Peds 3

A mother of two children, an 8-year- old and a 10-year- old, tells you that her husband has recently been deployed to the Middle East. The mother is concerned about the children's constant interest in watching TV news coverage of activities in the Middle East. Which suggestion by the nurse to the mother is most appropriate? 1. "Spend time with your children, and take cues from them about how much they want to discuss." 2. "Allow the children to watch as much television as they want. This is how they are coping with their father's absence." 3. "The less that you discuss this, the quicker the children will adjust to their father's absence. Try to keep them busy and use distractions to keep their mind off of it." 4. "It will just take some time to adjust to their father's absence and then everything will return to normal."

"Spend time with your children, and take cues from them about how much they want to discuss."

A toddler is prescribed digoxin (Lanoxin) for cardiac failure. Which should the nurse instruct the toddler's parents to monitor for as a manifestation associated with digoxin toxicity? 1. Bradycardia 2. Tinnitus 3. Ataxia 4. Hypotension

1. Bradycardia

A school-age client is diagnosed with rheumatic fever. Which parental statement indicates the need for further education by the nurse? 1. "I understand rheumatic fever is a strep infection of the heart." 2. "My child will be on bed rest for several weeks." 3. "My child will be treated with aspirin and/or corticosteroids." 4. "Once my child has recovered, she will still need to be monitored for sequelae to the disease."

1. "I understand rheumatic fever is a strep infection of the heart."

Which should the nurse include in the plan of care for a child with a minor burn to enhance nutrition and healing? 1. Protein 2. Minerals 3. Carbohydrates 4. Fats

1. Protein

Which parental statement regarding preventative strategies for insect bites and stings indicate the need for further education? 1. "If my child wears bright colors and floral prints when outdoors, she will blend in with the surroundings, and the stinging insects will not sting her." 2. "We should remove any items with standing water from our yard and surrounding area to prevent mosquito reproduction." 3. "My child can use insect repellent containing DEET of 10% or less." 4. "My child should avoid heavy colognes, perfumes, and soaps so that insects are not attracted to them."

1. "If my child wears bright colors and floral prints when outdoors, she will blend in with the surroundings, and the stinging insects will not sting her."

Which statements should the nurse include in the discharge medication teaching for a child diagnosed with asthma who is prescribed cromolyn sodium (a mast cell stabilizer)? Select all that apply. 1. "The medication works to prevent exacerbations." 2. "The medication should be administered at the first symptom of an asthmatic attack." 3. "The medication should be taken on a daily basis." 4. "The medication should not be administered if the child has a cold." 5. "The medication desensitizes the child against specific allergens."

1. "The medication works to prevent exacerbations." 3. "The medication should be taken on a daily basis.

Which parental statement indicates correct understanding for the reason a cardiac catheterization is needed for a child who is diagnosed with a congenital heart defect? 1. "This procedure will keep the ductus arteriosus open and oxygenated and unoxygenated blood mixed." 2. "This procedure is used to close the ductus arteriosus to prevent mixing of arterial and venous blood." 3. "This procedure will redirect the blood so that blood bypasses the right ventricle." 4. "This procedure connects the ventricle to the atrium."

1. "This procedure will keep the ductus arteriosus open and oxygenated and unoxygenated blood mixed.

Which parental statement indicates to the nurse accurate understanding regarding the care of their child with tinea capitis (ringworm of the scalp)? 1. "We will give the griseofulvin with milk or peanut butter." 2. "We're glad ringworm isn't transmitted from person to person." 3. "Once the lesion is gone, we can stop the griseofulvin." 4. "Well, at least we don't have to worry about the family cat getting the ringworm."

1. "We will give the griseofulvin with milk or peanut butter."

Which neonate requires a close nursing assessment for the development of retinopathy of prematurity (ROP)? 1. 28-weeks'- gestation infant who has been on long-term oxygen and weighed 1400 g 2. 32-weeks'- gestation infant of African heritage with a congenital heart defect who needed no oxygen and weighed 1850 g 3. 28-weeks'- gestation female infant who was on short-term oxygen, weighed 1420 g, and was treated with phototherapy 4. 36-weeks'- gestation, small-for- gestational-age infant who was in an oxyhood for 12 hours and weighed 1800 g

1. 28-weeks'- gestation infant who has been on long-term oxygen and weighed 1400 g

Which nursing diagnosis should the nurse include in the plan of care for an infant diagnosed with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Ineffective Peripheral Tissue Perfusion 3. Acute Pain 4. Decreased Cardiac Output

1. Activity Intolerance

Which is the priority nursing intervention for a 4-year- old client brought to the emergency department (ED) for treatment of frostbite? 1. Administer analgesics. 2. Immerse the hands in extremely warm water (120°F). 3. Do not remove clothing. 4. Place the extremity in a dependent position.

1. Administer analgesics.

An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply. 1. Administer oxygen. 2. Place the child in knee-chest position. 3. Administer morphine and propranolol intravenously as ordered. 4. Draw blood for a serum hemoglobin. 5. Administer diphenhydramine (Benadryl) as ordered.

1. Administer oxygen. 2. Place the child in knee-chest position. 3. Administer morphine and propranolol intravenously as ordered.

Which treatment options should the nurse anticipate for a 10-month- old infant admitted to the emergency department with supraventricular tachycardia? Select all that apply. 1. Administering intravenous adenosine (Adenocard) 2. Administering intravenous amiodarone (Cardarone) 3. Preparing for cardioversion 4. Applying ice to the face 5. Having the child perform a Valsalva maneuver

1. Administering intravenous adenosine (Adenocard) 2. Administering intravenous amiodarone (Cardarone) 3. Preparing for cardioversion 4. Applying ice to the face

Which is the priority nursing diagnosis during the acute phase of a third-degree circumferential burn of the right arm for a pediatric client? 1. Altered Tissue Perfusion, Risk for 2. Infection, Risk for 3. Impaired Physical Mobility 4. Altered Nutrition: Less than body Body requirementsRequirements, Risk for

1. Altered Tissue Perfusion, Risk for

Which should the nurse include in the plan of care for a pediatric client who is diagnosed with periorbital ecchymosis? Select all that apply. 1. Apply ice to the site for 5 to 15 minutes every hour for the first 1 to 2 days. 2. Apply warm compresses beginning on day 3. 3. Apply antibiotic ointment to the conjunctiva for 7 to 10 days. 4. Apply a patch to the affected eye for 5 to 7 days. 5. Apply antibiotic drops to the conjunctiva for 7 to 10 days.

1. Apply ice to the site for 5 to 15 minutes every hour for the first 1 to 2 days. 2. Apply warm compresses beginning on day 3

Which nursing action is accurate when applying a 5% permethrin lotion to a toddler with scabies? 1. Applying the lotion to the scalp, forehead, and everywhere below the chin 2. Applying the lotion only on the areas with evidence of activity 3. Applying the lotion only to the hands 4. Applying the lotion only to the scalp only

1. Applying the lotion to the scalp, forehead, and everywhere below the chin

Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply. 1. Assessing for respiratory distress 2. Auscultating the lungs for wheezing 3. Prescribing oxygen for low saturations 4. Administering prescribed prophylactic antibiotic therapy 5. Providing support to the family

1. Assessing for respiratory distress 2. Auscultating the lungs for wheezing 5. Providing support to the family

Which skin conditions should the nurse identify as having a genetic or inherited component during a presentation to the staff nurses who work in the integument clinic? Select all that apply. 1. Atopic dermatitis 2. Seborrheic dermatitis 3. Epidermolysis bullosa 4. Molluscum contagiosum 5. Psoriasis

1. Atopic dermatitis 3. Epidermolysis bullosa 5. Psoriasis

Which feeding techniques should the nurse include in the teaching session for the parents of an infant who is being discharged in order to gain weight for the corrective surgery needed for a congenital heart defect? Select all that apply. 1. Breastfeed if possible. 2. Complete each feeding within 30 minutes. 3. Position the infant flat to promote swallowing. 4. Dilute the formula with extra water to ensure adequate fluid intake. 5. Burp the infant frequently.

1. Breastfeed if possible. 2. Complete each feeding within 30 minutes. 5. Burp the infant frequently.

Which is the most likely cause for a bright red perianal inflammation with scaly plaques and small papules noted by the nurse during the assessment of a 12-month- old infant? 1. Candida albicans (yeast) 2. Impetigo (staphylococcus) 3. Infrequent diapering 4. Urine and feces

1. Candida albicans (yeast)

A child is admitted to the pediatric medical unit with a diagnosis of Kawasaki disease. Which provider prescription should the nurse question? 1. Contact isolation 2. Oral aspirin every 8 hours 3. Echocardiogram 4. Vital signs every 4 hours

1. Contact isolation

Which topics should be includedinclude in a teaching session with parents of school-age children to prevent frostbite? Select all that apply. 1. Dressing in layers 2. Having extra clothing available 3. Removing wet gloves immediately 4. Applying sunscreen twice per day 5. Wearing sunglasses while outside

1. Dressing in layers 2. Having extra clothing available 3. Removing wet gloves immediatel

Which assessment data would cause the nurse to suspect that a pediatric client is experiencing hypovolemic shock? Select all that apply. 1. Dyspnea 2. Bradycardia 3. Tachycardia 4. Capillary refill time greater than 3 seconds. 5. Blood pressure 72/42 mmHg

1. Dyspnea 3. Tachycardia 4. Capillary refill time greater than 3 seconds

Which athletic activity should the nurse recommend for a school-age child who is diagnosed with pulmonary artery hypertension? 1. Golf 2. Basketball 3. Cross-country running 4. Soccer

1. Golf

Which common eye disorders should the nurse include in a teaching session for the parents of pediatric clients? Select all that apply. 1. Hyperopia 2. Myopia 3. Astigmatism 4. Strabismus 5. Cataracts

1. Hyperopia 2. Myopia 3. Astigmatism

Which is the priority nursing diagnosis when planning care for an infant who is diagnosed with a severe case of oral thrush (Candida albicans)? 1. Ineffective Infant Feeding Pattern related to discomfort 2. Ineffective Breathing Pattern related to oral thrush 3. Activity Intolerance related to oral thrush 4. Ineffective Airway Clearance related to mucus

1. Ineffective Infant Feeding Pattern related to discomfort

A child had an appendectomy and was discharged home at 48 hours postoperative. A week later, the child is readmitted for delayed wound healing. Which causes of delayed wound healing will the nurse review prior to assessing the child? Select all that apply. 1. Infection 2. Predisposing chronic condition, such as diabetes 3. Hypervolemia 4. Inadequate nutrition 5. Hypoxemia

1. Infection 2. Predisposing chronic condition, such as diabetes 4. Inadequate nutrition 5. Hypoxemia

Which is the priority action by the school nurse for an adolescent who drops to the ground and is unresponsive during a high school basketball game? 1. Initiating cardiopulmonary resuscitation (CPR) 2. Calling 911 3. Offering the parents comfort 4. Assessing for hemorrhage

1. Initiating cardiopulmonary resuscitation (CP

Which visual screenings should the school nurse conduct when conducting annual assessments for school-age children? Select all that apply. 1. Light reflex assessment 2. Cover-uncover test 3. Acuity testing 4. Visualization of the tympanic membrane 5. Cranial nerve VIII testing

1. Light reflex assessment 2. Cover-uncover test 3. Acuity testing

Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply. 1. Mucous membranes 2. Nail beds 3. Skin 4. Sclerae 5. Corneas

1. Mucous membranes 2. Nail beds 3. Skin

Which independent nursing action is appropriate for a 2-month- old infant who is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event)? 1. Place the child on an apnea monitor. 2. Place the child on nasal cannula oxygen. 3. Draw blood for arterial blood gases. 4. Place the child on contact isolation.

1. Place the child on an apnea monitor.

Which topics should be include included in a teaching session with parents of school-age children to prevent sunburn? Select all that apply. 1. Playing in the shade 2. Wearing a hat while outdoors 3. Restricting outside activities between 10 a.m. and 2 p.m. 4. Using sunscreen with an SPF of 30 or higher 5. Avoiding sunglasses

1. Playing in the shade 2. Wearing a hat while outdoors 4. Using sunscreen with an SPF of 30 or higher

Which topics should the nurse include in a teaching session to the parents of a 10-month- old infant who experiences frequent ear infections? Select all that apply. 10 Copyright © 2017 Pearson Education, Inc. 1. Prohibiting tobacco smoke in the home 2. Avoiding use of a pacifier while the child is sleeping 3. Breastfeeding the infant 4. Cleaning the child's ears nightly with peroxide 5. Avoiding use of wood-burning stoves

1. Prohibiting tobacco smoke in the home 2. Avoiding use of a pacifier while the child is sleeping 5. Avoiding use of wood-burning stoves

Which clinical manifestation does the nurse anticipate for a pediatric client who is admitted with congestive heart failure (CHF)? 1. Tachycardia 2. Weight loss 3. Hypertension 4. Bradycardia

1. Tachycardia

Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with early compensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5. Decrease in systolic blood pressure

1. Tachycardia 2. Weak distal pulses 4. Normal blood pressure

Which is the rationale for why young children are more prone to otitis media that the nurse should include in the teaching session with a parent? 1. The eustachian tube is shorter, wider, and horizontal in younger children. 2. The eustachian tube is shorter, more narrow, and horizontal in younger children. 3. The eustachian tube is longer, wider, and vertical in younger children. 4. The eustachian tube is longer, more narrow, and vertical in younger children.

1. The eustachian tube is shorter, wider, and horizontal in younger childre

A toddler-age client presents to the emergency department with a sore throat and difficulty swallowing. The nurse suspects acute epiglottitis. Which nursing action is avoided based on the current assessment data? 1. Throat culture 2. Medical history 3. Vital signs 4. Auscultation of breath sounds

1. Throat culture

Which assessment finding is considered normal for a school-age client? 1. Tonsils are large and seem to fill the throat. 2. Child is complaining of sore throat and drooling 3. White patches are observed on the tonsils. 4. Throat appears red, and child has a low-grade fever

1. Tonsils are large and seem to fill the throat.

Which nursing action is appropriate when providing care to a child with a mild hearing loss who reads lips to enhance adaptation during hospitalization? 1. Touching the child lightly before speaking 2. Using a picture board as the main means of communication 3. Speaking in a loud voice while facing the child 4. Speaking directly to the parents for communication

1. Touching the child lightly before speaking

Which pain interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury? Select all that apply. 1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care 4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound

1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care

Which strategies should the nurse recommend for a school-age client who is at risk for developing hypertension as an adult? Select all that apply. 1. Using seasoning substitutes for salt 2. Providing a list of foods high in sodium 3. Decreasing television time 4. Increasing physical activity 5. Monitoring blood pressure daily

1. Using seasoning substitutes for salt 2. Providing a list of foods high in sodium 3. Decreasing television time 4. Increasing physical activity

Which preventative strategies for tinea pedis, a fungal infection, also known as athlete's foot, should the nurse include in a teaching session for an adolescent client? Select all that apply. 1. Wear 100% white cotton socks, changed twice a day. 2. Use talc on feet daily. 3. Use an over-the- counter corticosteroid cream to treat the area. 4. Wear foot covers such as flip flops in the locker room and shower. 5. Apply heat to the area twice a day.

1. Wear 100% white cotton socks, changed twice a day. 2. Use talc on feet daily. 4. Wear foot covers such as flip flops in the locker room and shower.

The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child's urine was orange. Which response by the nurse is accurate? 1. "Encourage your child to drink cranberry juice." 2. "An orange discoloration of urine is expected while your child is on this medication." 3. "Bring your child to the clinic for a urinalysis." 4. "Bring your child to the clinic for a radiograph of the kidneys."

2. "An orange discoloration of urine is expected while your child is on this medication

Which adolescent statement regarding skin care and acne prevention would indicate the need for further education by the nurse? 1. "I shouldn't squeeze my blackheads or pimples." 2. "I need to watch my diet and cut out all chocolates." 3. "I should avoid applying drying materials, such as astringents, to my face" 4. "I should wash my hands frequently and avoid touching my face."

2. "I need to watch my diet and cut out all chocolates.

Which parental statements indicate correct understanding of the care that is needed for a pediatric client after the insertion of tympanostomy tubes? Select all that apply. 1. "It is important to limit my child's diet after surgery and only allow soft, bland foods." 2. "I should restrict my child to quiet activities after surgery." 3. "I should plan to administer a decongestant to my child for 1 to 2 weeks following surgery." 4. "It is important for my child to drink plenty of fluids after the procedure." 5. "I will remind my child to use ear plugs prior to showering and swimming."

2. "I should restrict my child to quiet activities after surgery." 4. "It is important for my child to drink plenty of fluids after the procedure." 5. "I will remind my child to use ear plugs prior to showering and swimming."

An infant who is diagnosed with a mild heart defect will not have surgical correction for at least 2 years. Which information should the nurse include in the discharge teaching regarding management in the home environment? 1. "Your child will have a low-grade fever until the defect is repaired." 2. "It is important for your child to maintain normal activity." 3. "Your child is not at risk for congestive heart failure." 4. "It is important to avoid antipyretics for the treatment of fever."

2. "It is important for your child to maintain normal activity."

The mother of a toddler-age client states, "My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate? 1. "You are incorrect in your assessment." 2. "The younger child's airways are smaller and more easily occluded." 3. "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children." 4. "Toddlers do not breathe as deeply as do older children."

2. "The younger child's airways are smaller and more easily occluded.

Which parental statements indicate correct understanding of the anatomy and physiology of the infant's mouth, nose, and throat? Select all that apply. 1. "My baby will breathe through her mouth during the first 3 months of life." 2. "When my baby has a cold she may have trouble with bottle feedings." 3. "My baby's tonsils will be largest during infancy." 4. "I should expect my baby's first tooth to erupt during the first 6 months of life." 5. "I should expect my baby to lose her first tooth during the first year of life."

2. "When my baby has a cold she may have trouble with bottle feedings." 4. "I should expect my baby's first tooth to erupt during the first 6 months of life.

The 10-year- old child is admitted to the hospital following an accident at school that resulted in a puncture wound of the abdomen. Two days after the injury, the child continues in the inflammation phase of healing. What would the nurse expect to see while changing the child's dressing and assessing the wound? 1. The wound is contracting, and the edges are growing together. 2. A blood clot has formed, sealing the wound. 3. Epithelial cells are growing into the wound. 4. The wound is pale and weepy.

2. A blood clot has formed, sealing the wound.

Which pediatric clients would require a nursing assessment for blunt chest trauma? Select all that apply. 1. A preschool-age client who is admitted after a house fire. 2. A toddler-age client who is admitted for injuries sustained in a motor vehicle accident. 3. A school-age client who is admitted for observation after a skateboarding accident. 4. An adolescent client admitted for an asthma exacerbation. 5. An infant admitted to rule out cystic fibrosis.

2. A toddler-age client who is admitted for injuries sustained in a motor vehicle accident. 3. A school-age client who is admitted for observation after a skateboarding accident.

Which should the nurse include in the plan of care for a pediatric client diagnosed with otitis media with effusion? Select all that apply. 1. Administration of antibiotic drops per order 2. Administration of pain relief measures 3. Assessment of hearing acuity over several months 4. Assessment of speech 5. Assessment of development

2. Administration of pain relief measures 3. Assessment of hearing acuity over several months 4. Assessment of speech 5. Assessment of development

Which nursing action is appropriate for the parents of a 4-month- old infant who died due to sudden infant death syndrome (SIDS)? 1. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints 2. Allowing parents to hold, touch, and rock the infant 3. Advising parents that an autopsy is not necessary 4. Interviewing parents to determine the cause of the incident

2. Allowing parents to hold, touch, and rock the infant

Which is the priority nursing assessment for a pediatric client who is postoperative for tonsillectomy? 1. Arrhythmias 2. Dehydration 3. Increased blood sugar 4. Increased urinary output

2. Dehydration

Which nursing assessment data would indicate that a pediatric client sustained a large pulmonary contusion in a motor vehicle crash? Select all that apply. 1. Eupnea 2. Dyspnea 3. Hemoptysis 4. Fever 5. Crackles

2. Dyspnea 3. Hemoptysis 4. Fever 5. Crackles

Which is the priority nursing action when providing care to a pediatric client who is diagnosed with hypovolemic shock? 1. Assessing the cause of bleeding 2. Establishing an open airway and administering oxygen 3. Administering analgesics for pain control 4. Providing replacement of volume

2. Establishing an open airway and administering oxygen

The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help prevent which complication? 1. Pain 2. Hypertrophic scarring 3. Poor circulation 4. Formation of thrombus in the burn area

2. Hypertrophic scarring

Which is the reason for a healthcare provider to recommend that a preschool-age male client with a documented hearing loss should attend preschool at least 2 days per week? 1. Help the child recognize his hearing deficit. 2. Increase the child's socialization skills. 3. Improve the child's immunity by increased exposure to organisms. 4. Teach other children that children are different.

2. Increase the child's socialization skills.

Which clinical therapy should the nurse anticipate when planning care for a toddler-age client who is admitted to the hospital unit with cellulitis of the neck? 1. Topical antibiotics 2. Intravenous antibiotics 3. Incision and drainage 4. Oral corticosteroids

2. Intravenous antibiotics

Which assessment finding indicates adequate peripheral perfusion for a child after a cardiac catheterization? 1. Capillary refill is greater than 3 seconds. 2. Lower extremities are warm, with a capillary refill of less than 3 seconds. 3. Sensation is decreased with a weakened dorsalis pedis pulse. 4. Dorsalis pedis pulse is palpable but posterior tibial pulse is weak.

2. Lower extremities are warm, with a capillary refill of less than 3 seconds.

Which is the priority nursing action when providing care to a child who is bitten by a snake? 1. Measuring the circumference of the extremity twice per hour 2. Monitoring respiratory status 3. Assessing vital signs 4. Evaluating response to pain medication

2. Monitoring respiratory status

A nurse is caring for a visually impaired school-age child. Which is the priority nursing intervention during the admission process to the hospital? 1. Explaining playroom policies 2. Orienting the child to where furniture is placed in the room 3. Taking the child on a tour of the unit 4. Letting the child touch equipment that will be used during the child's hospitalization

2. Orienting the child to where furniture is placed in the room

A nurse is caring for a visually impaired 20-month- old client who has not begun to walk. Which nursing diagnosis would be appropriate for this child? 1. Self-care Deficit 2. Impaired Physical Mobility 3. Impaired Home Maintenance 4. Delayed Development

4. Delayed Development

Which positions are appropriate for the nurse to include in a plan of care for the infant who is diagnosed with acute respiratory distress? Select all that apply. 1. Upright 2. Semi-Fowler position 3. Prone position 4. With the infant's head hyperextended 5. With the infant's head in a sniffing position

2. Semi-Fowler position 5. With the infant's head in a sniffing position

Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply. 1. Lung sounds clear to auscultation 2. Stridor 3. Substernal retractions 4. Nasal flaring 5. Strong cry

2. Stridor 3. Substernal retractions 4. Nasal flaring

Which nursing action is appropriate when providing care to a newborn with a respiratory rate of 102 breaths per minute with lungs that are clear to auscultation? 1. Administering the bath to the neonate in the nursery 2. Transferring to the neonatal intensive care unit for further observation 3. Allowing the neonate to room-in to promote bonding 4. Providing the first feeding in the nursery

2. Transferring to the neonatal intensive care unit for further observation

Which adolescent statements indicate the need for further education related to the prevention and treatment of acne? Select all that apply. 1. "I should wash my face each day with an approved cleanser." 2. "I should wash my hands frequently and avoid touching my face." 3. "I should stay away from greasy foods, such as pizza." 4. "I should shampoo my hair only once per week." 5. "I should use my topical medication only when acne is present."

3. "I should stay away from greasy foods, such as pizza." 4. "I should shampoo my hair only once per week." 5. "I should use my topical medication only when acne is present."

Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis? 1. "I will administer this medication 4 times each day." 2. "I will administer this medication twice each day." 3. "I will administer this medication with meals and snacks." 4. "I will administer this medication every 6 hours around the clock."

3. "I will administer this medication with meals and snacks."

Which parental statement regarding the use of cyclosporin A after a heart transplant indicate correct understanding of the information presented by the nurse? 1. "This medication is used to treat hypertension." 2. "This medication is used to reduce serum cholesterol level." 3. "This medication is used to prevent rejection." 4. "This medication is used to treat infections."

3. "This medication is used to prevent rejection."

Which parental statement indicates correct understanding of discharge instructions for a pediatric client after a tonsillectomy? 1. "We will call the healthcare provider for any indication of ear pain." 2. "We will be sure to give our child adequate amounts of citrus juices." 3. "We will plan on administering acetaminophen (Tylenol) for pain." 4. "We will keep our child on bed rest for 10 days after the surgery."

3. "We will plan on administering acetaminophen (Tylenol) for pain."

Which initial laboratory data does the nurse anticipate for a child who is admitted to the hospital with a cyanotic heart defect? 1. A low platelet count 2. A high white blood cell count 3. A high hemoglobin 4. A low hematocrit

3. A high hemoglobin

Which heart defect should the nurse suspect for an infant whose upper extremities have stronger pulses than the lower extremities and blood pressure is higher in the arms than in the legs? 1. Transposition of the great vessels 2. Patent ductus arteriosus 3. Coarctation of the aorta 4. Atrial septal defect

3. Coarctation of the aorta

Which discharge instruction is appropriate for an adolescent client who is a paraplegic due to a motor vehicle accident, in order to prevent decubitus ulcer formation on the buttock? 1. Contract the muscles 5 times every 2 hours. 2. Increase fat in the diet to provide a protective coating over the boney bony prominences. 3. Do wheelchair push-ups every 15 to 30 minutes. 4. Avoid use of sheepskin, as it prevents air from reaching the area.

3. Do wheelchair push-ups every 15 to 30 minutes.

The nurse is teaching a pregnant client about fetal circulation. Which is the correct sequence of blood flow that indicates the pregnant client understands the information presented? 1. Ductus arteriosus 2. Ductus venosus 3. Foramen ovale

3. Foramen ovale 1. Ductus arteriosus 2. Ductus venosus

A 2-month- old infant with a congenital heart defect is admitted to the pediatric intensive care unit with congestive heart failure. Which intervention should the nurse include in the infant's plan of care? 1. Monitor respirations during active periods. 2. Give larger feedings less often to conserve energy. 3. Organize activities to allow for uninterrupted sleep. 4. Force fluids appropriate for age.

3. Organize activities to allow for uninterrupted sleep

A neonate is diagnosed with a herpes simplex viral infection of the eye. Which medication should the nurse prepare to administer? 1. Oral erythromycin 2. Fluoroquinolone eyedrops or ointment 3. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment 4. Intravenous penicillin

3. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment

Which screening tool should the nurse use to screen a pediatric client for esotropia? 1. Examine the eye with an otoscope. 2. Check for the "red reflex" in the eyes. 3. Perform the cover-uncover test. 4. Use a tonometer to evaluate the eyes.

3. Perform the cover-uncover test.

Which adolescent behavior, reported by a parent, would cause the nurse to suspect possible substance abuse? 1. Becoming very involved with friends and in activities related to basketball 2. Becoming moody, crying, and weeping one minute and then cheerful and excited the next 3. Receiving numerous detentions for sleeping in class 4. Wearing baggy, oversized clothing and dyeing hair black

3. Receiving numerous detentions for sleeping in class

Which nursing actions are appropriate when providing care to a 12-year- old client who has lost several teeth as a result of a facial injury? Select all that apply. 1. Not worrying about the tooth loss, as children this age still have their "baby" teeth 2. Only handling the lost tooth by the roots and avoiding touching the crown of the tooth 3. Rinsing the lost tooth with sterile saline 4. Placing the tooth back into its socket and taking the child to an emergency dental facility 5. Keeping the tooth clean and dry during transport to an emergency dental facility

3. Rinsing the lost tooth with sterile saline 4. Placing the tooth back into its socket and taking the child to an emergency dental facility

Which is the rationale the nurse provides to the parents of an infant diagnosed with congestive heart failure (CHF) for the prescribed spironolactone? 1. Produces rapid diuresis 2. Blocks reabsorption of sodium and water in renal tubules 3. Spares potassium 4. Promotes vascular relaxation

3. Spares potassium

Which should the nurse include in a teaching session for the mother of a 3-year- old client who is concerned about her child choking? 1. Show the mother how to do cardiac compressions and rescue breathing. 2. Recommend the mother perform back blows and chest thrusts. 3. Teach the mother how to perform abdominal thrusts. 4. Tell the mother to do nothing until the child loses consciousness.

3. Teach the mother how to perform abdominal thrusts.

Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with moderate uncompensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5. Decrease in systolic blood pressure

3. Thready distal pulses 5. Decrease in systolic blood pressure

Which clinical manifestations does the nurse anticipate for a pediatric client who is diagnosed with the subacute stage of Kawasaki disease? Select all that apply. 1. High fever 2. Diarrhea 3. Thrombocytosis 4. Joint pain 5. Beau lines

3. Thrombocytosis 4. Joint pain

Which is an appropriate nursing intervention for a child who experiences epistaxis? 1. Laying the child down and applying a warm pack. 2. Tilting the child's head back, squeezing the bridge of the nose, and applying a warm moist pack to the nose. 3. Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose. 4. Immediately packing the nares with a cotton ball soaked with phenylephrine (Neo- Synephrine).

3. Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose.

Which immunization should the nurse include in a teaching session for parents of a toddler- age client to decrease the risk for epiglottitis? 1. Hepatitis B 2. Polio 3. Measles, mumps, and rubella (MMR) 4. Haemophilus influenzae type B (HIB)

4. Haemophilus influenzae type B (HIB)

During a well-child examination, the parents of a 4-year- old client inform the nurse that they are thinking of buying a television for their child's bedroom and ask for advice as to whether this is appropriate. Which response by the nurse is most appropriate? 1. "It is okay for children to have a television in their room as long as you limit the amount of time they watch it to less than 2 hours per day." 2. "Research has shown that watching educational television shows improves a child's performance in school." 3. "Don't buy a television for your child's room; he is much too young for that." 4. "Research has shown that children with a television in their bedroom spend significantly less time playing outside than other children."

4. "Research has shown that children with a television in their bedroom spend significantly less time playing outside than other children."

Which is an appropriate statement for the nurse to include in the discharge instructions to the parents of a child who is recovering from cardiac surgery? 1. "The child will have a fever for several weeks following the surgery." 2. "The child will be restricted from most play activities." 3. "The child will not receive routine immunizations." 4. "The child will receive prophylactic antibiotics prior to any dental procedures."

4. "The child will receive prophylactic antibiotics prior to any dental procedures.

Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented? 1. "We're glad the dog can continue to sleep in our child's room." 2. "We'll keep the plants in our child's room dusted." 3. "We'll be sure to use the fireplace often to keep the house warm in the winter." 4. "We will replace the carpet in our child's bedroom with tile."

4. "We will replace the carpet in our child's bedroom with tile."

Which should the nurse include in the discharge instructions for the parents of an infant who is diagnosed with acute otitis media? 1. Keep the baby in a flat position during sleep. 2. Administer a decongestant. 3. Place the baby to sleep with a pacifier. 4. Administer acetaminophen (Tylenol) to relieve discomfort.

4. Administer acetaminophen (Tylenol) to relieve discomfort.

Which laboratory test does the nurse anticipate for a child who is admitted to the hospital with suspected rheumatic fever? 1. Erythrocyte sedimentation rate 2. Throat culture 3. C-reactive protein 4. Antistreptolysin-O (ASO) titer

4. Antistreptolysin-O (ASO) tite

Which is a priority nursing assessment the nurse includes in the plan of care for a pediatric client who has received a cochlear implant? 1. Ringing in the ears 2. Pharyngitis 3. Hearing loss 4. Bacterial meningitis

4. Bacterial meningitis

A 7-year- old child is seen in the pediatric clinic 3 times in the last 2 months for complaints of abdominal pain. On each occasion, the physical examination and all ordered laboratory work have been normal. Which is the priority nursing assessment at this time? 1. The child's normal eating habits 2. Recent viral illnesses or other infectious symptoms 3. Review of the child's immunization history 4. Changes in school or home life

4. Changes in school or home life

Which is the priority nursing action for a child who presents in the emergency department after a motor vehicle accident with a sucking wound of the chest? 1. Placing the child in a Trendelenburg position 2. Beginning rescue breathing for the child 3. Beginning cardiac resuscitation for the child 4. Covering the child's wound with an air occlusive dressing

4. Covering the child's wound with an air occlusive dressing

The nurse admits a child with a ventricular septal defect (VSD) to the pediatric unit. Which is the priority nursing diagnosis for this child? 1. Hypothermia related to decreased metabolic state 2. Acute Pain related to the effects of a congenital heart defect 3. Ineffective Tissue Perfusion (peripheral) related to cyanosis secondary to congenital heart defect 4. Impaired Gas Exchange related to pulmonary congestion secondary to the increased pulmonary blood flow

4. Impaired Gas Exchange related to pulmonary congestion secondary to the increased pulmonary blood flow

Which interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury to decrease the risk for infection? Select all that apply. 1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care 4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound

4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound

Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis? 1. Rectal prolapse 2. Constipation 3. Steatorrheic stools 4. Meconium ileus

4. Meconium ileus

Which is the priority intervention when planning care for an infant who is diagnosed with eczema? 1. Applying antibiotics to lesions 2. Keeping the baby content 3. Maintaining adequate nutrition 4. Preventing infection of lesions

4. Preventing infection of lesions

Which information should the nurse include in a teaching session regarding treatment for the common cold in the pediatric population? 1. Aspirin should be taken for alleviation of fever if the common cold is contracted. 2. Antibiotics will eliminate the nasopharyngitis virus. 3. Vaccinations can prevent contraction of a nasopharyngitis virus. 4. Proper hand washing can prevent the spread of the common cold.

4. Proper hand washing can prevent the spread of the common cold.

Which teaching point should the nurse include in the discharge instructions for a pediatric client who has undergone cardiac surgery? 1. Should not receive routine immunizations. 2. Should be restricted from most play activities. 3. Fever is expected for several weeks following the surgery. 4. Prophylactic antibiotics are required for any dental, oral, or upper respiratory tract procedures.

4. Prophylactic antibiotics are required for any dental, oral, or upper respiratory tract procedures.

Which is the priority nursing action for a premature neonate who is experiencing apnea? 1. Administering oxygen 2. Performing back blows and chest thrusts 3. Calling a code blue 4. Providing stimulation by stroking the back

4. Providing stimulation by stroking the back

Which finding noted by the school nurse while conducting pediculosis capitis (head lice) checks would indicate the need for treatment? 1. White, flaky particles throughout the entire scalp region 2. Lesions on the scalp that extend to the hairline or neck 3. Maculopapular lesions behind the ears 4. Silver/white sacs attached to the hair shafts in the occipital area

4. Silver/white sacs attached to the hair shafts in the occipital area

The nurse is providing care to homeless adolescents at an outreach clinic. Which concept is important for the nurse to consider when providing care to this population? 1. Teens who are homeless will get a job and somewhere to live. 2. Teens who are homeless will seek help when needed. 3. Teens who are homeless will not be fearful of authority figures. 4. Teens who are homeless are most likely to have unprotected sex.

4. Teens who are homeless are most likely to have unprotected sex.

Which age-appropriate information should the nurse provide to a 4-year- old girl who is being emotionally prepared for open heart surgery? 1. The name of the surgeon who will be performing the procedure 2. What the surgical procedure will entail 3. The purpose of the heart-lung machine used during the procedure 4. What the environment will look and sound like when the child wakes up

4. What the environment will look and sound like when the child wakes up

The toddler pulled a pot of boiling water off the stove and suffered partial- and full- thickness burns to the chest. The child is now in the recovery-management phase of burn treatment. Which common complication should the nurse assess this client for based on the current data? 1. Asphyxia 2. Metabolic acidosis 3. Shock 4. Wound infection

4. Wound infection