Quiz 27, 40, 41 (ATI 16, 17, 18, 19, 20, 27, 28, and 29)

A child is to use an incentive spirometer four times daily. Which statement suggests that the child understands the purpose and correct technique of the procedure? ."To do this right, I take in a very deep breath." B."Using this will help me cough less." C."The harder I blow out, the better I am doing." D."This will make more room for my heart in my chest."

A. "To do this right, I take in a very deep breath." Rationale: The purpose of incentive spirometry is to make the child take a deep breath to aerate the lungs better.

A nurse is caring for a child who has cerebral palsy. Which of the following medications should the nurse expect to administer to treat painful muscle spasms? (Select all that apply) A. Baclofen B. Diazepam C. Oxybutynin D. Methotrexate E. Prednisone

A. Baclofen B. Diazepam

A nurse is caring for a child who has a fracture. Which of the following are manifestations of a fracture? (Select all that apply) A. Crepitus B. Edema C. Pain D. fever E. Ecchymosis

A. Crepitus B. Edema C. Pain E. Ecchymosis

The nurse notices that an infant's left foot does not straighten to midline after moderate pressure. The best information that can be given to the parents/caregivers is A.Effective intervention begins in the newborn period with a series of casts or braces. B.Stretching the foot into midline every day by the parents will solve the problem. C.Correction of the defect will be completed by the time the infant is 6 weeks old. D.Correction of this anomaly is not usually successful.

A. Effective intervention begins in the newborn period with a series of casts or braces. Rationale: "True" talipes disorders cannot be treated without casting during the newborn period or, at worse, with surgical intervention. A simple stretching of the foot into midline by the parents is not effective. Although the series of castings usually is complete by the time the infant is 6 weeks old, the infant may need to sleep in a splint or in high-top shoes for several more months. Correction of this anomaly usually is successful, although a guarantee cannot be made.

A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following findings should the nurse expect? (Select all that apply) A. Eryhema marginatu (rash) B. Continuous joint pain of the digits C. Tnderness subcutaneous nodules D. Decreased erythrocyte sedimentation rate E. Elevated c-reactive protein

A. Eryhema marginatu (Rash) E. Elevated c-reactive protein

A nurse is discussing risk factors for asthma with a group of newly licensed nurses. Which of the following conditions would the nurse include in the teaching? (Select all that apply) A. Family history of asthma B. Family history of allergies C. Exposure to smoke D. Low birth weight E. Being underweight

A. Family history of asthma B. Family history of allergies C. Exposure to smoke D. Low birth weight

A nurse is assessing a child who has epiglottitis. Which of the following findings should the nurse expect? (Select all that apply) A. Hoarseness and difficulty speaking B. Difficulty swallowing C. Low grade fever D. Drooling E. Dry barking cough F. Stridor

A. Hoarseness and difficulty speaking B. Difficulty swallowing D. Drooling F. Stridor

Which is the primary nursing responsibility when a 4-year-old child with a tracheostomy tube eats? A.Prevent aspiration of food or fluids into the tube. B.Limit ingestion of too much fluid. C.Foster smooth passage of foods through the tube opening. D.Prevent dyspnea from eating too rapidly.

A. Prevent aspiration of food or fluids into the tube. Rationale: Because preschoolers are not necessarily neat eaters, protecting the tube from food entering it is important.

A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following home care instructions should the nurse include in the teaching? (Select all that apply) A. Provide extra time for completion of ADLs B. Use cold compresses for joint pain C. Take Ibuprofen on an empty stomach D. Remain home during periods of exacerbation E. Perform range of motion exercises

A. Provide extra time for completion of ADLs E. Perform range of motion exercises

A nurse is reviewing the diagnostic findings for preschool-aged child who is suspected of having cystic fibrosis. Which of the following findings should the nurse identify as an indication of cystic fibrosis? A. Sweat chloride content 85 mEq/L B. Increased serum levels of fat soluble vitamins C. 72-hour stool analysis sample indicating hard packed stool D. Chest x-ray negative for atelectasis

A. Sweat chloride content 85 mEq/L

A nurse is admitting a child who has cystic fibrosis. Which of the following medications should the nurse anticipate including in the plan of care? (Select all that apply) A. Tobramycin B. Loperamide C. Fat soluble vitamins D. Albuterol E. Dornase alfa

A. Tobramycin C. Fat soluble vitamins D. Albuterol E. Dornase alfa

A nurse is assessing an infant who has coarctation of the aorta. Which of the findings should the nurse expect? (Select all that apply) A. Weak femoral pulses B. Cool skin of lower extremities C. Severe cyanosis D. Clubbing of the fingers E. Heart failure

A. Weak femoral pulses B. Cool skin of lower extremities E. Heart Failure

A nurse is performing an admission assessment for a child who has cystic fibrosis. Which of the following findings should the nurse expect? (Select all that apply) A. Wheezing B. Clubbing of fingers and toes C. Barrel-shaped chest D. Thin watery mucus E. Rapid growth spurts

A. Wheezing B. Clubbing of fingers and toes C. Barrel-shaped chest

A nurse is teaching a child who has asthma how to use a peak flow meter. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Zero that we do before each use B. Record the average of the C. Perform three attempts D. Deliver a long slow breath into the meter E. Sit in a chair with feet on the floor

A. Zero that we do before each use C. Perform three attempts

a nurse is providing discharge teaching for a child who has cystic fibrosis. which of the following instructions should the nurse include? A. Provide a low calorie low protein diet B. Administer pancreatic enzymes with meals and snacks C. Implement a fluid restriction during times of infection D. Restrict physical activity

B. Administer pancreatic enzymes with meals and snacks

A nurse is teaching a group of parents about fractures. Which of the following information should the nurse include in the teaching? A. "Children need a longer time to heal from a fracture than." B. "Epiphyseal plate injuries can result in altered bone growth." C. "A greenstick fracture is a complete break in the bone?" D. "Bones are unable to bend, so they break"

B. "Epiphyseal plate injuries can result in altered bone growth."

Which of the following criteria is used to define childhood hypertension? A.A systolic reading over 70 mmHg B.A systolic reading above the 95th percentile for the child's age C.Sustained increased systolic and diastolic readings of 20 mmHg or more after minimal exercise D.An increase in either systolic or diastolic reading after exercise

B. A systolic reading above the 95th percentile for the child's age Rationale: Hypertension in children is defined as a systolic reading above the 95th percentile.

A nurse is caring for a child in the postoperative following a tonsillectomy. Which of the actions should the nurse take? A. Encourage the child to blow her nose B. Administer analgesics on a schedule C. Offer orange juice D. Position the child supine

B. Administer analgesics on the schedule

A nurse is caring for a child who is in skeletal traction. Which of the following actions should the nurse take? (Select all that apply) A. Remove the weights to reposition the client B. Assess the child's position frequently C. Assess pain sites every 4 hours D. Ensure the weights are hung for freely E. Ensure the rope's not is in contact with the pulley

B. Assess the child's position frequently C. Assess pain sites every 4 hours D. Ensure the weights are hung freely

A nurse is caring for a two-year-old client who has a heart defect and is scheduled for cardiac catheterization. Which of the following actions should the nurse take? A. Olace on NPO status for 12 hours prior to the procedure B. Check for iodine or shellfish allergies prior to the procedure C. Elevate the affected extremity following the procedure D. Limit fluid intake following the procedure

B. Check for iodine or shellfish allergies prior to the procedure

a nurse is assessing an infant who has heart failure. which of the following findings should the nurse expect? select all that apply A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring

B. Cool extremities C. Peripheral E. Nasal flaring

A nurse is caring for a child who sustained a fracture. Which of the following actions should the nurse take? (Select all that apply) A. Place a heat pack on the site of injury B. Elevate the affected limb C. Assess neurovascular status frequently D. Encourage ROM of the affected limb E. Stabilize the injury

B. Elevate the affected limb C. Assess neurovascular status frequently E. Stabilize the injury

A nurse is developing a plan of care for a toddler who has cerebral palsy. Which of the following actions should the nurse include? A. Structure interventions according to the toddler's chronological age B. Evaluate the toddlers need for an evaluation of hearing ability C. Monitor the toddler's pain level routinely using a numeric rating scale D. Provide total care for daily hygiene activities

B. Evaluate the toddlers need for an evaluation of hearing

A nurse is assessing a child who has Legg-Calve-Perthes disease. Which of the following findings should the nurse expect? (Select all that apply) A. Longer effective leg B. Hip stiffness C. Intense pain D. Limited ROM E. Limp with walking

B. Hip stiffness D. Limited ROM E. Limp with walking

When planning the care for a child with Kawasaki disease, which of the following would be most important? A.Making sure he performs postural drainage daily B.Observing him for symptoms of bowel obstruction C.Encouraging him to breathe deeply and cough D.Teaching him to live with a chronic illness

B. Observing him for symptoms of bowel obstruction Rationale: Extreme enlargement of lymph nodes can occur with Kawasaki disease. If abdominal nodes increase in size, they can compress intestines, leading to bowel obstruction.

A nurse is caring for a child who is receiving a bronchodilator medication by nebulizer aerosol therapy. Which of the following actions should the nurse take? (Select all that apply) A. Instruct the child that the treatment will last 30 minutes B. Obtain vital signs prior to the procedure C. Tell the child to take slow deep breaths D. Determine if the child should use a mask E. Attach the device to an air source

B. Obtain vital signs prior to procedure C. Tell child to take slow deep D. Determine if the child should use a mask E. Attach the device to an air source

Parents are taught to place their infants on their backs to sleep to prevent sudden infant death syndrome (SIDS). Which disorder would require the infant to be placed on the side to sleep to avoid airway obstruction? A.Thyroglossal cyst B.Pierre Robin syndrome C.Preoperative cleft lip D.Repaired cleft lip

B. Pierre Robin syndrome Rationale: Infants with Pierre Robin syndrome may have complete airway obstruction if the large tongue falls back over the airway; thus, side-lying positioning is recommended.

A nurse is planning care for a child who has asthma. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Perform chest percussion B. Place the child in an upright position C. Monitor oxygen saturations D. Administer bronchodilators E. Administer dornase alpha daily

B. Place the child in an upright position C. Monitor oxygen saturations D. Administer bronchodilators

A nurse is teaching an adolescent to self-administer a corticosteroid medication using a metered dose inhaler. Which of the following instructions should the nurse include? (Select all that apply) A. Shake the device prior to use B. Rinse and expectorate after administration C. Inhale slowly with medication administration D. Exhale quickly after medication administration E. Wait 30 seconds between puffs

B. Rinse and expectorate after administration C. Inhale slowly with medication administration

When assessing a child for cyanosis, which is important for the nurse to remember? A.Cyanosis is an early indicator of respiratory distress. B.The degree of cyanosis is not an accurate indicator of the degree of hypoxia. C.Cyanosis is caused by a decrease in the depth of respirations. D.Cyanosis will be present if the child has had a large loss of blood volume.

B. The degree of cyanosis is not an accurate indicator of the degree of hypoxia. Rationale: If the hemoglobin is low (decreased number of RBCs), there may not be much cyanosis as the red blood cells, which when not completely oxygenated, are what gives the blood the dark color. Cyanosis is present with a PO2 of less than 40 mmHg, which is usually a later sign in respiratory distress.

A nurse is assessing a preschool-age child for developmental dysplasia of the hip. Which of the following assessments should the nurse include? A. Barlow test B. Trendelenburg sign C. Manipulation of foot and ankle D. Ortolain

B. Trendelenburg sign

A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply) A. Oxygen saturation 95% B. Wheezing C. Retractions of sternal muscles D. Warm extremities E. Nasal flaring

B. Wheezing C. Retractions of sternal muscles E. Nasal flaring

A nurse is providing teaching to a mother of an infant who has a prescription for digoxin. Which of the following instructions should the nurse include? A. "Do not offer your baby fluids after giving the medication." B. "Digoxin increases your baby's heart rate." C. "Give the correct dose of medication at the regularly scheduled times" D. "If your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount"

C. "Give the correct dose of medication at the regularly scheduled times."

A nurse is completing preoperative teaching with an adolescent client who is scheduled to receive spinal instrumentation for scoliosis. Which of the following information should the nurse include in the teaching? A. "You will go home the same day as the surgery." B. "You will have minimal pain." C. "You will need to receive blood." D. "You will not be able to eat until the day after surgery."

C. "You will need to receive blood."

A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? (Select all that apply) A. Administer oral prednisone B. Immediate chest percussion and postural drainage C. Administer humidified oxygen D. Suction the nasopharynx as needed E. Administer oral penicillin

C. Administer humidified oxygen D. Suction the nasopharynx is needed

a nurse in the emergency department is it is assessing a newly admitted infant. which of the findings is an early indication of hypoxemia? A. Non productive cough B. Hypoventilation C. Cyanosis D. Nasal stuffiness

C. Cyanosis

A nurse is caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first? A. Increase the oxygen flow rate B. Encourage the child to take deep breaths C. Ensure proper placement of the sensory probe D. Place the child in Fowler's position

C. Ensure proper placement of the sensory probe

A nurse is caring for a child who is in the postoperative. following a tonsillectomy. Which of the following is a clinical finding of post-operative bleeding? A. Hgb 11.6 and Hct 37% B. Inflamed and red and throat C. Frequent swallowing and clearing of the throat D. Blood-tinged mucus

C. Frequent swallowing and clearing of the throat

The best way in which a nurse can detect congenital hydrocephalus prior to brain tissue damage is to A. Assess for brow bulging. B. Perform a transillumination of the infant's skull. C.Measure the infant's head circumference at birth and then compare the measurement prior to discharge. D. Assess fontanelles for width and tension.

C. Measure the infant's head circumference at birth and then compare the measurement prior to discharge. Rationale: Rapid recognition of this condition is key to the infant's future cognitive and fine motor skill abilities, and comparison of head circumference within a 24- to 48-hour period allows for early detection. Treatment is most effective when this condition is recognized early, ideally by prenatal ultrasound. After birth, by the time that the infant's brow is bulging or there is significant fluid to transilluminate, or the fontanelles are tense, it is possible that brain damage has already started to occur.

A nurse is caring for a child who has a muscular dystrophy. For which of the following findings should the nurse assess? (Select all that apply) A. Purposeless, involuntary abnormal movements B. Spinal defect and sac-like protrusion C. Muscular weakness in lower extremities D. Unsteady, wide-based or waddling gait E. Upward slant to the eyes

C. Muscular weakness in the lower extremities D. Unsteady, wide base or waddling gait

An 18-year-old with hypertension attends the ambulatory clinic. She currently takes an oral contraceptive and an over-the-counter vitamin pill daily. What health teaching should the nurse initiate with her? A.Teach her not to take the oral contraceptive in the morning when blood pressure is highest. B.Suggest she discontinue the vitamin tablet to help reduce her blood pressure. C.Suggest she speak to her physician about whether she should remain on the oral contraceptive. D.Nothing. There is no relationship between use of oral contraceptives or vitamins and hypertension.

C. Suggest she speak to her physician about whether she should remain on the oral contraceptive. Rationale: Adolescents with hypertension are advised not to take oral contraceptives because these elevate blood pressure.

A nurse is teaching a group of parents about influenza. Which of the following information should the nurse include in the teaching? A. "Amantadine will prevent the illness." B. "Rimantadine is administered intramuscularly." C. "Zanamivir can we given two children one year or older." D. "Oseltamivir should be given within 48 hours of the onset of symptoms."

D. "Oseltamivir should be given within 48 hours of the onset of symptoms."

A nurse is caring for a toddler who is diagnosed with hip dysplasia and has been placed in a hip spica cast. The child's mother asks the nurse why Pavlik harness is not being used. Which of the following responses should the nurse make? A. "The Pavlik harness is used for children with scoliosis not hip dysplasia." B. "The Pavlik harness is used for school age children." C. "The Pavlik harness cannot be used for your child because your condition is too severe." D. "The Palvik harness is used for infants less than 6 months of age."

D. "The Palvik harness is used for infants less than 6 months of age."

A nurse is teaching an adolescent about the appropriate use of asthma medications. Which of the following medications should the nurse instruct the client to use as needed before exercise? A. Fluticanaone/salmeterol B. Montelukast C. Prednisone D. Albuterol

D. Albuterol

A nurse is caring for an infant who has a myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care? A. Assisted the mother was cuddling the infant B. Assess the infant's temperature rectally C. Place the infant in the supine position D. Apply is sterile, moist dressing to the sac

D. Apply sterile, moist dressing to the sac

A nurse is caring for a child who is in a plaster sepia cast. Which of the following actions should the nurse take? A. Use a heat lamp to facilitate drying B. Avoid turning the child until the cast is dry C. Assist the client with crutch walking after the cast is dry D. Applying moleskin to the edges of the cast

D. Applying moleskin to the edges of the cast

A nurse is caring for a child who is suspected of having Legg-Calve-Perthes disease. The nurse should prepare the child for which of the following diagnostic procedures? A. Bone biopsy B. Genetic testing C. MRI D. Radiographs

D. Radiographs

A nurse is caring for a child who is receiving oxygen. which of the following findings indicates oxygen toxicity? A. Increased blood pressure B. Hyperventilation C. Decreased PaCO2 D. Unconsciousness

D. Unconsciousness