Peds ATI 2019 A
a nurse in an ED is assessing a toddler who has kawasaki disease. which of the following should the nurse expect?
Increased temperature is correct. Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics.Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia.Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia.Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction.Cervical lymphadenopathy is correct. A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.
a nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. which should be included?
"Award your child with a sticker when they sit on the potty chair." A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair.
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?
"I should keep my child indoors when I mow the yard."The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks.
A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?
"I should secure the car seat using lower anchors and tethers instead of the seat belt."Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.
A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?
"I will give myself a shot of regular insulin 30 minutes before I eat breakfast."The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.
A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make?
"Let's talk about some of the ways you have handled previous stressors in your life."
A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include?
"Shake the medication prior to administration."The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension.
A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" Which of the following responses should the nurse make?
"You can sign the consent form because you are married."The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age.
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.)
-Ankle clonus-Exaggerated stretch reflexes-Contractures
A nurse is receiving change-of-shift report on four children. Which of the following children should the nurse see first?
A school-age child who has sickle cell anemia and reports decreased vision in the left eye.When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.
The nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect?
Abdominal distention The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?
Administer an analgesic to the child.Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder.
a nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective?
Decreased edema MY ANSWER A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema.
The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take?
First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control?
Have a designated stethoscope in the infant's room.The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.
a nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. which should the nurse do?
Have the adolescent sign a consent form for treatment. MY ANSWER The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent.
A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan?
Implement seizure precautions for the infant.An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child.
a nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. which of the following should be included?
Increase fat content in the child's diet to 40% of total calories. A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake. The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis, NOT 2 hours.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?
Initiate seizure precautions for the child.A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
Loud, harsh murmurThe nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?
Oral rehydration solutionA toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.
A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?
Petechiae on the lower extremitiesThe presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?
Provide small, frequent meals for the child.The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.
a nurse is planning developmental activities for a newly admitted 10 y/o child with neutropenia. which of the following actions should the nurse take?
Provide the child with a book about adventure. MY ANSWER The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read.
A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?
Respiratory rate 45/minThe nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.
A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?
Screen the child's visitors for indications of infection.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?
Serum creatinine 3.0 mg/dL Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.
A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings in an indication of early septic shock?
Temperature 39.1° C (102.4° F)The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills.
a nurse is planning an educational program for school-age child and their parents about bicycle safety. which should be included?
The child should be able to stand on the balls of their feet when sitting on the bike. To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar.
a nurse is planning care for a school-age child who has a tunneled central venous access device. which of the following interventions should be planned?
Use a semipermeable transparent dressing to cover the site. The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.
A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?
Withhold the measles, mumps, and rubella (MMR) vaccine.The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.
a charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. which of the following statements should the nurse include
a 6 year old should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands
a nurse is caring for a 12 month old infant following the surgical repair of a cleft palate. the nurse should plan to feed the infant using which instrument?
a cup
a nurse is caring for a 4-month-old child who is hospitalized. which of the following toys should the nurse provide for the child?
a plastic mirror
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?
apply a topical analgesic cream to the site 1 hr prior to procedure
a nurse is providing discharge teaching to the guardian of an infant who has a tracheostomy. which should the nurse ID as an item that should be in the infant's home prior to discharge
bag-valve mask The nurse should teach the guardian that the infant's home should contain the equipment necessary to care for and maintain oxygenation, such as a bag-valve mask. The nurse should instruct the infant's guardian to notify the utility company, as well as local emergency medical services, of the infant's condition prior to discharge.
A nurse in the emergency department is caring for a toddler who has a partial thickness burns on their right arm. Which of the following actions should the nurse take?
cleanse with mild soap and water
a nurse is admitting a 4-month old infant who has heart failure. which of the following findings is the nurse's priority?
episodes of vomiting When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. not weight because: The infant should gain 680 g (1.5 lb) per month until the age of 5 months.
a nurse is providing teaching about car seat safety with the guardian of an 18 month old toddler who weighs 9.1 kg. which of the following responses by the guardian indicates an understanding of the teaching
i will place the car seat rear-facing in the back seat of my car
A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis?
increased protein concentration
school age children are attempting to master which of the following?
industry vs. inferiority
a nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. which of the following interventions should the nurse include in the plan?
maintain the child on bed rest
a nurse is planning care for a preschooler who is immediately postoperative following the replacement of a ventriculoperitoneal shunt. which of the following interventions should the nurse include in the plan?
position the child NOT on the shunt side post-op to avoid pressure on the site
A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?
substernal retractions
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as suggestive of potential physical abuse?
symmetric burns of the lower extremities
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?
tachypnea
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following?
tachypnea
a nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has HIV. which of the following should the nurse include in the teaching?
the pneumococcal and influenza vaccines are recommended for your child
a nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. the child's parent asks the nurse to explain the purpose of the test. which of the following responses should the nurse provide?
the test shows us if your child had a recent strep infection.
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area?
zinc oxide
A nurse is caring for a 15 year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
Mental confusionA child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur.
a nurse is caring for a child who has tetralogy of fallot. which of the following labs should the nurse expect to find?
RBC 6.8 million
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?
Sodium 140 mEq/LThe nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective.
A nurse is admitting a school-age child who has Pertussis. Which of the following actions should the nurse take?
initiate droplet precautions
a nurse is assessing a school-aged child who has acute glomerulonephritis. which of the following manifestations should the nurse expect
periorbital edema
a nurse is teaching the parent of a 13-month-old toddler about home safety precautions. which of the following statements should the nurse make?
provide your child's milk and juice in a cup instead of a bottle The nurse should instruct the parent to wean the toddler from a bottle by 14 months of age. Drinking milk or juice from a bottle, especially at bedtime, coats the teeth in sugar and increases the risk for tooth decay.
a nurse is caring for a school-age child who has varicella. the parent asks the nurse when their child will no longer be contagious. which is correct?
when your child's lesions are crusted, usually about 6 days after they appear The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.
A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?
your daddy will be back after you eat
a nurse is admitting a preschooler who is suspected to have pharyngeal diphtheria. what transmission-based precautions should the nurse initiate
droplet
a nurse is providing teaching to the guardians of a school-age child who has partial seizures and a new prescription for gabapentin. which of the following info should the nurse included in the teaching
monitor the child for new or worsening depression Gabapentin can cause neuropsychiatric adverse effects, such as new or worsening depression, suicidal thoughts, confusion, and dizziness. The nurse should instruct the guardians to monitor the child closely for behavior changes that could indicate depression or suicidal thoughts
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?
place child in side-lying position
A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?
place diapers under the harness straps
a nurse is caring for a 10 y/o child following a head injury. which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus
sodium 155 A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L.
The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the inter professional team should the nurse initiate a referral?
speech therapist
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?
my child will receive antibiotics for several weeks
a nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. which should the nurse state?
You should offer your child high-protein meals and snacks throughout the day." MY ANSWER The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?
epinephrine
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
give morphine
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?
give the infant a pacifier
a school nurse is caring for a child following a tonic-clonic seizure. which of the following actions should the nurse take first?
check the child's respiratory rate When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths.
a nurse is caring for a 3 year old child on a pediatric unit. the nurse should identify which of the following as an appropriate toy for the child?
coloring book and crayons
a nurse is caring for a toddler. which of the following labs would the nurse report to the provider?
creatinine 0.9
A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?
cuts an outlined shape using scissors
a nurse is preparing to administer ondansetron to a school-age child who is receiving chemotherapy to treat cancer. which of the following assessment findings should the nurse id as an indication that the ondansetron has been effective
decreased nausea Chemotherapy can cause nausea and vomiting. Administration of ondansetron 30 min before chemotherapy can minimize nausea and vomiting. Scheduled administration of ondansetron should continue for at least 24 hr following chemotherapy.
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?
denies discomfort during assessment of injuries
a nurse is providing teaching to the family of a school age child who has juvenile idiopathic arthritis. which should be included?
Encourage the child to perform independent self-care." MY ANSWER The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem.
A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
Playing dress-up The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child.
A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?
White riceThe nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?
absence of peristalsis
A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
administer epinephrine IM to the child
a nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis which of the following actions should the nurse take
administer ibuprofen
a nurse is caring for a child who has paralytic poliomyelitis. which of the following actions should the nurse take?
administer oral analgesics prior to exercises
A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?
administer the immunization using a 24 gauge needle
a nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. which of the following conditions should the nurse include as a maternal risk factor?
alcohol consumption
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
dry, hacking cough
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?
A unilateral rib humpWhen assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?
Schedule the toddler for a yearly rescreening.The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.
A nurse is caring for a school-age child who in in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take?
Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling.
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?
Perform a finger stick.The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
a nurse is admitting an infant who has intussuscpetion. which of the following findings should the nurse expect?
MY ANSWER Steatorrhea is incorrect. The nurse should expect an infant who has intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis.Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel.Lethargy is correct. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake.Constipation is incorrect. The nurse should expect an infant who has intussusception to have mucus-filled and red jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen.Weight gain is incorrect. The nurse should expect an infant who has intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.
The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?
The toddler received tobramycin during a hospitalization 2 weeks ago.The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
a nurse is reviewing the lab results of a 6 month old infant who has GER and is receiving treatment with lansoprazole. which of the following should indicate that the lansoprazole should be withheld and the provider should be notified?
magnesium 1.1 mEq/L A magnesium level of 1.1 mEq/L is below the expected reference range of 1.4 to 1.7 mEq/L for a 6-month-old infant. Decreased magnesium levels, which can be seen with lansoprazole therapy, can cause cardiac dysrhythmias, respiratory depression, and diminished deep tendon reflexes. Therefore, the nurse should withhold the lansoprazole and notify the provider immediately.
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?
Hematocrit 28%The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity.
A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point?
The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness.
A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy. Which of the following lab values should the nurse report to the provider?
Hgb 8.5 g/dLA child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider.