Capstone Nursing Care of Children

a school nurse is assessing a child who fell from playground equipment and landed headfirst, what clinical manifestations should the nurse recognize as indicating increased intracranial pressure

report of diplopia

a nurse is caring for a child who has bacterial meningitis, what action should the nurse take

initiate seizure precautions

a nurse is assessing a toddler who has infective endocarditis, what findings should the nurse expect

new heart murmur

a nurse working on an outpatient surgical unit is providing discharge teaching to the parent of a preschooler following the placement of tympanoplasty tubes. the parent asks, what should I do if the tubes fall out. What should the nurse instruct?

notify the provider that the tubes have fallen out

a nurse is assessing a child who has sickle cell anemia and is experiencing a Vaso occlusive crisis, what manifestations should the nurse expect

pain

a nurse is developing a plan of care for a 4yr old who has hemophilia and is experiencing acute hemarthrosis, what interventions should the nurse include in the plan

place ice packs on the affected joints

a nurse is caring for a school-age child who has hemophilia and reports increased bruising, what lab values explain the finding

plt count 120,000

a nurse is providing teaching to an adolescent who has type 2 diabetes mellitus and a new prescription for metformin, what instruction should the nurse include

take the medication at the same time each day

a nurse is caring for a child who has cancer and is receiving chemo, the parent tells the nurse that she wants to d/c treatment and take the child home, what responses should the nurse make

tell me more about your reasons for making this decision today

a nurse is assessing a 5-month-old infant during a well-child visit, what finding should the nurse report to the provider

the infant does not make consonant sounds

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority?

Encourage the child to use an incentive spirometer

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

Frequent swallowing

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider?

BP 86/40 mm Hg

A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching?

Barking cough

A nurse is caring for a 12-month-old infant following surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments?

Cup

a nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5/101.3, what findings should the nurse suspect

a UTI incontinence

a nurse is caring for a child who has acute glomerulonephritis without edema, what action should the nurse take to obtain

daily weight

a nurse is assessing a child who has received the first 50 mL of a blood transfusion, what findings indicate the child may be experiencing an air embolism

sharp pain in the middle of the chest

a nurse is providing teaching to the parents of a school-age child who has pediculosis capitis, what instruction should be included

soak her brushes in boiling water for 10min

a nurse is assessing a 6-month-old infant during a well-child visit, what findings should the nurse report to the provider

the infant does not roll over from his abdomen to his back

a nurse is providing teaching to the parent of a child who has a new prescription for methylphenidate, what instruction should the nurse include to administer

the second dose of the medication at lunchtime

a nurse is providing teaching to the parent of a preschooler about health promotion, what response by the parent indicates an understanding of the teaching I should encourage my child to have

1 hour of physical activity each day

A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make?

An abdominal ultrasound will confirm the pocket in the intestine

A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider?

Potassium 2.5 mEq/L

A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level?

FACES

A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching?

I can take my brace off for about an hour daily to shower

a nurse is providing teaching to parents of a school-age child who has ADHD and a new prescription for methylphenidate ER capsules, what responses by the parent indicate an understanding of the nurse's instruction

I will inform my child's teacher that he is taking this medication

A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching?

I will inspect my child's mouth every day for sores

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

Murmur at the left sternal border

A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching?

The pneumococcal and influenza vaccines are recommended for your child

a nurse is teaching the parents of a toddler about strategies to manage temper tantrums, what instructions should the nurse include in the teaching to establish

a structured daily routine for the child

a nurse is caring for a 4m old infant who is immediately postop following cleft palate repair, what intervention should the nurse take

apply elbow restraints to the infant

a nurse is providing discharge teaching to the parents of a 6-month-old infant following a surgical procedure to repair hypospadias, what instructions should the nurse include in the teaching

avoid giving the infant a tub bath until the stent is removed

a nurse is providing discharge teaching to the parent of a school-age child who has an infection of the throat caused by group A beta-hemolytic streptococci, what instructions should the nurse give to the parent

continue to administer the prescribed antibiotic for 10d give your child acetaminophen or children ibuprofen for fever

a home health nurse is providing teaching about post-seizure management to the parents of a school-age child who has epilepsy, what should be included

- record the length and character of the child's postictal period following a seizure - call for emergency medical services if the size of the child's pupils are unequal after the seizure

A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect?

1.035

A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first?

Determine the child's breathing pattern.

a nurse is assessing an infant who has intussusception, what manifestation is expected

gelatinous red stool

a nurse in the ED is creating a plan of care for a child who has an acute head injury following a fall from playground equipment, what interventions should the nurse include to initiate

seizure precautions for the child

a nurse is assessing an infant who has hydrocephalus, what clinical manifestations should the nurse expect

separated cranial sutures

a nurse is caring for an infant who has GERD, what action should the nurse take to avoid regurgitation

thicken the pt's formula and avoid giving the pt citrus juices position the child with the head elevated after meals

a nurse is providing teaching to an adolescent who has a new prescription for cefazolin, what adverse effect should the nurse monitor for and report to the physician

urticaria

a nurse is teaching the parent of an infant about preventing SIDS, what following statement should the nurse make

you should put your infant in bed with a pacifier

a nurse is providing teaching to a mother who plans to breastfeed her 3-day-old infant, what info should the nurse include in the teaching

your baby will need a follow-up evaluation by her provider within the next 3 days

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 make?

"The test shows us if your child had a recent strep infection."

a nurse is caring for a school-age child who has metastatic osteosarcoma, the child asks the nurse "am I going to die?", what should the nurse respond

"It sounds like you are worried. tell me what you have been told"

A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching?

"My child should consume 1,000 calories per day."

A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first?

Demonstrate the injection technique on an orange.

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?

Drooling

a nurse is assessing a 12m old infant who is immediately postop hernia repair surgery, what pain measurement tools should the nurse use to determine if the infant is experiencing pain

FLACC

A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider?

Hg 6g/dL

A nurse is teaching a newly hired nurse about the care of an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications

Hydrocephalus

a nurse is providing teaching to the parent of an infant about care seat safety, what statement by the parent indicates an understanding of the teaching

I should place the car seat rear facing until my child is 2

A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

I will add rice cereal to my baby's feedings.

A nurse is teaching the parent of a preschool-age child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching?

I will give my child a dose of albendazole today and again in 2 weeks

A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching?

I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible

A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching?

I will record the highest reading of three attempts.

A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make?

Increase the child's protein intake.

A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia. Which of the following instructions should the nurse include in the plan?

Inspect the toddler's toys for sharp edges

A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?

Keep the child away from people who have an infection

A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect?

Koplik spots

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following interventions should the nurse include in the plan?

Maintain the child on bed rest

A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include?

Massage the anterior area of the infant's ear following administration

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?

Monitor the child for increased temperature

a nurse is caring for a child who has a congenital heart defect, the nurse should recognize which of the following defects is associated with increased pulmonary blood flow

PDA

A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?

Periorbital edema

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?

Place a plastic bag over the cast when showering

A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take?

Put a "no abdominal palpation" sign over the child's bed.

a nurse in a pediatric clinic is discussing the physiology of Reye syndrome with a newly licensed nurse, what statements by the newly licensed nurse indicate an understanding of the disorder

Reye's syndrome causes fatty changes in the liver

A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend?

Scrambled eggs

A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure?

Small, frequent bottle feedings of electrolyte solution

A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take?

Suction the infant gently with a bulb syringe PRN

A nurse in an emergency department is assessing a school-age child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider?

Sudden decrease in wheezing

A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration?

Tachypnea

a nurse is reviewing the medical record of a 16 yr old brought in by his parents to receive a physical, the record indicates he received his last immunization 10 years ago, what immunizations should the nurse expect to administer to the adolescent

Tdap

A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider?

Weight gain of 1.8 kg (4 lb)

a nurse is suctioning the tracheostomy of a child, what assessment findings indicate the effectiveness of the procedure

clear breath sounds

a nurse is assessing a child who has acute renal failure, what clinical manifestations are expected

edema

a nurse is preparing a teaching plan for the parent of a school-age child who has asthma, the nurse should include what manifestation as an "exacerbation" of asthma

hacking, non-productive cough

a nurse is teaching a school-age child and her parents about managing diabetes mellitus during illness, the nurse determines teaching has been effective when they indicate they will provide which of the following when the child is ill

increase fluids

a nurse is providing discharge teaching to the parents of a child who has sickle cell anemia and was hospitalized after experiencing a Vaso occlusive crisis. what instructions should the nurse include in the teaching

increase your child's intake of oral fluids

a nurse is admitting a child who has bacterial meningitis, what actions should the nurse take first

initiate antibiotic therapy for the child

a nurse in the emergency department is caring for a preschooler who has epiglottitis, what action should the nurse take

initiate droplet precautions for the child

a nurse is caring for a toddler who drinks 950mL (32oz) of milk per day and has a poor appetite, the nurse should identify that the toddler is at risk for

iron deficiency anemia

a school nurse is assessing the visual acuity of a school-age child, what finding indicates that the child should be evaluated for strabismus

movement of the uncovered eye during a cover test

a charge nurse is assisting a newly licensed nurse with the preoperative assessment of a 2-year-old child who has a Wilm's tumor, what actions by the newly licensed nurse require intervention from the charge nurse

palpating the child's abdomen

a nurse is assessing a 3yr old preschooler at a well-child visit, what developmental tasks should be expected uses

primarily two-word phrases

a nurse is instilling otic drops into a toddler's ears, what method is used

pull the pinna down and back

a nurse in a pediatric clinic is performing a history and physical for a toddler who is going to receive an MMR immunization, which indicates that it should be withheld

receiving prednisone for nephrotic syndrome