ATI: Pediatrics
Nevus simplex or Stork bite
Discoloration that typically blanches with pressure and becomes more prominent with crying. This finding does not require notification of the provider.
The infant's anterior fontanel is expected to close around?
The infant's anterior fontanel is expected to close around 12 months of age
Measles (Rubeola)
A child who has measles might develop Koplik spots, a transient cephalocaudal rash of maculopapular eruptions of the upper trunk and face. The rash becomes more confluent as it spreads to the lower areas of the body.
Tetanus
A child who has tetanus will develop lockjaw and muscle rigidity; however, there is no rash associated with tetanus. The DTaP immunization aids the prevention of this disease
Cerebral palsy
A loss or deficiency of motor control with involuntary spasms caused by permanent brain damage present at birth
6 - 12 YEARS
BP: 100-120 /60-80 mm Hg Heart Rate: 70-120 / min. Respiratory Rate: 18-25 / min.
Buck's traction
Buck's traction is skin traction, which works without the use of pins Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hours
Varicella
Children who have varicella may present first with a maculopapular rash that progresses to vesicles on erythematous bases, which eventually rupture and crust over.
A nurse is teaching the parent of a preschool-aged child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will give my child a dose of albendazole today and again in 2 weeks." B. "I will collect specimens immediately after my child has a bowel movement." C. "I will give my child a tub bath twice each day." D. "I will place my child's bed linens in a sealed plastic bag for 7 days."
Correct Answer: A. "I will give my child a dose of albendazole today and again in 2 weeks." The nurse should instruct the parent to repeat the dose of albendazole in 2 weeks to eradicate the parasite and prevent reinfection. Incorrect Answers: B. Pinworm specimens are collected in the morning as soon as the child wakes up and before the child bathes or has a bowel movement. C. To prevent reinfection, the child should be given a shower rather than a tub bath. D. The child's bed linens and clothing should be washed in hot water because pinworms can survive on surfaces for an extended period of time
A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hirschsprung's disease D. Crohn's disease
Correct Answer: A. Celiac disease The nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. Other malabsorption conditions include short-bowel syndrome, lactose intolerance, and congenital enzyme deficiency. Incorrect Answers: B. Ulcerative colitis causes chronic diarrhea because it is an inflammatory bowel disease. C. Hirschsprung's disease causes chronic diarrhea because of motility disorders. D. Crohn's disease causes chronic diarrhea because it is an inflammatory bowel disease
A nurse is assessing an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing? A. High-pitched cry B. Sunken fontanel C. Tachycardia D. Increased awake time
Correct Answer: A. High-pitched cry The nurse should identify that an infant's high-pitched cry is an indication of increased ICP. Other indications include a bulging fontanel, a high-pitched cry, and increased sleeping. Incorrect Answers: B. The nurse should identify that a firm and bulging fontanel is an indication of increased ICP. C. The nurse should identify bradycardia as an indication of increased ICP. D. The nurse should identify increased sleep time as an indication of increased ICP.
A nurse is assessing a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect? A. Hypertension B. Abdominal obesity C. Bradycardia D. Loose stools
Correct Answer: A. Hypertension The nurse should expect a child who has pheochromocytoma to exhibit hypertension due to the increased production of catecholamines. Other manifestations include sweating, weight loss, and polyuria. Incorrect Answers: B. The nurse should expect a child who has pheochromocytoma to exhibit anorexia and weight loss. C. The nurse should expect a child who has pheochromocytoma to exhibit tachycardia. D. The nurse should expect a child who has pheochromocytoma to exhibit constipation
A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? A. Koplik spots B. Parotitis C. Strawberry tongue D. Paroxysmal coughing
Correct Answer: A. Koplik spots Koplik spots are small, irregular oral lesions with a bluish-white center. They are characteristic of measles (rubeola). Koplik spots appear about 2 days before the maculopapular rash and are accompanied by fevers, malaise, conjunctivitis, and other cold manifestations. Incorrect Answers: B. Swollen parotid glands are an expected finding in a child who has MUMPS. C. Strawberry tongue is an expected finding in a child who has SCARLET FEVER. D. Paroxysmal coughing is an expected finding in a child who has PERTUSSIS
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? A. Upper right quadrant abdominal pain B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia
Correct Answer: B. Rigid abdomen A rigid abdomen is an expected manifestation of appendicitis. Incorrect Answers: A. RLQ abdominal pain is an expected manifestation of appendicitis. C. Decreased or absent bowel sounds are an expected manifestation of appendicitis. D. Tachycardia and rapid, shallow breathing are expected manifestations of appendicitis
A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take? A. Position the adolescent supine during the procedure B. Have the adolescent drink 240 mL (8 oz) of fluid prior to the procedure C. Obtain the adolescent's weight prior to the procedure D. Monitor the adolescent's vital signs every 4 hours during the procedure
Correct Answer: C. Removing waste, salt and extra water to prevent them from building up in the body. keeping a safe level of certain chemicals in your blood, such as potassium, sodium and bicarbonate. helping to control BP. Obtaining the adolescent's weight prior to the procedure The nurse should obtain a baseline weight prior to the initiation of the procedure and again following the procedure. Incorrect Answers: A. The nurse should ELEVATE HOB to minimize upward pressure on the diaphragm from the dialysate. B. The nurse should have the adolescent EMPTY BLADDER prior to the procedure to allow maximum space in the anterior peritoneal cavity. The adolescent does not need to drink fluids prior to the procedure. D. The nurse should monitor the adolescent's VS at least Q hour during the procedure
A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? A. Monitor the child's blood pressure twice per day B. Maintain the child on bed rest for 3 days C. Weigh the child once each day D. Increase the child's daily intake of sodium
Correct Answer: C. Weigh the child once each day The nurse should weigh the child at the same time each day to monitor fluid balance. Incorrect Answers: A. Glomerulonephritis can cause hypertension that can lead to cerebral ischemia. Therefore, the nurse should monitor the child's blood pressure every 4 hours. B. The child should participate in activities as tolerated. Bed rest is not required. D. The nurse should offer the child a regular diet with moderate sodium restriction and ensure no salt is added to foods.
A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? A. "I will give you an antibiotic before your procedure." B. "I will place you on your side during the procedure." C. "You might have a headache following the procedure." D. "I will place a pressure dressing over the area following the procedure."
Correct Answer: D. "I will place a pressure dressing over the area following the procedure." Applying a pressure dressing over the area following the procedure helps prevent bleeding from the site. Incorrect Answers: A. The child should not receive an antibiotic prior to a bone marrow biopsy because the use of an antibiotic might skew the test results. B. The child should be in the prone position because the provider will obtain the specimen from the iliac crest. C. Bone marrow aspiration will not affect the brain or its fluids. Lumbar punctures are likely to cause headaches
A nurse is assessing a preschooler who has HIV. Which of the following manifestations should the nurse expect? A. Generalized petechiae B. Jaundice C. Obesity D. Chronic diarrhea
D. Small bowel bacterial overgrowth is possible in people with HIV. Intestinal problems may make a person with HIV more likely to have an overgrowth of bacteria. This may lead to diarrhea and other digestive issues Incorrect Answers: A. Generalized petechiae are not a manifestation of HIV in a preschooler. B. Jaundice is not a manifestation of HIV in a preschooler. C. Failure to thrive and weight loss are expected findings for a preschooler who has HIV.
Fifth Disease
5th disease usually begins with bright red cheeks, producing a "slapped-cheek" appearance. Then, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance.
A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? A. Place a plastic bag over the cast when showering B. Insert a dull knitting needle into the cast to rub itchy skin C. Exercise fingers every 8 hr for the first 24 hr D. Draw on the cast using magic markers
Correct Answer: A. Place a plastic bag over the cast when showering The nurse should instruct the adolescent to keep the cast dry by placing a plastic bag over it while showering. Incorrect Answers: B. Placing any instruments inside the cast can injure the skin and cause an infection. C. The fingers should be moved and exercised every 4 hours for the first 24 hours. D. Fiberglass cast material is porous; therefore, magic markers should not be used to draw on or autograph the cast.
A nurse is assessing a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypokalemia B. Decreased blood pressure C. Increased urine volume D. Periorbital edema
Correct Answer: D. Periorbital edema Periorbital edema is a manifestation of acute glomerulonephritis. Swelling is usually worse in the mornings and spreads throughout the day to the genitalia, abdomen, and extremities. Incorrect Answers: A. Hypokalemia is not a manifestation of acute glomerulonephritis. B. The blood pressure of a school-aged child who has acute glomerulonephritis can suddenly become dangerously high. C. A reduced urine volume is a manifestation of acute glomerulonephritis NOT increased urine volume
A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL
Correct Answer: D. RBC 6.8 million/uL A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts. Male: 4.3-5.9 million/mm3 Female 3.5 -5.5 million/mm3 Incorrect Answers: A. A platelet count of 20,000/mm^3 is below the expected range. A child who has tetralogy of Fallot will NOT have a decreased platelet count. B. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has tetralogy of Fallot will NOT have neutropenia. C. 7.0 µU/mL above the expected reference range (0.5-5.0 µU/mL). A child who has tetralogy of Fallot will not have changes in thyroid function levels.
Corn syrup & honey + infants
The parents should not add corn syrup or honey to the infant's food. Both corn syrup and honey may contain botulism spores, which can lead to infantile botulism.
Zinc oxide
Zinc oxide can be applied as a barrier ointment to areas that are reddened or open and moist. While removing the waste material, zinc oxide should be left in place as much as possible during a diaper change. More ointment can be applied as needed. The ointment can be removed, if necessary, by applying mineral oil to the area and gently wiping.
Congenital hypotonia
Congenital hypotonia is a paralytic form of spinal muscular atrophy that is characterized by progressive weakness and wasting of skeletal muscles
A nurse is providing teaching for a 14-year old client who has acne. Which of the following instruction should the nurse include? A. "Use an exfoliating cleanser." B. "Keep hair off your forehead." C. "Take tetracycline after meals." D. "Squeeze acne lesions as they appear."
Correct Answer: B. "Keep hair off your forehead." Hair and scalp care can provide relief from the manifestation of acne. Frequent shampooing and keeping hair away from the face can improve acne. Incorrect Answers: A. Abrasive skin agents such as exfoliating cleansers can worsen acne and cause trauma to the skin. Only gentle skin cleansers should be used. C. Tetracycline should be taken on an empty stomach to improve the absorption of the medication. D. The nurse should instruct the client not to squeeze or pick acne lesions. Squeezing acne lesions ruptures glands and causes sebum to spread into the skin, which increases inflammation.
A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL. C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32% Check Answer Incorrect
Correct Answer: C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL The initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report this result so that the provider can adjust the client's insulin dosage. Incorrect Answers: A. An elevated WBC count is an expected finding with bacterial pneumonia. B. A low calcium level is an expected finding with chronic kidney disease. D. A decreased hematocrit is an expected finding with leukemia.
A nurse is caring for a 6-year-old child who is experiencing encopresis. Which of the following actions should the nurse take? A. Instruct the child's guardian to limit stool softener use to no more than twice per week B. Encourage the child to attempt to have a bowel movement 4 times per day C. Determine if there are any recent stressors in the child's environment D. Urge the child's guardian to provide negative consequences when the child has a bowel accident
Correct Answer: C. Determine if there are any recent stressors in the child's environment Encopresis can be caused by stress or changes in the child's environment. Incorrect Answers: A. Treatment for encopresis includes emptying the bowel of impacted stool, followed by the administration of daily stool softeners for 2 to 3 months. B. The nurse should encourage the child to attempt to have a bowel movement twice daily. This will help the child establish a regular pattern of defecation. D. The guardian should pay as little attention as possible to bowel accidents and offer praise when encopresis does not occur.
Glycogen storage disease
Glycogen storage disease is a congenital disorder in which glycogen, which is usually stored in the liver and metabolized into glucose when needed, cannot be metabolized into glucose due to a missing or deficient enzyme. As a result, the infant develops HYPOglycemia and can experience neurological damage. Treatment involves continuous NG or gastrostomy feedings during the night. However, breastfeeding is not contraindicated for infants who have glycogen storage disease
TSH Range:
(0.5-5.0 µU/mL
Pheochromocytoma
A benign tumor of the adrenal medulla that causes the gland to produce excess catecholamines
A nurse is teaching an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching? A. "You should drink 8 oz of a regular soft drink if you experience hypoglycemia." B. "You should drink 4 oz of orange juice if you experience hypoglycemia." C. "You should take 2 glucose tablets if you experience hypoglycemia." D. "You should take 3 tsp of sugar if you experience hypoglycemia."
Correct Answer: B. "You should drink 4 oz of orange juice if you experience hypoglycemia." The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs. Incorrect Answers: A. The nurse should tell the client to drink 6 oz (NOT 8 oz) of a regular soft drink if hypoglycemia occurs. C. The nurse should tell the client to take 4 glucose tablets (NOT 2) if hypoglycemia occurs. D. The nurse should tell the client to take 2 tsp (NOT 3) of sugar if hypoglycemia occurs
A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss >10% C. Lethargy D. Dry mucous membranes
Correct Answer: D. Dry mucous membranes Dry mucous membranes are an expected finding of moderate dehydration. Incorrect Answers: A. Absent tears is an expected finding of SEVERE dehydration. B. A weight loss of >10% is an expected finding of SEVERE dehydration. C. Lethargy is an expected finding of SEVERE dehydration
AT 6 months, how should the infants legs be?
Legs that are crossed and extended when supine is an unexpected finding and requires further assessment. Crossed and extended legs when supine is associated with cerebral palsy. At 6 months of age, the infant's legs flex at the knees when the infant is supine.
A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis
Correct Answer: D. Metabolic acidosis Metabolic acidosis is an expected finding for clients who have acute renal failure. Incorrect Answers: A. Hyperkalemia is an expected finding for clients who have acute renal failure. B. Hypocalcemia is an expected finding for clients who have acute renal failure. C. An elevated plasma creatinine level is an expected finding for clients who have acute renal failure
RBC Range:
Male: 4.3-5.9 million/mm3 Female 3.5 -5.5 million/mm3
A school nurse is assessing an adolescent who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma B. Deficient dietary intake C. Exposing peers to the illness D. Straining sore joints
Correct Answer: A. Potential for sustaining abdominal trauma An adolescent who has mononucleosis will have lymphadenopathy AND often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in TRAUMA TO THE ENLARGED SPLEEN. Incorrect Answers: B. Although an adolescent who has mononucleosis might have difficulty swallowing in the early phases of the illness, after returning to school, he should not have deficient dietary intake. C. Epstein-Barr virus causes mononucleosis and is spread primarily through direct contact with the saliva of an infected individual. Casual contact during gym and recess would be no more hazardous than having the child in a classroom. D. An adolescent who has mononucleosis will not have joint inflammation
A nurse is assessing a 6-year-old client at a well-child visit. Which of the following findings requires further assessment by the nurse? A. Presence of sparse, fine pubic hair B. Decreased head circumference compared to full height C. Increased leg length in relation to height D. Presence of a loose central incisor
Correct Answer: A. Presence of sparse, fine pubic hair The development of sexual characteristics prior to the age of 9 years in boys and 8 years in girls is an indication of precocious puberty and requires further evaluation. Incorrect Answers: B. The head circumference of a school-age child decreases when compared to full height due to skeletal lengthening. C. Body proportion varies with a slimmer appearance and longer legs in a school-age child. Leg length increases and waist circumference decreases related to height in this age group. D. The deciduous teeth start shedding at this age, beginning with the lower central incisors
A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Fractured rib
Correct Answer: A. Tension pneumothorax The nurse should identify these manifestations as an indication the infant is developing a tension pneumothorax. The infant might also become cyanotic and show asymmetry of the thorax. Incorrect Answers: B. Manifestations of flail chest include a pulling of the traumatized rib area inward during inspiration and outward during expiration. C. Manifestations of pulmonary contusion include decreased breath sounds, tachycardia, tachypnea, and blood-tinged secretions. D. Manifestations of a rib fracture include pain and ecchymosis in the area of trauma, swelling, and muscle spasms.
A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? A. Implement droplet precautions B. Administer oral analgesics prior to exercises C. Use humidified oxygen to thin secretions D. Initiate seizure precautions
Correct Answer: B. Administer oral analgesics prior to exercises Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of CNS paralysis. ROM exercises are necessary to prevent contractures, but they can cause the child discomfort. Incorrect Answers: A. The nurse should implement CONTACT PRECAUTIONS for a client with poliomyelitis. This virus is spread by direct contact with FECES / OROPHARYNGEAL secretions. C. Respiratory complications from poliomyelitis are due to paralysis of the respiratory muscles. The nurse should assess the child for signs of weak respiratory effort such as difficulty talking, ineffective coughing, and shallow and rapid respirations. D. Seizures are not an expected complication of a poliomyelitis infection
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? A. Maintain the child on bed rest B. Monitor the child for increased temperature C. Administer oxygen to the child D. Monitor the child for bleeding
Correct Answer: B. Monitor the child for increased temperature Leukopenia places the child at risk of infection; therefore, the nurse should monitor the child for a fever. Incorrect Answers: A. The nurse should maintain bed rest for the child who has decreased RBCs. C. The nurse should administer oxygen to a child who has decreased RBCs and low oxygen saturation. D. The nurse should monitor a child who has a low platelet level for bleeding.
A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure
Correct Answer: B. Murmur at the left sternal border A ventricular septal defect (a hole in the septal wall between the ventricles) is an acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal border. The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area. Incorrect Answers: A. A diastolic murmur is an expected finding in a child who has an ATRIAL SEPTAL DEFECT. C. Cyanosis that increases with crying is an expected finding in a child who has an AV CANAL DEFECT. D. Widened pulse pressure is an expected finding in a child who has PDA
A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelets 500,000 mm^3 B. RBCs 2.5 million/uL C. WBCs 4,000/mm^3 D. Hct 60%
Correct Answer: B. RBCs 2.5 million/uL An RBC count of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC count. Leukemia is a type of cancer found in your blood and bone marrow and is caused by the rapid production of abnormal white blood cells. These abnormal white blood cells are not able to fight infection and impair the ability of the bone marrow to produce red blood cells and platelets Incorrect Answers: A. A platelet count of 500,000 mm^3 is above the expected reference range (150-400). A child who has acute lymphocytic leukemia has a low platelet count. C. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has acute lymphocytic leukemia has a very high WBC count. D. An Hct level of 60% is above the expected reference range (41-53 M - 36-46 F). A child who has acute lymphocytic leukemia has a low Hct level.
A nurse is providing teaching to a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding of the teaching? A. "Impetigo is caused by a virus." B. "Impetigo is contagious for 48 hours after vesicles rupture." C. "I will wash my child's clothes in hot water." D. "My child now has immunity against impetigo."
Correct Answer: C. "I will wash my child's clothes in hot water." The parent should wash the child's clothes in hot water to kill bacteria. The parent should also keep the child's towels and washcloths separate from those of other members of the household. Incorrect Answers: A. Impetigo is a bacterial infection of the skin caused by staphylococci or streptococci bacteria. B. Impetigo is spread via direct contact and is contagious from the time of initial appearance of lesions UNTIL ALL LESIONS have healed. D. Impetigo does not cause the formation of antibodies that prevent reinfection. Therefore, the child can get impetigo again in the future.
A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. A blue coloring of the sclera D. A patchy, red rash with raised centers
Correct Answer: C. A blue coloring of the sclera This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding. Incorrect Answers: A. This discoloration is known as a nevus simplex, or stork bite. It typically blanches with pressure and becomes more prominent with crying. This finding does not require notification of the provider. B. This discoloration is known as a Mongolian spot. It is typically observed in infants who have increased skin pigmentation (e.g., those of African, Asian, or Hispanic descent) and does not require notification of the provider. D. This discoloration is known as erythema toxicum, or newborn rash. It is a benign, transient finding and does not require notification of the provider.
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? A. Lethargy B. Spontaneous coughing C. Drooling D. Hoarseness
Correct Answer: C. Drooling Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is an expected finding due to the toddler's inability to swallow saliva. Incorrect Answers: A. A toddler who has epiglottitis is restless and appears ANXIOUS rather than lethargic. B. A toddler who has epiglottitis has an absence of spontaneous coughing due to inflammation of the epiglottis. D. Hoarseness would be present in a toddler who has acute spasmodic laryngitis rather than epiglottitis.
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse provide? A. "The test determines the level of antibiotics in your child's blood." B. "The test tells us if your child ever had measles." C. "The test verifies the amount of albumin in your child's blood." D. "The test shows us if your child had a recent strep infection."
Correct Answer: D. "The test shows us if your child had a recent strep infection." An ASO titer indicates the child had a recent strep infection. When determining a definitive diagnosis for acute glomerulonephritis, this must be documented because the condition is usually the result of this type of infection. Incorrect Answers: A. A therapeutic blood level indicates a medication (e.g. an antibiotic) is effective. B. A RUBELLA TITER indicates the presence of measles. C. A serum albumin level is monitored in a child who has nephrotic syndrome.
A nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Administer an NSAID B. Perform passive range-of-motion exercises on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint
Correct Answer: D. Apply an ice pack to the joint Immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint. Incorrect Answers: A. The nurse should avoid giving clients with hemophilia aspirin or NSAIDs because these medications can interfere with the action of platelets. B. Passive range-of-motion exercises should never be performed on a client with hemophilia. Over-stretching and tearing could inadvertently occur, resulting in further joint bleeding. C. Cryoprecipitate is no longer used to treat clients with hemophilia due to the inability to remove hepatitis and HIV completely from the product. Hemophilia is currently treated with factor VIII replacement products or a synthetic form of vasopressin.
A nurse is preparing to administer an enema to a 10-month-old infant. Which of the following actions should the nurse plan to take? A. Administer the enema using room-temperature tap water B. Insert the tubing 7.5 cm (3 in) into the rectum C. Position the infant sitting upright on a bedpan while administering the enema D. Hold the infant's buttocks together after administering the fluid Check Answer
Correct Answer: D. Hold the infant's buttocks together after administering the fluid Because the infant is incontinent, the nurse should hold the buttocks together for a short time to maintain retention of the enema. Incorrect Answers: A. Tap water is hypotonic and can cause a rapid fluid shift and fluid overload. An isotonic solution of 0.9% sodium chloride should be used. B. For an infant, the tubing should be inserted 2.5 cm (1 in) into the rectum for the administration of the enema. C. The infant should be placed in a supine position with the buttocks over a bedpan and the head and back supported by pillows.
Osteogenesis imperfecta
Inherited condition when bone formation is incomplete, leading to fragile, easily broken bones
Osteomyelitis
Osteomyelitis results from an organism gaining access to the bone
