Peds ATI
A nurse is assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? • A. Grasping a small object with just the thumb and index finger • B. Dropping a cube when passing from 1 hand to the other • C. Falling from a standing position to sitting D. Losing balance when leaning sideways while sitting
B
A nurse is assessing a school-aged child who is 30 minutes postoperative following a cardiac catheterization using the left femoral artery. Which of the following findings should the nurse identify as the priority to report to the provider? • A. The child rouses to verbal stimuli • B. The pulse strength of the child's left popliteal artery site is decreased • C. The child's respiratory rate is 20/min D. The child rates his pain at the catheter insertion site at a 7 on a scale of 0 to 10
B
A nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? A. Increased blood pressure B. Lanugo over the back C. Oily skin with acne D. Elevated body temperature
B
A nurse is assessing the dynamics of a family in which child maltreatment is suspected. Which of the following findings should the nurse report to the provider? A. The parents provide emotional support to the child during the assessment process. B. The child has several unexplained scars and bruises. C. The child cries and appears afraid of the health care provider. D. The parents offer consistent, detailed stories about the child's injuries.
B
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? • A. Jump rope • B. Coloring book and cravons c. Checkers game • D. Jack-in-the-box
B
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? • A. Maintain the child on strict bed rest • B. Check the child's blood pressure every 4 hr • C. Administer albumin to the child every 8 hr D. Provide the child with a low-carbohydrate diet
B
A nurse is caring for a child who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medications should the nurse plan to administer? • A. Digoxin immune fab • B. Acetylcysteine • C. Naloxone • D. Vitamin K
B
A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. Obtain a portable suction machine and suction tubing B. Ease the child to the floor in Sims' position c. Time the length of the seizure D. Notify the child's parents
B
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should recommend which of the following immunizations prior to moving into a campus dormitory? • A. Pneumococcal polysaccharide • B. Meningococcal polysaccharide • C. Rotavirus • D. Herpes zoster
B
A nurse is caring for an infant following the surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? A. Keep the infant's mouth open by using a tongue blade for 4 hr following surgery B. Suction the infant gently with a bulb syringe PRN C. Place the infant in a prone position D. Clean the infant's incision with chlorhexidine
B
A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following actions should the nurse take? A. Place the infant in a lateral position B. Perform oropharyngeal suctioning C. Administer ranitidine orally D. Thicken the infant's formula
B
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? A. Maintain the child on bed rest B. Monitor the child for increased temperature C. Administer oxygen to the child D. Monitor the child for bleeding
B
A nurse is providing teaching about home care to the parent of a child who has a newly applied fiberglass leg cast. Which of the following statements should the nurse include? A. "Monitor the color of your child's toes every 4 hours for 24 hours." B. "Your child can scratch the skin inside the cast with a small wooden ruler" C. "Expect the cast to remain damp for 72 hours." D. "You can take your child swimming and give baths as usual."
A
A nurse is providing teaching about home safety to the parent of a 2-month-old infant. Which of the following information should the nurse include? A. Remove bibs before the infant goes to sleep B. Cover the infant with a lightweight blanket at bedtime C. Place the infant in direct sunlight for at least 10 minutes each day D. Set the hot water heater to 60°C (140°F)
A
A nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions? A. HiP B. Upper arm C. Thigh D. Lower leg
A
A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). Which of the following pieces of information should the nurse include in the teaching? A. Add fortified rice cereal to the infant's formula B. Alternate feedings between several family members C. Offer the infant juice between feedings D. Provide feedings on demand rather than on a schedule
A
A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? • A. Bulky stools • B. Weakened rectal sphincter C. Elevated pancreatic enzymes • D. Decreased intra-abdominal pressure
A
A nurse is providing teaching to the parent of an infant who has developmental hip dysplasia and a new prescription for a Pavlik harness, Which of the following parent statements indicates an understanding of the teaching? • A. "I will apply the harness over a t-shirt and knee socks" • B. "I will put my baby's diaper over the harness" c. " will make the required harness adjustments as my baby grows." • D. "I will apply powder around the harness buckles each day."
A
A nurse is evaluating the outcome of surgery for an infant who had a bile duct obstruction. Which of the following findings should indicate to the nurse that the surgery was successful? • A. The infant's stool becomes fatty • B. The color of the infant's stool is yellowish-brown C. The infant's direct bilirubin level has increased • D. A palpable mass is noted in the infant's right upper quadrant
B
A nurse is planning to teach a 9-year-old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-age children are attempting to master which of the following developmental tasks? • A Initiative vs. guilt B. Industry vs. inferiority • C. Trust vs. mistrust • D. Identity vs, role confusion
B
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? A. Administer the medication while the infant is supine B. Give the medication at the side of the infant's mouth C. Add the medication to a full bottle of the infant's formula D. Administer the medication slowly while holding the nares closed
B
A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend? • A. 1/2 cup whole milk • B. 1/2 cup cooked pinto beans • C. 1 cup green leaf lettuce • D. 1 cup apple juice
B
A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider? A. HCt 40%6 B. Potassium 2.5 mEg/L C. Serum creatinine 0.4 mg/dL D. BUN 6 mg/dL
B
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? • A. Platelets 150,000/mm^3 • B. Hgb 6 g/dL C. WBC 6,000/mm^3 • D. Potassium 4.5 mEg/L
B
A nurse is teaching the family of a child about hospice care. Which of the following statements should the nurse include in the teaching? A. "The hospice staff will be the primary caregivers for the child." B. "Hospice staff members consider the family's needs to be just as important as those of the child." C. "Hospice care will end with the death of your child." D. "The priority of hospice care is to provide curative treatment for the child."
B
A nurse is teaching the parent of a child who has type 1 diabetes mellitus how to manage the child's disorder during an illness such as a cold. Which of the following statements by the parent indicates an understanding of the teaching? • A 'TIl reduce my child's food intake" • B. "ll check his blood glucose more often." C. "TIl limit his fluid intake between meals." D. "I won't administer his long-acting insulin dose."
B
A nurse on a pediatric unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? • A. Age 10 years • B. Frequent hospitalizations C. Parent bonding with child D. Calm, quiet demeanor
B
A nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? A. Withhold the medication if the infant's heart rate is less than 110/min B. Mix the medication in 120 mL (4 oz) of infant formula C. Expect the infant to vomit frequently while taking this medication D. Double the dose if the infant has increased edema
A
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include as an expected finding for this age group? • A Copying a circle • B. CUtting foods using a table knife C. Beginning to write in cursive • D. Printing the first and last name clearly
A
A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? A. "The infant might be dehydrated." B. "The infant might be anemic." C. "The infant might have received too much fluid." D. "The infant might have leukemia."
A
A school nurse is assessing an adolescent who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? • A. Potential for sustaining abdominal trauma B. Deficient dietary intake • C. Exposing peers to the illness D. Straining sore joints
A
The nurse is preparing to administer an oral medication to an 8-month-old infant. Which of the following actions should the nurse take? A. Mix the medication with 1 tsp of honey to sweeten the taste for the infant B. Use an oral syringe to place the medication alongside the infant's tongue C. Add the medication to the infant's bottle of formula D. Place the infant in a supine position to administer the medication
B
urse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the lowing interventions should the nurse include in the plan of care? ) A. Assign an assistive personnel to feed the child ) B. Explain the sounds the child is hearing ) C. Have the child use a cane when ambulating ) D. Rotate nurses caring for the child
B
A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include? • A. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." • B. "A toddler first shows interest in looking at pictures at 20 months of age." C. "A toddler should have daytime control of his bowel and bladder by 24 months of age." • D. "Your child should be able to scribble spontaneously using a crayon at 15 months of age."
D
A nurse at a community health department is discussing the nutritional needs of children with a group of parents and guardians. Which of the following pieces of information should the nurse include? A Infants should be transitioned to low-calorie milk at 12 months. B. Preschoolers need 10-12 g of protein per day. C. Toddlers can be given up to 120-180 mL (4-6 oz) of juice per day. D. School-age children should be encouraged to avoid afternoon snacks.
C
A nurse in an emergency department is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report as an indication of impending airway obstruction? A. Bradycardia B. Respiratory depression C. Nasal flaring D. Barking cough
C
A nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? • A. Administer IV morphine • B. Administer topical antimicrobials • C. Administer IV fluid replacement • D. Administer tetanus prophylaxis
C
A nurse in the emergency department is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as an indication of digoxin toxicity? • A Irritability • B. Diaphoresis c. Vomiting • D. Tachycardia
C
A nurse is assessing a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggests a possible delay in development? • A. Inability to tie shoes • B. Adding 3 parts to a stick figure • C. Speaking using 2- or 3-word sentences • D. Inability to walk backward
C
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? • A The child prefers playmates of the same sex. • B. The child is competitive when playing board games. C. The child complains daily about going to school. • D. The child enjoys spending time alone.
C
A nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A. Bruising of the right elbow B. Dislocated left shoulder revealed by X-ray C. Thin, frail extremities D. Abrasions on both wrists
C
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? • A Slight thirst • B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production
C
A nurse is assessing the vital signs of a 1-month-old infant. Which of the following actions should the nurse perform? A. Use a cuff to auscultate blood pressure B. Determine heart rate by taking the radial pulse C. Count respirations before taking other vital signs D. Measure temperature by placing the thermometer in the infant's ear
C
A nurse is caring for a 15-month-old client who requires droplet precautions. Which of the following actions should the nurse take? A. Have the toddler wear a disposable gown when in the unit's playroom. B. Wear sterile gloves when changing the toddler's diapers. C. Wear a mask when assisting the toddler with meals. D. Ask visitors to wear an N-95 mask when entering the toddler's room.
C
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. A board book with large pictures B. A toy with movable parts C. A plastic mirror D. Push-pull toy
C
A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of 0 to 10 B. The child's hands are cool bilaterally c. The child reports tightness at the wrist D. The child's grasp is weak
C
A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take? A. Position the adolescent supine during the procedure B. Have the adolescent drink 240 mL (8 oz) of fluid prior to the procedure C. Obtain the adolescent's weight prior to the procedure D. Monitor the adolescent's vital signs every 4 hours during the procedure
C
A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client? • A. Less extracellular fluid B. Reduced body surface area • C. Longer intestinal tract • D. Decreased rate of metabolism
C
A nurse is performing a nutritional screening for a 12-year-old client who weighs 41 kg (90 lb) and has a height of 1.5 m (60 in). Which of the following values is the client's body mass index (BMI)? • A. 1.5 • B. 3.6 • C. 18.2 • D. 27.3
C
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? A. Apply cold compresses to the child's extremities B. Administer meperidine every 4 hr until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for 8 hr
C
A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? • A Fasten the diaper loosely • B Cleanse the meningeal sac with povidone-iodine daily • C. Palpate the abdomen for bladder distension • D. Cover the sac with a dry, sterile gauze dressing
C
A nurse is providing dietary teaching to the parent of a toddler who has phenylketonuria. Which of the following foods should the nurse recommend? • A. Whole milk B. Ground beef • C. Cooked carrots • D. Eggs
C
A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? • A. Plain flour pastry • B. Wheat cereal • C. scrambled eggs • D. Rye toast
C
A nurse is providing teaching about poisoning prevention to a group of parents with toddlers. Which of the following statements should the nurse make? • A. "Keep medications on a counter that is out of reach of the toddler." • B. "Do not keep live plants in the house." • C. "Put all cleaning supplies in a locked cabinet." • D. "Allow your child to eat from his or her favorite ceramic bowls."
C
A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? • A. "If you take too much insulin, drink a sugar-free cola." • B. "You will need to decrease your insulin dosage when you become a teenager." • C. "You can use a vial of insulin for up to 30 days." • D. "Stop taking your insulin if you are vomiting."
C
A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse identify as a manifestation of this complication? A. Slow heart rate B. Protruding eyeballs C. Deep, rapid respirations D. Decreased urinary output
C
A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop-side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons." D. "I should ensure the crib slats are no more than 3 inches apart."
C
A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? • A. A child who has asthma and a pulse oximetry of 94% • B. A child who has nephrotic syndrome and 1+ protein on urine dipstick • C. A child who has sickle cell anemia and a urine specific gravity of 1.030 • D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL
C
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? • A. Cutting Figures from colored paper • B. Drawing stick figures using crayons • C. Riding a tricycle D. Building towers with blocks
D
A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices due to the high protein content? • A Medium baked potato B. Wheat bagel with 1 tbsp of apricot jam • C. Large orange D. 1/2 cup of peanut butter with apple slices
D
A nurse is caring for a child with a vesicular rash that has been present for 6 days. The nurse should expect that the child has which of the following conditions? A. Measles B. Fifth disease C. Tetanus D. Varicella
D
A nurse is caring for a school-age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hr during the night B. Ensure the child's meal tray contains no high-fiber foods C. Perform passive range-of-motion exercises on the child's involved joints every 4 hr D. Place the child on a pressure-reduction mattress
D
A nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Administer an NSAID B. Perform passive range-of-motion exercises on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint
D
A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take first? A. Reduce the temperature of the child's room B. Redress the child in minimal clothing C. Apply cool compresses to the child's forehead D. Administer an antipyretic to the child
D
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? • A. Hypotension • B. Stomatitis • C. Bloody diarrhes • D. Periorbital edema
D
A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? • A Dilated pupils • B. Tremors c. Yawning • D. Pruritus
D
A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? • A. Assess for edema of the extremities • B. Apply warm compresses to the neck area • C. Initiate airborne precautions • D. Maintain a cardiorespiratory monitor
D
A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hr B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the skin before attaching the sensor D. Cover the oximetry sensor with clothing
D
A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia c. Decreased plasma creatinine level D. Metabolic acidosis
D
A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following replies should the nurse provide? • A You should give your child a stool softener daily. • B. "Toddlers gain weight at a rapid pace." • C. You should have your child assessed for a spinal deformity:" • D. "Toddlers do not have well-developed abdominal muscles."
D
A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following directions should the nurse provide? • A. "Your child will need to take estrogen daily when she reaches puberty." • B. "Your child will need monthly blood coagulation studies." • C. "Your child will need surgery to remove the diseased thyroid." • D. "Your child will need to take thyroid hormone replacement for her entire life."
D
A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child c. Orfer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short
D
A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age
A
A nurse is preparing to administer diphenhydramine 5mg/kg/day PO divided equally every 8 hr to a school-age child who weighs 50 lb. Diphenhydramine oral solution 12.5 mg/S ml is available. How many mL should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)
15
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV infused over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number and use a leading zero if applicable. Do not use a trailing zero.)
25
A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium c. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry
A
A nurse is caring for a 16-year-old client who reports dysmenorrhea and asks about alternative therapies for treatment. Which of the following statements should the nurse make? • A. "Herbal medication can be effective but should be monitored by your provider. • B. "You should place a cold compress on your lower abdomen to decrease inflammation." C. "You should limit exercise, which can increase the pain." • D. "Avoid touching the painful areas because this can increase your discomfort."
A
A nurse is caring for a 2-day-old infant who has myelomeningocele. Which of the following actions should the nurse take? • A. Monitor the infant's head circumference • B. Position the infant supine • C. Place the infant under a radiant warmer D. Tape a piece of plastic over the protruding membranes
A
A nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include? A. Begin after the extrusion reflex has diminished. B. Introduce solids between 2 and 3 months of age. C. Wait until the infant's first tooth erupts. D. Add a sweetener such as light corn syrup to bland foods.
A
A nurse is caring for a female adolescent who is being treated for frequent urinary tract infections (UTIs). Which of the following statements by the adolescent indicates a possible cause of the UTIs? A. " have bowel movements every 4 to 5 days." B. "My mom taught me to wipe from front to back after going to the bathroom." C. "I urinate every 2 to 3 hr during the day." D. "I don't wear nylon underwear."
A
A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? • A. Transposition of the great arteries B. Ventricular septal defect C. Coarctation of the aorta • D. Patent ductus arteriosus
A
A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? • A. Monitor the child's oxygen saturation level • B. Administer prescribed antibiotics to the child • C. Increase the child's fluid intake • D. Apply warm compresses to the child's affected joints
A
A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DTaP) B. Pneumococcal (PCV C. Haemophilus influenzae type B (Hib) D. Hepatitis B (Hep B)
A
A nurse is assessing a 6-year-old client at a well-child visit. Which of the following findings requires further assessment by the nurse? • A. Presence of sparse, fine pubic hair • B. Decreased head circumference compared to full height • C. Increased leg length in relation to height • D. Presence of a loose central incisor
A
A nurse is assessing a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect? • A. Hypertension • B. Abdominal obesity • C. Bradycardia • D. Loose stools
A
A nurse is assessing an infant who has untreated congenital hypothyroidism. Which of the following manifestations should the nurse expect? A. Constipation B. Hyperreflexia C. Oily skin D. Hyperthermia
A
A nurse is assessing an infant who is at risk for increased intracranial pressure (IC). Which of the following findings should indicate to the nurse that this complication is developing? • A. High-pitched cry • B. SUnken fontanel • C. Tachycardia D. Increased awake time
A
A nurse is assessing the gross motor skills of a 4-year-old preschooler. The nurse should expect the preschooler to perform which of the following activities? • A. Hopping on 1 foot • B. Skipping on alternate feet • C. Jumping rope D. Roller skating
A
A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? • A. Celiac disease • B. Ulcerative colitis C. Hirschsprung's disease • D. Crohn's disease
A
A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (Select all that apply.) A. "I should eat extra food on busy days when I am more active." B. "I should wait for 2 hr after eating before going swimming with my friends." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." E. "I should have a 16 oz sports drink if I start feeling weak or shaky."
A,C,D
A home health nurse is developing a plan of care a toddler who has hemophilia. Which of the following instructions for the parents should the nurse include in the plan? • A. Administer low-dose aspirin for pain. B. Inspect the toddler's toys for sharp edges. • C. Perform passive range-of-motion of the affected joint during a bleeding episode. • D. Avoid contact with people who have respiratory infections.
B
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head-to-toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical terminology D. Stop the assessment if the child becomes uncooperative
B
A nurse in a provider's office is assessing a client. The nurse determines the client's body mass index is 21.2. This finding is classified as which of the following? A. Underweight B. Healthy weight C. Overweight D. Obese
B
A nurse in an acute pediatric unit is caring for a 2-year-old child who has separation anxiety when her parents to leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. The child tries to bite the nurse. B. The child is withdrawn and refuses to talk. c. The child attempts to run away to find her parents. D. The child screams and cries loudly.
B
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing B. Check the child's respiratory status C. Administer an antidote to the child D. Establish IV access for the child
B
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor
B,D,E
A nurse is teaching the parent of an infant about home safety. Which of the following pieces of information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker. B. Place soft pillows around the edge of the infant's crib. C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49°C (120°F).
C,D,E
A nurse is assessing the fine motor skills of a 3-year-old preschooler. Which of the following findings should the nurse expect? • A. The preschooler can draw a stick figure that has 7 parts • B. The preschooler can print her first name • C. The preschooler can cut out a picture using scissors • D. The preschooler builds a tower of 9 cubes
D
A nurse is assessing an adolescent who is receiving fentanyl via epidural. Which of the following assessments should the nurse identify as the priority? • A. Skin around the catheter site • B. Blood pressure • C. Pain level • D. Oxygen saturation
D
A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? • A Skipping around the room • B. Hopping on 1 foot • C. Throwing a ball overhead • D. Standing on 1 foot
D