Peds Midterm (exam 2)

The nurse providing client education on tetralogy of fallot knows that which of the following statements provide the best explanation of what a "tet spell" is? a. "Cyanosis that occurs when the client's oxygen needs are greater than their blood supply" b. "Cyanosis that occurs while the client is sleeping and resting" c. "Jaundice that occurs secondary to the lysis of red blood cells" d. "Cyanosis that occurs when the client's oxygen needs are less than their blood supply"

a. rationale: Crying and feeding are common causes of increased oxygen demands in children with tetralogy of Fallot and may cause a "tet spell" where the client becomes cyanotic and hypoxic.

The nurse caring for a newborn diagnosed with a heart defect knows that which of the following is the most common cyanotic lesion? a. Tetralogy of fallot b. Truncus arteriosus c. Tricuspid atresia d. Hypoplastic left heart

a. rationale: Tetralogy of fallot is the most common cyanotic lesion

The nurse is caring for a client who has a sudden asthma attack. Which inhaler does the nurse know to give first? a. Albuterol b. Fluticasone c. Cromolyn d. Azmacort

a. rationale: This is a beta-2 agonist, which is an acute bronchodilator and should be given first.

The nurse caring for a one-year-old with intussusception knows which of the following are signs of peritonitis? Select all that apply. a. Fever b. Abdominal distention c. Pallor d. Tachycardia e. Red currant Jelly stool

a., b., c., d. rationale: Peritonitis is inflammation and infection of the abdomen, which can cause a fever.Peritonitis is inflammation and infection of the abdomen, which can cause progressive abdominal distention.Peritonitis can cause severe infection and sepsis. This can increase the child's heart rate.Decreased circulation and a low blood pressure from infection can cause pallor. Red currant jelly stool is a sign of intussusception, not peritonitis.

The nurse caring for a child who is mildly dehydrated and has been vomiting for the past 48 hours is explaining to the mother how to provide oral rehydration. Which of the following statements should the nurse include in the teaching? Select all that apply. a. "Do no force fluids if your child is sleepy or not responding to you" b. "Only offer drinks when your child's asks for a drink to avoid distressing them" c. "For mild dehydration the goal is to give 50 ml/kg/day of oral rehydration solution" d. "You should use an oral rehydration solution" e. "Offer 2-5 mls of fluid every 2-3 minutes"

a., c., d. e. rationale: Oral rehydration solutions help prevent electrolyte imbalances associated with frequent vomiting.Children are unlikely to be able to self-regulate their thirst and hydration needs, so fluids should be offered frequently in small amounts.If the child is tired or has a decreased level of responsiveness they are at increased risk of aspirating. Additionally, a child who is not responsive enough to drink fluids needs to be seen by a provider.A child who is mildly dehydrated and able to drink fluids safely should have 50 ml/kg/day of oral rehydration solution. A child with moderate dehydration should have 100 ml/kg/day.

The nurse is assessing a client and recognizes that this client is having a bronchospasm. Which treatments should the nurse anticipate? Select all that apply. a. Bronchodilators b. Suctioning c. Diuretics d. Steroids e. Chest tube

a., d. rationale: When a client is having a bronchospasm, treatment will include steroids and bronchodilators to relax the smooth muscle and open up the airway.Steroids is a treatment for bronchospasm, usually given with a bronchodilator.

Beta-Adrenergic agonists and methylxanthines are often prescribed for a child with an asthma attack. Which describes their action? a. Liquefy secretions b. Dilate the bronchioles c. Reduce inflammation of the lungs d. Reduce infection

b. rationale: Beta-Adrenergic agonists and methylxanthines work to dilate the bronchioles in acute exacerbations. These medications do not liquefy secretions or reduce infection. Corticosteroids and mast cell stabilizers reduce inflammation in the lungs.

The nurse is assessing a child with acute epiglottitis. Examining the child's throat by using a tongue depressor might precipitate which symptom or condition? a. Inspiratory stridor b. Complete obstruction c. Sore throat d. Respiratory tract infection

b. rationale: If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Stridor is aggravated when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract.

The nurse caring for a 14-year-old client who has just returned from surgery following a perforated appendix knows which of the following interventions should be given top priority? a. Assisting with ambulation b. Giving IV antibiotics c. Measuring strict inputs and outputs d. Monitoring for a fever

b. rationale: When a perforation has occurred, infection has spread to the entire abdomen and this client is at increased risk for sepsis. IV antibiotics must be given as ordered to treat the infection.

A nurse recognizes which physiologic responses as a manifestation of pain in a neonate? (Select all that apply.) a. Decreased respirations b. Diaphoresis c. Decreased SpO2 d. Decreased blood pressure e. Increased heart rate

b. , c., e. rationale: The physiologic responses that indicate pain in neonates are increased heart rate, increased blood pressure, rapid, shallow respirations, decreased arterial oxygen saturation (SaO2), pallor or flushing, diaphoresis, and palmar sweating.

It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently because which disease or assessment findings may develop? a. Cough b. Osteoporosis c. Slowed growth d. Cushing syndrome

c. rationale: The growth of children on long-term inhaled steroids should be assessed frequently to assess for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term systemic steroids.

The nurse caring for a ten-year-old with appendicitis knows which of the following symptoms may be a sign of perforation? a. A palpable abdominal mass b. A sudden spike in blood pressure c. Sudden relief from pain d. Sudden intensification of pain

c. rationale: The pain felt with appendicitis may suddenly go away when the appendix ruptures.

The nurse caring for a 5-year-old assesses the following assessment findings: stridor, drooling, high fever, toxic appearance, increased heart rate, and respiratory rate. Which of the following should be avoided during the assessment? a. Auscultating the lung sounds b. Checking the child's capillary refill time c. Assessing the throat d. Applying a continuous pulse ox monitor

c. rationale: This could upset the child and cause spasms in the airway leading to complete airway obstruction.

The nurse is caring for a client who has been diagnosed with appendicitis and is scheduled for surgery later today. Which of the following assessment findings is the MOST concerning? a. Abdominal pain at McBurney's point b. Rebound tenderness c. Sudden pain relief d. Increased WBC on CBC

c. rationale: This is the most concerning because it indicates that the appendix has ruptured.

A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which pain assessment tool should the nurse use to assess this child for the presence of pain? a. FACES pain rating tool b. Numeric scale c. Oucher scale d. FLACC tool

d. rationale: A behavioral pain tool should be used when the child is preverbal or doesn't have the language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all self-report pain rating tools. Self-report measures are not sufficiently valid for children younger than 3 years of age because many are not able to accurately self-report their pain.

The parents of a 6-year-old are seeking treatment for the child's cardiac condition. The child will need surgery to correct coarctation of the aorta. During the history and physical, the parents tell the nurse that the child was adopted from another country last year. The parents are planning to sign informed consent for the procedure. Which of the following responses from the nurse is most appropriate? a. I'm sorry, I must have the parent or legal guardian sign the consent form b. I will need a copy of your legal adoption paperwork before we can sign this consent c. You do not have authority to sign paperwork until the child has been legally adopted d. I will get the paperwork for you to sign as the parent

d. rationale: A child who must undergo a surgical procedure must have a consent form signed by a parent or legal guardian before starting the surgery. Because the child is 6 years old in this case, the parents must sign the consent, since the child is not developmentally mature enough to understand the process. Although the parents adopted the child from another country, they are considered the parents and/or legal guardians if they legally adopted. They can sign the consent for the child.

A nurse is conducting parenting classes for parents of children ranging in ages 2 to 7 years. The parents understand the term egocentrism when they indicate it means: a. selfishness. b. self-centeredness. c. preferring to play alone. d. unable to put self in another's place.

d. rationale: According to Piaget, children ages 2 to 7 years are in the preoperational stage of development. Children interpret objects and events not in terms of their general properties but in terms of their relationships or their use to them. This egocentrism does not allow children of this age to put themselves in another's place. Selfishness, self-centeredness, and preferring to play alone do not describe the concept of egocentricity.

The nurse is caring for a client who has been brought to the emergency department for an asthma exacerbation. Which of the following would NOT be an expected finding when completing a comprehensive respiratory assessment of this client? a. Diminished breath sounds b. Tachypnea c. Wheezes d. Cheyne-Stokes respirations

d. rationale: This is an abnormal respiratory pattern with periods of apnea. It is not an expected clinical finding in a client experiencing an acute asthma exacerbation. All other assessment findings would be expected with this clinical picture.

A three month old infant needs an IM injection of palivizumab for prevention of RSV. Which site is most appropriate for the nurse to administer this medication? a. Ventrogluteal site b. Deltoid site c. Vastus lateralis site d. Dorsogluteal site

c. rationale: The vastus lateralis site is the most common site for intramuscular injection in infants. This site is easy to access and typically has a large enough muscle that medication can be injected into the area. The nurse should avoid using the deltoid site on a 3-month old because the infant will not have enough muscle in this area.

A client presents to the emergency department for RLQ pain. While the client is talking to the nurse, he sits up straight on the stretcher and says, "That's weird, my stomach stopped hurting." What is the number one concern right now? a. Pre-seizure sign b. Bowel movement c. Perforated appendix d. Pseudo pain episode

c. rationale: When a client with appendicitis suddenly has relief from pain, this is an indication that the appendix has perforated, or 'burst'. This is an emergency situation, and the client must be taken to surgery immediately.

The nurse is caring for a client in status asthmaticus. Which of the following is a priority nursing action? a. Monitor the client's respiratory status for signs of hypoxia b. Administer aminophylline IV per provider order c. Give inhaled bronchodilator therapy as ordered d. Provide emotional support

c. rationale: While all the options are appropriate actions for a client in status asthmaticus, inhaled bronchodilators work the fastest and should always be given first in this client scenario.

The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.) a. Warm flushed extremities b. Weight loss c. Decreased urinary output d. Sweating (inappropriate) e. Fatigue

c. , d., e. rationale: The signs and symptoms of heart failure include decreased urinary output, sweating, and fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain, not weight loss.

Which of the following foods should the nurse encourage for a child who is prescribed furosemide? Select all that apply. a. Grapes b. Berries c. Bananas d. Legumes e. Onions

c., d. rationale: Furosemide is a potassium wasting diuretic. Eating foods that are high in potassium, like bananas and legumes, will help prevent hypokalemia.

The nurse caring for a 6-year-old with bronchitis knows which of the following symptoms are commonly associated with this diagnosis? a. Cough that sounds like a seal barking b. Cough spasms followed by a "whooping" sound c. A cough that worsens with exercise d. Dry, hacking cough that worsens at night

d. rationale: The cough associated with bronchitis tends to be dry and gets worse at night.

When assessing the respiratory rate of a 6-month-old who has been admitted with bronchitis, the nurse knows to count breath sounds for how long to ensure accuracy? a. 30 seconds b. 90 seconds c. 60 seconds d. 45 seconds

c. rationale: Infants are irregular breathers so respirations should be counted for a full minute to insure accuracy.

Which type of croup is always considered a medical emergency? a. Laryngitis b. Epiglottitis c. Spasmodic croup d. Laryngotracheobronchitis (LTB)

b. rationale: Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment. Laryngitis is a common viral illness in older children and adolescents, with hoarseness and URI symptoms. Spasmodic croup is treated with humidity. LTB may progress to a medical emergency in some children.

The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement? a. Administering penicillin b. Avoiding salicylates (aspirin) c. Imposing strict bed rest for 4 to 6 weeks d. Administering corticosteroids if chorea develops

a. rationale: The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment.

A nurse is receiving report on a newborn admitted yesterday after a gastroschisis repair. In the report, the nurse is told the newborn has a physician's prescription for an NG tube to low intermittent suction. The reporting nurse confirms that the NG tube is to low intermittent suction and draining light green stomach contents. Upon initial assessment, the nurse notes that the newborn has pulled the NG tube out. Which is the priority action the nurse should take? a. Replace the NG tube and continue the low intermittent suction. b. Leave the NG tube out and notify the physician at the end of the shift. c. Leave the NG tube out and monitor for bowel sounds. d. Replace the NG tube, but leave to gravity drainage instead of low wall suction.

a. rationale: A newborn with a gastroschisis performed the day before will require bowel decompression with an NG tube to low wall intermittent suction. The nurse's priority action is to replace the NG tube and continue with the low wall intermittent suctioning. The NG tube cannot be left out this soon after surgery. The physician's prescription was to have the NG tube to low wall intermittent suction, so the tube cannot be placed to gravity drainage.

The nurse caring for a child diagnosed with rheumatic fever knows that which of the following positive cultures are part of the child's medical history? a. Throat for group A strep b. Urine for escherichia coli c. Blood for staphylococcus aureus d. Throat for staphylococcus aureus

a. rationale: Acute rheumatic fever is caused by an abnormal immune response to a group A strep infection that is usually in the throat.

Upon performing an initial exam after the birth of an infant, the provider hears a murmur when auscultating the baby's heart. The provider suspects that the baby has an atrial septal defect. Which of the following tests would be performed to diagnose this condition? a. Echocardiogram b. Isotope test c. Chemical stress test d. Nuclear imaging

a. rationale: An atrial septal defect (ASD) occurs as a hole in the septum between the atria of the heart. An ASD can cause blood to flow between the two chambers and can decrease oxygenation in the baby's blood. The condition is most commonly diagnosed by an echocardiogram, which is performed as an ultrasound of the heart to check pumping strength, heart valves and visualize the two chambers.

The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for? a. Cardiac arrhythmia b. Hypostatic pneumonia c. Heart failure d. Rapidly increasing blood pressure

a. rationale: Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization

A nurse is caring for a 5-year-old child who has been diagnosed with bronchiectasis. Based on the nurse's understanding of this condition, the nurse knows to expect signs and symptoms of which of the following? a. Chronic cough that produces green sputum b. Sharp chest pain with each breath c. Wheezing and a barrel chest d. Absence of respiratory effort

a. rationale: Bronchiectasis is a lung condition that causes permanent dilation of the bronchi, resulting in breathing difficulties and pooling of sputum in the bronchial tree that can progressively worsen. The nurse should assess for signs and symptoms of a productive cough with thick or green sputum. Occasionally, the client may also cough up blood. As the disease progresses, sputum production tends to increase.

A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of which diagnosis? a. Bronchitis b. Bronchiolitis c. Viral-induced asthma d. Acute spasmodic laryngitis

a. rationale: Bronchitis is characterized by these symptoms and occurs in children older than 6 years. Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children between 3 months and 3 years of age.

The mother of a 10-year-old diagnosed with bronchitis asks the nurse about treatment options. Which of the following is the best response? a. "Treatment is focused on managing your child's symptoms" b. "Your child will need to start oral antibiotics" c. "Your child will need one dose of steroids" d. "Treatment is focused on managing your child's allergies"

a. rationale: Bronchitis is usually a self-limiting disease that is caused by a virus. Treatment focuses on managing symptoms like fever and discomfort.

Which describes a child who is abused by the parent(s)? a. Unintentionally contributes to the abusing situation b. Belongs to a low socioeconomic population c. Is healthier than the nonabused siblings d. Abuses siblings in the same way as child is abused by the parent(s)

a. rationale: Child's temperament, position in the family, additional physical needs, activity level, or degree of sensitivity to parental needs unintentionally contribute to the abusing situation. Abuse occurs among all socioeconomic levels. Children who are ill or have additional physical needs are more likely to be abused. The abused child may not abuse siblings.

Michael, age 18 months, has just been admitted with croup. His parent is tearful and tells the nurse, "This is all my fault. I should have taken him to the doctor sooner so he wouldn't have to be here." Which is appropriate in the care plan for this parent who is experiencing guilt? a. Clarify misconception about the illness. b. Explain to the parent that the illness is not serious. c. Encourage the parent to maintain a sense of control. d. Assess further why the parent has excessive guilt feelings.

a. rationale: Guilt is a common response of parents when a child is hospitalized. They may blame themselves for the child's illness or for not recognizing it soon enough. The nurse should clarify the nature of the problem and reassure parents that the child is being cared for. Croup is a potentially serious illness. The nurse should not minimize the parent's feelings. It would be difficult for the parent to maintain a sense of control while the child is seriously ill. No further assessment is indicated at this time; guilt is a common response for parents.

The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate? a. Notify practitioner b. Measure abdominal girth c. Auscultate for bowel sounds d. Take vital signs, including blood pressure

a. rationale: Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner.

The nurse is caring for a three-year-old with intussusception who is waiting for surgery. The nurse knows to notify the provider of which of the following clinical findings? a. Passage of brown stool b. Bright red blood in the stool c. Signs of abdominal pain d. Palpable, sausage-shaped mass in the upper right quadrant

a. rationale: Passage of brown stool would indicate that the intussusception resolved on its own and the child may not need surgery.

A child with respiratory acidosis has developed supraventricular tachycardia. The healthcare staff has tried to correct the condition with vagal maneuvers without success. Which medication would the staff most likely give to correct the situation? a. Adenosine b. Enoxaparin c. Clopidogrel d. Lisinopril

a. rationale: Supraventricular tachycardia (SVT) is a type of cardiac arrhythmia in which the heart beats very rapidly due to a malfunctioning node above the ventricles. The condition can sometimes be corrected by having the client perform a vagal maneuver. With infants, placement of an ice pack on the baby's face may also correct the situation. When these options are unsuccessful, administration of adenosine may convert the heart to a normal rhythm.

The nurse caring for a 4-month-old with bronchiolitis knows that which of the following complications commonly occurs with this respiratory illness? a. Peritonsillar abscess b. Retinopathy c. Dehydration d. Malnutrition

c. rationale: Bronchiolitis is associated with copious nasal secretions and tachypnea which can make it difficult for infants to feed.

The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot? a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

a. rationale: Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.

A baby is born at full term and is taken to the NICU for further observation for potential cardiac issues. After diagnostic testing, the provider determines that the infant has tetralogy of Fallot. The four components of this condition include a ventricular septal defect (VSD), overriding aorta, right ventricular hypertrophy, and which of the following? a. Pulmonary stenosis b. Atrial septal defect (ASD) c. Patent ductus arteriosus d. Patent foramen ovale (PFO)

a. rationale: Tetralogy of Fallot is a serious cardiac condition that develops before birth. It consists of four conditions that affect the heart; when combined, these abnormalities cause decreased oxygenation and poor blood flow and the condition must be surgically corrected. Tetralogy of Fallot consists of a VSD, overriding aorta, ventricular hypertrophy, and pulmonary stenosis.

A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child's pulse oximetry status? a. Continuous b. Every 30 minutes c. Every hour d. Every 2 hours

a. rationale: The child on supplemental oxygen requires intermittent or continuous oxygenation monitoring, depending on severity of respiratory compromise and initial oxygenation status. The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring.

The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct? a. "You may need to increase the caloric density of your infant's formula." b. "You should feed your baby every 2 hours." c. "You may need to increase the amount of formula your infant eats with each feeding." d. "You should place a nasal oxygen cannula on your infant during and after each feeding."

a. rationale: The metabolic rate of infants with heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a 4-hour schedule is too long. Fluids must be carefully monitored because of the heart failure. Infants do not require supplemental oxygen with feedings.

A nurse is caring for a 7-year-old who has recently been diagnosed with asthma and is providing education on the importance of avoiding triggers that can cause an asthma exacerbation. Which of the following would be a trigger for asthma? Select all that apply. a. Anxiety b. Exercise c. Cold weather d. Allergens e. Infections

a. b., c., d., e. rationale: all are common triggers of asthma attacks or exacerbation

The nurse caring for a client diagnosed with hypoplastic left heart syndrome knows that which of the following are signs of heart failure? Select all that apply. a. Gallop rhythm b. Grunting c. Periorbital edema d. Prolonged capillary refill e. Hypertension

a., b., c., d. rationale: In heart failure, there is often an increased amount of blood in the ventricles which causes a gallop rhythm. Clients with heart failure are unable to pump adequate amounts of blood into the systemic circulation causing poor perfusion and symptoms like delayed capillary refill (>2 seconds).In heart failure it is common for the lungs to become congested causing signs of respiratory distress like grunting, tachypnea, and hypoxia.Heart failure cause systemic venous congestion which causes edema.

A nurse has been assigned to float to the pediatrics unit for a shift. The nurse has been assigned three clients, including an infant with rotavirus, a child recovering from an appendectomy, and a baby with respiratory syncytial virus. Which practices should be implemented that would best protect the nurse from contracting an infectious disease? Select all that apply. a. The nurse keeps one set of vital sign equipment in each client room to avoid cross-contamination b. The nurse considers every client to be infected with transmittable disease whether their diagnosis is known or not c. The nurse practices hand hygiene before and after providing client care d. The nurse does not recap needles after use e. The nurse asks for a different assignment than the infant because the nurse has not been vaccinated against rotavirus

a., b., c., d. rationale: When working with clients who have infectious diseases, the nurse can best protect him or herself and other clients by using items carefully and not sharing items between clients. The nurse should wash hands before and after every client contact, and immediately discard used needles in a sharps container. Recapping needles is dangerous for the nurse, due to the risk for needlestick injury. Standard precautions should always be followed, which includes protecting self against exposure to blood and body fluids from every client, as if each client has an infectious condition.

Which of the following would be appropriate nursing interventions for a child with appendicitis? Select all that apply. a. Administer analgesics as ordered b. Monitor temperature and vital signs c. Administer IV Fluids d. Maintain a regular diet e. Administer antibiotics as ordered

a., b., c., e. rationale: These children will be experiencing a lot of pain and it is important to reduce their discomfort.There is a risk of infection and the antibiotics will treat this.It is important to monitor the child for signs of infection.This will help correct any fluid deficit that may have occurred.

The nurse administering digoxin to a 9-month-old knows to assess which of the following prior to administration? a. Respiratory rate b. Blood pressure c. Pulse rate d. Temperature

c. rationale: Digoxin should not be given if the pulse is below 90-110 in infants and young children or <70 in older children. The drug order should specify specific parameters for when the drug should be withheld.

Which of the following are classified as reasons for performing a bronchoscopy? Select all that apply. a. Removing a foreign object that has accidentally been inhaled b. Visualizing a tumor in the lung c. Removing a hematoma that has developed in the pleural space d. Aspirating sputum from the main bronchus for testing e. Monitoring oxygen saturation levels of the client

a., b., d. rationale: Bronchoscopy is a test that involves inserting a tube into the client's throat and advancing it into the lungs, where the provider can visualize the lung fields. Bronchoscopy may be performed for conditions such as visualizing a tumor that has developed in the lung, taking a sample of tissue from an abscess or from mucus in the respiratory tract, or finding and removing a foreign object that has entered the lung fields.

A newborn is in the OR for surgery to correct a VSD. There is confusion about the extent of the defect on the echocardiogram, so the nurse calls a time out. Surgery can continue when which of the following happens? Select all that apply. a. The surgeon verifies the correct procedure b. The surgical team identifies the client through two sources of identification c. Another echocardiogram is ordered d. The surgeon verifies the correct surgical site e. The nurse re-establishes a sterile field

a., b., d. rationale: Time-outs in the OR are to clear up any confusion before the procedure begins, but the three main reasons for a time-out are to verify correct client, correct surgical site, and the correct procedure.

The nurse providing care to an infant diagnosed with aortic stenosis knows to expect which of the following symptoms? Select all that apply. a. Faint pulses b. Hypotension c. Exercise intolerance d. Poor feeding e. Hypertension

a., b., d. rationale: The stricture in the aorta causes decreased cardiac output which causes faint pulses and hypotension.The stricture in the aorta causes decreased cardiac output which causes faint pulses and hypotension.The client is an infant. Exercise intolerance would be an expected symptom in a child with aortic stenosis but not an infant.The stricture in the aorta causes decreased cardiac output. The decrease in cardiac output results in decreased energy making it difficult for infants to feed.

A three-year-old child has been brought in to the hospital with a diagnosis of Haemophilus influenza B. After testing, the provider determines that the child has epiglottitis and treatment is started. Which information would the nurse provide to the parents of this child about caring for this condition? Select all that apply. a. The child should not lie flat b. Encourage the child to eat plenty of cold foods c. Use a cool mist humidifier in the room d. Encourage the child not to cry e. Gently use a tongue depressor to keep the mouth open

a., c., d. rationale: Epiglottitis is a life-threatening condition because the client's epiglottis becomes swollen and can obstruct the airway. It occurs most often in children ages two to eight, often from Haemophilus influenzae type B or streptococcus pneumoniae. Treatment is centered on maintaining airway patency and administration of antibiotics. The child should be kept calm, because agitation can lead to further airway compromise. The head of the bed should be raised because when the child lies flat, it affects respiratory status.The child should be kept calm, because agitation can lead to further airway compromise.The nurse should place a cool mist humidifier in the room to help decrease swelling.

The nurse is teaching parents of a child with croup on home treatments. Which of the following does the nurse recommend? Select all that apply. a. Sleep with cool humidified air b. A cool bath for fever reduction c. Placement in a whirlpool bath d. Expose the child to cool, night air e. Place the child near a steamy shower

a., d., e. rationale: A steamy shower helps reduce swelling in the airway of a child with croup. Additional home behaviors include keeping the child calm, giving acetaminophen or ibuprofen for pain, and keeping the child hydrated.Humidified air will reduce irritation to the airways.Cool night air is beneficial for a child with croup.

The nurse caring for a child diagnosed with coarctation of the aorta is demonstrating signs of respiratory distress. The nurse suspects this is a sign of which of the following? a. Digoxin toxicity b. Pulmonary congestion c. Aspiration pneumonia d. Systemic congestion

b. rationale: A child with coarctation of the aorta is likely to experience respiratory distress because the decreased cardiac output causes pulmonary congestion.

A client who is newly diagnosed with asthma is learning about how to use a metered dose inhaler. Which information from the nurse is correct to use the inhaler correctly and to avoid medication errors? a. Prime the inhaler 10 times before using it to ensure the medication reaches the client b. Breathe out before administering the medication and then breathe in to inhale the drug c. The metered-dose inhaler can only be used with a spacer in place d. Hold the medication in the mouth for 10 seconds after taking it in through the inhaler

b. rationale: A metered-dose inhaler may be used to deliver medication to a client who needs an inhaled dose of a drug. A metered-dose inhaler delivers a set amount of the medication and is designed to hold a specific number of doses per canister. It diminishes the potential for error because the amount is well controlled. The nurse can teach the client to breathe out before using the inhaler, then take a big breath in to pull the medication into the lungs.

A two-year-old is brought in by his parents with severe abdominal pain and bright red blood in his diaper. The nurse caring for this child knows that these care clinical manifestations of which of the following diagnosis? a. Umbilical hernia b. Intussusception c. Peptic ulcer disease d. Celiac disease

b. rationale: Bright red blood in the stool is a common clinical manifestation of Intussusception.

A student nurse caring for a 6-year-old diagnosed with bronchitis asks what this means. Which of the following is the best explanation of the diagnosis related to where inflammation and infection occur? a. The trachea b. The lower airways c. The upper airways d. The bronchioles

b. rationale: Bronchitis is when there is inflammation in the large airways, the trachea and bronchi, which are part of the lower airways.

The nurse caring for a 15-year-old with chronic bronchitis asks the client about which of the following? a. Exercise tolerance b. Tobacco and marijuana use c. Seasonal allergies d. Their immunization record

b. rationale: Chronic bronchitis in teenagers is often associated with tobacco and marijuana use.

The nurse caring for a 4-year-old who has been admitted with the diagnosis of epiglottitis asks the mother about which of the following childhood immunizations? a. Pneumococcal b. Measles, Mumps & Rubella c. Haemophilus Influenzae type B d. Diphtheria, Tetanus and Pertussis

c. rationale: Epiglottitis is often caused by Haemophilus Influenza type B.

An 8-year-old who has just been diagnosed with asthma wants to know why it is important to take the medication fluticasone on a daily basis. Which of the following statements by the nurse should be included? a. "Fluticasone is a pill that you need to take daily to help alleviate allergies" b. "Fluticasone is an inhaled steroid that helps prevent inflammation in your lungs" c. "Fluticasone is an inhaled B-Adrenergic agonist that is a rescue medication for when you can't breath" d. "Fluticasone is a steroid that provides quick relief for when you are having bronchospasms"

b. rationale: Fluticasone is a steroid given via inhalation. They are used to help prevent inflammation in the lungs with helps prevent asthma exacerbations.

Cardiopulmonary resuscitation (CPR) is begun on a toddler. Which pulse is usually palpated because it is the most central and accessible? a. Radial b. Carotid c. Femoral d. Brachial

b. rationale: In a toddler, the carotid pulse is palpated. The radial pulse is not considered a central pulse. The femoral pulse is not the most central and accessible. Brachial pulse is felt in infants younger than 1 year.

The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk? a. Minimize seizures b. Prevent dehydration c. Promote cardiac output d. Reduce energy expenditure

b. rationale: In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.

The nurse caring for a 6-month-old diagnosed with bronchiolitis knows which of the following is most likely the cause? a. Rotavirus b. Respiratory Syncytial Virus c. Varicella zoster virus d. Haemophilus influenzae type B

b. rationale: RSV is the most common cause of bronchiolitis in children.

The nurse knows that which of the following medications is commonly used to help prevent Exercise-induced bronchospasm? a. Omalizumab b. Salmeterol d. Montelukast sodium e. Ipratropium

b. rationale: Salmeterol is a long acting bronchodilator is used to help prevent asthma exacerbations caused by exercise.

A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. What should the nurse suspect? a. Unintentional injury b. Shaken-baby syndrome c. Sudden infant death syndrome (SIDS) d. Congenital neurologic problem

b. rationale: Shaken-baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. SIDS and congenital neurologic problems would not appear this way.

A 4-month-old infant has GERD but is thriving without other complications. Which should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

b. rationale: Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula have been recommended. Milk-thickening agents have been shown to decrease the number of episodes of vomiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in a Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive.

A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? a. Atrial septal defect b. Tetralogy of Fallot c. Ventricular septal defect d. Patent ductus arteriosus

b. rationale: Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the ventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow.

The nurse caring for a 6-year-old diagnosed with acute rheumatic fever knows the parents understand the treatment plan by making which of the following statements about taking medication? a. "Diuretics daily until he is 21-years-old" b. "Prophylactic antibiotics until he is 21-years-old" c. "Ibuprofen daily to until he is 21-years-old" d. "Daily steroids until he is 21-years-old"

b. rationale: The child will be an increased risk for recurrent infections and repeat RHD that can cause more damage to the valves. Therefore antibiotics must be given prophylactically to prevent infection.

The nurse is caring for a client with right lower quadrant abdominal pain, nausea and a fever of 101.5 degrees Fahrenheit. Which of the following interventions is appropriate for the nurse to perform prior to the diagnosis? a. Give the client an enema b. Apply an ice bag to alleviate the pain c. Put a heating pad on the affected area of pain d. Give narcotic pain relief

b. rationale: The client likely has appendicitis but before the diagnosis is made, the nurse would place an ice bag on the affected area to alleviate the pain. The client does not need an enema and a heating pad is contraindicated. No analgesics should be given until the diagnosis has been made.

According to Erikson, which psychosocial task is developing in adolescence? a. Intimacy b. Identity c. Initiative d. Independence

b. rationale: Traditional psychosocial theory holds that the developmental crises of adolescence lead to the formation of a sense of identity. Intimacy is the developmental stage for early adulthood. Independence is not one of Erikson's developmental stages.

The nurse caring for a child diagnosed with acute rheumatic fever (ARF) knows that which of the following is considered to be the most significant complication of ARF? a. Systemic vasculitis b. Cardiac valve damage c. Infective endocarditis d. Hyperlipidemia

b. rationale: Valve damage in the heart is the most significant complication of ARF and is the leading cause of Heart Failure in children.

A nurse is admitting an infant with asthma. What usually triggers asthma in INFANTS? a. Medications b. A viral infection c. Exposure to cold air d. Allergy to dust or dust mites

b. rationale: Viral illnesses cause inflammation that causes increased airway reactivity in asthma. Medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with asthma have no evidence of allergic disease

An 8-year-old child is undergoing surgery for an appendectomy. Which of the following best explains informed assent when caring for this child? a. The parents sign the informed consent on behalf of the child b. The child participates in the decision making about the procedure c. The parents tell the child that he will need to have the surgery d. The nurse helps the child to sign the consent form for the surgery

b. rationale: When an adult client is planning for surgery, he must sign an informed consent stating that the client understands the risks and benefits. When a minor child must have surgery, the parents usually sign the consent for the child, but if the child is old enough to understand some of the situation, the child should take part in discussing the risks and benefits of the procedure. When a minor child agrees to a procedure, they are giving "assent", which is similar to "consent" for an adult.

A nurse is expecting an 18-month-old with bronchiolitis from the emergency department, Which of the following protective gear should be worn when entering the child's room? Select all that apply. a. Shoe covers b. Mask c. Gown d. Gloves e. Respirator Mask

b., c., d. rationale: A bronchiolitis is most commonly caused by a respiratory syncytial virus which is spread through droplets that can live on surfaces, therefore droplet and contact precautions are required.

The nursing providing care to an infant with tricuspid atresia knows that which of the following nursing interventions would be appropriate to decrease cardiac demands? Select all that apply. a. Wait until the child is very hungry and crying for a feed b. Coordinate care to minimize disturbing the infant c. Provide smaller feedings every 3 hours d. Monitor the client's temperature closely e. Keep the client in the prone position

b., c., d. rationale: Reducing stress allows the child to rest which promotes the conservation of energy.Three hours spacing between feeds is optimum because it allows for adequate rest and prevents the child from becoming so hungry that they need a larger feed which they may not have the energy to consume.Hypothermia and hyperthermia will increase the child's need for oxygen causes an increased use of energy to regulate the temperature.

As the nurse caring for a 9-month-old with bronchiolitis, which of the following do you expect to be a part of their care while in hospital? Select all that apply. a. Chest percussion and postural drainage b. Oxygen administration c. Antibiotics d. Regular nasal suctioning e. Continuous pulse oximetry monitoring

b., d. , e. rationale: Hypoxia is a common symptom of bronchiolitis and children with this diagnosis will often need supplemental oxygen. Infants with bronchiolitis are likely to have copious amounts of nasal secretions. Regular nasal suctioning helps keep their airway open. Suctioning prior to feeding is particularly beneficial as it helps them to feed.The infected lower airways cause altered gas exchange and hypoxia. Therefore, these children need to have their oxygenation levels monitored closely.

An infant in the pediatrics unit has been diagnosed with respiratory syncytial virus (RSV). The nurse should include which of the following precautions in caring for this infant? Select all that apply. a. Ensure the client's room has negative-pressure ventilation b. Wear a surgical mask for close contact with the client c. Wear goggles if there is potential for splashing of body fluids d. Keep the client in a private room e. Have staff wear an N95 respirator when providing care for the client

b., d., c. rationale: Respiratory syncytial virus is an infectious condition that affects infants and young children. Standard plus contact precautions should be used, which includes wearing personal protective equipment whenever there is potential for contact with blood or body fluids. This includes keeping the client in a private room and wearing a gown, gloves, and goggles when providing care, and a surgical mask for close contact if the client is coughing or sneezing.

The nurse providing care for a 3-year-old diagnosed with epiglottitis expects orders for which of the following medications? Select all that apply. a. IV diuretics b. IV antibiotics c. Nebulized bronchodilators d. Nebulized epinephrine e. IV corticosteroids

b., e. rationale: Corticosteroids may be used to decrease inflammation in the airway. Antibiotics will treat the bacterial cause of epiglottitis. Research shows that bronchodilators and nebulized epinephrine are not effective in treating epiglottitis. Remember, it's an inflammation of the epiglottis, NOT the bronchus.

A 3-month-old is awaiting surgery to repair a truncus arteriosus. The nurse educating the parents on managing symptoms at home includes which of the following in the teaching? Select all that apply. a. "Administer prophylactic antibiotics daily" b. "Limit feeding to 30 minutes to avoid over-tiring" c. "Provide chest physiotherapy twice a day" d. "Restrict feedings to only 3 times a day to avoid fluid overload" e. "Weight your child daily on the same scale"

b., e. rationale: Feeding for longer than 30 minutes can exhaust the child as they are likely to have activity intolerance. However, feeding less frequently is likely to upset the child which would cause an increase in cardiac demands. Additionally, fluid restriction is rarely necessary in infants with heart failure because of their difficulties with feeding. Weighing the child daily is an important intervention to monitor for weight gain which may be a sign of fluid accumulation.Prophylactic antibiotics are not indicated prior to surgical repair of the heart defect.

Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

c. rationale: Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.

A nurse is conducting an in-service on childhood gastrointestinal disorders. Which statement is most descriptive of Meckel diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem.

c. rationale: Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel diverticulum is the most common congenital malformation of the GI tract and is present in 1% to 4% of the general population. The standard therapy is surgical removal of the diverticulum.

According to Piaget, the 6-month-old infant should be in which developmental stage? a. Use of reflexes b. Primary circular reactions c. Secondary circular reactions d. Coordination of secondary schemata

c. rationale: Infants are usually in the secondary circular reaction stage from ages 4 to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results. Shaking is performed to hear the noise of the rattle, not just for shaking. The use of reflexes is primarily during the first month of life. Primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from ages 1 to 4 months. The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.

The nurse caring for a newborn diagnosed with transposition of the great vessels knows that which of the following interventions is a priority? a. Daily weights at the same time b. Administer IV furosemide c. Administer IV prostaglandin E1 d. Record intake and output

c. rationale: It is essential that the ductus arteriosus be kept open to allow blood to mix. If the ductus arteriosus closes there will be no communication between oxygenated blood and deoxygenated blood resulting in extreme hypoxia.

The nurse caring for a newborn diagnosed with transposition of the great arteries is speaking to the mother about the pregnancy. The nurse is aware that which of the following maternal infections increases the risk for the development of congenital heart defects? a. Influenza b. Varicella c. Rubella d. Mumps

c. rationale: Maternal exposure to rubella during pregnancy increases the risk of developing congenital heart defects.

The nurse is caring for a client with a history of Mediterranean fever. What is the concern for this client? a. Hemorrhage b. PE c. Endocarditis d. DVT

c. rationale: Mediterranean fever is a genetic inflammatory disorder which can cause episodes of rheumatic fever. This lead to endocarditis, or infection of the lining of the heart, which must be treated with antibiotics right away. Endocarditis can cause valve disorders and life-threatening arrhythmias.

Which action by the school nurse is important in the prevention of rheumatic fever? a. Encourage routine cholesterol screenings. b. Conduct routine blood pressure screenings. c. Refer children with sore throats for throat cultures. d. Recommend salicylates instead of acetaminophen for minor discomforts.

c. rationale: Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A b-hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A beta-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.

What clinical manifestation is included in toxic shock syndrome? a. Severe hypertension b. Subnormal temperature c. Erythematous macular rash d. Papular rash over extremities

c. rationale: One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma. Hypotension is one of the manifestations. Fever of 38.9° C or higher is a characteristic. Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks.

The nurse administering digoxin to a 1-year-old knows which of the following is a sign of toxicity? a. Diarrhea b. Widespread rash c. Nausea and vomiting d. Tachycardia

c. rationale: Signs of digoxin toxicity in children are nausea, vomiting, anorexia, bradycardia, and dysrhythmias.

A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is: a. not necessary because of child's age. b. not necessary because colostomy is temporary. c. necessary because it will be an adjustment. d. necessary because the child must deal with a negative body image.

c. rationale: The child's age dictates the type and extent of psychological preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms, with the use of visual aids. It is necessary to prepare a 3-year-old child for procedures. The preschooler is not yet concerned with body image

Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures? a. Pulmonary congestion b. Congenital heart defect c. Heart failure d. Systemic venous congestion

c. rationale: The definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body's metabolic demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.

A 2-week-old infant was admitted with difficulty feeding and weight loss. During the assessment, the nurse assesses absent femoral pulses and knows this is a sign of which of the following congenital heart defects? a. Ventricular septal defect b. Tetralogy of fallot c. Coarctation of the aorta d. Tricuspid atresia

c. rationale: The narrowing in the aorta occurs in the descending aorta after the subclavian artery. This results in increased pressure in the upper extremities and decreased pressure in the lower extremities which causes weak or absent femoral pulses.

The nurse caring for an infant diagnosed with coarctation of the aorta knows to expect which of the following on assessment. a. Bounding pulses in the lower extremities and weak or absent pulses in the upper extremities b. Bounding central pulses and weak or absent peripheral pulses c. Bounding pulses in the upper extremities and weak or absent pulses in the lower extremities d. Bounding peripheral pulses and weak or absent central pulses

c. rationale: The narrowing in the aorta occurs in the descending aorta after the subclavian artery. This results in increased pressure in the upper extremities and decreased pressure in the lower extremities.

The nurse is caring for a six-year-old who is very tired and experiencing frequent episodes of vomiting. The nurse knows that which of the following positions will reduce the risk of aspirating? a. Reverse Trendelenburg b. Sims position c. Side-lying d. Supine

c. rationale: The side lying position helps prevent the child from aspirating on their vomit while they are resting.

The parents of an 18-month-old who has just been diagnosed with intussusception and signs of peritonitis are concerned and want to know how this can be treated. The nurse accurately tells them which of the following? Select all that apply. a. Your child will go to surgery for a pyloromyotomy b. Your child will need to have a colostomy placed c. Your child will need to have their bowel surgically repaired d. Your child will need IV Fluids and IV antibiotics e. The provider will try to reduce the telescoping bowel with an air enema

c., d. rationale: This child has signs of peritonitis which means they will have to have surgery because their bowel has perforated.Since this child has signs of peritonitis, their bowel has perforated and bacteria has spread throughout the abdominal cavity. This requires treatment with IV antibiotics and IV fluids. A pyloromyotomy is the surgical procedure done to treat pyloric stenosis.While intussusception can be repaired with an air enema, this child has signs of peritonitis which means they will have to have surgery due to a perforated bowel.Colostomy would rarely be indicated for the repair of intussusception.

The nurse knows to expect which of the following diagnostic tests for a client with suspected Acute Rheumatic Fever? a. Monospot test b. Antinuclear antibody titer c. Indirect coombs test d. Antistreptolysin O titre

d. rationale: Antistreptolysin O titer tests are for streptococcal antibodies which would confirm that the client had a recent Group A strep infection.

The child of 15 to 30 months is likely to be struggling with which developmental task? a. Trust b. Initiative c. Autonomy d. Intimacy

d. rationale: Autonomy vs shame and doubt is the developmental task of toddlers. Trust vs mistrust is the developmental stage of infancy. Initiative vs guilt is the developmental stage of early childhood. Intimacy and solidarity vs isolation is the developmental stage of early adulthood.

The nurse is caring for a client who has been taking erythromycin. For which of the following side effects should the nurse monitor? a. Constipation b. Increased urinary output c. Rash d. Nausea and vomiting

d. rationale: Erythromycin is a macrolide antibiotic that carries the common side effects of nausea and vomiting, abdominal pain, and cramps.

The nurse caring for a 2-year-old who presented to an urgent care center with stridor and excessive drooling knows that which of the following interventions should be given top priority? a. Place the child on 2L via NC and prepare for intubation b. Assess the throat for signs of a cherry red epiglottis c. Place an IV in preparation for giving IV antibiotics d. Keep the child calm until emergency airway equipment is available

d. rationale: If the child becomes upset or cries it could cause the airway to spasm more resulting in complete airway obstruction. Children with possible epiglottis should only be examined in a setting that has emergency airway equipment readily available.

Which describes the cognitive abilities of school-age children? a. Have developed the ability to reason abstractly b. Are capable of scientific reasoning and formal logic c. Progress from making judgments based on what they reason to making judgments based on what they see d. Are able to classify, to group and sort, and to hold a concept in their minds while making decisions based on that concept

d. rationale: In Piaget's stage of concrete operations, children have the ability to group and sort and make conceptual decisions. Children cannot reason abstractly and logically until late adolescence. Making judgments based on what they reason to making judgments based on what they see is not a developmental skill.

The nurse caring for an infant who is prescribed digitalis knows to monitor which of the following electrolytes when administering this medication? a. Calcium b. Sodium c. Magnesium d. Potassium

d. rationale: Increased potassium levels will decrease the effectiveness of digoxin.

What is invagination of one segment of bowel within another called? a. Atresia b. Stenosis c. Herniation d. Intussusception

d. rationale: Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Invagination of one segment of bowel within another is the definition of intussusception, not atresia, stenosis, or herniation.

A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is which result? a. Hepatic dysfunction b. Dehydration secondary to vomiting c. Esophageal stricture and shock d. Bronchitis and chemical pneumonia

d. rationale: Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic issue of hydrocarbon ingestion.

A nursing caring for an eight-year-old with appendicitis knows that the most intense area of pain may be at McBurney's point, which is located where on the abdomen? a. Right upper quadrant b. Left upper quadrant c. Left lower quadrant d. Right lower quadrant

d. rationale: McBurney's Point is located in the right lower quadrant of the abdomen.

Physiologic measurements in children's pain assessment are: a. the best indicator of pain in children of all ages. b. essential to determine whether a child is telling the truth about pain. c. of most value when children also report having pain. d. of limited value as sole indicator of pain.

d. rationale: Physiologic manifestations of pain may vary considerably, not providing a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain-rating scale, behavioral assessment, and parental report. When the child states that pain exists, it does. That is the truth.

Which explanation regarding cardiac catheterization is appropriate for a preschool child? a. Postural drainage will be performed every 4 to 6 hours after the test. b. It is necessary to be completely "asleep" during the test. c. The test is short, usually taking less than 1 hour. d. When the procedure is done, you will have to keep your leg straight for at least 4 hours.

d. rationale: The child's leg will have to be maintained in a straight position for approximately 4 hours. Younger children can be held in the parent's lap with the leg maintained in the correct position. Postural drainage will not be performed unless the child has corresponding pulmonary problems. The child should be sedated to lie still, but being completely asleep is not necessary. The test will vary in length of time from start to finish.

A nurse is triaging a 5-year-old that has difficulty breathing and is rapidly getting worse. On assessment, loud croaking sounds on inspiration are noted. The nurse also assesses drooling and a preference to sit in a tripod position. Which of the following diagnoses do you suspect? a. Acute Nasopharyngitis b. Acute laryngotracheobronchitis c. Bronchiolitis d. Epiglottitis

d. rationale: These are the signs and symptoms associated with the diagnosis epiglottis where the epiglottis becomes inflamed and can cause airway obstruction. It is usually caused by the bacteria Haemophilus influenza type B.

The nurse providing care to a 10-year-old that presented to the ER with an asthma exacerbation knows to be most concerned by which of the following assessment findings? a. A hacking, non-productive cough b. Prolonged expiration c. Hyperresonance on percussion d. A silent chest

d. rationale: This indicates that air movement in the chest is so restricted that there are no breath sounds. This is an ominous sign that indicates respiratory failure.

The nurse is assessing a 10-month-old child who was brought to the ER by parents because is having a difficult time breathing. Upon examination, the child is in no distress, airway is intact and skin is pink, warm, dry. The provider orders a breathing treatment and some steroids. When the nurse enters the room to administer the medications, the child is drooling and red in the face. What is the first action the nurse should take? a. Tell the child to stop drooling b. Give the breathing treatment c. Reposition the child by sitting the child up d. Call a rapid response

d. rationale: When a child is drooling and having breathing problems, they are having symptoms of epiglottitis. This is a medical emergency and the nurse should activate the rapid response team, call for emergency airway equipment, and administer oxygen. The nurse should not leave the child.

The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the child's care? (Select all that apply.) a. Place in a mist tent. b. Administer antibiotics. c. Administer cough syrup. d. Encourage the child to drink 8 ounces of formula every 4 hours. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring.

d., e., f. rationale: Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended. Mist tents are no longer used. Antibiotics do not treat illnesses with viral causes. Cough syrup suppresses clearing of respiratory secretions and is not indicated for young children.