Saunders Comprehensive Review for the NCLEX-RN® -Pt2

The nurse is collecting data on a child brought to the health care clinic by the mother with a one-week-old cat scratch. While assessing the scratch the nurse notes redness, heat, swelling, and red streaking surrounding the area. The child states that the scratch hurts. Cellulitis is diagnosed. When providing home care instructions, which of the following statements made by the mother indicates a need for further education? 1. "The child should rest in bed." 2. "I should apply cool, moist soaks every 4 hours." 3. "I should take the child's temperature and watch for a fever." 4. "The affected extremity should be elevated and immobilized."

2 Rationale: The child with cellulitis should rest in bed, and the affected extremity should be elevated and immobilized. Warm moist soaks applied every 4 hours increase circulation to the infected area, relieve pain, and promote healing.

A nurse is developing a plan of care for a 4-year-old child scheduled for a renal biopsy. Based on the developmental level of the child the nurse considers which of the following? 1. Masturbation is common in this age group. 2. Body image may be a concern for the child. 3. Fears of mutilation may be present in the child. 4. The urination pattern will cause embarrassment for the child.

3 Rationale: During the preschool years, a child's fears of separation and mutilation are great, because the child is facing the developmental task of trusting others.

The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation? 1. Heart rate 2. Lung sounds 3. Level of consciousness 4. Amount of edema at the site of the burn injury

3 Rationale: The sensorium, or level of consciousness, is an important guide to the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of consciousness in the child. .

The nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by: 1. Covering the bladder with a sterile gauze dressing 2. Covering the bladder with a dry sterile dressing 3. Applying sterile water soaks to the bladder mucosa 4. Covering the bladder with a sterile, non-adhering dressing * bladder exstrophy: is a birth defect. It's a condition where the bladder and parts around it form inside-out. The skin, muscle, and pelvic (hip) bones at the lower part of the belly or abdomen are not joined. As a result, the inside of the bladder pokes outside the belly.

4 Rationale: Care should be taken to protect the exposed bladder tissue from drying while allowing drainage of urine.

The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which of the following is a priority in the plan of care? 1. Wound care 2. Pain control measures 3. Measurement of intake 4. Cold and heat applications *Orchiopexy (or orchidopexy) is a surgery to move an undescended (cryptorchid) testicle into the scrotum and permanently fix it there. Orchiopexy typically also describes the surgery used to resolve testicular torsion.

1 *The most common complications associated with orchiopexy are bleeding and infection.

A nursing student is assigned to care for a child following surgery to correct cryptorchidism. The nursing instructor reviews the plan of care developed by the student and determines that the student is adequately prepared to care for the child if the student identifies which priority in the plan of care following this type of surgery? 1. Prevent tension on the suture. 2. Force oral fluids, and monitor I&O. 3. Monitor urine for glucose and acetone. 4. Encourage coughing and deep breathing every hour. * cryptorchidism: the most common abnormality of male sexual development. In this condition, the testis is not located in the scrotum. It can be ectopic, incompletely descended, retractile, and absent or atrophic.

1 *When a child returns from surgery, the testicle is held in position by an internal suture that passes through the testes and scrotum and is attached to the thigh. It is important not to dislodge this suture, and it should be immobilized for 1 week.

The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse would expect to note which of the following findings documented in the child's record? 1. Polyuria 2. Weight gain 3. Hypotension 4. Grossly bloody urine

2 Rationale: Massive edema resulting in dramatic weight gain is a characteristic finding in nephrotic syndrome. Urine is dark, foamy, and frothy, but only microscopic hematuria is present frank. Urine output is decreased, and hypertension is likely to be present.

The nurse is providing instructions to the mother of a child with herpetic gingivostomatitis. Which of the following responses, if stated by the mother after teaching, would indicate that further instruction is required? 1. "I will offer my child soft, bland foods." 2. "I will encourage my child to drink fluids." 3. "I will give my child frozen ice pops to assist with fluid intake." 4. "I will not give my child anything to eat for 2 days to allow the lesions to heal and crust over." *herpetic gingivostomatitis: is often the initial presentation during the first ("primary") herpes simplex infection. It is of greater severity than herpes labialis (cold sores) which is often the subsequent presentations. Primary herpetic gingivostomatitis is the most common viral infection of the mouth.

4 Rationale: Fluid intake is very important, and the child must be encouraged to drink. Frozen ice pops, noncitrus juices, and flat soft drinks are best. Small feedings of bland soft foods should be offered to the child.

The mother of a newborn male infant with hypospadias asks the nurse why circumcision cannot be performed. The most appropriate response by the nurse is which of the following? 1. "Circumcision will cause an infection." 2. "Circumcision is not performed in a newborn." 3. "Circumcision will cause difficulty with urination." 4. "Circumcision has been delayed to save tissue for surgical repair." *hypospadias: A condition in which the opening of the penis is on the underside rather than the tip.

4 Rationale: The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias.

The nurse is developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. The nurse determines that which of the following is a priority for the child? 1. Promoting bed rest 2. Restricting oral fluids 3. Encouraging visits from friends 4. Allowing the child to play with the other children in the playroom

1 Rationale: Bed rest is required during the acute phase, and activity is gradually increased as the condition improves.