ch 32

A nurse is reinforcing teaching with a parent of a 1-month-old-infant who is to undergo the initial surgery to treat Hirschsprung's disease. Which of the following statements should indicate to the nurse that the parent understands the goal of the surgery? a. im glad that the ostomy is only temporary b. im glad my child will have normal bowel movements now c. i want to learn how to use the feeding tube as soon as possible d. the operation will straighten out the kink in the intestine

a. I'm glad that the ostomy is only temporary

A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (SATA) a. vomiting b. weight loss c. rigid abdomen d. wheezing e. pallor

a. vomiting b. weight loss d. wheezing

A nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. a. shingles b. athlete's foot c. fever blister d. pinworms

b. athlete's foot

A nurse is providing teaching about iron deficiency anemia to the parents of a 14 month old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia? a. avoid a diet consisting primarily of milk b. administer fat-soluble vitamins daily c. include whole grains and legumes in the diet d. limit intake of high-protein foods

a. avoid a diet consisting primarily of milk

A nurse is caring for an 8 year old child who ha sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching? a. drink eight glasses of fluid daily b. avoid playground activities at school c. maintain an updated haemophilus influenza type B immunization d. assume postural drainage positions every 6 hours

a. drink eight glasses of fluid daily (hydration decreases the viscosity of the blood. a decreased viscosity helps lower the risk for sickling as a result of venous stasis.

A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? a. projectile vomiting b. bile-colored vomit c. absent bowel sounds d. fever

a. projectile vomiting

A nurse caring for a 2 week old infant whose mother requests additional information about sudden infant death syndrome (SIDS). Which of the following responses should the nurse make? a. you should place your baby on her back when sleeping to decrease the risk of SIDS b. SIDS is directly correlated to diptheria, tetanus, and pertussis vaccines c. SIDS rates have been rising over the last 10 years d. sleep apnea is the main cause of SIDS

a. you should place your baby on her back when sleeping to decrease the risk of SIDS

A nurse is collecting data from an 8 month old infant who has increased ICP. Which of the following manifestations should the nurse expect? a. insomnia b. bulging fontanel c. low-pitched cry d. positive babinski reflex

b. bulging fontanel

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority? a. place the child on a no salt added diet b. check the child's weight daily c. educate the parents about potential complications d. maintain a saline-lock

b. check the child's weight daily

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flood? a. coarctation of the aorta b. patent ductus arteriosus c. tetralogy of fallot d. tricuspid atresia

b. patent ductus arteriosus (the area between the pulmonary artery and aorta remains open, allowing blood to flow through the patent ductus arteriosus and back to the pulmonary artery and lungs)

A nurse is reinforcing teaching with a school-age child who has type 1 diabetes and his parent about illness management. Which of the following instructions should the nurse include? a. withhold insulin dose if feeling nauseous b. notify the provider if blood glucose levels are over 350 c. test the urine for ketones d. limit fluid intake during meal time

c. test the urine for ketones

A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child? a. broth b. cherry gelatin c. apple juice d. pedialye

d. pedialye

A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take? a. obtain a throat culture b. prepare the child for a neck radiograph c. initiate airborne precautions d. visualize the epiglottis using a tongue depressor

b. prepare the child for a neck radiograph (the nurse should prepare the child for a lateral radiograph of the neck. A professional who has advanced skills with airway management should remain with the child at all times)

A nurse is contributing to the plan of care for a 2 month old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care? a. feed the infant half strength formula for first 48 hours b. remove elbow restraints while the infant is sleeping c. keep the infant in a side-lying position d. administer pain medication PRN for the first 48 hour

c. keep the infant in a side lying position (to promote draining)

A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first? a. fluticasone b. methyliprednisolone c. montelukast d. albuterol

d. albuterol (rescue medication with rapid onset. beta2 adrenergic agonist that promotes bronchodilation and suppresses histamine release in lungs)

A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? a. administer a bronchodilator to the child after chest percussion therapy b. a pigeon-shaped chest might become evident as the disease progresses c. bradycardia is an early indicator of a pnemothorax d. engage the child in daily aerobic exercise

d. engage the child in daily aerobic exercise (engaging the child in daily exercise stimulates mucous excretion, exhances self-esteem, and is recommended as a daily adjunct to chest percussion therapy)

A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes. Which of the following statements by the parent requires a clarification of the teaching? a. the onset of low blood glucose usually occurs rapidly b. my son might complain of feeling shaky when he has a low blood glucose level c. sweating can occur with hypoglycemia d. my son might have nausea and vomiting with hypoglycemia

d. my son might have nausea and vomiting with hypoglycemia

A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect? a. metabolic acidosis b. effortless regurgitation c. distended abdomen d. projectile vomiting

d. projectile vomiting

A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect? a. drooling b. increased appetite c. jaundice d. mucus in stools

d. mucus in stools

A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes. Which of the following manifestations should the nurse include in the teaching? a. headache b. acetone breath c. rapid respirations d. diminished reflexes

a. headache

A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teacher? a. i will keep my baby in an upright position after feeding b. my baby's formula can be thickened with oatmeal c. i will have to feed my baby formula, rather than breast milk d. i should move my baby into a side-lying position during sleep

a. i will keep my baby in an upright position after feedings

A nurse is reinforcing teaching with the parents of a child who is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching? a. the medication should be administered in one large dose per day b. restricting fiber from our child's diet will help with iron absorption c. the medication will be more effective if it is administered with meals d. our child's blood count will need to be monitored routinely for several weeks

d. our child's blood count will need to be monitored routinely for several weeks (the child's response to treatment is determined by monitoring the hemoglobin and hematocrit levels through routine blood tests. Treatment can take up to 3 months to be effective)

A nurse is caring for a child who is postoperative following the insertion of a VP shunt. The nurse should place the child in which of the following positions? a. on the nonoperative side b. a 45 head elevation c. prone d. supine

a. on the nonoperative side

A nurse is caring for a 4 year old child who is 2 days postoperative following the insertion of a VP shunt. Which of the following findings should the nurse identify as the priority? a. lethargy b. lying flat on the unaffected side c. respiratory rate 20 d. urine output 50ml in 2 hour

a. lethargy

A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect? a. polyuria b. periorbital edema c. orange-tinged urine d. hypertension

b. periorbital edema

A nurse is reinforcing teaching with the parent of a school-age child who has a new diagnosis of asthma. Which of the following responses should the nurse make? a. you should give your child cromoly sodium at the first sign of breathing difficulty b. your child should stop playing basketball, but she can swim instead c. your child will need a written excuse to stay out of physical education class d. repeat back to me what to do if your child has trouble breathing

d. repeat back to me what to do if your child has trouble breathing

A nurse is caring for a school-age child who has acute glomerulonephritis. The child has peripheral edema and is producing 35 ml of urine per hour. Which of the following diets should the nurse anticipate the provider will prescribe? a. low-sodium, fluid restricted b. regular diet, no added salt c. low-carb, low-protein d. low protein, low potassium

a. low-sodium, fluid restricted

A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take? a. withhold opioids to avoid dependence b. initiate a 2L/day fluid restriction c. encourage exercise d. assist with administering a blood transfusion

d. assist with administering a blood transfusion (an adolescent who is having a sickle cell crisis can receive a blood transfusion to treat anemia and to decrease the viscosity of the blood)

A nurse is collecting data from a child who has spina bifida occula. Which of the following findings should the nurse expect? a. hip dislocation b. flaccid paralysis of lower extremities c. hydrocephalus d. dimple in sacral area

d. dimple in sacral area

A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take? a. perform a neurovascular check of lower extremites b. keep the client's leg in a dependent position c. discourage the client from ambulating d. use a hair dryer on hot setting to dry the case

a. perform a neurovascular check of lower extremities

A nurse is reinforcing teaching with the mother of a toddler who has acute nephrotic syndrome. The nurse should emphasize the need to report which of the following manifestations to the provider? a. yellow nasal discharge b. facial edema c. poor appetite d. irritability

a. yellow nasal discharge

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following findings should the nurse expect? (SATA) a. symptoms are continual throughout the day b. daytime symptoms occur more than twice per week c. nighttime symptoms occur approximately twice per month d. minor limitations occur with normal activity e. peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.

b. daytime symptoms occur more than twice per week d. minor limitations occur with normal activity e. PEF is greater than or equal to 80% of the predicted value

A nurse is collecting data from an infant who has a large patent ductus arteriosis. Which of the following is clinical manifestations should the nurse expect? a. cyanosis with crying b. machine-like murmur c. weak pulses d. chronic hypoxemia

b. machine-like murmur (a patent ductus arteriosis is the failure of the opening connecting the aorta and pulmonary artery to close after birth causing a left-to-right shunt. a machine-like murmur is a clinical manifestation found.)

A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority? a. blood glucose 110 mg/dl b. potassium 2.5 meq/l c. sodium 142 meq/l d. urine specific gravity 1.025

b. potassium 2.5 meq/l (expected reference range is 3.4 to 4.7)

A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority? a. 2+ pedal pulse b. respiratory rate 24 c. capillary refill less than 2 sec d. tingling in the right foot

d. tingling in the right foot

A nurse is caring for a pre-school age child who has croup. Which of the following findings should the nurse report to the provider? a. barky cough b. paroxysmal attacks of laryngeal spasm at night c. hoarseness d. drooling

d. drooling (the presence of drooling can indicate epiglottitis, which requires immediate medical attention)

A nurse is collecting data from a 1-year-old child who has Wilms' tumor. Which of the following findings should the nurse expect? a. jaundice b. swollen joints c. abdominal mass d. diarrhea

c. abdominal mass

A nurse is contributing to the plan of care of a 14 month old toddler who is 24 hour postoperative following a cleft palate repair. Which of the following interventions should the nurse include in the plan? a. provide soft foods for the toddler b. suction the toddler nose and mouth every hour c. maintain elbow restraints on the toddler d. give the toddler a hard tipped sippy cup to drink fluids

c. maintain elbow restraints on the toddler

A nurse is collecting data from a child who has sickle disease and is experiencing a vaso-occlusive crisis. Which of the following findings should the nurse expect? a. vomiting b. bradycardia c. pain d. constipation

c. pain (a client who is experiencing a vaso-oclusive crisis typically has severe pain resulting from tissue hypoxia and necrosis.)

A school nurse is screening an 11 year old child for scoliosis. Which of the following instructions should the nurse give the child for the exam? a. lie prone on the exam table b. touch your chin to your chest, and then look up at the ceiling c. turn to the side, and remain in relaxed position d. bend forward from the waist with your head and arms downward

d. bend forward from the waist with your head and arms downward