PN 131 Quiz 4 NCLEX

Symptoms of an earache in an infant include: 1. external drainage, pain, decrease in temperature 2. tugging at the ear and rolling head from side to side 3. crying and pointing to the affected ear 4. redness of the cheeks and cyanosis of the ear

2 Earaches in infants may be manifested by general irritability, frequent rubbing or pulling at the ear, and rolling of the head from side to side.

Which toy is appropriate for a 3-year-old child? 1. A bicycle 2. A puzzle with large pieces 3. A pull toy 4. A computer game

2. A puzzle with large pieces RATIONALE: A puzzle is the most appropriate toy because, at age 3, children like to color, draw, and put together puzzles. A bicycle is appropriate for a 5- or 6-year-old child; a pull toy, for a toddler; and a computer game, for a school-age child.

A mother brings her preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment will the physician probably order? 1. Administration of a dose of ipecac syrup 2. Insertion of a nasogastric tube and administration of an antacid 3. I.V. infusion of normal saline solution 4. Gastric lavage and administration of activated charcoal

4. Gastric lavage and administration of activated charcoal RATIONALE: The physician will probably order gastric lavage or activated charcoal administration. Ipecac syrup is no longer recommended and an antacid isn't an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting, but in itself isn't effective in eliminating the poisonous substance.

A child diagnosed with cerebral palsy has recurring absence seizures. Which of the following are characteristic of this type of seizure? Choose all answers that apply: A) Lip smacking B) Bicycling movements C) Blank stare D) Generalized contractions

A, C

The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction? A) Tell children they should not taste anything but food. B) Store all toxic agents and medicines in locked cabinets. C) Provide special play areas in the house and restrict play in other areas. D) Punish children if they open cabinets that contain household chemicals.

B) The only reliable way to prevent poisonings in young children is to make them inaccessible, B. Teaching children not to taste is important, A, but ineffective for young children. C and D, will not control a child's curiosity.

The healthcare provider is assessing a child who has a diagnosis of autistic spectrum disorder (ASD). Which of these clinical findings supports this diagnosis? A) Annoys others deliberately B) Uninterested in playing with others C) Cries for attention at inappropriate times D) Utilizes manipulative behavior

B) Uninterested in playing with others

A child is diagnosed with autistic spectrum disorder (ASD). Which of the following, if present in the patient's health history, will the healthcare provider identify as a factor associated with this disorder? Choose all answers that apply: A) Southeast Asian or Middle Eastern descent B) Sibling diagnosed with Asperger syndrome C) Concurrent diagnosis of fetal alcohol syndrome D) Advanced age of the mother or father E) Exposure to vaccines containing thimerosal

B, C, D

Distinct phases of a grand-mal epileptic seizure include (SATA): 1. aura 2. agitation 3. tonic/clonic movements 4. postictal lethargy

Correct answers: 1, 3, 4 Rationale: The most common generalized seizure is the tonic-clonic or grand mal. A grand mal epilepsy has three distinct phases: an aura (subjective sensation), a tonic-clonic seizure, and postictal lethargy or a short period of sleep. A person experiencing this type of seizure will present with a sudden cry (or aura), fall, and rigidity, followed by muscle jerking; shallow, irregular breathing; and possible loss of bladder or bowel control. It usually lasts seconds to minutes, followed by some confusion, a period of sleep, and then a return to full consciousness.

A nurse should begin screening for lead poisoning when a child reaches which age? 1. 6 months 2. 12 months 3. 18 months 4. 24 months

2. 12 months RATIONALE: The nurse should start screening a child for lead poisoning at age 12 months and perform repeat screenings at 24 months. High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron deficiency anemia at age 6 months. Regular dental visits should begin at age 24 months.

A toddler is having a tonic-clonic seizure. What should the nurse do first? 1. Restrain the child. 2. Place a tongue blade in the child's mouth. 3. Remove objects from the child's surroundings. 4. Check the child's breathing.

3. Remove objects from the child's surroundings. RATIONALE: During a seizure, the nurse's first priority is to protect the child from injury caused by uncontrolled movements. Therefore, the nurse must first remove objects from the child's surroundings and pad objects that can't be removed. Restraining the child or placing an object in the child's mouth during a seizure isn't appropriate because it may cause injury. When the seizure stops, the nurse should then check for breathing and, if indicated, initiate rescue breathing.

When planning care for a 7-year-old boy with Down syndrome, the nurse should: 1. plan interventions at the developmental level of a 7-year-old because that is the child's age. 2. plan interventions at the developmental level of a 5-year-old because the child will have developmental delays. 3. assess the child's current developmental level and plan care accordingly. 4. direct all teaching to the parents because the child can't understand.

3. assess the child's current developmental level and plan care accordingly. RATIONALE: Nursing care should be planned at the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. Directing all teaching to parents isn't appropriate because a child with Down syndrome is capable of learning, especially one with mild limitations.

Signs of ICP in a 3 year old child include: 1. headache, lethargy 2. high pitched cry, bulging fontanels 3. apnea, crossed eyes 4. painful head movement, anorexia

1 Subtle signs of increased ICP in a 3-year-old child include a change in alertness or muscle twitching. Headache is also an indicator of ICP.

A nurse is teaching parents about accident prevention for a toddler. Which guidelines is most appropriate? Select all that apply 1. Always make the toddler wear a seat belt when riding in a car. 2. Make sure all medications are kept in containers with childproof safety caps. 3. Never leave a toddler unattended on a bed. 4. Teach rules of the road for bicycle safety.

1, 2 RATIONALE: Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline because poisoning accidents are common in toddlers owing to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not a seat belt. A seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers shouldn't be allowed in the road unsupervised.

A nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which observation indicates that teaching has been effective? 1. The toddler stays neat while eating. 2. The toddler finishes the meal within a specified period of time. 3. The child lies down to rest after eating. 4. The child eats finger foods by himself.

4. The child eats finger foods by himself. RATIONALE: The child eating finger foods by himself indicates effective teaching because a child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to feed himself. Because spasticity affects coordinated chewing and swallowing as well as the ability to bring food to the mouth, it's difficult for the child with cerebral palsy to eat neatly. In terms of a specified period of time, the child with cerebral palsy may require more time to bring food to the mouth; thus, chewing and swallowing shouldn't be rushed. A child shouldn't lie down to rest after eating because doing so may cause the child to vomit from a hyperactive gag reflex. Therefore, the child should remain in an upright position after eating to prevent aspiration and choking.

A child diagnosed with cerebral palsy has damage to the cerebellum. Which type of movement problems will the healthcare provider anticipate? Choose all answers that apply: A) Clumsiness B) Unsteady gait C) Hyperreflexia D) Twisting movements E) Problems with balance

A, B, E

A nurse who is working in the Poison Control Center receives several telephone calls from parents whose children have ingested possible poisons. The nurse should recommend inducing vomiting for which child? A) 8-month-old who ate 4 to 6 ibuprofen tablets. B) 3-year-old who drank an unknown amount of charcoal lighter fluid. C) 16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir. D) 2-year-old who ate a handful of automatic dishwasher detergent

C) Emesis should be induced for the child who drank the large dose of acetaminophen, Tylenol, elixir, C, because this medication is hepatotoxic. Vomiting is contraindicated for: children under 1 year of age, A, petroleum distillates, B, such as charcoal lighter fluid, and corrosives, D, such as dishwasher detergents.

A 39-year-old woman is undergoing prenatal screening for Down syndrome. Which of the following diagnostic tests gives the most accurate information about the probability of Down syndrome? A) Ultrasound B) Amniotic fluid index C) Amniocentesis D) Serum alpha fetoprotein (AFP)

C) amniocentesis

Before performing an otoscopic examination on a child, where should the nurse palpate for tenderness? 1. Tragus, mastoid process, and helix 2. Helix, umbo, and tragus 3. Tragus, cochlea, and lobule 4. Mastoid process, incus, and malleus

1. Tragus, mastoid process, and helix RATIONALE: Before inserting the otoscope, the nurse should palpate the child's external ear, especially the tragus and mastoid process, and should pull the helix backward to determine the presence of pain or tenderness. The umbo, incus, and malleus (parts of the middle ear) and the cochlea (part of the inner ear) aren't palpable.

A practice that has been helpful in preventing intellectual disability is: 1. administering the Stanford- Binet test 2. a blood test at birth 3. careful preschool developmental screening 4. a urine test at age 6 months

2 Nurses can contribute to preventing disorders by promoting genetic counseling, immunizations, newborn screening, and good prenatal care. Nurses can also reiterate the need for early assessment and treatment.

An assessment of a child reveals deficits in communication and social interaction. The child tends to engage in repetitive behaviors such as arranging and rearranging toys. Based on this assessment, the healthcare provider suspects which of these disorders? 1) cerebral palsy 2) autism spectrum disorder 3) down's syndrome 4) concusion

2) autism

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur? 1. 1 to 2 years 2. 1 week to 1 year, peaking at 2 to 4 months 3. 6 months to 1 year, peaking at 10 months 4. 6 to 8 weeks

2. 1 week to 1 year, peaking at 2 to 4 months RATIONALE: SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months.

A nurse is developing a plan to teach a mother how to reduce her infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan? 1. Administer antibiotics whenever the infant has a cold. 2. Place the infant in an upright position when giving a bottle. 3. Avoid getting the infant's ears wet while bathing or swimming. 4. Clean the infant's external ear canal daily.

2. Place the infant in an upright position when giving a bottle. RATIONALE: Feeding an infant a bottle in an upright position reduces the pooling of formula or breast milk in the nasopharynx. Formula, in particular, provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal eustachian tubes. Administering antibiotics whenever the infant has a cold, avoiding getting the ears wet, and cleaning the external ear canal daily don't reduce the risk of an infant developing otitis media.

A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: 1. "Does your child's ear hurt?" 2. "Does your child have any hearing problems?" 3. "Does your child tug at either ear?" 4. "Does anyone in your family have hearing problems?"

3. "Does your child tug at either ear?" RATIONALE: Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful because a young child usually can't describe symptoms accurately.

Which item in the care plan for a toddler with a seizure disorder should a nurse revise? 1. Padded side rails 2. Oxygen mask and bag system at bedside 3. Arm restraints while asleep 4. Cardiorespiratory monitoring

3. Arm restraints while asleep RATIONALE: The nurse should revise a care plan that includes restraints. Restraints should never be used on a child with a seizure disorder because they could harm him if a seizure occurs. Padded side rails will prevent the child from injuring himself during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure.

A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the child, what is the nurse's highest priority? 1. Administering platelets as ordered 2. Taking measures to prevent infection 3. Frequently assessing the child's level of consciousness (LOC) 4. Discussing a safe play environment with the parents

3. Frequently assessing the child's level of consciousness (LOC) RATIONALE: In hemophilia, one of the factors required for blood clotting is absent, significantly increasing the risk of hemorrhage after injury. Therefore, the nurse must assess the child frequently for signs and symptoms of intracranial bleeding, such as an altered LOC, slurred speech, vomiting, and headache. To manage hemophilia, the absent blood clotting factor is replaced via I.V. infusion of factor, cryoprecipitate, or fresh frozen plasma; this may be done prophylactically or after a traumatic injury. Platelet transfusions aren't necessary. Clients with hemophilia aren't at increased risk for infection. Discussing a safe play environment with the parents is important but isn't the highest priority.

An adolescent is diagnosed with lead poisoning. After emphasizing the importance of consuming dietary iron, the nurse asks him to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? 1. Grapefruit and white toast 2. Pancakes and a banana 3. Ham and eggs 4. Bagel and cream cheese

3. Ham and eggs RATIONALE: Good sources of dietary iron include red meat, egg yolks, whole wheat breads, seafood, nuts, legumes, iron-fortified cereals, and green, leafy vegetables. Fresh fruits and milk products contain only small amounts of iron. White bread isn't a good iron source.

A 2-year-old child is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: 1. question the mother about the child's allergies. 2. initiate standard precautions. 3. evaluate the child's neurologic status. 4. examine the child's throat and ears.

3. evaluate the child's neurologic status. RATIONALE: Petechiae across the child's chest, abdomen, and back are signs of meningitis. The priority is to evaluate neurologic status. Petechiae aren't allergic reactions, so the nurse shouldn't ask about allergies. Standard precautions should be used when there is risk of contacting body fluids. Contact precautions should be instituted for the client diagnosed with meningitis. Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis.

A nurse is assessing a severely depressed adolescent. Which finding indicates a risk of suicide? 1. Excessive talking 2. Excessive sleepiness 3. A history of cocaine use 4. A preoccupation with death

4. A preoccupation with death RATIONALE: An adolescent who demonstrates a preoccupation with death (such as by talking frequently about death) should be considered at high risk for suicide. Although depression, excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents, they also occur in adolescents who aren't suicidal. Verbal and emotional withdrawal, not excessive talking, are signs of possible depression and suicide risk in an adolescent.

A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant? 1. Vomiting 2. Papilledema 3. Vital sign changes 4. Irritability

4. Irritability RATIONALE: An infant with increased ICP is commonly fussy, irritable, and restless at first as a result of a headache cause by the ICP. Vomiting occurs later. Papilledema is a late sign of increased ICP that may not be evident. Changes in vital signs occur later; pressure on the brainstem slows pulse and respiration.

What should a nurse do to ensure a safe hospital environment for a toddler? 1. Place the child in a youth bed. 2. Move stacking toys out of reach. 3. Pad the crib rails. 4. Move the equipment out of reach.

4. Move the equipment out of reach. RATIONALE: Moving the equipment out of reach ensures a safe environment because toddlers are curious and may try to play with items within their reach. Toddlers in a strange hospital environment still need the security of a crib. Stacking toys don't need to be moved out of reach because they don't present a safety hazard and are appropriate for this age-group. Padded crib rails are necessary only if seizure activity is present.

A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include: 1. a depressed fontanel. 2. slurred speech. 3. tachycardia. 4. an altered level of consciousness.

4. an altered level of consciousness. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge — not depress — if he had increased ICP. Slurred speech isn't a sign of increased ICP in an infant because the child isn't able to speak at this age. However, a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.

A student is assisting the healthcare provider to care for a baby diagnosed with Down syndrome (DS). Which the following statements made by the student indicates the student requires additional instruction about the disorder? A) "Both male and female patients diagnosed with Down syndrome are infertile." B) "The baby will be scheduled for an ultrasound of the heart to check for problems." C) "The baby's red and white blood cells and platelets will need to be monitored closely." D) "We will be checking the baby's thyroid hormone levels now and periodically."

A) "Both male and female patients diagnosed with Down syndrome are infertile."

A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her infant can't sit alone or roll over. An appropriate response by the nurse would be: 1. "This is very abnormal. Your child must be sick." 2. "Let's see about further developmental testing." 3. "Don't worry, this is normal for her age." 4. "Maybe you just haven't seen her do it."

2. "Let's see about further developmental testing." RATIONALE: Stating that further developmental testing is necessary is appropriate because at age 12 months a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Saying the infant's behavior is abnormal or suggesting that the mother hasn't seen her infant do these milestones isn't therapeutic and can cut off communication with the mother. Telling the mother that the infant's behavior is normal misleads the mother with false reassurance.

A nurse is caring for an adolescent girl who was admitted to the hospital's medical unit after attempting suicide by ingesting acetaminophen (Tylenol). The nurse should incorporate which interventions into the care plan for this girl? Select all that apply. 1. Limit care until the girl initiates a conversation. 2. Ask the girl's parents if they keep firearms in their home. 3. Ask the girl if she's currently having suicidal thoughts. 4. Assist the girl with bathing and grooming as needed. 5. Inspect the girl's mouth after giving oral medications. 6. Assure the girl that anything she says will be held in strict confidence.

2. Ask the girl's parents if they keep firearms in their home. 3. Ask the girl if she's currently having suicidal thoughts. 4. Assist the girl with bathing and grooming as needed. 5. Inspect the girl's mouth after giving oral medications. RATIONALE: Safety is the primary consideration when caring for suicidal clients. Because firearms are the most common method used in suicides, the girl's parents should be encouraged to remove firearms from the home, if applicable. Safety also includes assessing for current suicidal ideation. In many cases, clients who are suicidal are depressed and don't have the energy to care for themselves, so the client may need assistance with bathing and grooming. Because depressed and suicidal clients may hide pills in their cheeks, the nurse should inspect the girl's mouth after giving oral medications. Rather than limit care, the nurse should try to establish a trusting relationship through nursing interventions and therapeutic communication. The girl can't be assured of confidentiality when self-destructive behavior is an issue.

Parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment? 1. Stuttering 2. Using gestures to express desires 3. Babbling continuously 4. Playing alongside rather than interacting with peers

2. Using gestures to express desires RATIONALE: Using gestures instead of verbal communication to express desires — especially in a child older than age 15 months — may indicate a hearing or communication impairment. Stuttering is normal in children ages 2 to 4, especially boys. Continuous babbling is a normal phase of speech development in young children. In fact, its absence, not presence, would be cause for concern. Parallel play — playing alongside peers without interacting — is typical of toddlers. However, in an older child, difficulty interacting with peers or avoiding social situations may indicate a hearing deficit.

A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? 1. Registered dietitian 2. Physical therapist 3. Occupational therapist 4. Nursing assistant

3. Occupational therapist RATIONALE: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy but isn't trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nursing assistant can help a child eat; however, the nursing assistant isn't trained in modifying utensils.

A nurse is teaching a parent how to administer antibiotics at home to a toddler with acute otitis media. Which statement by the parent indicates that teaching has been successful? 1. "I'll give the antibiotics for the full 10-day course of treatment." 2. "I'll give the antibiotics until my child's ear pain is gone." 3. "Whenever my child is cranky or pulls on an ear, I'll give a dose of antibiotics." 4. "If the ear pain is gone, there's no need to see the physician for another examination of the ears."

1. "I'll give the antibiotics for the full 10-day course of treatment." RATIONALE: The mother demonstrates understanding of antibiotic therapy by stating she'll give the full 10-day course of treatment. Antibiotics must be given for the full course of therapy, even if the child feels well. Otherwise, the infection won't be eradicated. Antibiotics should be taken at ordered intervals to maintain blood levels and not as needed for pain. A reexamination at the end of the course of antibiotics is necessary to confirm that the infection is resolved.

A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg P.O. every 12 hours. If the child weighs 22 lb (10 kg), how many milligrams will the nurse administer with each dose? 1. 50 mg 2. 100 mg 3. 110 mg 4. 220 mg

1. 50 mg RATIONALE: The dose is 5 mg/kg and the child weighs 10 kg. To determine the dose, the nurse would calculate: 5 mg/1 kg × 10 kg = 50 mg per dose.