Ch. 44, 45
A 2-month-old boy is admitted to the emergency room with severe diarrhea. Intravenous fluid is prescribed for him. Before adding potassium to this solution, which assessment would you record? A) He has voided. B) He cries with tears. C) His hands are restrained. D) He "attunes" to a music box.
A
A boy with hemophilia A is scheduled for surgery. Which precautions would you institute with him? A) Handle him gently when transferring him to a stretcher. B) Caution him not to brush his teeth before surgery. C) Do not allow a dressing to be applied postoperatively. D) Mark his chart for him to receive no analgesia.
A
A preschooler has celiac disease. Her mother is preparing a gluten-free diet. By preparing which breakfast foods would you believe she understands the diet? A) Eggs and orange juice B) Wheat toast and grape jelly C) Cheerios (oat cereal) and skim milk D) Rye toast and peanut butter
A
During the assessment of a preschool-age child, the nurse notes that the child's tongue is tender and there are cracks in the corners of the child's mouth. Which vitamin deficiency does the nurse suspect this child is experiencing? A) Vitamin A B) Vitamin B1 C) Vitamin C D) Vitamin D
A
When providing care for a child immediately after a bone marrow aspiration, which nursing action is priority? A) Monitor the site dressing and vital signs. B) Evaluate pain and administer medication. C) Educate the family on proper handwashing. D) Allow the child to play with a doll and syringe.
A
A 1-month-old infant is diagnosed with gastroesophageal reflux. Which intervention should the nurse teach the mother to help with the symptoms of this disorder? A) Hold in a horizontal position while feeding. B) Place on the back immediately after feeding. C) Feed with formula thickened with rice cereal. D) Administer prescribed medications before each feeding.
C
A 14-year-old child is brought into the emergency room with manifestations consistent with a ruptured appendix. What is the first action that the nurse should take in the care of this child? A) Apply oxygen. B) Position flat in bed. C) Place in the semi-Fowler's position. D) Insert an indwelling urinary catheter.
C
A 9-month-old boy with iron-deficiency anemia is given ferrous sulfate therapy. Which assessment would best help you determine that he is actually taking it daily? A) His reticulocyte count will have decreased. B) He will develop diarrhea. C) His stools will appear black. D) He will be less irritable than he was at his last visit.
C
A 9-year-old child is admitted to the hospital with a diagnosis of idiopathic thrombocytopenic purpura. When receiving shift handoff, which description is anticipated? A) Purpural lesions on the forehead and chest B) Crusted lesions on the roof of the mouth C) A hemorrhagic rash on the lower extremities D) Vesicular lesions along the fifth cranial nerve
C
A child's anemia was caused by exposure to an insecticide. What advice would you give his parents on discharge from the hospital? A) He should eat a high-protein diet to maintain his energy. B) He must return to the hospital for desensitization to the insecticide. C) He must not be further exposed to the insecticide. D) He will need to be administered a chelating agent weekly.
C
A preschool-age child has been experiencing severe vomiting for over 24 hours. The child's respiratory rate is currently 10 breaths/min. On which health problem will the nurse focus when caring for this child? A) Overhydration B) Metabolic acidosis C) Metabolic alkalosis D) Hypertonic dehydration
C
A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in his care should be given priority? A) Beginning active range-of-motion exercises B) Seeing that he ingests a protein-rich diet C) Maintaining a fluid intravenous line D) Encouraging him to take deep breaths hourly
C
If an adolescent has hepatitis B, what would be an important nursing action? A) Conscientious collection of stool for ova and parasites B) Strict calculation of caloric and vitamin B intake C) Strict enforcement of standard precautions D)Close observation to detect cerebral hallucinations
C
A 6-month-old boy is diagnosed with pyloric stenosis. When you take a health history from his mother, which symptom would you expect to hear her describe? A) Refusal to eat B) Vomiting about 2 hours after feeding C) Chronic diarrhea D) Vomiting immediately after feeding
D
Some children with iron-deficiency anemia may be prescribed iron dextran by injection. This should be injected A) intradermally. B) subcutaneously. C) intramuscularly. D) via Z-track technique.
D
The nurse is caring for a 4-year-old with sickle cell anemia. A physical finding you might expect to see in him is: A) enlarged mandibular growth. B) depigmented areas on the abdomen. C) increased growth of long bones. D) slightly yellow sclerae.
D
The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which nursing diagnosis should the nurse use to guide care during the immediate postoperative period? A) Anxiety related to new feeding method used postoperatively B) Ineffective tissue perfusion related to pressure on heart chambers C) Excess fluid volume related to increased fluid intake prescribed postoperatively D) Risk for infection of incision line, related to disruption of skin barrier during surgery
D
A 2-month-old infant experiencing severe diarrhea is prescribed intravenous fluid replacement. Before adding potassium to this solution, which assessment should the nurse make? A) Is voiding B) Is sleeping C) Is crying with tears D) Hands are restrained
A
A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has: A) severe dehydration. B) failure to thrive. C) malabsorption syndrome. D) risk for fluid volume deficit.
A
The nurse suspects that an infant is experiencing intussusception. What did the nurse assess in this infant? (Select all that apply.) A) Crying as if in severe pain B) Pulse rate of 78 beats/min and irregular C) Sudden drawing up of the legs D) Vomit that looks like currant jelly E) Leg drawing up and crying repeats every 15 minutes
A, C, D, E
A child weighing 10 kg is admitted with severe vomiting for the past 3 days. The nurse writes a nursing diagnosis of Risk for deficient fluid volume related to vomiting. When the nurse reassesses the child, which outcomes would indicate the effectiveness of the treatment plan? Select all that apply. A) urine specific gravity of 1.008 B) urine output of 15 mL/hour C) tolerating sips of clear fluids D) skin recoil > 5 seconds on abdomen E) drinks 16 ounces (480 mL) of whole milk per shift
A
An adolescent boy is diagnosed with hepatitis A. Which problem should be considered when planning care? A) He will become fatigued easily. B) He will be very irritable and perhaps require sedation. C) Hypothermia is common. D) His urine will be dark and infectious.
A
Following surgery for pyloric stenosis, an infant should be well-bubbled following feedings primarily to prevent A) pressure on the incision line. B) abdominal discomfort. C) contaminating flatulence. D) intestinal obstruction.
A
The nurse has received morning report on a group of pediatric clients. Which pediatric client will the nurse see first? A) a child with hemophilia reporting knee pain and edema B) a child with sickle-cell anemia requesting a cool compress C) a child experiencing a palpable purpural rash and arthralgia D) a child reporting lethargy with a history of thalassemia major
A
The nurse is assessing a school-age child with sickle-cell anemia. Which assessment finding is consistent with this child's diagnosis? A) Slightly yellow sclera B) Enlarged mandibular growth C) Increased growth of long bones D) Depigmented areas on the abdomen
A
The nurse is caring for a 3 year old with repeated diarrhea. The client is listless ad clings to the parent. The nurse reviews the laboratory work which reports a pH- 7.33, HCO3- 21, PaCO2- 42. Which would be documented? A) Metabolic acidosis. B) Metabolic alkalosis. C) High serum pH. D) Normal serum pH.
A
The nurse is evaluating teaching provided to the mother of a child with celiac disease. Which type of breakfast indicates that instruction has been effective? A) Eggs and orange juice B) Oat cereal and skim milk C) Wheat toast and grape jelly D) Rye toast and peanut butter
A
The nurse is working with a school district to ensure students do not develop food-borne illnesses. Which intervention should the nurse emphasize that supports the 2020 National Health Goals regarding food preparation? A) Refrigerate foods promptly. B) Provide fresh fruits and vegetables. C) Ensure all students are appropriately immunized. D) Examine the number of students who contract food-borne illnesses.
A
To prevent further sickle cell crisis, you would advise the parents of a child with sickle cell anemia to: A) notify a health care provider if the child develops an upper respiratory infection. B) prevent the child from drinking an excess amount of fluids per day. C) encourage the child to participate in school activities, such as long-distance running. D) administer an iron supplement daily.
A
Which nursing diagnosis would be most appropriate for a child with idiopathic thrombocytopenic purpura? A) Ineffective tissue perfusion related to poor platelet formation B) Risk for altered urinary elimination related to kidney impairment C) Risk for infection related to abnormal immune system D) Ineffective breathing pattern related to decreased white blood count
A
While receiving a transfusion of packed red blood cells, a school-age child begins to experience itchy skin, hives, and wheezes. What should the nurse do first for this child? A) Stop the transfusion. B) Obtain a blood culture. C) Slow the transfusion rate. D) Provide a diuretic as prescribed.
A
The nurse is caring for a school-age child recovering from an allogeneic stem cell transplant. What nursing action best ensures the child does not develop an infection after the transplant? Select all that apply. A) Restrict all visits from other children. B) Provide sterilized age-appropriate play materials. C) Send for total body irradiation immediately after the transplant. D) Arrangement time for studying while in the hospital. E) Encourage eating raw vegetables for each meal after the procedure.
A, B
The mother of a 3-month-old infant is distraught because the child vomits after every feeding. After an assessment, the nurse determines that the infant is experiencing regurgitation and not vomiting. What did the nurse assess in the infant? (Select all that apply.) A) Slight sour smell B) Occurs after a feeding C) Accompanied by prolonged crying D) Runs out of the mouth with no force E) Volume amount similar to entire stomach contents
A, B, D
The nurse has been asked to participate in a community health teaching session. Which interventions would the nurse include to help achieve the 2020 National Health Goals to reduce the incidence of anemias? Select all that apply. A) Explain the importance of healthy eating for adolescent participants. B) Instruct pregnant women to take iron supplementation as prescribed. C) Emphasize ways to reduce unintentional injuries at home, work, and play. D) Review foods that are rich in iron that should be a part of school-age children's diets. E) Examine strategies for elderly community members to improve the quality of life.
A, B, D
An 18-month-old child is diagnosed with insufficient platelets. What should the nurse instruct the parents to reduce the risk of the child bleeding when at home? (Select all that apply.) A) Check that all toys have soft corners. B) Engage in limited amounts of rough play each day. C) Ensure mouth care is performed with a soft toothbrush. D) Do not apply Band-Aids or adhesive tape onto the skin. E) Pad the side and crib rails on the bed at home to prevent bruising.
A, C, D, E
The nurse is evaluating the effectiveness of teaching provided to the parents of a school-age child prescribed liquid ferrous sulfate for iron-deficiency anemia. Which observations indicate that teaching has been effective? Select all that apply. A) Parent places medication in orange juice. B) Parent provides medication with a glass of milk. C) Child consumes fresh raw fruit and drinks water. D) Parent provides liquid-prepared medication to the child with a straw. E) Child goes to the bathroom to brush teeth immediately after taking the medication.
A, C, D, E
A child with hypoplastic anemia develops hemosiderosis. The therapy for this is: A) ferrous sulfate. B) deferoxamine. C) prednisone. D) aspirin.
B
A child with hypoplastic anemia develops hemosiderosis. What nursing instruction promotes the treatment goals? A) Avoid all products containing aspirin B) Infuse deferoxamine at home C) Administer daily doses of ferrous sulfate D) Adhere to a strict schedule of prednisone
B
A school-aged child with Crohn's disease will receive enteral nutrition for the next 6 weeks. What should the nurse counsel the parents to do to support this child's needs? A) Provide the feeding during regular meal times. B) Encourage the child to stay with the family during routine meal times. C) Suggest the child stay in the bedroom during routine meal times with the family. D) Explain that this might be a permanent method to have nutrition going forward.
B
A school-aged girl with Crohn's disease will receive total parenteral nutrition (TPN) for the next 6 weeks. Which would best help her accept the treatment plan? A) Help her ambulate with the bottles. B) Provide some time to talk to her several times a day. C) Help her give the bottles nicknames and personalities. D) Explain that TPN substitutes for normal food.
B
An adolescent patient is diagnosed with hepatitis A. Which problem should the nurse consider when planning the care for this patient? A) The patient will develop hypothermia. B) The patient will become easily fatigued. C) The patient's urine will be dark and infectious. D) The patient will be very irritable and perhaps require sedation.
B
An infant has surgery to relieve pyloric stenosis. Which of the following nursing diagnoses would apply in the immediate postoperative period? A) Excess fluid volume related to increased fluid intake prescribed postoperatively B) Risk for infection of incision line, related to disruption of skin barrier during surgery C) Ineffective tissue perfusion related to pressure on heart chambers D)Anxiety related to new feeding method used postoperatively
B
The nurse is assessing children in an ambulatory clinic. Which child would be most likely to have iron-deficiency anemia? A) A 3-month-old boy who is totally breastfed B) A 15-year-old girl who has heavy menstrual periods C) An 8-year-old girl who carries her lunch to school D) A 7-month-old boy who has started table food
B
When planning care for a child with idiopathic thrombocytopenic purpura, the nurse plans to teach her: A) what foods are high in folic acid. B) not to pick or irritate her nose. C) to use mainly cold water to wash. D)to apply a soothing cream to lesions
B
When providing diaper care to an infant after pyloric stenosis surgery, which approach is indicated? A) Diapers should be folded so that the incision line is well covered to prevent infection. B) Diapers should be folded so that the incision line does not become contaminated. C) Diapers should not be used. D) Sterile diapers should be used.
B
Which assessment below would increase your suspicion that iron-deficiency anemia may be present in a child? A) A 3-month-old boy sucks his thumb B) A 15-year-old girl constantly sucks ice cubes C) An 8-year-old girl is shy and does not participate in class D) A 7-month old boy does not say whole words yet
B
Which assessment finding would suggest that a child's postoperative feeding schedule following pyloric stenosis surgery should be slowed? A) Flatulence B) Vomiting C) Semiformed bowel movements D) Falling asleep at each feeding
B
Which nursing diagnosis should the nurse identify as being the most appropriate for a child with idiopathic thrombocytopenic purpura? A) Risk for infection related to abnormal immune system B) Risk for bleeding related to insufficient platelet formation C) Risk for altered urinary elimination related to kidney impairment D) Ineffective breathing pattern related to decreased white blood count
B
You care for a 12-year-old girl with Crohn disease. A primary assessment you would want to make when caring for her would be to note if: A) lung sounds are clear. B) she has a temperature. C) her joints are not swollen. D) she has a headache.
B
While administering a blood transfusion to a child with a hematologic disorder, the nurse notes the child develops urticaria and wheezing. Which collaborative interventions will the nurse begin? Select all that apply. A) Administer a diuretic. B) Give an antihistamine. C) Obtain a blood culture. D) Apply oxygen as needed. E) Discontinue the transfusion.
B, D, E
The nurse is instructing the parents of a child with sickle-cell anemia on safety precautions. What should the nurse emphasize during this teaching? A) Suggest the child participate in sports activities without restriction. B) Treat upper respiratory infections with over-the-counter medication. C) Ensure a consistent and daily intake of adequate fluids to prevent dehydration. D) Remind to avoid immunizations to prevent the introduction of bacteria into the body.
C
Which assessment findings suggests that an infant with diarrhea is severely dehydrated? A) Moist and flushed skin, fontanelles depressed B) Salty saliva and tears with crying C) Elevated hematocrit and depressed eye globes D) Low specific gravity of urine, moist skin
C
A 6-year-old child is suspected of having aplastic anemia. For diagnosis, the child will have a bone marrow aspiration. How would the nurse explain the procedure when preparing the child? A) The procedure will be done under general anesthesia. B) A narrow needle is used so the child will not feel pain. C) The child can expect to experience leg pain afterward. D)The child will have to lie on the stomach for the aspiration
D
A school-age child is scheduled for a bone marrow aspiration to confirm the diagnosis of aplastic anemia. What should the nurse instruct the child about this procedure? A) Leg pain will occur after the procedure. B) It will be done under general anesthesia. C) A narrow needle is used so there is no pain. D) The child will have to lie on the stomach for the procedure.
D
It is determined that a preschool-age child developed anemia after exposure to an insecticide. What should the nurse teach the parents before the child is discharged from the hospital? A) Schedule weekly chelating treatments. B) Provide the child with a high-protein diet. C) Schedule hospital visits to desensitize the child to the insecticide. D) Ensure that the child has no further exposure exposed to the insecticide.
D
The nurse is advising a group of new parents on how to care for their infant at home if the baby develops mild diarrhea. Which statement indicates that teaching has been effective? A) "I should offer milk after each episode of diarrhea." B) "I should take the baby's temperature and call my physician." C) "I could give Kaopectate as long as I follow the directions on the bottle." D) "I should offer Pedialyte after 1 hour and frequently thereafter to prevent dehydration."
D
The nurse is concerned that a school-age child has iron-deficiency anemia. What did the nurse assess in this client? A) Shyness B) Thumb-sucking C) Asking many questions D) Craving for ice cubes
D
The nurse is demonstrating to the parent how to feed their neonate following pyloromyotomy? Which position is best? A) Supine with feet elevated B) Fowler's C) Prone D) Right side
D
The nurse is instructing new parents on caring for their infant if gastroenteritis symptoms should occur. Which parental statement indicates understanding of appropriate care? A) "I should offer foods and fluid frequently to prevent dehydration." B) "I could give Kaopectate as long as I follow the directions on the bottle." C) "I should offer milk after each episode of diarrhea." D) "I should take the baby's temperature and call my health care provider."
D
The nurse is planning care for a school-age child recovering from being hit by a motor vehicle while riding a bicycle. For what will the nurse assess to determine the onset of disseminated intravascular coagulation in this child? A) Blurred vision B) Nausea and vomiting C) Sudden onset of knee pain D) Bleeding from intravenous sites
D