ATI RN Pediatric Nursing Online Practice 2023 B

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?

-A unilateral rib lump Rationale: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.

A nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect?

-Abdominal distention Rationale: The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness.

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?

-Administer the immunization using a 24-gauge needle Rationale: The nurse should administer an immunization for a 4-year-old child using a 22- to 25-gauge needle to minimize the amount of pain the child experiences.

A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?

-Epinephrine Rationale: This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta-adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.

A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?

-For 24 hr following initiation of antimicrobial therapy Rationale: The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0-10. Which of the following actions should the nurse take?

-Give morphine 0.05 mg/kg IV. Rationale: A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief.

A nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is priority for the nurse to report to the provider?

-Substernal retractions Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.

A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan?

-Use a semipermeable transparent dressing to cover the site Rationale: The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.

A nurse is planning an educational program to teach caregivers about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?

-"Choose a waterproof sunscreen with a minimum SPF of 15." Rationale: The nurse should instruct caregivers to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement in infection control?

-Have a designated stethoscope in the infant's room Rationale: The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and stethoscope, should be placed in the infant's room.

A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory tests should the nurse review to evaluate the anemia?

-Hgb Rationale: A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels.

A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?

-Increase fat content in the child's diet to 40% of total calories. Rationale: A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.

A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?

-Increased protein concentration Rationale: The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?

-Initiate seizure precautions for the child Rationale: A decreased sodium level indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?

-Loud, harsh murmur Rationale: The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?

-Nasal flaring Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress.

A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?

-Oral rehydration solution Rationale: A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.

A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?

-Palpate the dorsum of the child's feet Rationale: The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema.

The nurse is caring for the child 4 days after admission. After reviewing the child's assessment, which of the following findings should the nurse address first? Complete the following sentence by using the lists of options.

The nurse should first address the client's temperature, followed by the client's pain. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that an increased temperature is a priority finding, because it can indicate an infection and sepsis. Wound sepsis is most likely to occur between the third and fifth day after a burn. Therefore, the nurse should first address the child's temperature. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing.

A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?

-"I should secure the car seat using lower anchors and tethers instead of the seat belt." Rationale: Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.

A nurse is teaching the guardian of a 6-month-old infant about teaching. Which of the following statements should the nurse make?

-"Your baby might pull at their ears when they are teething." Rationale: The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first?

-A toddler who has a concussion and is experiencing an episode of forceful vomiting Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.

A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching?

-"I will teach challenging academic subjects to students who have ADHD in the morning." Rationale: Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective.

A nurse in a provider's office is caring for a school-age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make?

-"When your child's lesions are crusted, usually 6 days after they appear." Rationale: The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated?

-Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas: Contraindicated -Insert an indwelling urinary catheter: Anticipated -Provide 100% oxygen via face mask: Anticipated -Weigh the child: Anticipated Rationale: Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. The nurse should cover the burn with a clean, dry cloth to prevent contamination and hypothermia. Inserting an indwelling urinary catheter is essential and allows for accurate measurement of urine output. Urine output is an indicator of the fluid status of the child. A child who has major burns will lose a significant amount of fluid due to increased capillary permeability, which increases the risk for hypovolemic shock. It is important to maintain accurate hourly I&O to manage fluid replacement. Upon admission to the emergency department, the nurse should recognize the need to provide 100% oxygen via face mask as an essential prescription. The child's SaO2 is below the expected reference range and their respiratory rate is increased. The nurse should recognize the need to weigh the child as essential. Children of the same age weigh different amounts. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight.

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?

-Perform a finger stick Rationale: The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.

A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?

-Deep respirations of 32/min Rationale: The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis.

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?

-Place the child in a side-lying position Rationale: The nurse should place the child in a side-lying position to prevent aspiration.

A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first?

-Check the child's respiratory rate Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths.

A nurse in an emergency department is caring for a toddler who has partial thickness burns on their right arm. Which of the following actions should the nurse take?

-Cleanse the affected area with mild soap and water Rationale: The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.

A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature?

-Dress the toddler in minimal clothing Rationale: The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature.

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant?

-Great toe Rationale: The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse.

A nurse is caring for an infant who is receiving IV fluids for the treatment of tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take?

-Place the infant in a knee-chest position Rationale: The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

-Respiratory rate 45/min Rationale: The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.

A nurse is caring for a toddler. Click to highlight the findings that require follow-up.

-Toddler appears lethargic -Toddler is uninterested in eating -Ribbon-like, foul-smelling stools -Hypoactive bowel sounds -Abdomen distended -Palpable fecal mass -Blood pressure 110/70 mm Hg Rationale: When recognizing cues, the nurse should identify that the assessment findings of lethargy, disinterest in eating, hypoactive bowel sounds, distended abdomen, palpable fecal mass, ribbon-like, foul-smelling stools and elevated blood pressure require follow-up. These findings indicate the toddler's constipation has worsened and the toddler needs further evaluation for suspected Hirschsprung's disease.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?

-Flank pain Rationale: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? Round to the nearest whole number.

1 Rationale: 75 lb = 34.0909 kg 1.2 mg x 34.0909 kg = 40.9090 40.9090 / 40 = 1.02 = 1

A nurse is caring for an infant who is receiving treatment for severe dehydration. The nurse should identify which of the following findings as indicators that the treatment is effective?

-Capillary refill less than 2 seconds Rationale: The nurse should identify that a capillary refill less than 2 seconds indicates the current treatment regimen the infant is receiving for dehydration is effective.

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

-"I will give myself a shot of regular insulin 30 minutes before I eat breakfast." Rationale: The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.

A nurse is teaching the parent of an infant about ways to prevent sudden unexplained infant death (SUID). Which of the following instructions should the nurse include?

-"Give the infant a pacifier at bedtime." Rationale: The nurse should inform the parent that protective factors against SUID include breastfeeding and the use of a pacifier when the infant is sleeping.

A nurse is providing discharge teaching to the guardian of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral?

-Speech therapist Rationale: The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.

A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

-White rice Rationale: The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and that sometimes lactose deficiency can be secondary to this disease.

A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for temperature above 38.0 C (100.5 F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100 mg/5mL. How many mL should the nurse administer to the infant per dose? Round to the nearest whole number.

2 Rationale: 17.6 lb = 8 kg 5 mg x 8 kg = 40 40 mg / 100 mg = 0.4 0.4 x 5 mL = 2

A nurse on a pediatric unit is admitting a preschooler. After reviewing the information in the medical record, the nurse should identify that the child is at risk for developing which of the following conditions? Complete the following sentence by using the list of options.

The nurse should identify that the child is at risk for developing splenomegaly as evidenced by positive mononucleosis rapid test. Rationale: The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis.

A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make?

-"Let's talk about some of the ways you have handled previous stressors in your life." Rationale: This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.

A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should the nurse include?

-"Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." Rationale: The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly.

The nurse is providing discharge teaching to the child and their parent 36 days after admission. Select 6 statements by the parent that indicate an understanding of the discharge teaching.

-"I should apply a moisturizer to the scar tissue." Rationale: Frequent application of a non-perfume moisturizer should be applied to the scar tissue to help reduce itching the child might experience. -"I will use a measured spoon or medicine cup to give my child hydroxyzine." Rationale: All liquid medications should be administered with a measured spoon or cup to provide an accurate amount of the prescribed dose of medication. -"I can give my child hydroxyzine every 6 hours as needed." Rationale: Hydroxyzine is administered every 6 to 8 hr each day as needed. -"Puppet play can be helpful for my child." Rationale: Preschoolers engage in imaginative play. The use of puppets will encourage the child to express their feelings through imaginary play. -"I need to assess for any redness or open skin areas before applying my child's left arm split." Rationale: It is important that the child's skin be assessed for redness, open areas, or blisters prior to putting on a splint. The splint is used to prevent contractures of the extremities and promote normal alignment during the healing process. Because the splint might be worn for a long period of time, the child's growth might cause the splint to not fit properly and can cause a pressure injury. -"My child will need to use a compression garment to decrease blood supply to the scarred tissue." Rationale: Using a compression garment on the scar tissue decreases the blood supply to avoid nourishing the hypertrophic tissue. It also forces the collagen into a more normal alignment. Compression garments are worn during the healing of the burned tissue and should be worn as much as possible.

A nurse in a provider's office is caring for a preschooler. Which of the following statements by a guardian indicate that the discharge teaching was effective? Select all that apply.

-"We should apply a skin emollient immediately after bathing out child." Rationale: An emollient is an oil that moisturizes the skin and should be applied immediately after bathing, while the skin is damp, to prevent drying. Therefore this statement by the guardian indicates the teaching has been effective. -"We should keep our child's fingernails trimmed short." Rationale: The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. Therefore this statement by the guardian indicates the teaching has been effective. -"We should use a mild detergent for our laundry." Rationale: The use of mild detergents for laundry helps prevent allergens and itching. Therefore this statement by the guardian indicates the teaching has been effective.

A nurse is caring for a preschool-age child. For each assessment finding, click to specify if the finding is consistent with nightmares or sleep terrors. Each finding may support more than 1 disease process.

-Timing of child's crying: Nightmares -Child's responsiveness to guardian: Nightmares -Child's return to sleeping: Sleep terrors -Child's description of the dream: Nightmares -Impulsivity: Sleep terrors and Nightmares -Child's concentration: Sleep terrors and Nightmares -Daytime alertness: Sleep terrors and Nightmares Rationale: When analyzing cues, the nurse should recognize that manifestations of nightmares include awakening during the night after a scary dream. Nightmares are a sleep disturbance that cause distress after the dream is over. The child might be crying, fearful of returning to sleep, and believe the dream is real. Sleep disturbances cause interruptions in the sleep-wake cycle and can cause impaired concentration, daytime fatigue, and impulsive behaviors. When analyzing cues, the nurse should recognize that manifestations of sleep terrors include a partial awakening during a deep sleep. Sleep terrors are sleep disturbances that cause a child to exhibit behaviors such as thrashing, screaming, moaning, and diaphoresis that disappear once the child awakens. The child does not remember the episode and is not comforted by others during the disturbance. The child usually falls asleep easily afterwards. Sleep terrors cause interruptions in the sleep-wake cycle and can cause impaired concentration, daytime fatigue, and impulsive behaviors.

A nurse is caring for a toddler. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Potential Condition: Cystic Fibrosis Actions to take: 1: Educate the guardian about swear chloride testing. 2: Prepare toddler for chest physiotherapy. Parameters to Monitor: 1: Oxygen saturation level 2: Stools Rationale: Upon recognizing and analyzing client findings, the nurse's priority hypothesis is that the toddler is most likely experiencing cystic fibrosis and that is it important to generate solutions and take actions by planning to educate the guardian about sweat chloride testing for the toddler and prepare the toddler for chest physiotherapy. The toddler is most likely experiencing cystic fibrosis, as evidenced by reports of recurring respiratory infections, wheezing, coughing, tachypnea, tachycardia, labored respirations, decreased oxygen saturation, nasal congestion, inability to gain weight, loose fatty stool, salty tasting sweat, and hyponatremia. To evaluate the toddler's response to these interventions, the nurse should monitor the toddler's oxygen saturation level and stools. These are parameters that indicate if the toddler is further experiencing respiratory distress, inadequate intake, and dehydration, which can lead to further complications, including pneumothorax, respiratory failure, and failure to thrive.

A nurse on a pediatric unit is caring for a school-age child. After reviewing the information in the child's medical record, which of the following findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.

-Arterial blood gases Rationale: The child's arterial blood gases (ABGs) indicate respiratory alkalosis, which is associated with complications of asthma, such as hyperventilation and hypoxia. Therefore, the nurse should report these findings to the provider. -WBC Count Rationale: The child's WBC count is above the expected reference range, which could be an indication of infection or inflammation. Therefore, the nurse should report this finding to the provider. -Oxygen Saturation Rationale: The child's oxygen saturation level has decreased below the expected reference range despite the use of supplemental oxygen. Therefore, the nurse should report this finding to the provider. -Respiratory Assessment Rationale: The child's respiratory assessment indicates increased respiratory distress, as evidenced by the presence of tachypnea, retractions, and increased wheezing. Therefore, the nurse should report these findings to the provider.

The nurse is continuing to care for the child. After examining the child during hydrotherapy, the provider enters prescriptions into the child's medical record. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child.

-Change the morphine route to family-controlled analgesia via a PCA pump: Anticipated -Obtain a wound culture: Anticipated -Place the child on a pressure-reduction mattress: Anticipated -Limit daily protein intake: Contraindicated Rationale: A pain rating of 8 indicates severe pain. The use of a PCA pump should increase the effectiveness of pain management during movement and procedures. The nurse should teach the child's primary caregiver about the use of the PCA pump. The child has an elevated temperature and malodorous green wound drainage. The nurse should obtain a wound culture to determine the causative organism and an antibiotic should be administered. The child has developed a stage 1 pressure injury on their occiput. A pressure-reduction mattress can help prevent further tissue injury. Children who have major burns require a high-protein, high-calorie diet to help with wound healing. The nurse should provide high-protein snacks to the child between meals.

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?

-Denies discomfort during assessment of injuries Rationale: The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.

A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

-Difficulty concentrating Rationale: The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem.

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). The nurse should identify that which of the following findings require immediate follow-up? Select the 3 findings that require immediate follow-up.

-Partial- and full-thickness burns to the left upper anterior chest and anterior neck Rationale: Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate follow-up due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. -SaO2 89% on room air Rationale: Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the low oxygen saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. -Heart rate 150/min Rationale: Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the child's increased heart rate. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock due to fluid loss.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?

-Petechiae on the lower extremities Rationale: The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.

A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider?

-Potassium chloride Rationale: The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia.

The nurse is caring for the child 14 days after admission. The child has returned to the unit following the procedure. Which of the following actions should the nurse take? Select all that apply.

-Provide 100% oxygen via face mask Rationale: The nurse should provide 100% oxygen via face mask to the child because of their SaO2 and respiratory rate. The SaO2 should be maintained at 95% or higher and if the SaO2 falls below 95%, supplemental oxygen should be initiated. -Check anterior neck and chest dressing for bleeding Rationale: Upon return from the procedure, all surgical dressings should be assessed for drainage and to ensure the dressing is intact. -Place a warm blanket on the child Rationale: The child is exhibiting hypothermia. It is important for the child to have a stable body temperature because vasoconstriction can diminish blood flow to the surgical sites and impair healing. -Keep the child's head in a neutral position Rationale: The child's head should be kept in a neutral alignment to prevent hyperextension or hyperflexion and to prevent graft loss.

A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take?

-Provide the child with a book about adventure Rationale: The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read.

A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following findings to the provider?

-Restricted ability to move the toes Rationale: The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours.