Peds Ch. 24, 25, 28, 31

The nurse explains that Bryants traction is reserved for children who weigh less than _____ pounds.

ANS: 30

The child with Duchennes muscular dystrophy must push on his legs and walk up the leg in order to rise to a standing position. The nurse recognizes this characteristic behavior as _______________ maneuver.

Gowers

What should the nurse explain to the parent of a child with exercise-induced asthma about when to inhale Cromolyn? a. Before exercise to prevent attacks b. At the initial onset of the attack c. During the attack to relieve symptoms d. As often as 4 times a day

a. Before exercise to prevent attacks

What factor(s) may trigger abuse in a parent? (Select all that apply.) a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit relative to child care

a. Being abused as a child c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit relative to child care

On entering the room of a child in Bucks traction, the nurse makes all of the following observations. Which observation requires a nursing intervention? a. Childs heels are placed firmly against the foot of the bed. b. Head of bed is elevated 20 degrees. c. Weights are hanging freely. d. Ropes are on pulleys.

a. Childs heels are placed firmly against the foot of the bed.

After a closed head injury, the unconscious 10-year-old child begins to excrete copious amounts of pale urine with an attendant drop in blood pressure (BP). Based on these symptoms, what does the nurse suspect has developed? a. Diabetes insipidus b. Diabetes mellitus c. Hypothyroidism d. Hyperthyroidism

a. Diabetes insipidus

Which laboratory result indicates good metabolic control for a child with type 1 diabetes mellitus? a. Glycosylated hemoglobin value of 8% b. Fasting blood glucose level less than 140 mg/dL c. Glucose tolerance test result of 190 mg/dL d. No glucose or ketones present in the urine

a. Glycosylated hemoglobin value of 8%

The nurse describes the allergic salute as a cluster of what signs related to chronic allergy? (Select all that apply.) a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes d. Productive cough e. Reddened conjunctiva

a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes e. Reddened conjunctiva

What nursing action will significantly decrease the risk of serious complications for a child in Bryant's traction? a. Neurovascular checks are done frequently. b. Bandages are wrapped tightly. c. The child is restrained from rolling over. d. The child's buttocks are resting on the bed.

a. Neurovascular checks are done frequently.

A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child? a. Pain resulting from tissue trauma b. High risk for impaired skin integrity resulting from immobility c. Altered growth and development related to separation from family d. Altered urinary elimination related to immobility and traction

a. Pain resulting from tissue trauma

What will the nurse teach the child with cystic fibrosis to take in order to facilitate digestion and absorption of nutrients? a. Pancreatic enzymes b. Water-soluble minerals c. Fat-soluble vitamins d. Salt supplements

a. Pancreatic enzymes

A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. What will be the nurses' priority goal of the infants care? a. Prevent fluid and electrolyte imbalance. b. Prevent nutritional deficiency. c. Prevent skin breakdown. d. Prevent malabsorption.

a. Prevent fluid and electrolyte imbalance.

The nurse demonstrates which similarities among all traction devices? (Select all that apply.) a. Pull the limb into extension b. Decrease muscle spasm c. Reduce pain d. Align two bone fragments e. Immobilize the limb

a. Pull the limb into extension b. Decrease muscle spasm d. Align two bone fragments e. Immobilize the limb

Which observation may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs? a. Red, green, and yellow bruises on his body b. Bruises are dispersed on his head, arms, and legs c. A broken arm last year, and the child being described as accident-prone d. The mother is very anxious for her son to get medical attention

a. Red, green, and yellow bruises on his body

The home health nurse is monitoring an 8-month-old child with hypothyroidism taking levothyroxine (Synthroid). Which symptoms does the nurse recognize as signs of overdose? (Select all that apply.) a. Tachycardia b. Irritability c. Vomiting d. Weight gain e. Diaphoresis

a. Tachycardia b. Irritability e. Diaphoresis

On the second day of hospitalization for a 3-month-old brought in for treatment for gastroenteritis, the nurse makes all of the assessments listed below. Which assessment finding indicates ineffectiveness of treatment? a. Weight loss of 4 ounces b. Dry mucous membranes c. Decreased skin turgor d. Depressed fontanelle

a. Weight loss of 4 ounces Weight loss is the most significant indicator of dehydration because an infants weight comprises 77% water.

What intervention will the nurse caring for a child in Bucks skin traction implement? a. Position in high Fowlers position. b. Assist the child to be pulled up in bed. c. Keep child's heel on the bed surface. d. Maintain child's feet against the foot of the bed.

b. Assist the child to be pulled up in bed. Bucks traction is a type of skin traction that relies on the child's weight as counterbalance. The child must be kept with head elevated no more than 20 degrees and pulled up in bed, and the feet should not touch the bed surface or the foot of the bed.

An infant is hospitalized with RSV bronchiolitis. What is the priority nursing diagnosis? a. Fatigue related to increased work of breathing b. Ineffective breathing pattern related to airway inflammation and increased secretions c. Risk for fluid volume deficit related to tachypnea and decreased oral intake d. Fear and/or anxiety related to dyspnea and hospitalization

b. Ineffective breathing pattern related to airway inflammation and increased secretions

What condition does the nurse suspect when a child with type 1 diabetes mellitus has hyperglycemia, diaphoresis, and headaches in the morning? a. Dawn phenomenon b. Somogyi phenomenon c. Honeymoon effect d. Ketoacidosis

b. Somogyi phenomenon

What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child? a. Has inward-turned knees while standing b. Walks on the toes c. Appears to have flat feet d. Swings his arms when walking

b. Walks on the toes

Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year-old to be? a. 2 days b. 4 days c. 6 days d. 8 days

c. 6 days

The nurse is speaking to the parent of a 3-year-old child who has mild diarrhea. What dietary modification would the nurse advise? a. Soft foods with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution, such as Pedialyte d. Chicken soup because it is high in sodium

c. An oral rehydrating solution, such as Pedialyte

What does the nurse expect the appearance of the stools of a child with celiac disease to be? a. Ribbon like b. Hard, constipated c. Bulky, frothy d. Loose, foul-smelling

c. Bulky, frothy

What will the nurse include when caring for a child in Bucks extension? a. Positioning the child with hips flexed 90 degrees at all times b. Keeping the weights in contact with the floor c. Checking for skin irritation from traction equipment d. Releasing the weights on a schedule

c. Checking for skin irritation from traction equipment

What classic sign would the nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, expect to find? a. Fine crackles b. Coarse rhonchi c. Expiratory wheezing d. Decreased breath sounds at lung bases

c. Expiratory wheezing

What characteristic manifestation does the nurse caring for a child with Duchennes muscular dystrophy document? a. Ambulates by holding onto furniture b. Exhibits atrophy of the calf muscles c. Falls frequently and is clumsy d. Has delayed fine-motor development

c. Falls frequently and is clumsy

The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select all that apply.) a. Pulse is equal to uncasted limb. b. Patient is aware of touch and warm and cold application. c. Limb is cool to the touch. d. Capillary refill is 5 seconds. e. Distal limb can flex and extend.

c. Limb is cool to the touch. d. Capillary refill is 5 seconds.

A child is sent to the school nurse for assessment because she comes to school every day disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do these finding indicate? a. Sexual abuse b. Physical abuse c. Physical neglect d. Emotional abuse

c. Physical neglect

When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the nurse immediately report? a. Respiration rate decrease from 40 to 32 breaths/min b. Heart rate decrease from 110 to 100 beats/min c. Quiet chest from previous assessment of wheezing d. Oxygen saturation of 90%

c. Quiet chest from previous assessment of wheezing

A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur. What type of fracture would be the most likely to alert the nurse to the possibility of physical abuse? a. Stress fracture b. Compound fracture c. Spiral fracture d. Greenstick fracture

c. Spiral fracture

Why are rapid respirations a possible cause of dehydration? a. They prevent the child from drinking. b. They increase circulation, thus increasing urine production. c. They cause evaporation of fluid on the mucous membranes. d. They often lead to vomiting.

c. They cause evaporation of fluid on the mucous membranes.

Which statement indicates that the child's parents understand how to perform respiratory therapy? a. We do her postural drainage before the aerosol therapy. b. We give her respiratory treatments when she is coughing a lot. c. We give the aerosol followed by postural drainage before meals. d. She needs respiratory therapy every day when she has an infection

c. We give the aerosol followed by postural drainage before meals.

What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace? a. Wear the brace directly against the skin. b. Wear the brace over regular clothing. c. Wear the brace over a T-shirt 23 hours a day. d. Remove the brace before sleeping.

c. Wear the brace over a T-shirt 23 hours a day.

A child is brought to the pediatric clinic because he has been vomiting for the past 2 days. What acid-base imbalance would the nurse expect to occur from this persistent vomiting? a. Hyperkalemia b. Hypernatremia c. Acidosis d. Alkalosis

d. Alkalosis

What finding would the nurse assessing the neurovascular status of a child in Russell traction report immediately? a. Skin that's warm to the touch b. Capillary refill less than 3 seconds c. Ability to wiggle toes d. Bluish coloration of skin

d. Bluish coloration of skin

The teaching plan for the use of a dry powder inhaler for the treatment of asthma should include the warning to rinse the mouth after inhaling the powder. What does this prevent? a. Discoloration of tooth enamel b. Halitosis c. Irritation of oral membranes d. Candidiasis

d. Candidiasis

Which is the most appropriate nursing action when planning care for a child with cystic fibrosis? a. Provide chest physiotherapy before meals every day. b. Assess weight monthly. c. Administer pancrease with protein food at mealtime. d. Ensure high-protein, high-calorie diet.

d. Ensure high-protein, high-calorie diet.

What is the best intervention for the nurse caring for a child experiencing an acute asthma attack? a. Offer plenty of fluids, particularly carbonated beverages. b. Place the child in a humidified cool mist tent with oxygen. c. Administer sedatives as ordered to decrease anxiety. d. Position the child with arms resting on the overbed table

d. Position the child with arms resting on the overbed table

Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary? a. Pulses b. Capillary refill c. Movement d. Pupils

d. Pupils

How does Russell traction provide adequate skin traction? a. Subluxates the tibia b. Does not interfere with range of motion c. Prevents the knee from flexing d. Supplies continuous pull in two directions

d. Supplies continuous pull in two directions

The nurse is instructing a mother how to administer oral nystatin suspension prescribed to treat thrush. What will the nurse include? a. Pour the prescribed amount into a nipple and have the infant suck the medication. b. Squirt the prescribed dose into the back of the mouth and have the infant swallow. c. Give the medication mixed with a small amount of juice in a bottle. d. Use a sterile applicator to swab the medication on the oral mucosa.

d. Use a sterile applicator to swab the medication on the oral mucosa.

The nurse, assessing an elevated erythrocyte sedimentation rate (ESR) for an infant with gastroenteritis, recognizes that this confirms the _______________ process that is part of this disease.

inflammatory