RN HESI: Peds Retake

A mother has brought her 5-year-old son into the healthcare clinic for a physical to prepare for kindergarten. The nurse is reviewing the child's immunization history and notes that he has had one MMR vaccine in his life. Which response of the nurse is the most appropriate?

"He will need one MMR before he starts kindergarten."

The nurse is teaching the mother of a 5-year-old boy with a history of impaction how to administer enemas at home. Which response from the mother indicates a need for further teaching?

"I should position him on his abdomen with knees bent."

The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which question would be most likely to elicit valuable information?

"What are your new classmates like?"

M.B. is a 17 year old patient who is being seen for a sports physical. He is accompanied by his parents who are present while the nurse takes the patient's history. The nurse notes a certain amount of tension when discussing the teen's high-risk behaviors. The nurse wants to establish a relationship of confidentiality with the patient, in case he wants to discuss private matters but doesn't want to talk in front of his parents. Which one of the following statements made by the nurse is correct?

"You can have your parents stay while I examine you or they can wait outside until we are done."

The parents of a child with autism talk with a nurse about their feelings of being overwhelmed in caring for their child. They state that they do not get a break from their child, his needs are almost more than they can handle, and they are considering divorce. Which of the following initial responses from the nurse is most important?

"You may want to talk with a respite provider who can care for your child sometimes."

Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply. 1. Coughing 2. Respiratory rate of 35 bp/m 3. Heart rate of 95 bpm 4. restlessness 5. malaise 6. diaphoresis

1. Coughing 2. Respiratory rate of 35 bp/m 4. restlessness 6. diaphoresis

A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse include in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear a mask at all times when in contact with the infant. 4. Place the infant in a tent that delivers warm humidified air. 5. Position the infant side-lying, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

1. Place the infant in a private room. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

1. Time the seizure. 3. Stay with the child. 5. Move furniture away from the child. Rationale: A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side prevents aspiration because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding? 1.Positive 2.Negative 3.Inconclusive 4.Definitive and requiring a repeat test

1.Positive Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in children with chronic illness or at high risk for exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as a child with an immunosuppressive condition or a child with human immunodeficiency virus (HIV) infection. A reaction of 15 mm or more is positive in children 4 years or older without any risk factors.

Which of the following situations would involve mandatory reporting?

A nurse suspects that an 11-year-old child is being abused in his home

Which of the following best describes the role of a child life specialist on an interdisciplinary team?

A person who helps a child and his family to prepare for procedures and hospitalization in a developmentally appropriate way.

The mother of a hospitalized 2 year old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."

3. "Antibiotics are not indicated unless a bacterial infection is present."

A 3-year-old child with a tracheostomy will soon be discharged. What most important recommendation should the nurse share with the family? 1. Tub baths cannot be given. 2. Child cannot be allowed to play outdoors. 3. Avoid exposure to noxious fumes such as paint or varnish. 4. Cover tracheostomy with a plastic bib when exposed to cold air.

3. Avoid exposure to noxious fumes such as paint or varnish. The child with a tracheostomy should not be exposed to noxious fumes such as paint, varnish, or hair spray or to substances such as talc. The parent and child must be cautioned about safety measures around bodies of water. Baths can be taken, but parents must observe the necessary safety precautions. The child may play outdoors with a scarf or other protection that allows air through.

A 7-year-old child with a history of asthma controlled without medications is referred to the school nurse by the teacher because of persistent coughing. Which of the following should the nurse do first? 1.Obtain the child's heart rate. 2.Give the child a nebulizer treatment. 3.Call a parent to obtain more information. 4.Have a parent come and pick up the child.

3.Call a parent to obtain more information. R: Because persistent coughing may indicate an asthma attack and a 7-year-old child would be able to provide only minimal history information, it would be important to obtain information from the parent. Although determining the child's heart rate is an important part of the assessment, it would be done after the history is obtained. More information needs to be obtained before giving the child a nebulizer treatment. Although it may be necessary for the parent to come and pick up the child, a thorough assessment including history information should be obtained first.

When developing the discharge teaching plan for a child with chronic renal failure and the family, the nurse should emphasize restriction of which of the following nutrients? 1. Ascorbic acid. 2. Calcium. 3. Magnesium. 4. Phosphorus.

4. Phosphorus.

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

4. Suctioning equipment and oxygen A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not perform ed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside, but would be available in the treatment room or nearby on the nursing unit.

A 16-year-old patient is being seen for treatment of an inguinal hernia. The patient's parents are with him while he talks to the physician but he does not want the recommended treatment. The parents are considering his position as a mature minor to let him make the decision. Which of the following best describes a mature minor?

A minor patient who is considered developmentally old enough to make the decision to consent or refuse.

The nurse is caring for infants having the condition failure to thrive (FTT). Which of the following infants would be at high risk for this condition? Select all answers that apply. A) A newborn baby with tetralogy of Fallot B) An infant with a cleft palate C) An infant born to a diabetic mother D) An infant born to an impoverished mother E) An infant with bronchopulmonary dysplasia F) An infant born to a teenage mother

A) A newborn baby with tetralogy of Fallot B) An infant with a cleft palate D) An infant born to an impoverished mother E) An infant with bronchopulmonary dysplasia

Prior to administering morphine to a 10-year-old child, the nurse reviews the adverse effects of the drug. Which system is primarily affected by the drug, causing most of the adverse effects? A) Central nervous system B) Peripheral nervous system C) Digestive system D) Musculoskeletal system

A) Central nervous system

The nurse is caring for a special needs infant. Which intervention will be most important in helping the child reach her maximum developmental potential? A) Directing her parents to an early intervention program B) Monitoring her progress in elementary school C) Serving on an individualized education program committee D) Preparing a plan for her to transition to college

A) Directing her parents to an early intervention program Feedback: Early intervention is critical to maximizing the child's developmental potential by laying the foundation for health and development. While important, intervention in elementary or secondary school does not have the impact of early intervention. When the time arrives, it is important to have a written plan for transition to college, if this is a possibility for the grown child.

The nurse is caring for a 7-year-old girl hospitalized in isolation. The nurse notices that she has begun sucking her thumb and changing her speech patterns to those of a toddler. What condition is the girl manifesting? A) Regression B) Suppression C) Repression D) Denial

A) Regression

Which of the following would be least effective in gaining the cooperation of a toddler during a physical examination? A) Tell the child that another child the same age wasn't afraid. B) Allow the child to touch and hold the equipment when possible. C) Permit the child to sit on the parent's lap during the examination. D) Offer immediate praise for holding still or doing what was asked.

A) Tell the child that another child the same age wasn't afraid.

The nurse is preparing to administer medication to a child with a gastrostomy tube in place. What is a recommended guideline for this procedure? Select all that apply. A) Verify proper tube placement prior to instilling medication. B) Mix liquid medications with a small amount of water and add directly into the tube. C) Mix powdered medications well with cold water first. D) Crush tablets and mix with warm water to prevent tube occlusion. E) Open up capsules and mix the contents with warm water. F) Flush the tube with water after administering medications.

A) Verify proper tube placement prior to instilling medication. D) Crush tablets and mix with warm water to prevent tube occlusion. E) Open up capsules and mix the contents with warm water. F) Flush the tube with water after administering medications. The correct procedure includes checking proper tube placement prior to instilling medication, crushing tablets and mixing with warm water to prevent tube occlusion, opening up capsules and mixing the contents with warm water, and flushing the tube with water after administering medications. The nurse should give liquid medications directly into the tube and mix powdered medications well with warm water first.

The nurse is caring for a hospitalized 13-year-old girl, who is questioning everything the medical staff is doing and is resistant to treatment. How should the nurse respond? A)"Let's work together to plan your day along with your treatments." B)"The sooner you cooperate, the sooner you are going to leave." C)"If you are more cooperative, perhaps we can arrange a visit from friends." D)"Please don't make me call your parents about this."

A)"Let's work together to plan your day along with your treatments." Feedback: Collaborating with the adolescent will provide the teen with increased control. The nurse should work with the teen to provide a mutually agreeable schedule that allows for the teen's preferences while incorporating the required nursing care. Threatening to call the parents will most likely promote further resistance. The nurse should try to immediately engage the girl, rather than making the nurse's cooperation conditional upon the girl's cooperation. Telling the girl that the sooner she cooperates, the sooner she will leave is inappropriate. The nurse is incorrectly implying that her behavior, rather than her medical needs, is going to determine when she will be discharged from the hospital.

The nurse is caring for a 4-year-old girl with special care needs in the hospital. Which intervention would have the most positive effect on this child? A)Taking her on an adventure down the hall B)Helping her do a simple craft project C)Introducing her to children in the playroom D)Limiting the staff providing care for her

A)Taking her on an adventure down the hall Feedback: Preschool-age children need to develop a sense of initiative, and helping the child to explore her area of the hospital would help accomplish this developmental need. Craft projects and introducing the child to other children would help build a sense of industry and peer relationships, both of which are needs of the school-age, not preschool, child. Limiting the number of people providing care is a trust-building intervention, beginning in infancy.

A physician orders a medication dosage that is above the normal dosage. The nurse administers the medication without questioning the dosage. What error did the nurse make? A)The nurse violated one of the "rights" of medication administration. B)The nurse performed an act outside the scope of practice for nursing. C)The nurse has not made an error, but the physician did by ordering the wrong dosage of medication. D)The nurse has committed an act of maleficence by administering the medication.

A)The nurse violated one of the "rights" of medication administration. The nurse violated one of the "rights" of medication administration, the right dosage, because the nurse is responsible for being aware and questioning an incorrect dosage of medication. Medication administration is within the scope of nursing practice. Maleficence is performing a harmful act intentionally.

11.For which child would nonopioid analgesics be recommended? A. A child with juvenile arthritis B. A child with end stage cancer C. A child with a broken arm D. A child with severe postoperative pain

A. A child with juvenile arthritis These agents are used to treat mild to moderate pain such as arthritis, joint, and muscle pain

A nurse is caring for a baby who was born 72 hours ago. The nurse notes that the child has not had a bowel movement or has passed meconium stool on her shift. The nurse checks the records and notes that the child has not had any bowel movements documented since birth. Which action should the nurse perform next? A. contact the provider to report the situation B. check the infants HR, BP, and skin temp C. continue to monitor and note when the baby has a BM D. insert a rectal thermometer to stimulate the infant to have stool

A. contact the provider to report the situation A newborn infant should pass the first stool of meconium within approximately 24 hours of birth. An initial assessment of a newborn typically looks for signs of a patent anal opening, but an internal condition affecting the colon could cause difficulties with stooling. Hirschsprung disease is a condition characterized by severe constipation and mechanical obstruction of the bowel; the nurse can assess for Hirschsprung disease in the newborn by noting the time and number of stools of the infant.)

Parents are concerned that their 6-year-old son continues to occasionally wet the bed. What does the nurse explain? a. This is likely because of increased stress at home. b. Enuresis usually ceases between 6 and 8 years of age. c. Drug therapy will be prescribed to treat the enuresis. d. Testing will be necessary to determine what type of kidney problem exists

ANS: B Further data must be gathered before the diagnosis of enuresis is made. Enuresis is the inappropriate voiding of urine at least twice a week. This child does meet the age criterion, but the parents need to be questioned about and keep a diary on the frequency of events. If the bedwetting is infrequent, parents can be encouraged that the child may grow out of this behavior. Drug therapy will not be prescribed until a more complete evaluation is done. Additional assessment information must be gathered, but at this time, there is no indication of renal disease.

The nurse has documented that a child's level of consciousness is obtunded. Which describes this level of consciousness? a. Slow response to vigorous and repeated stimulation b. Impaired decision making c. Arousable with stimulation d. Confusion regarding time and place

ANS: C Obtunded describes a level of consciousness in which the child is arousable with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.

A 4-year-old child is being prepared for surgery for an umbilical hernia repair. Which best identifies the most appropriate method of providing comfort for a child before surgery?

Allow a support person, such as a parent, to remain with the child as long as possible

A nurse who works in the pediatric unit walks into a 3-year-old patient's room and finds him lying on the floor. His parents are with him and they tell the nurse, "he fell out of bed!" Which response from the nurse is the most appropriate?

Assist the patient back to bed, assess him for injuries and file an incident report

The nurse is preparing a nursing care plan for a child hospitalized for cardiac surgery. Which are examples of interventions that nurses perform in the 'building a trusting relationship' stage? Select all that apply. A) Gathering information about the child using the child's own toys B) Preparing the child for a procedure by playing games C) Explaining in simple terms what will happen during surgery D) Allowing the child to devise an exercise plan following surgery E) Praising the child for how well he is doing following instructions F) Giving the child a favorite toy to cuddle following a painful procedure

B) Preparing the child for a procedure by playing games C) Explaining in simple terms what will happen during surgery The introduction phase involves the initial contact with children and their families and it establishes the foundation for a trusting relationship. A trusting relationship can be built by using appropriate language, games, and play such as singing a song during a procedure, preparing the child adequately for procedures, and providing explanations and encouragement. In the decision-making phase, the nurse gives some control over to the child by allowing him to participate in making certain decisions, such as devising an exercise. Finally, the comfort and reassurance phase uses techniques such as praising the child and providing opportunities to cuddle with a favorite toy.

The nurse is preparing a presentation to a local parent group about pediatric health supervision. Which of the following would the nurse emphasize as the focus? A) Injury prevention B) Wellness C) Health maintenance D) Developmental surveillance

B) Wellness The focus of pediatric health supervision is wellness. Injury and disease prevention, health maintenance and promotion, and developmental surveillance are all critical components of wellness.

The nurse is providing teaching for the mother of an infant who receives all of his nutrition through a tube. The nurse is reviewing interventions to promote growth and development. Which response from the mother indicates a need for further teaching? A)"I will give him a pacifier during feeding time." B)"We need to keep feeding time very quiet." C)"We need to make sure he doesn't lose the desire to eat by mouth." D)"Sucking produces saliva, which aids in digestion."

B)"We need to keep feeding time very quiet." The nurse needs to emphasize that it is important to talk, play music, cuddle, and rock the infant to promote a normalized feeding time. The other statements are correct.

The nurse is caring for children who are receiving IV therapy in the hospital setting. For which children would a central venous device be indicated?A) A child who is receiving an IV push B)A child who is receiving chemotherapy for leukemia C)A child who is receiving IV fluids for dehydration D)A child who is receiving a one-time dose of a medication

B)A child who is receiving chemotherapy for leukemia Although central venous access devices can be used short term, the majority are used for moderate- to long-term therapy, such as chemotherapy. Central venous access devices are indicated when the child lacks suitable peripheral access, requires IV fluid or medication for more than 3 to 5 days, or is to receive specific treatments, such as the administration of highly concentrated solutions or irritating drugs that require rapid dilution. Peripheral IV devices are used for most other IV therapies.

A nurse is working with the family of a 1-day-old infant who was born prematurely and who is dying, which of the following interventions would most likely demonstrate that the nurse recognizes the family's grief in this situation?

Letting the family baptize the child and dress him

The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statements accurately describes a recommended guideline for setting the tone of the examination for a school-age child? A)Keep up a running dialogue with the caregiver, explaining each step as you do it. B)Include the child in all parts of the examination; speak to the caregiver before and after the examination. C)Speak to the child using mature language and appeal to his or her desire for self-care. D)Address the child by name; speak to the caregiver and do the most invasive parts last.

B)Include the child in all parts of the examination; speak to the caregiver before and after the examination. For a school-age child, the nurse should include the child in all parts of the examination, and speak to the caregiver before and after the examination. For a newborn the nurse should keep up a running dialogue with the caregiver, explaining each step as it is done. The nurse should speak to the early teen using mature language and appeal to his or her desire for self-care. For an infant, the nurse should address the child by name, and speak to the caregiver and do the most invasive parts last.

The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child? A)Reduce noise as much as possible. B)Provide age-appropriate toys and games. C)Discourage visits from family members. D)Put on mask prior to entering the room.

B)Provide age-appropriate toys and games. Children in this setting may experience sensory deprivation due to the limited contact with others and the use of personal protective equipment such as gloves, masks, and gowns. The nurse should stimulate the child by playing with her with age-appropriate toys/games. Reducing noise would be appropriate for sensory overload. The nurse should encourage the family to visit often, introduce himself or herself before entering the room, and allow the child to view his or her face before applying a mask.

During the health history, the mother of a 4-month-old child tells the nurse she is concerned that her baby is not doing what he should be at this age. What is the nurse's best response? A) "I'll be able to tell you more after I do his physical." B) "Fill out the questionnaire and then I can let you know." C) "Tell me what concerns you." D) "All mothers worry about their babies. I'm sure he's doing well."

C) "Tell me what concerns you." Asking about the mother's concerns is assessment and is the first thing the nurse should do. The mother has intimate knowledge of the infant and can provide invaluable information that can help structure the nurse's assessment. Relying on the physical assessment ignores the value of the mother's input. A screening questionnaire is no substitute for a developmental assessment. Minimizing the mother's concerns reduces communication between the mother and the nurse.

The nurse is administering pain medication for a child with continuous pain from internal injuries. Which of the following methods would be ordered to dispense the medication? A) Administer the medication PRN (as needed). B) Administer the mediation when pain has peaked. C) Administer the medication around the clock at timed intervals. D) Administer the medication when the child complains of pain.

C) Administer the medication around the clock at timed intervals.

The nurse is caring for a toddler with special needs. Which developmental tasks related to toddlerhood might be delayed in the child with special needs? A) Developing body image B) Developing peer relationships C) Developing language and motor skills D) Learning through sensorimotor exploration

C) Developing language and motor skills In special needs children, developmental delays may occur in all stages. In particular, motor and language skill development may be delayed if the toddler is not given adequate opportunities to test his or her limits and abilities. Development of body image may be hindered in the preschooler due to painful exposures and anxiety. Development of peer relationships may be delayed in the school-age and adolescent child. The infant's ability to learn through sensorimotor exploration may be impaired due to lack of appropriate stimulation, confinement to a crib, or increased contact with painful experiences.

Which signs and symptoms would lead a nurse to suspect a child has tetralogy of Fallot? Select all that apply.

Murmur History of squatting Cyanosis Tachypnea

The nurse is explaining to the student nurse the therapeutic effects of total parenteral nutrition (TPN). What accurately describes the use of TPN? A) It is used short term to supply additional calories and nutrients as needed. B) It is delivered via the peripheral vein to allow rapid dilution of hypertonic solution. C) It is a highly concentrated solution of carbohydrates, electrolytes, vitamins, and minerals. D) It is usually used when the child's nutritional status is within acceptable parameters.

C) It is a highly concentrated solution of carbohydrates, electrolytes, vitamins, and minerals. TPN is a highly concentrated solution of carbohydrates, electrolytes, vitamins, and minerals. TPN provides all nutrients to meet a child's needs. It is delivered via central venous access to allow rapid dilution of hypertonic solution. It is usually used in a child with a nonfunctioning gastrointestinal (GI) tract, such as a congenital or acquired GI disorder; a child with severe failure to thrive or multisystem trauma or organ involvement; and preterm newborns.

The nurse working in the emergency room monitors the admission of children. Statistically, for which disorder would children younger than 5 years most commonly be admitted? A) Mental health problems B) Injuries C) Respiratory disorders D) Gastrointestinal disorders

C) Respiratory disorders Feedback: According to Child Health USA 2010, diseases of the respiratory system, such as asthma and pneumonia, account for the majority of hospitalizations in children younger than 5 years of age, while diseases of the respiratory system, mental health problems, injuries, and gastrointestinal disorders lead to more hospitalizations in older children.

A school-aged child with an infectious disease is placed on transmission-based precautions. Which nursing diagnosis would most likely be a priority? A) Impaired skin integrity related to trauma secondary to pruritus and scratching B) Fluid volume deficit related to increased metabolic demands and insensible losses C) Social isolation related to infectivity and inability to go to the playroom D) Deficient knowledge related to how infection is transmitted

C) Social isolation related to infectivity and inability to go to the playroom

The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination? A)The child B)The parents C)Chief complaint D)Developmental age

C)Chief complaint The next step after the health history is the physical examination. It should focus on the chief complaint or any of the systems that engaged the nurse's critical thinking while obtaining the history. The child and parents are involved in the assessment but the focus is on the health problem. The nurse should conduct a physical examination with the child's developmental age in mind.

The nurse is caring for a 4-year-old girl who has been hospitalized for over a week with severe burns. Which would be a priority intervention to help satisfy this preschool child's basic needs? A)Encourage friends to visit as often as possible. B)Suggest that a family member be present with her 24 hours a day. C)Explain necessary procedures in simple language that she will understand. D)Allow her to make choices about her meals and activities as much as permitted.

C)Explain necessary procedures in simple language that she will understand. Feedback: Preschoolers fear mutilation and are afraid of intrusive procedures since they do not understand the body's integrity. They interpret words literally and have an active imagination; therefore, procedures should be demonstrated and/or explained in simple terms. Adolescents typically do not experience separation anxiety from being away from their parents; instead, their anxiety comes from being separated from friends, and therefore encouraging friends to visit is a priority intervention. Toddlers are especially susceptible to separation anxiety and would benefit from a family member being present as much as possible. School-age children are accustomed to controlling self-care and typically are highly social; they would benefit from being involved in choices about meals and activities.

Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain. Which assessment finding would most likely indicate the need for this child to be hospitalized? A)Fever B)Oxygen saturation level of 96% C)Tachypnea with retractions D)Pale skin color

C)Tachypnea with retractions Pneumonia is usually a self-limiting disease. Children with bacterial pneumonia can be successfully managed at home if the work of breathing is not severe and oxygen saturation is within normal limits. Hospitalization would most likely be required for the child with tachypnea, significant retractions, poor oral intake, or lethargy for the administration of supplemental oxygen, intravenous hydration, and antibiotics. Fever, although common in children with pneumonia, would not necessitate hospitalization. An oxygen saturation level of 96% would be within normal limits. Pallor (pale skin color) occurs as a result of peripheral vasoconstriction in an effort to conserve oxygen for vital functions; this finding also would not necessitate hospitalization.

The student nurse is learning about the effects of heat and cold when used in a pain management plan. What accurately describes one of these effects?

Cold alters capillary permeability.

The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which question would be most likely to elicit valuable information? A) 'Do you like your new school?' B) 'Are you happy with your teacher?' C) 'Do you enjoy reading a book?' D) 'What are your new classmates like?'

D) 'What are your new classmates like?' A careful conversation and interview with the child and/or the caregiver will provide important information about the child's health. Depending on the intent of the health assessment, many of the questions will be direct, and many will require the caregiver or child to answer simply "yes" or "no." In other than emergency situations, though, asking open-ended questions such as 'What are your classmates like?' offers an excellent opportunity to learn more about the child's life.

The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next? A) Contact the physician B) Offer a snack and administer another dose C) Immediately administer another dose D) Administer next dose as ordered in 12 hours

D) Administer next dose as ordered in 12 hours Feedback: Digoxin should be administered at regular intervals, every 12 hours, 1 hour before or 2 hours after feeding. If the child vomits digoxin, the nurse should not give a second dose and should wait until the next scheduled dose. It is not necessary to contact the physician.

A new parent expresses concern to the nurse regarding sudden infant death syndrome. She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? A) Side or prone B) Back or prone C) Stomach with face turned D) Back rather than on stomach

D) Back rather than on stomach Rationale:SIDS is the unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fail to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses should encourage parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffocation. The infant may have the ability to turn to a prone from the side-lying position.

The nurse is providing home care for a 1-year-old girl who is technologically dependent.Which intervention will best support the family process? A) Finding an integrated health program for the family B) Teaching modifications of the medical regimen for vacation C) Assessing family expectations for the special needs child D) Creating schedules for therapies and interventions

D) Creating schedules for therapies and interventions

The nurse is caring for an 8-year-old boy hospitalized for a bone marrow transplant. His parents are in and out of his room throughout the day. Which behaviors of the child would alert the nurse that he is in the second stage of separation anxiety? A) He ignores his parents when they return to his room. B) He cries uncontrollably whenever they leave. C) He forms superficial relationships with his caregivers. D) He sits quietly and is uninterested in playing and eating.

D) He sits quietly and is uninterested in playing and eating. Feedback: Separation anxiety consists of three stages—protest, despair, and detachment. In the protest stage, the child reacts aggressively to separation and exhibits great distress by crying, expressing agitation, and rejecting others who attempt to offer comfort. In the despair phase the child displays hopelessness by withdrawing from others, becoming quiet without crying, and exhibiting apathy, depression, lack of interest in play and food, and overall feelings of sadness. In the detachment stage the child shows interest in the environment, starts to play again, and forms superficial relationships with the nurses and other children. If the parents return, the child ignores them. A child in this phase of separation anxiety exhibits resignation, not contentment.

The nurse is weighing an underweight infant diagnosed with failure to thrive (FTT) and notes that the baby does not make eye contact and is less active than the other infants. What would be a probable cause for the FTT related to the infant's body language? A) Congenital heart defect B) Cleft palate C) Gastroesophageal reflux disease D) Maternal abuse

D) Maternal abuse

A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority? A) Hyperextending the child's head while placing him on his side B) Using a tongue blade to pry open the child's jaw C) Loosening the child's clothing to ensure a patent airway D) Protecting the child from harm during the seizure

D) Protecting the child from harm during the seizure During a seizure, the child should not be held down in a specific position. Protecting the child's head and body during the seizure is the priority. Ensuring a patent airway is an important intervention but is not accomplished by loosening the child's clothing or hyperextending his head. The child should be placed on his side and nothing should be inserted into his mouth to forcibly open the jaw.

The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury? A) Recommend the bed's side rails be raised throughout the day and night. B) Suggest a caregiver be present continuously to prevent falls from bed. C) Encourage a loose restraint to be used when he is in bed. D) Recommend raising the bed's side rails when a caregiver is not present.

D) Recommend raising the bed's side rails when a caregiver is not present. The nurse should recommend that side rails on the bed be elevated when a caregiver is not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver be present at all times places undue stress on the family. Close observation is more appropriate. Recommending side rails be elevated at all times may be upsetting to the child and make him feel like a "baby."

The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? A) Heart B) Abdomen C) Lungs D) Throat

D) Throat Feedback: If the infant is asleep, the nurse should auscultate the heart, lungs, and abdomen first while the baby is quiet. The nurse performs the assessment in a head-to-toe manner, leaving the most traumatic procedures, such as examination of the ears, nose, mouth, and throat, until last.

The nurse uses the FLACC behavioral scale to assess a 6-year-old's level of postoperative pain and obtains a score of 9. The nurse interprets this to indicate that the child is experiencing: A) little to no pain. B) mild pain. C) moderate pain. D) severe pain.

D) severe pain. The Riley Infant Pain Scale measures six parameters: facial expression, body movement, sleep, verbal or vocal ability, consolability, and response to movements and touch. The Pain Observation Scale for Young Children (POCIS) measures seven parameters: facial expression, cry, breathing, torso, arms and fingers, legs and toes, and state of arousal. The CRIES tool assesses five parameters: cry, oxygen required for saturation levels less than 95%, increased vital signs, facial expression, and sleeplessness. The FLACC tool measures five parameters: facial expression, legs, activity, cry, and consolability. FLACC Scores: 0 Relaxed and comfortable 4-6 Moderate pain 1-3 Mild discomfort 7-10 Severe discomfort or pain or both

A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the disease? a) cracked lips b) a normal appearance c) conjunctival hyperemia d) desquamation of the skin

c) conjunctival hyperemia

The nurse is preparing to obtain a blood specimen via capillary heel puncture. Which action would be most appropriate for the nurse to do? A)Apply a cool compress for several minutes before collection. B)Elevate the extremity used after puncturing it. C)Squeeze the area to facilitate specimen collection. D)Wipe away the first drop of blood with dry gauze.

D)Wipe away the first drop of blood with dry gauze. When obtaining a blood specimen by capillary puncture, the nurse should wipe away the first drop of blood with a cotton ball or dry gauze pad and then collect the sample without squeezing the foot to prevent possible hemolysis. Prior to the puncture, the nurse can apply a commercial heel warmer or warm compress for several minutes to promote vasodilation. The extremity being used should be placed in the dependent position after puncturing the heel.

The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which approach would be most appropriate to elicit the child's cooperation? A)"Can you cough for me please?" B)"You must blow in this or you might get pneumonia." C)"If you don't try, I will have to get the doctor." D)"Can you blow this cotton ball across the tray?"

D. "Can you blow this cotton ball across the tray?" Children are more likely to cooperate with interventions if play is involved. Encourage deep breathing by playing games. Asking the boy to cough is less likely to engage him. Telling the child he might get pneumonia is not age appropriate and is unhelpful. Threatening to call the doctor is unhelpful and inappropriate. Remember, however, that the incentive spirometer works on the principle of the amount of air inhaled, not exhaled. Having the child take a deep breath prior to blowing the cotton ball is a beginning step.

he nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to: A. notify physician. B. apply new bandage with more pressure. C. place the child in Trendelenburg position. D. apply direct pressure above catheterization site.

D. apply direct pressure above catheterization site. If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities.

The nurse tells a joke to a 12-year-old to distract him from a painful procedure. What pain management technique is the nurse using? A) Relaxation B) Distraction C) Imagery D) Thought stopping

Distraction

A nurse is caring for a child who has been diagnosed with pertussis. Which type of precautions should the nurse take when caring for this child?

Droplet precautions

When providing end-of-life care to a 4-year-old child who is dying of cancer, which of the following interventions would the nurse utilize to ensure that she is providing adequate pain control?

Encourage the child to verbalize pain by using the appropriate pain scale

A nurse is performing a clinic intake assessment on a 16-year-old patient. When the nurse asks the patient about alcohol consumption, the patient admits that he sometimes drinks to excess with his friends. Which response should the nurse utilize to talk about this topic with the patient?

Explain short- and long-term effects of alcohol use on health

A nurse is working with a family whose child has an intellectual disability that occurred as a result of trauma. Which of the following situations would best describe an example of this type of event?

Falling down a flight of stairs

What type of diet should the nurse teach the parents to give an older infant with cystic fibrosis?

High-calorie diet

A nurse is caring for a 9-year-old patient who is considered a fall risk because of her history of seizures. Which of the following interventions should be implemented to prevent falls in a pediatric patient? Select all that apply.

Keep the patient's bed in the lowest position Provide non-slip socks for the patient to wear while ambulating Move furniture and room items so that there is a clear walkway

An 11-year-old boy has been diagnosed with depression after his parents' divorce. The nurse understands that depression in most children of this age most commonly manifests as:

Lack of interest with friends and families

A child with laryngotracheobronchitis (CROUP) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. The appropriate nursing action is to:

Let the mother hold the child and direct the cool mist over the child's face

After teaching a class on the role of white blood cells in infection, the instructor determines that the teaching was successful when the class identifies which type of white blood cells as important in combating bacterial infections?

Neutrophils Explanation: Elevations in certain portions of the white blood cell count reflect different processes occurring in the body. Neutrophils function to combat bacterial infection. Eosinophils function in allergic disorders and parasitic infections. Basophils combat parasitic infections and some allergic disorders. Lymphocytes function in viral infections.

When assessing a 2-year-old child with a Wilms Tumor, what should the nurse avoid?

Palpating the child's abdomen

A nurse is reviewing the policies for safety with a family who's 1-year-old child has been admitted to the pediatric unit. Which information would the nurse most likely give to the parents about maintaining the child's safety while he is a patient in the pediatric unit?

Parents who are staying with the child should not fall asleep while holding the child, but should keep him in his bed

A nurse who works in the newborn nursery must check a blood glucose level on an infant. The nurse performs the heel stick using a retractable lancet. Following the procedure, what should the nurse do with the lancet?

Place it in a sharps container

The parents of a 12-year-old girl complain to the nurse that their daughter never listens to them when they talk. Which of the following skills should the nurse teach to the parents about conflict resolution with their child?

Practice active listening with the child

What is the role of the peer group in the life of school-age children?

Provides them with security as they gain independence from their parents.

A community health nurse provides screening for a family whose child has a likelihood of developing cystic fibrosis because of their genetic background. Which of the following community health intervention does this describe?

Risk identification

A child with Kawasaki disease is receiving low-dose aspirin. The mother calls the clinic and states that the child has been exposed to influenza. Which recommendation should the nurse make? Select all that apply.

Stop the aspirin Watch for fever.

The nurse is preparing to administer insulin to a diabetic child. Which would be the recommended route for this administration?

Subcutaneous

A nurse is caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse assess the infant for which early sign of CHF?

Tachycardia

A community health nurse is teaching a new mother about caring for her baby. The mother is worried about her child developing food allergies and asks the nurse what she can do to prevent it. Which information is most appropriate in this situation?

Tell the mother not to introduce solid foods in the baby's diet until he is at least 4 to 6 months' old

A 7-year old girl is being seen at a healthcare clinic; the nurse suspects that the child is being neglected and physically abused at home. Beyond physical markings on the child, which of the following can also indicate signs of a child being abused or neglected? Select all that apply.

The patient is wearing dirty, poorly-fitted clothes The patient misses school approximately once per week The child has body odor and rotting teeth

A child is being cared for in the ICU after suffering a head injury. The patient requires a ventilator and he is sedated. The child is at risk of pressure ulcers because of his immobility. Which of the following nursing interventions is most appropriate to prevent skin breakdown in this child?

Turn or reposition the child in bed every 2 hours

A nurse is assessing an 8-year old with diabetes who is experiencing hyperglycemia. Which symptoms indicate that hypoglycemia requires immediate intervention. Select all that apply.

Weakness Thirst Dizziness

Discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin should include which information? Select all that apply. a. Give the medication at regular intervals. b. Mix the medication with a small volume of breast milk or formula. c. Repeat the dose one time if the child vomits immediately after administration. d. Notify the HCP of poor feeding or vomiting. e. Make up any missed doses as soon as realized. f. Notify the HCP if more than two consecutive doses are missed.

a. Give the medication at regular intervals. d. Notify the HCP of poor feeding or vomiting. f. Notify the HCP if more than two consecutive doses are missed.

A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes which action(s)? (Select all that apply.) a. Monitoring and maintaining systemic blood pressure b. Administering corticosteroids c. Minimizing environmental stimuli d. Discussing long-term care issues with the family e. Monitoring for respiratory complications

a. Monitoring and maintaining systemic blood pressure b. Administering corticosteroids e. Monitoring for respiratory complications Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury. It is not necessary to minimize environmental stimuli for this type of injury. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.

A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub the leg. c. Apply powder to absorb material. d. Carefully pick material off of the leg.

a. Soak in a bathtub. Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceoussecretions. It may take several days to eliminate the accumulation completely. The parents and child should beadvised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation andbleeding. Oil or lotion, but not powder, may provide comfort for the child.

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 child participates in decision making with the procedure b. The nurse helps a child sign the consent form c. informed parent signs the consent form for the child d. The parents tell the child that they will have surgery

a. The child participates in decision making with the procedure

The nurse is teaching the family of an infant with cerebral palsy how to administer a diazepam (Valium) pill by gastrostomy tube. What should the nurse include in the teaching session? a. The pill should be crushed and mixed with a small amount of water. b. The pill should be crushed and mixed with the infant's formula. c. After administering the medication, flush the tube with air. d. Before administering the medication, check the placement of the tube.

a. The pill should be crushed and mixed with a small amount of water. Pills may be crushed and mixed with small amounts of water but not other liquids, such as formula or elixir medications, because these may act together to form a sludge that can interfere with gastrostomy tube function. When crushed pills or tablets are administered, flush the feeding tube with more water after instilling the dissolved pill in water. The tube should not be flushed with air, and placement does not need to be checked because it is directly into the stomach.

Which factor, if described by the parents of a child with Cystic Fibrosis, indicates understanding the underlying problem of the disease a. an abnormality in the body's mucus secreting glands b. formation of fibrous cysts in various body organs c. failure of the pancreatic ducts to develop properly d. reaction to the formation of antibodies against streptococcus

a. an abnormality in the body's mucus secreting glands

A nurse is caring for an infant with a diagnosis of hydrocephalus. Preoperatively, a priority nursing intervention is to: a) test the urine for protein b) reposition the infant frequently c) provide a stimulating environment d) assess blood pressure every 15 minutes

b) reposition the infant frequently Hydrocephalus occurs as a result of imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure. In infants w/ hydrocephalus, the head grows at an abnormal rate, and if infant is not repositioned frequently, pressure ulcers can occur on the back & side of the head. An egg crate mattress under the head is also a nursing intervention. Stimulus should be kept at a minimum b/c of the increase in ICP. It is not necessary to check the BP every 15mins.

The parents of a 4-month-old infant cannot visit except on weekends. Which action by the nurse indicates an understanding of the emotional needs of a young infant? a. Place her in a room away from other children. b. Assign her to the same nurse as much as possible. c. Tell the parents that frequent visiting is unnecessary. d. Assign her to different nurses so she will have varied contacts.

b. Assign her to the same nurse as much as possible. The infant is developing a sense of trust. This is accomplished by the consistent, loving care of a nurturing person. If the parents are unable to visit, then the same staff nurses should be used as much as possible. Placing her in a room away from other children would isolate the child. The parents should be encouraged to visit. The nurse should describe how the staff will care for the infant in their absence.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? a.Warm, dry skin b.Decreased wheezing c.Pulse rate of 90 beats/minute d.Respirations of 18 breaths/minute

b. decreased wheezing Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10 year old is 70-110 beats/min and normal respiratory rate is 16-20 breaths/minute.

Parents bring a 7-year-old child to the clinic for evaluation of an injured wrist after a bicycle accident. The parents and child are upset, and the child will not allow an examination of the injured arm. What priority nursing intervention should occur at this time? a. Send the child to radiology so radiography can be performed. b. Initiate an intravenous line and administer morphine for the pain. c. Calmly ask the child to point to where the pain is worst and to wiggle fingers. d. Have the parents hold the child so that the nurse can examine the arm thoroughly.

c. Calmly ask the child to point to where the pain is worst and to wiggle fingers. Initially, assessment is the priority. Because the child is alert but upset, the nurse should work to gain the child's trust. Initial data are gained by observing the child's ability to move the fingers and to point to the pain. Other important observations at this time are pallor and paresthesia. The child needs to be sent for radiography, but initial assessment data need to be obtained. Sending the child for radiography will increase the child's anxiety, making the examination difficult. It is inappropriate to ask parents to restrain their child. These parents are upset about the injury. If restraint is indicated, the nurse should obtain assistance from other personnel

A nurse has just administered medication via an orogastric tube. What is the priority nursing action following administration? a. Check tube placement. b. Retape the tube. c. Flush the tube. d. Remove the tube.

c. Flush the tube. Feedback: After administration, the nurse should flush the tube to maintain patency and ensure that the entire amount of medication has been given. The tube should be checked prior to administering the medication. It is not necessary to retape the tube following administration. It is not appropriate to remove the tube unless it has been specifically ordered

When preparing the teaching plan for the mother of a child with asthma, what info should the nurse include as a sign to alert the mother that her child is having an asthma attack a. secretion of thin, copious mucus b. tight, productive cough c. wheezing on expiration d. temp of 99.4

c. wheezing on expiration

A nurse is working with a child who has a learning disability because she is unable to discriminate between different speech sounds. This disorder is most accurately described as:

phonological processing deficit

A nurse is caring for a 13-year-old girl who is sexually active and whose partner is her 19-year- old boyfriend. The girl asks the nurse not to tell her parents about her sexual activity. This patient's situation is best described as:

statutory rape