ATI Care of Children Practice Assessment B 2017

A nurse is preparing to leave the room after performing nasal suctioning for an infant who has respiratory syncytial virus (RSV). Identify the sequence in which the nurse should remove all of the following personal protective equipment (PPE). 1. Mask 2. Gown 3. Gloves 4. Goggles

1. Gloves 2. Goggles 3. Gown 4. Mask Rationale: The infant is on droplet and contact precautions due to the RSV. First, the nurse should remove his gloves, because these are the most contaminated. Second, the nurse should remove goggles, so they do not interfere with removing the other PPE. The nurse should then remove the gown, and finally the mask, to decrease exposure to the disease.

A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22 lb). The prescription reads phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer with each dose?

6.25 mL PO every 12 hr Rationale: Ratio and Proportion Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2.5 mg/kg = 2.5 x 10 = 25 mg Step 3: What is the dose available? Dose available = Have 20 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. Have/Quantity = Desired/X 20 mg/5 mL = 25 mg/X mL X = 6.25 Step 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 20 mg/5 mL and the provider prescribed 25 mg, it makes sense to administer 6.25 mL every 12 hr. The nurse should administer phenobarbital 6.25 mL PO every 12 hr. Desired Over Have Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2.5 mg/kg = 2.5 x 10 = 25 mg Step 3: What is the dose available? Dose available = Have 20 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 5 mL Step 6: Set up an equation and solve for X. Desired x Quantity/Have = X 25 mg x 5 mL/20 mg = X mL 6.25 = X Step 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 20 mg/5 mL and the provider prescribed 25 mg, it makes sense to administer 6.25 mL every 12 hr. The nurse should administer phenobarbital 6.25 mL PO every 12 hr. Dimensional Analysis Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the quantity of the dose available? 5 mL Step 3: What is the dose available? Dose available = Have 20 mg Step 4: What is the dose the nurse should administer? Dose to administer = Desired 2.5mg/kg = 2.5 x 10 = 25 mg Step 5: Should the nurse convert the units of measurement? No Step 6: Set up an equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ X mL = 5 mL/20 mg x 25 mg/ X = 6.25 Step 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 20 mg/5 mL and the provider prescribed 25 mg, it makes sense to administer 6.25 mL every 12 hr. The nurse should administer phenobarbital 6.25 mL PO every 12 hr.

A nurse is reinforcing teaching about home care with the guardian of a 14-month-old toddler who has spastic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will perform daily stretching exercises to my toddler's affected muscles." B. "I will ensure my toddler avoids activities that involve repetitive joint movements." C. "I will place my toddler on his stomach to nap after meals." D. "I will give my toddler pain medication just after he performs strenuous activities."

A. "I will perform daily stretching exercises to my toddler's affected muscles." Rationale: The nurse should reinforce that performing stretching exercises of the toddler's affected muscles will prevent muscle contractures. The nurse should encourage play activities that involve repetitive joint movements to assist with fine and gross motor development. The nurse should recommend positioning the toddler semi-upright after meals to prevent choking and aspiration. The nurse should reinforce that pain medication should be administered approximately 60 min prior to performing strenuous activities, such as stretching exercises or active play.

A nurse in a pediatric clinic is caring for an infant who has heart failure and a prescription for digoxin. Which of the following statements by the parent indicates the desired therapeutic effect of the medication? A. "My baby is breathing easier than she used to." B. "My baby is taking longer naps." C. "My baby is having fewer wet diapers." D. "My baby's heart rate is faster than it used to be."

A. "My baby is breathing easier than she used to." Rationale: The nurse should identify that the desired effect of digoxin is to increase cardiac output and decrease venous pressure and pulmonary edema, which will reduce respiratory demands. The nurse should identify that the desired effect of digoxin is to increase cardiac output, which will decrease fatigue. The nurse should identify that the desired effect of digoxin is to increase urinary output due to improved cardiac output, which will increase the number of wet diapers. The nurse should identify that the desired effect of digoxin is to increase cardiac output, which will reduce the heart rate.

A nurse is reinforcing teaching regarding the immunization schedule with the parent of a 6-month-old infant during a well-baby visit. Which of the following statements by the parent indicates an understanding of the teaching? A. "My baby will receive his third DTaP vaccine today." B. "My baby is old enough to receive the varicella vaccine today." C. "My baby will receive his final polio vaccine today." D. "My baby will receive his first hepatitis B vaccine today."

A. "My baby will receive his third DTaP vaccine today." Rationale: The nurse should reinforce with the parent that the infant should receive his third diphtheria, tetanus, and pertussis (DTaP) immunization at 6 months of age. The nurse should reinforce with the parent that the infant should not receive the varicella immunization until at least 12 months of age. The nurse should reinforce with the parent that the infant should receive four doses of the polio immunization at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years. The nurse should reinforce with the parent that the infant should receive his first hepatitis B immunization after birth and before being discharged from the facility.

A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the following by the parent requires immediate intervention by the nurse? A. "My child has refused to drink any fluids for the past 8 hours." B. "My child has been coughing throughout the night." C. "My child is very hoarse and has a fever of 100.4 degrees Fahrenheit." D. "My child recently had the flu."

A. "My child has refused to drink any fluids for the past 8 hours." Rationale: An inadequate fluid intake indicates the child is at greatest risk for dehydration and electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention by the nurse. The child is at risk for exhaustion due to coughing throughout the night and should be allowed to rest during the day as much as possible. However, another statement by the parent requires immediate intervention by the nurse. A fever and being hoarse will contribute to the preschooler's feelings of lethargy and malaise. However, another statement by the parent requires immediate intervention by the nurse. The child's recent illness of influenza indicates the probable source of the current findings of croup. However, another statement by the parent requires immediate intervention by the nurse.

A nurse is reinforcing teaching about vital signs with the guardian of a 1-year-old toddler. Which of the following statements by the guardian indicates an understanding of the teaching? A. "My child's pulse could increase to 150 beats a minute with activity." B. "My child's temperature should be 96.8 degrees Fahrenheit." C. "My child should take 40 breaths a minute." D. "My child's pulse could get as low as 60 beats a minute while asleep."

A. "My child's pulse could increase to 150 beats a minute with activity." Rationale: A pulse rate of 150/min is within the expected reference range for a toddler during physical activity. A temperature of 36.0° C (96.8° F) is below the expected reference range for a 1-year-old toddler. A respiratory rate of 40/min is above the expected reference range for a 1-year-old toddler. A pulse of 60/min during sleep is below the expected reference range for a 1-year-old toddler.

A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse. "I'm a bad parent, and I can't deal with this." Which of the following responses should the nurse make? A. "Tell me more about what you are feeling." B. "I understand how you are feeling." C. "Let's talk about home care for your child." D. "I'm sure you're just tired right now."

A. "Tell me more about what you are feeling." Rationale: The nurse should use open-ended statements that will allow the parent to share his feelings and emotions. During times of grief, the parent needs to express his emotions. The use of an open-ended statement relays the message that it is safe to do so with the nurse. A sympathetic response is a nontherapeutic technique that infers pity and discourages further exploration of the client's feelings and thoughts. Sympathy also limits problem solving. Changing the subject is a nontherapeutic technique that can leave the parent feeling even more hopeless. Minimizing the parent's feelings is a nontherapeutic technique that limits further discussion and problem solving by the parent.

A nurse is reinforcing dietary teaching with an adolescent who is lacto-vegetarian and has iron deficiency anemia. The nurse should recommend which of the following as the best source of iron? A. 1 cup (8 oz) shredded wheat cereal B. 1 cup (8 oz) apple juice C. ½ cup (4 oz) sweet green peppers D. ⅛ cup (1 oz) low-fat cheese

A. 1 cup (8 oz) shredded wheat cereal Rationale: The nurse should determine that shredded wheat cereal is an iron-fortified food. Therefore, it is the best option to recommend because it contains 1 g of iron per serving. The nurse should identify that apple juice contains potassium and vitamin C. The nurse should identify that green peppers contain vitamin A. The nurse should identify that low-fat cheese contains calcium.

A nurse is caring for a toddler who has otitis media and a temperature of 102.4 F. Which of the following actions should the nurse take first? A. Administer an antipyretic. B. Reduce the room temperature. C. Dress the child in minimal clothing. D. Apply cool compresses to the child's forehead.

A. Administer an antipyretic Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Reducing the room temperature is an effective method of reducing the toddler's temperature when implemented approximately 1 hr after administration of an antipyretic. Therefore, this is not the first action the nurse should take. Dressing the child in minimal clothing is an effective method of reducing the toddler's temperature when implemented approximately 1 hr after administration of an antipyretic. Therefore, this is not the first action the nurse should take. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented approximately 1 hr after administration of an antipyretic. Therefore, this is not the first action the nurse should take

A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate? A. Apical B. Radial C. Carotid D. Femoral

A. Apical Rationale: The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line. The radial pulse in an infant is deep and difficult to palpate, because the blood pressure in an infant is low and the pulse rate is high. Therefore, it is difficult to accurately assess the pulse at this site. The radial pulse can be used to obtain a pulse on a child older than 2 years of age. The carotid pulse in an infant is deep and difficult to palpate. Therefore, it is difficult to accurately assess the pulse at this site. The femoral pulse in an infant is deep and difficult to palpate, because the blood pressure in an infant is low and the pulse rate is high. Therefore, it is it difficult to accurately assess the pulse at this site.

A nurse is assisting with the care of a child who is postoperative and received a transfusion during a surgical procedure. Which of the following findings indicates the child is hemolytic reaction? A. Chills and flank pain B. Pruritus and flushing C. Rales and cyanosis D. Bradycardia and diarrhea

A. Chills and flank pain Rationale: Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify this finding as an indication that the child is having a hemolytic reaction. Pruritus and flushing are findings that indicate a response to allergens present in the transfused blood product. The nurse should identify that the child is having an allergic reaction. Rales and cyanosis are findings that indicate the blood product might have been administered too quickly. The nurse should identify these findings as an indication that the child is experiencing fluid overload. Bradycardia and diarrhea are findings that indicate a complication due to the transfusion of large amounts of blood or a problem with the kidneys. The nurse should identify these findings as an indication that the child is experiencing an electrolyte imbalance.

A nurse is reinforcing teaching with the parent of a 4-month-old infant who has a new prescription for nystatin to treat oral candidiasis and is breastfeeding. Which of the following instructions should the nurse include in the teaching? A. Continue nystatin for 2 weeks after the symptoms disappear. B. Clean the infant's pacifier every 2 days. C. Discontinue breastfeeding until the infant is symptom-free. D. Wipe the white patches from the infant's tongue using a gauze pad.

A. Continue nystatin for 2 weeks after the symptoms disappear. Rationale: To prevent relapse, nystatin therapy should continue for at least 2 weeks after the lesions disappear. The parent should clean the infant's pacifier once daily by boiling it for 20 min. Discontinue breastfeeding until the infant is symptom-free. The parent can continue to breastfeed the infant during treatment. The parent should also receive treatment to prevent reinfection. It is not possible to remove candidiasis with a gauze pad and attempting to do so can cause bleeding and further discomfort to the infant.

A nurse is assisting with the care of a 4-year-old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure? SOA A. Discuss benefits of the procedure. B. Provide the child with a detailed explanation of the procedure. C. Implement interactive sessions of 30 min. D. Give the child needleless IV supplies to play with. E. Allow the child to perform the procedure with a doll.

A. Discuss benefits of the procedure. D. Give the child needleless IV supplies to play with. E. Allow the child to perform the procedure with a doll. Rationale: The nurse should discuss the benefits of the procedure with the child, because this action is an age-appropriate activity that will decrease the child's anxiety about the procedure. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Detailed explanations are likely to increase the child's anxiety about the procedure and should be avoided. Instead, the nurse should explain the procedure using simple words and phrases. To maintain the child's attention, the nurse should limit interactive sessions for a preschooler to 10 to 15 min each. The nurse should allow the child to see, hold, and collect the supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. The nurse should allow the child to mimic the procedure with a doll to alleviate anxiety. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure.

A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect? A. Hgb 9.0 g/dL B. Hct 37% C. Iron 100 mcg/dL D. Total iron binding capacity 325 mcg/dL

A. Hgb 9.0 g/dL Rationale: The nurse should expect a child who has iron deficiency anemia to have an Hgb level below the expected reference range of 9.5 to 15.5 g/dL. An Hgb of 9.0 g/dL is below the expected reference range. The nurse should expect a child who has iron deficiency anemia to have an Hct level below the expected reference range of 30% to 44%. A level of 37% is within the expected reference range. The nurse should expect a child who has iron deficiency anemia to have an iron level below the expected reference range of 50 to 120 mcg/dL. A level of 100 mcg/dL is within the expected reference range. The nurse should expect a child who has iron deficiency anemia to have an elevated total iron binding capacity above the expected reference range of 250 to 460 mcg/dL. A level of 325 mcg/dL is within the expected reference range.

A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints? A. Mummy restraint B. Jacket restraint C. Elbow restraints D. Wrist restraints

A. Mummy restraint Rationale: The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the toddler that involves the head and neck. The nurse should always use the least amount of restraint necessary. The nurse should identify that a jacket restraint is used to keep a toddler safe in a chair or in a horizontal position in a crib. This type of restraint is not effective for immobilizing a toddler during a procedure. The nurse should identify that elbow restraints are used to prevent a toddler from reaching for her face after a procedure. This type of restraint is not effective for immobilizing during a procedure, because the toddler will be able to move her arms to resist the procedure. The nurse should identify that wrist restraints are used to prevent a toddler from pulling or touching invasive equipment, such as an IV infusion catheter. This type of restraint is not effective for immobilizing a toddler during a procedure.

A nurse is contributing to the plan of care for a 10-month-old infant who is postoperative following a cleft palate repair. Which of the following actions should the nurse include in the plan of care? A. Place the infant in side-lying position. B. Offer the infant liquids with a straw. C. Prohibit the guardian from holding the infant for 8 hr. D. Cleanse the suture line with a lemon glycerin swab.

A. Place the infant in side-lying position. Rationale: The nurse should place the infant in side-lying position to promote healing and prevent injury to the surgical site. The nurse should offer the infant liquids with a soft cup and avoid placing straws, spoons, or other hard objects inside the infant's mouth, which can disrupt the sutures. The nurse should encourage the infant's guardian to use nonpharmacological methods of pain management, including cuddling, rocking, and holding, which can also facilitate bonding. The nurse should cleanse the suture line with sterile saline or water and a sterile, cotton-tipped applicator. Lemon glycerin swabs can burn and cause discomfort.

A nurse is caring for a 1-month-old infant who has a nasogastric tube in place for intermittent feedings. Which of the following actions should the nurse take? A. Position the head of the crib at a 30° angle between feedings. B. Place the infant on her left side after a feeding. C. Administer feedings over 5 min. D. Flush the tube with 30 mL of tap water.

A. Position the head of the crib at a 30° angle between feedings. Rationale: The nurse should place the infant with the head of the crib elevated 30° to 45° to prevent aspiration. The nurse should place the infant on her right side for 30 to 60 min after a feeding to prevent aspiration. The nurse should administer the feeding over 15 to 30 min to prevent nausea, regurgitation, and aspiration. The nurse should flush small tubes with 1 to 2 mL of sterile water, and large tubes with 5 to 15 mL of sterile water, to clear tubes of formula and prevent clogging.

A nurse is collecting data from an 18-month-old toddler. Which of the following deviation from expected growth and development that the nurse should report to the provider? A. The toddler is unable to recognize familiar objects by name. B. The toddler is unable to dress himself in simple clothing. C. The toddler is unable to talk in complete sentences. D. The toddler is unable to draw a circle.

A. The toddler is unable to recognize familiar objects by name. Rationale: The nurse should report that the toddler is unable to recognize familiar objects by name, because this is a deviation from expected growth and development. The toddler should be able to accomplish this task by 12 months of age. The nurse should recognize that the toddler is not expected to dress himself in simple clothing until 24 months of age. The nurse should recognize that the toddler is not expected to talk in complete sentences until 3 years of age. The nurse should recognize that the toddler is not expected to draw a circle until 30 months of age.

A nurse is reinforcing discharge teaching with the guardians of a 6-month-old infant following a surgical procedure to repair hypospadias. Which of the following instructions should the nurse include? A. Wait 1 week before giving the infant a tub bath. B. Apply antifungal ointment to the infant's penis. C. Avoid giving the infant fruit juice. D. Apply dry gauze dressing to the infant's penis twice daily.

A. Wait 1 week before giving the infant a tub bath. Rationale: The nurse should instruct the guardians to keep the infant's penis as dry as possible until the stent or catheter is removed. The parent should provide sponge-baths to the child until the stent or catheter is removed. The nurse should instruct the guardians to apply an antibacterial ointment to the infant's penis daily to decrease the risk for infection. The nurse should instruct the guardians to increase the infant's fluid intake. The nurse should not instruct the guardians to apply gauze dressing to the infant's penis, because the surgical site does not require a dressing.

A nurse is reinforcing dietary teaching with the parent of a child of a 2-year-old toddler. Which of the following should the nurse include in the teaching? A. "It is recommended that the toddler consumes no more than 12 ounces of fruit juice each day." B. "An appropriate serving size is 1 tablespoon of food per year of age." C. "Introduce healthy finger foods like carrots and celery sticks." D. "Encourage 5 cups of low-fat milk each day."

B. "An appropriate serving size is 1 tablespoon of food per year of age." Rationale: The nurse should include that an appropriate serving size for a 2-year-old toddler is 1 tbsp of food per year of age. The nurse should recommend limiting the consumption of fruit juice to ½ to ¾ cup (4 to 6 oz) per day for toddlers. A high consumption of juice can lead to dental caries and diarrhea. The nurse should include that foods, such as carrots and celery sticks, should be avoided until the toddler is 4 years of age because of the risk for choking. The nurse should include that the toddler should drink 2 to 3 cups (16 to 24 oz) of low-fat milk each day. Too much milk in the toddler's diet can replace foods that provide iron, resulting in an iron deficiency.

A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with a parent of a 1-month-old infant. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will let my baby sleep with me in bed at night." B. "I will allow my baby to have a pacifier while sleeping." C. "I will place my baby on a soft mattress to sleep." D. "I will cover my baby with a quilt while he is sleeping."

B. "I will allow my baby to have a pacifier while sleeping." Rationale: The nurse should reinforce with the parent that allowing the infant to fall asleep with a pacifier in his mouth decreases the risk for SIDS. The nurse should reinforce with the parent that sharing a bed with the infant increases the risk for SIDS and suffocation. The nurse should reinforce with the parent that placing the infant on a soft mattress to sleep increases the risk for SIDS and suffocation. The nurse should reinforce with the parent that covering the infant with a quilt while he is sleeping increases the risk for SIDS and suffocation.

A nurse is reinforcing teaching with the guardians of a school-age child who has frequent nosebleeds. Which of the following instructions should the nurse include? A. Place ice on the child's forehead. B. Apply pressure to the child's nose. C. Have the child lie down to rest until the bleeding stops. D. Tape cotton gauze on the child's nose.

B. Apply pressure to the child's nose Rationale: The nurse should instruct the guardians to apply pressure to the child's nose for at least 10 min to decrease bleeding. The nurse should also instruct the guardians to tilt the child's head forward, because this position prevents aspiration of the blood. The nurse should instruct the guardians to apply ice to the bridge of the child's nose, which can decrease bleeding. The nurse should instruct the guardians to have the child sit up and lean forward to prevent aspiration. The nurse should instruct the guardians not to tape gauze on the child's nose. Instead, the guardians should pack the child's nostrils with cotton gauze to decrease bleeding.

A nurse is reinforcing anticipatory guidance to the parents of an adolescent. Which of the following recommendations should the nurse include? A. Compare the adolescent's behavior to older siblings. B. Be open to the adolescent's point of view. C. Select school activities for the adolescent. D. Provide the adolescent with flexible rules.

B. Be open to the adolescent's point of view. Rationale: During this stage of development, adolescents are developing autonomy and self-identity. The nurse should recommend that the parents actively listen and be open to the adolescent's point of view, even if the parents disagree with his viewpoint. During this stage of development, adolescents are developing autonomy and self-identity. Comparing the adolescent's behavior to older siblings implies judgment and does not consider the adolescent as a unique individual. During this stage of development, adolescents are developing autonomy and self-identity. Allowing the adolescent to choose activities to participate in demonstrates respect for his likes and dislikes. During this stage of development, adolescents are developing autonomy and self-identity; however, they still need structure and guidance. The parents should provide the adolescent with clear, consistent rules and consequences.

A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further? A. Respiratory rate 25/min B. Blood pressure 120/80 mm Hg C. Heart rate 110/min D. Rectal temperature 37.4° C (99.3° F)

B. Blood pressure 120/80 mm Hg Rationale: A blood pressure of 120/80 mm Hg is outside the expected reference range for an 18-month-old toddler and requires further investigation by the nurse. A respiratory rate of 25/min is within the expected reference range for an 18-month-old toddler. A heart rate of 110/min is within the expected reference range for an 18-month-old toddler. A rectal temperature of 37.6° C (99.7° F) is within the expected reference range for an 18-month-old toddler.

A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For which of the following adverse effects should the nurse monitor? A. Hypersalivation B. Depression C. Bradycardia D. Hyperreflexia

B. Depression Rationale: Clients taking isotretinoin can experience mental status changes, such as suicidal thoughts, aggression, emotional lability, and depression. The nurse should monitor the adolescent's mental status while taking isotretinoin. Clients taking isotretinoin can experience adverse effects affecting the oral cavity, such as gingivitis and xerostomia. The nurse should monitor the adolescent for dry mouth while taking isotretinoin. Clients taking isotretinoin can experience cardiovascular adverse effects, such as chest pain, palpitations, and tachycardia. Clients taking isotretinoin can experience musculoskeletal adverse effects, such as pain in the muscles and joints, tendonitis, and muscle weakness.

A nurse is reinforcing teaching with the parent of a child who is being treated with diphenhydramine for allergic rhinitis. The nurse should tell the parent to monitor which of the following? A. Polyuria B. Drowsiness C. Drooling D. Hypogeusia

B. Drowsiness Rationale: Diphenhydramine can cause drowsiness due to CNS depression. The nurse should reinforce with the parent to administer the medication at bedtime to avoid daytime sedation. The nurse should reinforce with the parent that diphenhydramine has anticholinergic properties, which can result in dry eyes and urinary retention. The nurse should reinforce with the parent that diphenhydramine has anticholinergic properties, which can result in dry eyes and a dry mouth. The nurse should reinforce with the parent that diphenhydramine has anticholinergic properties, which can result in dry mucous membranes. However, losing the sense of taste, or hypogeusia, is not an adverse effect associated with diphenhydramine.

A nurse is reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetamide. Which of the following instructions should the nurse include? A. Remove dried drainage with a cold washcloth. B. Instill medication immediately after cleansing the eye. C. Apply an occlusive gauze over the child's eye. D. Cleanse the eye by gently wiping from the outer aspect of the eye inward toward the nose.

B. Instill medication immediately after cleansing the eye. Rationale: The nurse should instruct the guardian to place the medication in the eye immediately after cleansing. The nurse should instruct the guardian that occlusive dressings promote bacterial growth and are contraindicated for a child who has conjunctivitis.The nurse should instruct the guardian to cleanse the eye by wiping from the inner to the outer canthus of the eye. The nurse should instruct the guardian to use a warm, moist compress to allow for easier removal of dried drainage from the affected eye.

A nurse is preparing to administer levalbuterol via nebulizer to a child with asthma. Which of the following data should the nurse collect prior to administering the medication? A. Peak flow reading B. Lung sounds C. ABGs D. Inspiratory reserve volume

B. Lung sounds Rationale: Levalbuterol is a bronchodilator used to increase air exchange. The nurse should evaluate lung sounds prior to and after the administration of the medication to determine changes in respiratory status. Levalbuterol is a bronchodilator used to increase air exchange. However, it is not necessary to determine the inspiratory reserve volume before administering levalbuterol. Levalbuterol is a bronchodilator used to increase air exchange. Prior to administering medication, the nurse should monitor the presence, color, and character of sputum. However, it is not necessary to collect a peak flow reading before administering levalbuterol.

A nurse is contributing to the plan of care for a child who is in Buck's traction. Which interventions should the nurse include in the plan? A. Remove the weights when changing the bed linens. B. Maintain the leg in an extended position. C. Monitor the halo device every 4 hr. D. Provide pin care as prescribed.

B. Maintain the leg in an extended position Rationale: The nurse should have the child maintain her affected leg in an extended position while in Buck's traction. This position decreases the risk for further injury to the extremity and minimizes the occurrence of muscle spasms. The nurse should maintain the weights in place to avoid discomfort to the child caused by muscle spasms. The nurse should identify that a halo device is used for a client who requires cervical traction. Buck's traction is used in the treatment of Legg-Calve-Perthes disease or other musculoskeletal disorders of the lower extremities. Providing pin care as prescribed is an appropriate nursing intervention for a child who is in skeletal traction. Buck's traction uses skin straps or a special boot for traction.

A nurse is reviewing the plan of care for a child who has cystic fibrosis. Which of the following is the priority goal for this child? A. The child will participate in age-appropriate recreational activities. B. The child will maintain an effective breathing pattern. C. The child will maintain an adequate bowel elimination pattern. D. The child will receive immunizations as recommended.

B. The child will maintain an effective breathing pattern. Rationale: Manifestations of cystic fibrosis, such as chronic cough, pulmonary infection, and bronchiolar obstruction lead to severely impaired ventilation and gas exchange, which causes long-term pulmonary complications. Therefore, when utilizing the airway, breathing, circulation approach to client care, maintaining an effective breathing pattern is the priority goal for the child who has cystic fibrosis. Cystic fibrosis is a genetic disorder, which requires daily treatments, dietary requirements, and multiple medications. A child who has cystic fibrosis can have a failure to thrive due to the disease process and is often smaller than other children of the same age. Frequent hospitalizations can limit interactions with other children. Therefore, participating in age-appropriate recreational activities is important to promote growth and development. However, there is another goal that is a higher priority for this child. Cystic fibrosis is a genetic disorder, which has systemic manifestations. Increased viscosity of the intestinal secretions can cause mechanical obstruction of the bowel. Maintaining an adequate bowel elimination pattern is important to prevent bowel obstruction. However, there is another goal that is a higher priority for this child. Cystic fibrosis is a genetic disorder, which has systemic manifestations. A child who has cystic fibrosis is at risk for multiple pulmonary infections. Receiving immunizations as recommended is important to prevent communicable diseases. However, there is another goal that is a higher priority for this child.

A nurse is preparing to administer an IM injection to an 11-month-old infant. In which of the following areas should the nurse administer the medication? A. Deltoid muscle B. Vastus lateralis C. Dorsogluteal muscle

B. Vastus lateralis Rationale: The nurse should not administer an intramuscular (IM) injection in the deltoid muscle of an 11-month-old infant. IM injections are administered in the deltoid muscle for children 18-months of age or older, and only with small volumes of medication. The nurse should administer an IM injection in the vastus lateralis muscle of an 11-month-old infant. The vastus lateralis is a well-developed muscle that is safe to use for infants and small children. The nurse should not administer an IM injection in the dorsogluteal muscle due to its close proximity to the sciatic nerve. Medications injected in or near the sciatic nerve can cause complications, such as pain, paralysis, and numbness.

A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance . Which of the following supplements should the nurse instruct the parent to include in the child's diet? A. Zinc B. Vitamin D C. Thiamine D. Folic acid

B. Vitamin D Rationale: Lactose intolerance is managed by eliminating dairy products from the diet. However, this can result in a decrease in bone density because of the lack of calcium and vitamin D in the diet. The nurse should instruct the parent to administer a vitamin D supplement to the child to enhance the absorption of calcium from foods other than those containing lactose. Zinc is an enzyme found in oysters, poultry, nuts, and cereals. While it plays an important role in wound healing and immune system functioning, zinc does not affect bone health. Thiamine is a coenzyme found in breads, cereals, nuts, and dried legumes. While it plays an important role in energy metabolism and CNS functioning, thiamine does not affect bone health. Folic acid is found in breads and enriched grains. While it plays an important role in cellular formations and DNA synthesis, folic acid does not affect bone health.

A nurse is reinforcing teaching with the parent of an infant who has a new diagnosis of human immunodeficiency virus (HIV). Which of the following statements made by the parent indicates an understanding of the teaching? A. "The antiretroviral medication will stop the progression of the disease." B. "It won't be possible for my child to attend daycare." C. "I should bring my child in for immunizations on schedule." D. "My child's nutritional needs will not change."

C. "I should bring my child in for immunizations on schedule." Rationale: Immunizations provide protection from communicable diseases and should be administered on schedule. Infants who have HIV experience decreased appetite and diarrhea, which will make nutritional management a priority. Standard precautions are utilized for infants who have HIV. However, attending daycare is permissible. The antiretroviral medication slows the progression and formation of viral cells, but does not stop the progression of the disease.

A nurse is reinforcing teaching about interventions for mild hypoglycemia with the parent of a child who has diabetes mellitus. Which of the following statements by the parent indicates that the teaching has been effective? A. "I should administer a glucagon injection to my child." B. "I should give my child 5 grams of a simple carbohydrate." C. "I should give my child 4 ounces of orange juice followed by cheese and crackers." D. "I should give my child a snack that is 10 percent of his daily caloric intake."

C. "I should give my child 4 ounces of orange juice followed by cheese and crackers." Rationale: The parent should treat mild hypoglycemia with 10 to 15 g of a simple carbohydrate, such as 4 oz of orange juice, and follow it with a starch-protein snack. The nurse should reinforce with the parent that offering a snack that is 10% of the child's daily caloric intake might not meet the needs of the child and does not ensure the parent is giving the child a simple carbohydrate. The nurse should instruct the parent to provide 10 to 15 g of simple carbohydrates for hypoglycemia. The nurse should reinforce with the parent that glucagon is given in cases of severe hypoglycemia when the child is unconscious or uncooperative.

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I should not give my child aspirin for pain or fever." B. "My child will take antibiotics for 6 months." C. "My child might have a period of irregular movement of the extremities." D. "I should expect there to be blood in my child's urine."

C. "My child might have a period of irregular movement of the extremities." Rationale: The nurse should instruct the guardian that the child might experience chorea weeks or months after the initial diagnosis. Chorea is a temporary lack of coordination and the presence of sudden, irregular movements or periods of clumsiness. The nurse should instruct the guardian to expect the child to have joint pain, fever, subcutaneous nodules, weakness, and anorexia. The nurse should instruct the guardian that the child will be on long-term antibiotic therapy due to the probability of re-infection. The duration of prophylactic treatment is dependent on the severity of the disease. The nurse should instruct the guardian to administer salicylates, such as aspirin, to treat fever and pain and to decrease inflammation in the joints.

A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when his child will no longer be contagious. Which of the following responses should the nurse make? A. "When your child no longer has a fever." B. "Three days after the rash started." C. "Six days after lesions appear if they are crusted." D. "When your child's lesions disappear."

C. "Six days after lesions appear if they are crusted." Rationale: The nurse should inform the guardian that a child will stop being contagious around 6 days after the lesions appeared, as long as they are crusted over. The lesions associated with varicella can take varying times to completely resolve. However, a child stops being contagious when the lesions have crusted over and are no longer draining. The rash associated with varicella progresses through several stages, over a period of days, from macule to vesicle. However, a child can still be contagious 3 days after the rash started. The fever associated with varicella develops prodromally about 24 hr before the rash appears. The length of fever varies and is not an indicator of contagiousness. However, the child can still be contagious without a fever.

A nurse is assisting with the care for a 7-month-old who has cleft palate. Which of the following actions should the nurse take to decrease the infant's risk for aspiration? A. Feed the infant in supine position. B. Encourage the mother to breastfeed the infant exclusively. C. Burp the infant frequently during feedings. D. Perform nasotracheal suctioning if coughing occurs.

C. Burp the infant frequently during feedings. Rationale: Infants with a cleft palate have difficulty creating a seal around a bottle. Burping the infant frequently, following every ounce of fluid consumed, dissipates swallowed air and helps to prevent aspiration. If indicated, the nurse should gently suction the infant's mouth and nose with a bulb syringe. The use of nasotracheal suctioning is contraindicated in the infant because of the risk for injury. The nurse should inform the infant's mother that the cleft palate inhibits the ability to form a seal and obtain breast milk. Instead, the nurse should encourage the mother to use breast milk in a bottle, to promote skin to skin contact and allow non-nutritive sucking by the infant. This can also help to promote maternal-infant bonding. Feeding should occur while the infant is in an upright position to direct the flow of fluid downward and prevent aspiration.

A nurse is caring for a toddler following tonsillectomy. Which of the following is the priority finding that the nurse should report to the provider? A. Drowsiness B. Throat pain C. Continuous swallowing D. Dark brown emesis

C. Continuous swallowing Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should identify that continuous swallowing is a manifestation of hemorrhage. Therefore, this is the priority finding for the nurse to report to the provider. The nurse should identify that dark brown emesis is an expected finding for a toddler who has had a tonsillectomy. Therefore, another finding is the nurse's priority to report to the provider. The nurse should identify that throat pain is an expected finding for a toddler who has had a tonsillectomy. Therefore, another finding is the nurse's priority to report to the provider. The nurse should identify that drowsiness following the administration of anesthesia is an expected finding. Therefore, another finding is the nurse's priority to report to the provider.

A nurse is caring for a child who has type 1 diabetes mellitus and has been receiving insulin via subcutaneous infusion pump. Which of the following laboratory tests would verify the average blood glucose level over the past 2 months? A. Postprandial blood glucose B. Fasting blood glucose C. Glycosylated hemoglobin D. Mean corpuscular hemoglobin

C. Glycosylated hemoglobin Rationale: Glycosylated hemoglobin provides an accurate average of the client's blood glucose level over the past 120 days. This test can be used to determine the effectiveness of, or compliance with, a treatment plan. It can also be used to diagnose diabetes mellitus. Mean corpuscular hemoglobin provides information about the hemoglobin content of red blood cells and is used to identify anemia. However, it is not an accurate indicator to verify the average blood glucose level. Fasting blood glucose is a measurement of the circulating blood glucose level after 8 hours without caloric intake. While it is a diagnostic tool used in the management of diabetes mellitus, it is not an accurate indicator of the client's average blood glucose level over an extended period of time. Postprandial blood glucose is the circulating glucose level at a specified time after a meal, However, it is not an accurate indicator to verify the average blood glucose level.

A nurse is administering an injection of epinephrine to a child who is experiencing manifestations of anaphylaxis. The nurse should monitor for which of the following adverse effects? A. Pinpoint pupils B. Decreased heart rate C. Increased systolic blood pressure D. Dry skin

C. Increased systolic blood pressure Rationale: Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should expect the child to have an increased systolic blood pressure following administration of epinephrine. Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should expect the child to have diaphoresis following administration of epinephrine. Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should expect the child to have an increased heart rate following administration of epinephrine. Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should not expect the child to have pinpoint pupils as an adverse effect of this medication.

A nurse is preparing to assist a provider with a lumbar puncture for a school-age child. Which of the following actions is the nurse's priority? A. Labelling collected specimens B. Providing reassurance to the child C. Marinating the child's position D. Monitoring the child's vital signs

C. Marinating the child's position Rationale: The greatest risk to the child is injury to the spinal nerves or the major vessels. Therefore, the priority action is for the nurse to maintain the child's position to prevent trauma. It is important to check the child's vital signs to monitor the child's status. However, another action is the nurse's priority. It is important to provide reassurance to the child to help reduce anxiety. However, another action is the nurse's priority. It is important for the nurse to label collected specimens so the prescribed tests are completed, enabling diagnosis and treatment for the child. However, another action is the nurse's priority.

During a well-child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make? A. Vary the time the toddler goes to bed each night. B. Allow the toddler to watch television before bedtime. C. Provide the toddler with a favorite toy at bedtime. D. Increase the toddler's activity prior to bedtime.

C. Provide the toddler with a favorite toy at bedtime. Rationale: The nurse should recommend to the parent that providing the toddler with a favorite toy at bedtime will help the toddler to feel more secure and facilitate sleep. The nurse should recommend to the parent that a consistent bedtime routine is helpful in promoting sleep for a toddler. The nurse should recommend to the parent that watching television before bedtime can cause the child to be stimulated, which can create sleep disturbances. The nurse should recommend to the parent that activity should be decreased prior to bedtime to facilitate sleep. Increased activity can cause the toddler to be stimulated and lead to sleep disturbances.

A nurse is reinforcing teaching with the parents of a 2-year-old toddler at a well-child visit. Which of the following should the nurse recommend as an age-appropriate activity for the toddler? A. Creating a rock collection B. Learning the alphabet with flash cards C. Putting together a large-piece puzzle D. Riding a tricycle

C. Putting together a large-piece puzzle Rationale: The nurse should recommend putting together a large-piece puzzle as an age-appropriate activity for a 2-year-old toddler. Puzzles provide the child an opportunity to develop fine motor skills. Other fine motor skill activities include finger painting and coloring with thick crayons. The nurse should recommend riding a tricycle as an age-appropriate activity for a 3-year-old toddler who has more coordination and motor skills than the 2-year-old toddler. The nurse should recommend learning the alphabet with flash cards as an age-appropriate activity for a preschooler. This type of educational toy allows for an activity for the preschooler whose vocabulary is expanding. The nurse should recommend creating a rock collection as an age-appropriate activity for a school-age child who enjoys quiet and solitary activities.

A nurse is collecting data from a child during a well-child visit. The nurse that which of the following findings places that child at higher risk for abuse? A. The child is 6 years old. B. The child is male. C. The child was born at 30 weeks of gestation. D. The child was born via cesarean birth.

C. The child was born at 30 weeks of gestation. Rationale: The nurse should identify that children who are born prematurely are at greater risk for abuse because of the potential for impaired bonding during early infancy. The nurse should identify that children between birth and 1-year-old are at greater risk for abuse than school-age children, because they are more dependent upon others for care and relay personal needs by crying. The nurse should identify that a female child is more likely to experience abuse than a male child. The nurse should identify that the method of delivery has no influence on the risk for abuse.

A nurse is collecting data from a 12-month-old infant during a well-child visit. At birth, the infant's weight was 8 lb and his length 20 in. Based on this data, which of the following should the nurse expect? A. The infant weighs 6.4 kg (14 lb) B. The infant is 101.6 cm (40 in) long C. The infant is 76.2 cm (30 in) long D. The infant weighs 14.5 kg (32 lb)

C. The infant is 76.2 cm (30 in) long Rationale: The nurse should expect a length of 76.2 cm (30 in), because the infant's length should increase by about 50% by 12 months of age. The nurse should expect the infant's birth weight to triple by 12 months of age. A weight of 14.5 kg (32 lb) is within the expected range for an infant who is 19 months of age. The nurse should anticipate an infant's length to increase by about 50% by 12 months of age. A length of 101.6 cm (40 in) long is within the expected range for an infant who is 21 months of age. The nurse should expect the infant's birth weight to triple by 12 months of age. This weight is less than the expected range.

A nurse is assisting with the development of a health promotion program for the guardian of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program? A. The sleep patterns of adolescents are well established. B. The percentage of adolescents that consider suicide is higher for males than for females. C. The leading cause of death in adolescents is physical injury. D. The caloric intake needs of adolescents are less than that of school-age children.

C. The leading cause of death in adolescents is physical injury. Rationale: The nurse should recommend including this information, because injuries from motor-vehicle crashes are the leading cause of death in the adolescent population. The nurse should identify that an adolescent's increased growth pattern requires a higher caloric intake than that of school-age children. The nurse should identify that female adolescents are more likely to consider suicide than male adolescents. The nurse should identify that sleep requirements vary in the adolescent period, depending on activities and growth pattern.

A nurse is reinforcing teaching about liquid oral iron supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will give my child a double dose of this medication if she misses a dose." B. "I will give this medication to my child with a cup of skim milk." C. "This medication will turn my child's stools white." D. "I will give this medication to my child with a straw."

D. "I will give this medication to my child with a straw." Rationale: The nurse should reinforce with the guardian to administer this medication with a straw to prevent staining the child's teeth. The nurse should reinforce with the guardian that the medication will turn the child's stools dark green or black. The nurse should reinforce with the guardian that consuming milk with this medication can decrease iron absorption. The nurse should reinforce with the guardian that doubling the dose can result in iron toxicity. The child should take a missed dose as soon as remembered or within 12 hr of the missed dose.

A nurse in a pediatric clinic is talking on the telephone with parent of a 6-month-old infant who has urinary tract infection and started taking an oral antibiotic the day before. Listen to the audio clip and determine which of the following responses the nurse should make. "Every time I try to give a dose of this medicine to my baby, she either refuses it or takes it then spits it out. Is there anything I can try that might get her to take it?" A. "Mix the medicine with ¼ cup of juice before giving it to your baby." B. "Mix the medicine with 1 teaspoon of honey before giving it to your baby." C. "Mix the medicine with ¼ cup of formula before giving it to your baby." D. "Mix the medicine with 1 teaspoon of applesauce before giving it to your baby."

D. "Mix the medicine with 1 teaspoon of applesauce before giving it to your baby." Rationale: To enhance acceptance of an oral medication, the parent can mix the medication with a small amount of a sweet, nonessential food item. The parent should not mix medication with an essential food item, such as formula, because the infant might refuse the food later. Consuming honey places the infant at risk for botulism. Therefore, another sweet-tasting substance should be used. The infant might refuse to drink ¼ cup (2 oz) of juice, resulting in an incomplete dose. Therefore, this amount is too large to mix the medication with.

A nurse is reinforcing teaching with the guardian of a child who has a new prescription for levalbuterol solution for use in a nebulizer. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I should store the unused medication in the freezer." B. "I should make sure I use the vial within 3 weeks of opening it from the foil package." C. "My child might be drowsy while taking this medication." D. "My child might experience palpitations after taking this medication."

D. "My child might experience palpitations after taking this medication." Rationale: Palpitations are an adverse effect of levalbuterol. If this occurs, the guardian should discontinue the medication and notify the provider. Nervousness and anxiety are adverse effects of levalbuterol, a bronchodilator. The guardian should use the levalbuterol within 1 week of opening the vial or within 2 weeks of opening the foil pouch. The guardian should store unused levalbuterol solution at room temperature.

A nurse is reinforcing teaching with an adolescent who has an inflamed, nonperforated appendix and is scheduled for a laparoscopic assisted appendectomy. Which of the following instructions should the nurse include in the teaching? A. "You can begin drinking fluids again 2 days after surgery." B. "You will need to ask for pain medication for the first 24 hours after surgery." C. "You will have your vital signs monitored every 8 hours after surgery." D. "You will sit in your chair at least twice a day after surgery."

D. "You will sit in your chair at least twice a day after surgery." Rationale: The nurse should instruct the client that she will sit in a bedside chair at least twice a day and will be encouraged to ambulate as soon as possible following surgery. This activity will enhance lung function and help prevent postoperative complications. The nurse should instruct the client that her vital signs will be monitored frequently during the initial postoperative period until she is stable, and then at least every 4 hr following surgery. The nurse should instruct the client that she will receive analgesia on a scheduled basis for the first 24 hr following surgery. The nurse should instruct the client that she will be encouraged to eat ice chips and progress to clear fluids shortly following surgery.

A nurse is caring for a 3-year-old female child who is prescribed an indwelling urinary catheter. Which of the following actions should the nurse take when performing this procedure? A. Place a nonsterile drape under the buttocks. B. Use a catheter that is 12 French in size. C. Insert the catheter another 10 cm (3.9 in) after urine returns. D. Apply 2% lidocaine lubricant into the urethral meatus.

D. Apply 2% lidocaine lubricant into the urethral meatus. Rationale: The nurse should apply 2% lidocaine lubricant into the urethral meatus to assist in decreasing the discomfort the child might experience during catheterization. The nurse should insert the catheter an additional 2.5 to 5 cm (1 to 2 in) after urine returns to ensure the catheter tip is within the bladder. The nurse should select a catheter that is 5 to 8 French in size for the catheterization of a 3-year-old child. The nurse should place a sterile drape under the child's buttocks, because this is a sterile procedure.

A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler? A. Ask the child to state her name. B. Ask the pharmacy for the child's room number. C. Ask the child to state her birthday. D. Ask the guardian to verify the child's name.

D. Ask the guardian to verify the child's name. Rationale: Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should ask the guardian to verify the identity of the child and use the identification band as the second identifier. Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should not consider the toddler a reliable source to validate identity. Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should not consider the room number as a verification of identity because this can change throughout the care of the toddler. Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should not consider the toddler a reliable source to validate identity.

A nurse is collecting data from a school-age child. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Recurrent urinary tract infections D. Bruises at various stages of healing

D. Bruises at various stages of healing Rationale: The nurse should recognize that bruises at various stages of healing are a clinical manifestation of physical abuse. The nurse should recognize that recurrent urinary tract infections are a manifestation of sexual abuse. That nurse should recognize that malnutrition is a manifestation of physical neglect. The nurse should recognize that depriving a child of medical and dental care is a manifestation of physical neglect.

A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate? A. Protective environment B. Contact precautions C. Airborne precautions D. Droplet precautions

D. Droplet precautions Rationale: The nurse should plan to initiate droplet precautions for this child, because bacterial meningitis caused by Haemophilus influenzae type B is transmitted through the air via large-particle droplets. The nurse should plan to initiate airborne precautions for a child who has an illness that is transmitted through the air via small-particle droplets. The nurse should plan to initiate contact precautions for a child who has an illness that is easily transmitted by direct contact. The nurse should plan to initiate a protective environment for a child who is receiving allogeneic hematopoietic stem cell transplants.

A nurse is preparing to obtain a peak expiratory flow rate from an adolescent. Which of the following actions should the nurse take? A. Document the average of the client's three attempts. B. Instruct the client to exhale slowly over 5 seconds into the meter. C. Determine the zone according to the client's age. D. Have the client stand during the procedure.

D. Have the client stand during the procedure. Rationale: To obtain the peak expiratory flow rate, the nurse should have the client stand during the procedure, which will allow the nurse to get an accurate reading. To obtain the peak expiratory flow rate, the nurse should determine the zone according to the client's best personal result over a 2-week period. To obtain the peak expiratory flow rate, the nurse should instruct the client to exhale a quick breath into the meter. To obtain the peak expiratory flow rate, the nurse should document the highest result of the three attempts.

A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats in a motor vehicle. Which of the following instructions should the nurse include in the teaching? A. Ensure the shoulder-lap portion of the seat belt fits across the child's abdomen when sitting in the booster seat. B. Use a no-back, belt-positioning booster seat if the motor vehicle does not have head rests. C. Discontinue using a booster seat when the child is 135 cm (4 feet 5 in) in height. D. Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt.

D. Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt. Rationale: The nurse should instruct the parents to secure both the child and the booster seat with the shoulder-lap seat belt inside the motor vehicle, because booster seats do not have built-in straps. The nurse should instruct the parents that the child should continue using a booster seat until she reaches 145 cm (4 feet 8 in) in height. The nurse should instruct the parents to use a no-back, belt-positioning booster seat in a motor vehicle that has head rests. The nurse should instruct the parents that the lap portion of the seat belt should fit across the child's pelvis, not the abdomen.

A nurse is collecting data from a 10-month-old infant. Which of the following findings should the nurse report to the provider? A. Pulls self to standing position B. Moves by creeping on hands and knees C. Takes intentional steps when standing D. Sits with support by leaning on hands

D. Sits with support by leaning on hands Rationale: The nurse should identify that sitting with support can indicate a developmental delay, because an infant should be able to sit unsupported by 8 months of age. Therefore, the nurse should report this finding to the provider. The nurse should identify that taking intentional steps when standing is an expected finding for a 10-month-old infant. The nurse should identify that moving by creeping on hands and knees is an expected finding for a 9-month-old infant. The nurse should identify that pulling up to a standing position is an expected finding for a 9-month-old infant.

A nurse is collecting physical data from a 4-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child's skin turgor? A. The child's sacral area. B. The top of the child's hand. C. The child's sternal area. D. The child's abdomen.

D. The child's abdomen. Rationale: The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. To check skin turgor, the nurse should grasp the skin on the child's abdomen, pull it taut, and release it quickly. The child who is dehydrated will have a prolonged period of tenting. The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. However, the sacral area will not provide adequate information about hydration status. The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. However, the area on top of the child's hand will not provide adequate information about hydration status. The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. However, the sternal area will not provide adequate information about hydration status.

A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend? A. Graham crackers B. Rye bread C. Whole wheat spaghetti D. Yellow corn

D. Yellow corn Rationale: A client who has celiac disease is unable to process gluten, a protein found in wheat, barley, rye, and oats. The nurse should instruct the family that the client's diet is restricted to foods that are free of gluten, such as corn, rice, and millet. A client who has celiac disease should avoid eating food items that contain gluten, such as graham flour, which is a component of graham crackers. A client who has celiac disease is unable to process gluten, a protein found in grains, such as rye. The nurse should instruct the family that the client should avoid eating food items that contain gluten, such as rye bread. A client who has celiac disease is unable to process gluten, a protein found in grains, such as wheat. The nurse should instruct the family that the client should avoid eating food items that contain gluten, such as wheat products.