 6-year-old child is to receive regularly scheduled immunizations. The parent states that the child is not feeling well and asks the nurse to defer the immunizations until next week. What is the best response by the nurse? a. Ask whether the child has missed school. b. Give the parent an immunization appointment for next week. c. Check the child's temperature. d. Ask whether the child has ever had a reaction to immunizations.

Answer: c. Check the child's temperature. Feedback: The child's temperature will help the nurse decide whether the child has a mild or severe illness. Postponing the immunization might result in a missed opportunity if the parent does not keep the appointment. Missing school is not a contraindication for immunizations. The nurse should ask about previous reactions to immunizations, but this is not related to withholding the immunization because the child is not feeling well.

A child is recently diagnosed with juvenile rheumatoid arthritis (JRA). What is of priority for this child and family? a. Anxiety reduction b. Optimum nutrition c. Growth and development d. Education

Answer: c. Growth and development Feedback: Although all of the answer choices are important, promoting growth and development is essential for a child in order for her to meet developmental tasks.

A father refuses the measles, mumps, and rubella (MMR) immunizations for his child because he does not want the child to suffer pain or injury, and he believes that the MMR vaccine injection might cause autism. What is the priority nursing diagnosis for this father? a. Risk for Infection related to incomplete immunization series b. Risk for Injury related to vaccine reaction c. Knowledge Deficit (parent): Potential Side Effects of Vaccines related to lack of correct information d. Acute Pain related to injection and associated anxiety

Answer: c. Knowledge Deficit (parent): Potential Side Effects of Vaccines related to lack of correct information Feedback: The father has incorrect information on immunizations, and is experiencing a knowledge deficit. The other nursing diagnoses are appropriate for the child, not the father, in this situation.

Which pain-assessment tool is the most appropriate for a 14-year-old client? a. FLACC behavioral pain assessment scale b. FACES pain rating scale c. Numeric scale d. Poker chip tool

Answer: c. Numeric scale Feedback: The FLACC scale is an observation scale used primarily with infants and preverbal children. Although the FACES scale and poker chip tool can be used for adolescents, a client this age should be very capable of using a numeric scale. The FACES scale and the poker chip tool are most appropriate with preschool- and young school-age children.

A 3-year-old child is being discharged from the hospital following treatment for an acute illness. The child is scheduled to return to the clinic in 1 week to have blood drawn by venipuncture to reassess electrolyte values. The child's parents ask whether there is anything they can do prior to arriving at the clinic to decrease the child's discomfort from the procedure. What is the most appropriate response by the nurse? a. Reassure the parents that the procedure is not painful. b. Suggest therapeutic play prior to the procedure. c. Obtain a prescription for EMLA or Ela-max from the primary healthcare provider and instruct the parents how and when to apply the medication. d. Suggest that the parents reassure the child that the procedure will not hurt.

Answer: c. Obtain a prescription for EMLA or Ela-max from the primary healthcare provider and instruct the parents how and when to apply the medication. Feedback: EMLA and Ela-max are topical anesthetics that are appropriate to use to prevent or decrease pain associated with minor medical procedures. Parents can be taught how and when to apply the medication. Venipuncture is a painful procedure. Although therapeutic play can be a useful method to teach the child briefly about the procedure and to help relieve anxiety following the procedure, it will not actually decrease the discomfort that a child this age will experience from a needlestick.

The nurse is evaluating the effectiveness of client-controlled analgesia for a 10-year-old client. Which outcome is the best indicator that this delivery of pain medication is effective? a. The child naps at frequent intervals. b. The child presses the button on a regular basis. c. The child reports a pain level of 0 on a 0-to-10 scale. d. There is no evidence of respiratory depression.

Answer: c. The child reports a pain level of 0 on a 0-to-10 scale. Feedback: The child's pain rating is the best indicator of whether the delivery method for pain medication is effective. The absence of respiratory depression does not indicate that the child has pain relief. Pressing the button on a regular basis indicates that the child knows how to use the device but does not indicate how much pain the child has. Although napping might indicate some pain relief, it also might serve as a coping measure. In addition, if pain is well controlled, the child might be able to sleep for longer intervals.

A nurse obtains a history from a single, breastfeeding mother with a small but hydrated 3-month-old infant who is listless following what the mother describes as a seizure. Which question would be most important for the nurse to ask? a. "Did you have gestational diabetes during pregnancy?" b. "Is this your first baby?" c. "Are you sure you didn't hurt the baby?" d. "Has your baby had seizures before?"

Answer: d. "Has your baby had seizures before?" Feedback: "Are you sure you didn't hurt the baby?" is judgmental and closed-ended. Questions should be open-ended. The nurse should be nonjudgmental in attitude and expressions.

The home health nurse is taking care of a 5-year-old with mumps and teaches his mother about his care. Which statement by the parent indicates understanding? a. "I have to keep my son out of school until the swelling subsides." b. "He can have all the orange juice he wants to keep him hydrated." c. "He will be contagious as long as his parotids are swollen." d. "I will watch him closely because he might contract viral meningitis."

Answer: d. "I will watch him closely because he might contract viral meningitis." Feedback: Viral meningitis is rare, but may occur. The parent should be alert for complications. Keep children out of school or child care until 5 days after parotid swelling occurs. Avoid foods and beverages that increase salivary flow and cause pain (e.g., citrus, spices, and candies). The child is contagious up to 5 days before and after the onset of parotid swelling.

A 10-year-old child has just received his first immunization of influenza vaccine. His lips begin to swell, and he states, "It feels like my throat is closing shut and my chest is tight when I breathe." Which reaction does the nurse recognize that the child is experiencing? a. A local allergic reaction to the influenza vaccine injection b. A common systemic allergic reaction to immunization c. An anxiety reaction due to receiving an injection d. A life-threatening reaction to the influenza vaccine

Answer: d. A life-threatening reaction to the influenza vaccine Feedback: This child's reaction describes angioedema, laryngeal edema, and respiratory distress, indicating impending anaphylactic shock. All the other answer choices are possible reactions to immunizations but are not life-threatening.

The nurse is assessing an 11-year-old client receiving conscious sedation to set a fractured leg. Which assessment finding indicates that the client might need respiratory support? a. Sleeping b. Regular respiratory rate c. Coughing d. Absent gag reflex

Answer: d. Absent gag reflex Feedback: The child who does not have a gag reflex is demonstrating signs of deep sedation. In deep sedation, protective reflexes are lost and respiratory support is needed. A child with a regular respiratory rate does not require respiratory support. Coughing is an indicator that the airway is intact. The child who is sleeping might just be under light sedation. This alone is not an indicator for respiratory support.

The nurse teaches parents about pediatric immunizations. What is considered an absolute contraindication to pediatric immunizations? a. Respiratory illness with low-grade fever b. Soreness, redness, and swelling at the previous injection site c. Febrile seizure 1 month after the previous injection of vaccine d. Anaphylactic reaction to previous immunization

Answer: d. Anaphylactic reaction to previous immunization Feedback: Anaphylaxis is a life-threatening reaction to an allergen or antigen and can occur again if the client is exposed to the offending allergen or antigen. Immunizations may be given if the child has a mild illness with or without fever. Redness and soreness are common reactions, not contraindications, to immunizations. One month is too long a time for febrile convulsions to be related to vaccine administration.

3. A preschool-age child diagnosed with AIDS has developed respiratory compromise. Which technique would the nurse utilize to encourage effective lung expansion? a. Incentive spirometry b. Chest physiotherapy c. Coughing and deep breathing d. Bubble blowing

Answer: d. Bubble blowing Feedback: Bubble blowing is most appropriate for the preschool-age group. Preschool-age children are at a developmental level where the other choices would be less appropriate. Although those choices could be done with the preschooler, they would require more time, and the child would be less compliant. Chest physiotherapy is directed primarily at promoting airway clearance.

The nurse is providing care for an 8-year-old client with a 2-year history of juvenile rheumatoid arthritis (JRA). The child takes nonsteroidal anti-inflammatory drugs (NSAIDs) on a regular basis to help control discomfort. What is the most appropriate nursing diagnosis for this client? a. Knowledge Deficit: Pain Management related to lack of previous teaching b. Coping Deficit related to discomfort associated with JRA c. Acute Pain related to JRA d. Chronic Pain related to JRA

Answer: d. Chronic Pain related to JRA Feedback: Based on the information in the stem, the child experiences pain on a regular basis related to JRA, which is a chronic illness. There are no data given to suggest that the child has acute pain, coping deficit, or knowledge deficit.

A child is 24 hours postoperative following major trauma, and has received a total of eight units of packed red blood cells during the perioperative period. The child is flaccid, and has diarrhea and peaked T-waves on the electrocardiogram. About which electrolyte abnormality would the nurse call the primary healthcare provider to obtain an electrolyte panel? a. Hypercalcemia b. Hypernatremia c. Hypermagnesemia d. Hyperkalemia

Answer: d. Hyperkalemia Feedback: Hypernatremia is associated with dehydration and thirst. Hypercalcemia causes neuromuscular depression and constipation. Etiology is related to malignancy, overintake, and parathyroid disorder. Hypermagnesemia symptoms are similar to hyperkalemia, but the etiology is different. Hypermagnesemia is due to renal failure or administration. This client could be experiencing renal failure but that information is not given.

A 17-year-old male taking codeine after surgery has a history of myocarditis. For which side effect does the nurse carefully monitor? a. Nausea and vomiting b. Constipation c. Sedation d. Respiratory depression

Answer: d. Respiratory depression Feedback: Carefully monitor for signs of respiratory depression (a major life-threatening complication), especially during drug-specific peak action time. Nausea and vomiting, constipation, and sedation are side effects from opioid administration, but are not the priority.

A mother of a child with juvenile rheumatoid arthritis (JRA) asks the nurse what activities the child can enjoy. Which would be the most appropriate response based on knowledge of the physiologic aspects of JRA? a. Bicycling b. Running c. Skiing d. Swimming

Answer: d. Swimming Feedback: High-impact activities and activities that overuse the joints are not indicated in a child with JRA.

Arterial blood gases results indicate pH 7.33 and PCO2 of 38 mmHg following arrest and subsequent resuscitation of a 3-year-old child. Which nursing intervention should be utilized to attempt to correct this metabolic disorder? a. Assess the effectiveness of the respiratory pattern. b. Determine whether the endotracheal tube is positioned correctly. c. Administer sodium bicarbonate 1 mEq/kg IV. d. Treat the cause of the acidosis.

Answer: d. Treat the cause of the acidosis. Feedback: Sodium bicarbonate is used to correct serious metabolic acidosis. Metabolic acidosis is present, but sodium bicarbonate is given only in serious imbalance. We do not have enough information to determine whether that is the case. The medication often complicates acid-base imbalance. Airway always is important to assess, but the PCO2 level indicates that respirations are not contributing to the problem. The best answer is to find and treat the cause of the acidosis.

A child is diagnosed with the HIV. The child's mother expresses concern about transmission at the daycare setting. What should the nurse teach the family regarding handling soiled diapers? a. Use gowns, gloves, and masks. b. Use gowns and gloves. c. Use gowns and goggles. d. Use standard precautions.

Answer: d. Use standard precautions. Feedback: Only standard precautions are needed in the care of the child. Standard precautions are hand hygiene and use of gloves.

7) A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a licensed vocational nurse (LVN), cautions the LVN to immediately report which clinical manifestation? 1. Seizures 2. Respiratory distress 3. Hyperthermia 4. Bradycardia

Answer: 1 Explanation: 1. A child with hyponatremia is at risk for seizures. 2. Respiratory distress is not a risk of hyponatremia. 3. Hyperthermia is not a risk of hyponatremia. 4. Bradycardia is not a risk of hyponatremia.

3) The nurse is teaching the mother of a newborn how the immune system functions. Which statement regarding the process that occurs when healthy children are exposed to infection indicates accurate understanding of the information presented? 1. "Children who are exposed to infection naturally develop antibodies." 2. "Children who are exposed to infection are found to be healthier." 3. "Children who are exposed to infection will acquire terminal illnesses." 4. "Children who are exposed to infection will have weakened immune systems."

Answer: 1 Explanation: 1. As healthy children are exposed to more infections, they naturally develop antibodies. 2. Being exposed to infections will not lead to healthy children. 3. Exposure to infections will not lead children to acquire terminal illnesses. 4. Exposure to infectious disease will not weaken children's immune systems.

16) As a result of opioid administration, a child's respirations are slow and shallow. Which should the nurse anticipate when assessing the child's arterial blood gas? 1. Increased PCO2 and respiratory acidosis 2. Decreased PCO2 and respiratory alkalosis 3. Low pH and low PCO2 4. High pH and high PCO2

Answer: 1 Explanation: 1. Due to inadequate respirations, the child retains CO2 and develops respiratory acidosis. 2. This statement is incorrect as the child retains carbon dioxide. 3. The pH would be acidic, but the pH would be high. 4. The child would have a low pH (acidosis) and high PCO2.

1) A parent of a newborn asks the nurse why young children seem to become ill so often when compared with older children and adults. Which is the best response by the nurse? 1. "Newborns have lower numbers of natural killer cells." 2. "Newborns have high levels of IgA in their systems." 3. "Newborns are lacking lymphoid tissue." 4. "Newborns have an immature thymus gland."

Answer: 1 Explanation: 1. Newborns have lower numbers of natural killer cells than do older children and adults, decreasing their ability to respond to certain antigens. 2. IgA is not present at birth. Development of IgA begins at 2 weeks of age but does not reach adult levels until the age of 6. 3. Lymphoid tissue, such as the spleen and tonsils, is present at birth. 4. The thymus is large at birth and grows during childhood, decreasing by adulthood.

2) The nurse is taking care of a postoperative school-age child. The child's mother requests that the child not receive narcotics because she is afraid the child will become addicted. The nurse should explain that children who do not receive adequate pain control will be at risk for which complication? 1. Respiratory 2. Urinary 3. Cardiac 4. Bowel

Answer: 1 Explanation: 1. The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory complications. 2. Uncontrolled pain does not usually lead to urinary complications. 3. Uncontrolled pain does not lead to cardiac complications. 4. Uncontrolled pain does not frequently lead to bowel complications.

3) The nurse is planning care for a child with acquired immune deficiency syndrome (AIDS). Which vaccines should be avoided in the child with AIDS? 1. Inactivated polio vaccine 2. Tetanus toxoid vaccination 3. Varicella vaccine 4. Acellular pertussis vaccine

Answer: 3 Explanation: 1. Killed virus vaccines are safe to administer to the child with AIDS as there is no risk of acquiring an infection. 2. A toxoid vaccination is made of a toxin that has been produced by the organism but does not include living organisms. 3. A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. 4. Acellular pertussis vaccine contains a protein from pertussis rather than the whole cell.

10) An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which should the nurse include in the teaching session regarding an activity that should be avoided? 1. Receiving a manicure and a pedicure 2. Washing the hair with shampoo daily 3. Using a tanning bed 4. Attending late night parties and dances

Answer: 3 Explanation: 1. Manicures and pedicures do not place the teenager at any risk. 2. Although one symptom of SLE can be alopecia, gentle shampooing is not a cause of this symptom. 3. Individuals with SLE have photosensitivity, and tanning beds can lead to exacerbations as well as skin damage from sun burns. 4. Although adequate rest is important for the teenager with SLE, the teenager can "catch up" on her sleep the next day. Page Ref: 1248

27) Which medication should the nurse include in a pamphlet to educate parents about methods to reduce the risk of children developing Reye syndrome? 1. Antibiotics 2. Acetaminophen 3. Ibuprofen 4. Aspirin

Answer: 4 Explanation: 1. Antibiotics are not associated with Reye syndrome. 2. Acetaminophen is not associated with Reye syndrome. 3. Ibuprofen use is not associated with Reye syndrome. 4. Administering aspirin to a child with a viral illness has been found to be associated with Reye syndrome.

5) A school-age client diagnosed with rheumatoid arthritis (RA) wants to participate in the school sports programs. The client asks the nurse to recommend a sporting activity that is appropriate. Which activity would be the most appropriate for the nurse to recommend? 1. Baseball 2. Basketball 3. Football 4. Swimming

Answer: 4 Explanation: 1. Baseball places stress on the knee joints. 2. Basketball involves running, which will stress the joints. 3. All positions in football will cause stress to the joints. 4. Swimming helps to exercise all the extremities without putting undue stress on joints

14) A child is receiving a nucleoside reverse transcriptase inhibitor for human immunodeficiency virus (HIV). Which laboratory value should the nurse include in the plan of care as needing to monitor? 1. Glucose 2. Sodium 3. Potassium 4. Red blood cell count

Answer: 4 Explanation: 1. The glucose value is a laboratory test for checking diabetes. A nucleoside transcriptase inhibitor does not affect glucose values. 2. Sodium is an electrolyte. A nucleoside transcriptase inhibitor does not affect sodium values. 3. Potassium is an electrolyte. A nucleoside transcriptase inhibitor does not affect potassium values. 4. A nucleoside transcriptase inhibitor causes bone marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes.

The nurse is caring for a school-age child who has chronic fluid overload with edema, and teaches the parents about skin care for their child. Which statement by the parents indicates the need to review the material further? a. "Pajamas sound ideal for clothes." b. "Places where the skin rubs together are risk areas for breakdown." c. "It is best to buy clothes that are loose-fitting, so they do not rub the skin." d. "We should check the skin daily to look for any red areas."

Answer: a. "Pajamas sound ideal for clothes." Feedback: The statement "Pajamas sound ideal for clothes" indicates further review is necessary. Dressing the child in pajamas promotes the sick role, singles the child out, and does not promote self-esteem. Body image is a concern with edema. The remaining statements are appropriate.

A child is diagnosed with lupus and is placed on steroid therapy. Which diet should be included in the child's plan of care? a. Increased calcium b. Increased protein c. Increased carbohydrates d. Increased iron

Answer: a. Increased calcium Feedback: Iron is needed in anemia, protein is needed to promote tissue healing, and carbohydrates are needed for increased energy. An increase in calcium is needed for persons undergoing steroid therapy.

A 5-year-old is showing signs of respiratory depression after receiving a dose of morphine postop surgical repair of a fracture to the right arm. For what signs and symptoms does the nurse observe? a. Small pupils and shallow breathing b. Tachypnea and sweating c. Vomiting and anxiety d. Delirium and hallucinations

Answer: a. Small pupils and shallow breathing Feedback: Clinical signs that indicate the development of respiratory depression include sleepiness, small pupils, and shallow breathing. Tachypnea, sweating, vomiting, anxiety, delirium, and hallucinations are not signs indicative of developing respiratory depression.

The nurse caring for a 13-year-old has identified imagery as a way to help the client with pain management. Which instructions could the nurse use to help the client use imagery? a. "Take some slow, deep breaths." b. "Think about your favorite place to go in the summer." c. "Relax while I rub your shoulders." d. "Count to 10 very slowly."

Answer: b. "Think about your favorite place to go in the summer." Feedback: Imagery involves a cognitive process in which the individual is encouraged to think about something positive, such as a favorite place. Taking slow, deep breaths is a breathing technique for pain control. Counting is a distraction technique. Touch is a type of cutaneous stimulation.

A child is diagnosed with lupus. Which nursing diagnosis is highest in priority? a. Impaired Gas Exchange b. Pain (chronic) c. Decreased Cardiac Output d. Alterations in Nutrition

Answer: b. Pain (chronic) Feedback: Although nutrition, gas exchange, and cardiac output all might be indicated for lupus, the first diagnosis seen would be related to pain.