Peds Exam 4 Lippincott

The 17-year-old client with a diagnosis of bulimia nervosa is hospitalized. The client weighs 5 lb (2.26 kg) less than her ideal weight for her height. She tells the nurse, "I do not have a problem. I am not really underweight." The nurse should respond by saying

"Even though your weight is almost ideal for your height, purging and using laxatives are harmful to your body."

A child with a brain tumor has a decreased respiratory rate and is less responsive to verbal commands than he was when the nurse assessed the client the previous hour. What should the nurse do next:

Notify the health care provider (HCP).

The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches their back (see figure). What action should the nurse take first?

Notify the health care provider (HCP).

A school-age child with leukemia is taking immunosuppressive drugs. What health maintenance recommendation should the nurse include in the teaching plan?

Avoid any live attenuated vaccines.

An adolescent at a mental health clinic tells the nurse about feeling an overwhelming sadness and isolation for several months. The adolescent states a lack of interest in school and family life and proclaims, "No one cares about me. I wish I were dead." Which information would be most important for the nurse to obtain in order to plan appropriate care?

Determine whether the adolescent has developed a plan for committing suicide.

A child is admitted to the hospital with a febrile seizure. What action should the nurse take?

Keep the room temperature low and bedclothes to a minimum.

A child diagnosed with tetralogy of Fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic, and the respiratory rate increases to 44 breaths/min. Which action should the nurse do first?

Place the child in a knee-to-chest position.

Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3 (0.4 X 109/L)?

Restrict staff and visitors with active infections.

The nurse is assessing an adolescent 1 hour after admission for a head injury. The nurse identifies that there have been changes since the baseline assessment, including apnea, bradycardia, and a widening pulse pressure. What is the primary reason for the nurse to notify the healthcare provider?

The changes suggest that the client's intracranial pressure is increasing.

A child has a seizure while a nurse is performing a bed bath. Which of the following are priority actions for the nurse to implement? Select all that apply.

Time the length of the seizure, Observe the stages of the seizure, Turn the child to a side-lying position.

A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options.

Trust versus mistrust, Autonomy versus shame and doubt, Initiative versus guilt, Industry versus inferiority, Identity versus role confusion

A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes priority?

a child who develops a fever during a blood transfusion

The nurse is providing postoperative care for an infant who had a ventriculoperitoneal shunt placed to correct hydrocephalus. Which clinical finding warrants immediate intervention?

abdominal distention

A physician orders digoxin elixir for a client with heart failure. Immediately before administering this drug, the nurse must check the client's

apical pulse.

A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern?

bradycardia

A 13-year-old with anorexia nervosa is admitted to the facility for I.V. fluid therapy and nutritional management. The client is worried that the I.V. fluids will cause weight gain. Which nursing diagnosis is most appropriate?

disturbed body image

A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which assessment findings are consistent with this syndrome?

fever, decreased level of consciousness (LOC), and impaired liver function

The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption by the toddler because excess milk consumption can lead to which problem?

iron deficiency

A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant?

irritability

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention would be most appropriate to institute?

keeping extraneous noise to a minimum

Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin?

nausea and vomiting

The parents of a child with sickle cell anemia ask about the chances of sickle cell disease occurring in future children. What does the nurse determine is the family's risk of having another child with sickle cell anemia?

one chance in four for each pregnancy

A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to

provide oral and I.V. fluids.

When teaching the parents of a child diagnosed with tetralogy of Fallot about the cardiac defects involved with this condition, which defects should the nurse describe? Select all that apply.

right ventricular hypertrophy, ventricular septal defect, overriding aorta, pulmonary stenosis

The nurse is providing an education program to a group of adolescents on the importance of testicular self-examinations. One of the participants asks the nurse, "when is the best time to do the examination?" What is the best response by the nurse?

when you are in the shower or immediately after