Evolve HESI Practice Questions

The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? Have you lost any weight in the last month? Are you experiencing any type of nervousness? When was the last time you took your synthroid? Are you having any problems with your vision?

Are you experiencing any type of nervousness? Assessing the client's physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism (B). Weight loss (even with a hearty appetite) (A) occurs in those with hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid (C). The client may have exophthalmus (bulging eyes) but hyperthyroidism does not cause vision problems (D).

A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding? Frequency of emesis in the last 8 hours. Serum BUN and creatinine levels. Current blood sugar level. Appearance of the stool.

Serum BUN and creatinine levels. Regardless of a client's age, adequate renal function must be present before adding potassium to IV fluids (B). (A) is important in determining the need for fluid replacement. (C) is not indicated. (D) is useful information, but will not impact administration of the prescribed IV solution.

A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client's social interaction, what intervention is best for the nurse to initiate? Encourage the client to use a hand-held video game that is popular with all his friends. Assign a 25-year-old female nursing student to offer support to the client. Arrange for an Internet connection in the client's room for email communication. Encourage the client's mother to arrange a surprise get together in the cafeteria.

Arrange for an Internet connection in the client's room for email communication. Body image and peer acceptance are key concerns for the adolescent. (C) allows for social interaction without face to face contact, thus protecting his self-image while also promoting social interaction. (A) does not promote social interaction. (B) does not encourage interaction with his own peer group, which is of greater importance. (D) does not respect the client's concern about his body image.

A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization? Explain hospital schedules to the child, such as mealtimes. Use terms, such as "honey" and "dear," to show a caring attitude. Provide a list of rules that limits visitation of siblings in the hospital. Orient the parents to the hospital unit and refreshment areas.

Explain hospital schedules to the child, such as mealtimes. Altered daily schedules and loss of rituals are upsetting to children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules (A) and establishing an individual schedule familiarizes the child to the hospital environment and decreases anxiety. (B) depersonalizes the child who should be addressed by name. Family and sibling visitation should be recommended and encouraged without limitation (C). Although (D) should be implemented, the direct involvement of the school-aged child incorporates the child's sense of initiate and cooperation.

During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing? Hearing tests. Eye exams. Chest x-rays. Fasting blood glucose tests.

Eye exams. Visual changes leading to blindness can occur in children with JRA. Regular eye exams (B) can help to prevent this complication. (A, C, and D) are not routinely necessary for management of JRA.

The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement? Reassure the parents that 3-year-olds are cooperative and therefore are less likely to be anxious. Obtain a video film of a cardiac catheterization to show to the child prior to the procedure. Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there. Obtain a cardiac catheter and demonstrate the procedure by pretending to put the catheter in a doll or stuffed animal.

Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there. Familiarizing the child and mother with the department (C) will help decrease anxiety of the child and mother (who may have more anxiety than the child). Three is a difficult age to undergo a procedure that requires cooperation. Restraints and possibly sedation may be required (A). At three, the child is too young to understand why this must be done, and (B) is not indicated. (D) is also not indicated because it is likely to be interpreted as painful.

The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that A. Only an RN should be assigned to monitor this child's temperature. Incorrect B. A tympanic measurement of temperature will provide the most accurate reading. C. The licensed practical nurse should be instructed to obtain rectal temperatures on this child. D. The healthcare provider should be asked to prescribe the method for measurement of the child's temperatures.

B. A tympanic measurement of temperature will provide the most accurate reading. (B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management--sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less accurate because of the possibility of stool in the rectum. (D) is unnecessary.

A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is calculated as a larger percentage of total body surface than an adult's? Head and neck. Arms and chest. Legs and abdomen. Back and abdomen.

Head and neck. A child's head and neck are proportionately larger to their body than an adult's (A). The standard "Rule of Nines" is inaccurate for determining burned body surface areas with children, and must be modified for use with children. Specially designed charts for children are commonly used to determine body surface area involvement. (B, C, and D) are not proportionately different.

A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first? Slowly pour hydrogen peroxide over the open wound. Apply ice to the area before rinsing with cold water. Wash the wound gently with mild soap and water. Gently cleanse with a sterile pad using povidone-iodine.

Wash the wound gently with mild soap and water. A small, superficial laceration to the skin should be washed gently with mild soap and water (C) for several minutes, followed by thorough rinsing. (A and D) are antiseptics that can be traumatic (painful) when cleaning fresh, open wounds. Applying ice (B) may reduce or prevent further edema, but the wound should be washed with mild soap and water first.

When assessing a child with asthma, the nurse should expect intercostal retractions during inspiration. coughing. apneic episodes. expiration.

inspiration. Intercostal retractions result from respiratory effort to draw air into restricted airways (A).

All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old child? Weighing diapers. Assessing fontanels. Checking skin turgor. Observing mucous membranes for moisture.

Assessing fontanels. All of these interventions evaluate fluid status in infants. But, how old is this child? Posterior fontanel closes at 2 months and anterior fontanel closes by 18 months of age (B)! Remember normal growth and development!

The nurse observes a 4-year-old boy in a daycare setting. Which behavior would the nurse consider normal for this child? Has a temper tantrum when told he must share his toys. Plays by himself most of the day. Demonstrates aggressiveness by boasting when telling a story. Begins to cry and is fearful when separated from his parents.

Demonstrates aggressiveness by boasting when telling a story. Four-year-old children are aggressive in their behavior and enjoy "tale telling" (C). Behaviors in (A and D) are typical of toddlers. The play of a preschooler is cooperative, so playing alone (B) is not typical.

The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? Description of vomiting episodes in past 24 hours. Number of wet diapers in last 24 hours. Feeding and sleep schedule. Amount of formula consumed during the past 24 hours.

Description of vomiting episodes in past 24 hours. A description of the vomiting episodes (A) will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant. (B and C) provide related information but are not as helpful as (A). (D) may be related to the vomiting, but the nurse should first obtain a better description of the vomiting episodes.

The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's repeated hospitalizations. Which is the best response that the nurse should offer? Inform the parent that the child is too young to visit the hospital. Suggest that the child visit a grandmother until the sibling returns home. Ask the mother if the child asks when the sibling will be discharged. Encourage the mother to have the children visit the hospitalized sibling.

Encourage the mother to have the children visit the hospitalized sibling. Needs of a sibling will be better met with factual information and contact with the ill child, so sibling visitation should be encouraged (D). Parents are experts on their children and should determine when their children are old enough to visit (A) in the hospital. Separation from family and home (B) may intensify fear and anxiety. Children may have difficulty expressing questions (C), so the support of parents and other caregivers are needed to help alleviate their fears.

The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication? Engage the child through drawing pictures. Suggest that the parent read a book to the child. Provide paper and pencil for the child to keep a diary. Ask the parent if the child is always uncommunicative.

Engage the child through drawing pictures. Drawing pictures (A) is a valuable form of non-verbal communication. As the nurse and child look at the drawings, a verbal story can be told that projects the child's thinking. (B) may distract the child, but does not establish communication with the nurse. (C) is useful for an older child who is able to write. (D) is important, but engaging the child is more effective in establishing communication patterns.

A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder? Nystatin (Mycostatin). Nitrofurantoin (Macrodantin). Norfloxacin (Noroxin). Neomycin sulfate (Mycifradin).

Nystatin (Mycostatin). Nystatin (Mycostatin) (A) is an antifungal drug that is effective in treating thrush, an oral fungal infection. (B, C, and D) are not indicated for the treatment of oral thrush.

When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement? Record weight daily. Assess for signs of anemia. Document sleeping patterns. Teach parenting skills.

Record weight daily. The most definitive measure of improved nutrition in an infant is obtaining the child's daily weight (A). (B, C, and D) may also be useful, but they are not as definitive as a daily weight measurement.

As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? A 6-month-old with failure to thrive that has a closed anterior fontanel. A 24-month-old with gastroenteritis that has a closed posterior fontanel. A 2-month-old with chickenpox that has an open posterior fontanel. A 28-month-old with hydrocephalus that has an open anterior fontanel.

A 6-month-old with failure to thrive that has a closed anterior fontanel. At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. (B and C) are normal findings. A child with hydrocephalus may have a delayed closing of the fontanel (D).

Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? A trial of adrenocorticotrophic hormone injections. Frequent stimulation of the cremasteric reflex. A trial of human chorionic gonadotrophic hormone. Frequent warm baths to gently dilate the scrotal area.

A trial of human chorionic gonadotrophic hormone. A trial of HCG (human chorionic gonadotrophic hormone) (C) may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric reflex. (A) is not indicated. Stimulation of the cremasteric reflex causes the testes to ascend rather than descend in the scrotum (B). (D) may relax the cremasteric muscle, but may not cause the testes to descend.

A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care? Minimize interactive play with other children to lessen chances for injury. Give low-dose children's chewable aspirin in orange flavor for joint discomfort. Use a firm and dry toothbrush to clean teeth at least twice per day. Apply pressure and ice for bleeding while elevating and resting the extremity.

Apply pressure and ice for bleeding while elevating and resting the extremity. Hemophilia, a blood disorder, causes joint bleeding which is treated with rest, ice, compression, and elevation (RICE) (D). (A, B, and C) are inaccurate.

A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first? Insert an indwelling urinary catheter. Administer IV pain medication. Collect blood specimen for laboratory studies. Assess the child's respiratory status.

Assess the child's respiratory status. Assessing the airway and the respiratory status is the highest priority (D) since burns to the face and chest place the child at risk for smoke inhalation injury and compromised airway. (A, B, and C) are implemented after (D).

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? Choking, coughing, and cyanosis. Projectile vomiting and cyanosis. Apneic spells and grunting. Scaphoid abdomen and anorexia.

Choking, coughing, and cyanosis. (A) includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea. Projectile vomiting (B) is characteristic of pyloric stenosis in the infant. Apneic spells often occur with prematurity or sepsis, and grunting (C) is a sign of respiratory distress. A scaphoid abdomen (D) is characteristic of diaphragmatic hernia.

A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior? Ability to communicate verbally. Response to separation from family. Concern for body integrity. Socialization with other children.

Concern for body integrity. The preschooler's major stressor is concern for his body integrity (C). He fears that his "insides will leak out." A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most concern to the toddler. (D) is not a prime concern in this situation.

The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? If the child's tongue darkens, discontinue the Pepto Bismol immediately. Do not give if the child has chickenpox, the flu, or any other viral illness. Avoid the use of Pepto Bismol until the child is at least 16 years old. Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache."

Do not give if the child has chickenpox, the flu, or any other viral illness. Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (A) is a common effect of Pepto Bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D), which is a complication of antacids containing calcium.

What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? Monitor for signs of metabolic acidosis. Estimate the quantity of diarrhea stools. Place in a supine position after feeding. Observe for projectile vomiting.

Observe for projectile vomiting. Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the classic sign of pyloric stenosis. (B) is not indicated. (C) is dangerous, due to the potential for aspiration with frequent vomiting.

Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations? Oven-baked potato chips and cola. Peanut butter and banana sandwich. Oatmeal-raisin cookies and milk. Graham crackers and fruit juice.

Oven-baked potato chips and cola. Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat, and barley. The child should avoid any products containing these ingredients to avoid symptoms such as diarrhea. (A) is the selection which avoids all of these ingredients. (B, C, and D) contain gluten in one form or another.

The nurse is planning care for school-aged children at a community care center. Which activity is best for the children? Building model airplanes. Playing follow-the-leader. Stringing large and small beads. Playing with Playdough and clay.

Playing follow-the-leader. School-aged children strive for independence and productivity (Erikson's Industry vs. Inferiority) and enjoy individual and group activities related to real-life situations, such as playing follow-the-leader (B). (A) is an individual activity that could contribute to feelings of inferiority and inadequacy if the task is too complex. Although school-aged children enjoy crafts, (C and D) are more appropriate for pre-school children.

An 18-month-old is admitted to the hospital with possible Hirschsprung's disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease? Foul-smelling and fatty. Bile-colored and watery. Semi-solid and yellow. Ribbon-like and brown.

Ribbon-like and brown. Hirschsprung's disease is a mechanical obstruction caused by inadequate motility in a part of the intestines. The condition results from failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis in the affected bowel segment causes constipation and small diameter, brown-colored stools (D). (A) is associated with cystic fibrosis. (B) is common in gastroenteritis. (C) is normal in breastfed neonates.

he vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first? Insert an indwelling urinary catheter. Start an IV infusion of normal saline. Send a specimen to the lab for urinalysis. Document the child's vital signs and pulses.

Start an IV infusion of normal saline. The current vital sign readings and the decreased peripheral pulse volume indicate that the child is experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume (B). (A) is useful in obtaining a precise urine output measure, but is a lower priority than restoring fluid volume at this time. (C) is not indicated based on the current assessment data, and (D) does not recognize the need for immediate action to combat the fluid volume deficit.

A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding? Diarrhea. Rhinorrhea. Galactorrhea. Steatorrhea.

Steatorrhea. Steatorrhea (D) is defined as stools with an abnormally high fat content that are usually foul smelling and float on water. (A, B, and C) do not describe this finding.

The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? Type of reaction to loud noises. Any surgeries on the ears since birth. Drainage from the infant's ears. Number of ear infections since birth.

Type of reaction to loud noises. Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises (A) helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant. (B, C, and D) are not associated with exposure to aspirin in utero.

The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication? Poor skin turgor resulting from dehydration. Changes in level of consciousness. Premature aging as the disease progresses. Severe edema from an excess of water and sodium.

Changes in level of consciousness. The child must be monitored for signs and symptoms of hyponatremia, which creates secondary central nervous system alterations such as changes in level of consciousness, seizure, and coma (B). Fluid overload occurs with SIADH, not (A) (which occurs with diabetes insipidus). (C) is caused by hypersecretion of growth hormone, not SIADH. (D) is not found in children with SIADH because edema is caused by an excess of both water and sodium.

The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit? Bradycardia. Machinery murmur. Weak pedal pulses. Clubbed fingers.

Clubbed fingers. Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of congenital heart disease. (B) is a classic sign of ventricular septal defect. (C) is characteristic of coarctation of the aorta.

A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome? Congenital heart disease. Fragile X chromosome. Trisomy 13. Pyloric stenosis.

Congenital heart disease. Congenital heart disease (A) is the most common associated defect in children with Down syndrome. (C) might have seemed possible since Down syndrome is a trisomal chromosomal abnormality of chromosome 21. (B) is a sex-linked abnormality also causing mental retardation. (D) is not associated with Down syndrome.

A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first? Insert N/G tube for gastric lavage. Determine the child's pulse and respirations. Assess the child's level of consciousness. Administer an IV D5/0.25 NS as prescribed.

Determine the child's pulse and respirations. The most important principle in dealing with a poisoning is to treat the child first, not the poison. Initiate immediate life support measures with assessment of vital signs (B), in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to (A). (C and D) should occur after assessing the airway.

When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline? Parental control should be consistent. Children as young as 4 years rarely need reprimand or punishment. Withdrawal of approval is effective. Parents should enforce rigid rules to be followed without question.

Parental control should be consistent. Discipline should be a positive and necessary component of childrearing that is started in infancy and should teach socially acceptable behavior, help children protect themselves from danger, and channel undesirable behavior into constructive activity. Misbehavior may result from inconsistent rules or messages, so parental attention should be clear, reasonable, and consistent (A). (B and C) are not helpful to the child. Children need boundaries that are firm but not rigid (D).

An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? Stop the flow of unoxygenated blood into systemic circulation. Increase the flow of unoxygenated blood to the lungs. Prevent the return of oxygenated blood to the lungs. Reduce peripheral tissue hypoxia and nailbed clubbing

Prevent the return of oxygenated blood to the lungs. Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.

Preoperative nursing care for a child with Wilms' tumor should include which intervention? Gently percuss the abdomen for evidence of trapped air. Observe the abdomen for any noticeable discolorations. Apply cold compresses to the abdomen to reduce edema. Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN."

Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." Prevention of abdominal palpation (D) minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis. (A) is unnecessary, and this action could traumatize the tumor in the same manner as palpation. (B and C) are incorrect since the abdomen is not discolored and cold compresses are not indicated.

A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child? Keep restraints on at all times. Remove restraints one at a time and provide range of motion exercises. Remove all restraints simultaneously and provide play activities. Renew the healthcare provider's prescription for restraints every 72 hours.

Remove restraints one at a time and provide range of motion exercises. Removing restraints one at a time (B) is safer than removing all of them at once (C). The child needs to exercise and should not be kept in restraints at all times (A). The renewal of the healthcare provider's prescription varies with hospitals (D), and it does not really answer the question.

Which class of antiinfective drugs is contraindicated for use in children under 8 years of age? Aminoglycosides. Tetracyclines. Penicillins. Quinolones.

Tetracyclines. Tetracyclines (B) cause enamel hypoplasia and tooth discoloration in children under 8 years of age. (A, C, and D) are not contraindicated for use in children.

The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child's cooperation? Use a colorful straw. Mix the medication in water. Administer the medication using an oral syringe. Ask the pharmacy to provide an enteric tablet.

Use a colorful straw. A liquid iron preparation administered through a straw may help the child to accept the medication since young children consider drinking from a colorful straw fun (A). (B) may cause staining of the child's teeth. (C) is often used if the child is uncooperative. (D) is ineffective and should be requested from the healthcare provider.

The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits? Is able to name four colors. Can count five blocks. Is capable of making a three word sentence. Half of child's speech is understandable.

Half of child's speech is understandable. Between approximately 15 and 24 months of age, a child's speech is only half understandable (D). (A and B) usually occur between 3 and 5 years of age. (C) is usually accomplished by 18 months of age.

To take the vital signs of a 4-month-old child, which order provides the most accurate results? Respiratory rate, heart rate, then rectal temperature. Heart rate, rectal temperature, then respiratory rate. Rectal temperature, heart rate, then respiratory rate. Rectal temperature, respiratory rate, then heart rate.

Respiratory rate, heart rate, then rectal temperature. The respiratory rate should be taken first (A) in infants, since touching them or performing unpleasant procedures usually makes them cry, elevating the heart rate and making respirations difficult to count (B). Rectal temperature is the most invasive procedure, and is most likely to precipitate crying, so should be done last (C and D).

A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis? Aplastic. Sequestration. Hyperhemolytic. Vaso-occlusive.

Sequestration. The findings support a sequestration crisis (B), where blood pools in the spleen, and is characterized by abdominal pain and anemia. (A and C) crises produce anemia but no abdominal pain or splenic enlargement. (D) crisis may produce abdominal pain, but no splenic enlargement or exacerbation of anemia.

A nurse who is working in the Poison Control Center receives several telephone calls from parents whose children have ingested possible poisons. The nurse should recommend inducing vomiting for which child? 8-month-old who ate 4 to 6 ibuprofen tablets. 3-year-old who drank an unknown amount of charcoal lighter fluid. 16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir. 2-year-old who ate a handful of automatic dishwasher detergent.

16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir. Emesis should be induced for the child who drank the large dose of acetaminophen (Tylenol) elixir (C) because this medication is hepatotoxic. Vomiting is contraindicated for: children under 1 year of age (A), petroleum distillates (B) such as charcoal lighter fluid, and corrosives (D) such as dishwasher detergents.

A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take? Dispense a tetanus antitoxin. Prepare human tetanus immune globulin. Administer tetanus toxoid booster. Delay the tetanus toxoid booster until due.

Administer tetanus toxoid booster. After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered (C). (A, B, and D) are not indicated.

A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? Apical heart rate of 60. Sweating across the forehead. Doesn't suck well. Respiratory rate of 30 breaths per minute.

Apical heart rate of 60. A heart rate of 60 (A) is much lower than normal for a 6-month-old and warrants immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM when awake, and a rate of 70 while sleeping is considered within normal limits. (B and C) are expected symptoms of heart failure in an infant. (D) is within normal limits for an infant.

A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first? Insert an indwelling urinary catheter. Administer IV pain medication. Collect blood specimen for laboratory studies. Assess the child's respiratory status.

Assess the child's respiratory status. Assessing the airway and the respiratory status is the highest priority (D) since burns to the face and chest place the child at risk for smoke inhalation injury and compromised airway. (A, B, and C) are implemented after (D)

A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior? Ability to communicate verbally. Response to separation from family. Concern for body integrity. Socialization with other children.

Concern for body integrity. The preschooler's major stressor is concern for his body integrity (C). He fears that his "insides will leak out." A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most concern to the toddler. (D) is not a prime concern in this situation.

Which finding in a 19-year-old female client should trigger further assessment by the nurse? Menstruation has not occurred. Reports no tetanus immunization since childhood. Denies having any wisdom teeth. History of painful, inward growth on bottom of foot.

Menstruation has not occurred. Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically occurs by age 18, so (A) should prompt further investigation to determine the cause of this primary amenorrhea. Children receive tetanus as part of the DPT childhood immunization series, and a booster is not typically given until age 16 (B). Wisdom teeth are the third molar teeth of the permanent dentition and are the last to erupt, so (C) is a normal finding. (D) describes a plantar surface wart, harmless but painful because of the pressure with walking or standing.

A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child's care? Daily iron supplements should be given. Plenty of fluids should be consumed daily. Immunizations should be delayed for a few years. Protective equipment should be worn for contact sports.

Plenty of fluids should be consumed daily. Adequate fluid intake (B) decreases the viscosity of the blood which affects the incidence of vasocclusive crisis. (A and D) are not commonly indicated for a child with sickle cell disease. A routine immunization schedule (C) is recommended for a children with SCD because of their increased susceptibility to infection that predisposes to sickling phenomena.

In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? Food planning and selection. Administering insulin injections. Process of glucose testing. Drawing up the correct insulin dose.

Process of glucose testing. Developmentally, a 5-year-old has the cognitive and psychomotor skills to use a glucometer (C) and to read the number (it is especially helpful if the nurse presents this activity as a game). (A, B, and D) require more advanced cognitive and psychomotor skills and have greater potential for errors

The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child? Risk for infection. Risk for hemorrhage. Altered skin integrity. Disturbance in body image.

Risk for infection. Chemotherapy (CT) suppresses phagocytotic neutrophils and places the child at risk for infection (A), which is the priority nursing diagnosis. (B, C, and D) may be related to the care of a child receiving CT are not related to neutropenia.

Which action by the nurse is most helpful in communicating with a preschool-aged child? Speak clearly and directly to the child. Use a doll to play and communicate. Approach when a parent is not present. Play a board game with the child.

Use a doll to play and communicate. Communicating through play with a doll (B) or other toy gives time for the child to feel comfortable with a stranger. (A) may frighten some children and is usually not as effective as (B). To provide security and comfort, preschool-aged children should be approached when a parent is present, not (C). (D) is too advanced for a preschooler.

When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it increases salivation. increases the respiratory rate. leads to vomiting. stresses the suture line.

stresses the suture line. Prevention of stress on the lip suture line (D) is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes (A, B, and C), these conditions do not create a problem for the child with a cleft lip repair.

A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The nurse determines the daily caloric need for this child is approximately 400 calories per day. 500 calories per day. 600 calories per day. 700 calories per day.

600 calories per day. 10 lbs 15 oz = 10.9 lbs. Convert lbs to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954 kg, rounded to 5 kg. An infant requires 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day. Tough question! You know that 400 calories are too few and 700 are too much, and a temperature elevation necessitates consumption of more calories, so choose the higher of the two choices left!

Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant? A lower sensitivity reactions to skin irritants. A thin stratum corneum that increases topical absorption. A smaller percentage of muscle mass. A greater body surface area that requires larger dosages.

A thin stratum corneum that increases topical absorption. Infants have a thin outer skin layer (stratum corneum), so the nurse should monitor the infant for a prompt onset and response to the application of topical medication (B). (A, C, and D) are unrelated to topical medication administration.

A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.) A. Monitor the the infant's weight and number of wet diapers per day. B. Increase the infant's intake per feeding by 1 to 2 ounces per week. C. Mix the dose of prophylactic antibiotic in a full bottle of formula. D. Allow the infant to rest and refeed on demand or every 2 hours. E. Use a softer nipple or increase the size of the nipple opening.

A. Monitor the the infant's weight and number of wet diapers per day. B. Increase the infant's intake per feeding by 1 to 2 ounces per week. D. Allow the infant to rest and refeed on demand or every 2 hours. E. Use a softer nipple or increase the size of the nipple opening. Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is consumed. They should be monitored for weight gain and at least 6 wet diapers per day (A). A one-month old infant should ingest 2 to 4 ounces of formula per feeding and progress to about 30 ounces per day by 4-months of age (B)

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? Give small, frequent feedings of fluids. Accurately chart observations regarding breath sounds. Have a bulb syringe readily available to remove secretions. Encourage older siblings to visit.

Have a bulb syringe readily available to remove secretions. A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making (C) the highest priority. (A) maintains hydration and prevent tiring, but an open airway has a higher priority! (B) is important for evaluation of therapy. When asked "priority" questions, REMEMBER MASLOW! Physical needs usually have a higher priority than psychosocial needs (D) and an open airway is the highest physiological need!

The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift? An RN should be assigned to take temperatures frequently. Tympanic and oral temperatures are equally accurate. The PN should take rectal temperatures on this child. The pediatrician should decide how to assess the temperature.

Tympanic and oral temperatures are equally accurate. A tympanic membrane sensor approximates core temperatures because the hypothalamus and eardrum are perfused by the same circulation. Tympanic readings obtained using proper technique correlated moderately to strongly with oral temperatures in recent research studies (B). The sensor is unaffected by cerumen or the presence of suppurative or unsuppurative otitis media. An RN is not required to take the child's temperature, but must assess readings received from assistive personnel (A). Although rectal readings are highly accurate (C), such an invasive procedure is unnecessary. (D) is not required.

A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? Call the healthcare provider immediately if his nail beds appear blue. Check his fingers hourly for the first 48 hours to see that he is able to move them without pain. Be sure his arm remains above his heart for the first 24 hours. Take his temperature q4h for the next two days and call if an elevation is noted.

Call the healthcare provider immediately if his nail beds appear blue. Cyanosis (A) indicates impaired circulation to fingers and should be reported immediately. Although the actions described in (B, C, and D) may be indicated, they are implemented rather excessively--and might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days (B). Elevating the arm above the heart will help to decrease swelling but (C) is stated in a frightening way. It is not necessary to take the child's temperature q4h unless indicated by other symptoms.

Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.) Child's height and weight. Adult dosage of medication. Body surface area of child. Average adult's body surface area. Average pediatric dosage of medication. Nomogram determined mathematical constant.

Child's height and weight. Body surface area of child. Nomogram determined mathematical constant. Correct selections are (A, C, and F). The most accurate calculations of pediatric dosages use the child's height and weight (A). The child's BSA is calculated using the square root of weight in kg times height in cm divided by 3600 or the square root of weight in lb times height in inches divided by 3131 (C), then the child's BSA is multiplied by the recommended published dose per BSA. The nomogram (F) is used to plot the child's height and weight, and the point at which they intersect is the BSA mathematical constant used to calculate the child's dose. (B, D, and E) are not used to calculate pediatric dosages.

The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand? Perform postural drainage before starting aerosol therapy. Give respiratory treatments when the child is coughing a lot. Administer aerosol therapy followed by postural drainage before meals. Ensure respiratory therapy is done daily during any respiratory infection.

Administer aerosol therapy followed by postural drainage before meals. Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and before meals (C) or at least 1 hour after eating to prevent nausea and vomiting. Postural drainage uses gravity to promote mucous removal after nebulization (A) treatments which open the airways. Pulmonary toileting or respiratory treatments should be given 3 to 4 times daily, not episodically (B and D).

A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents? Studies have shown that handling a sick newborn is not good for the baby and upsets the parents. The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her. Since your baby has been doing well under oxygen for 24 hours, I can let you hold the baby without oxygen. You can hold the baby with the oxygen blowing in the baby's face since the level is very close to room air.

The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her. The baby is at 35% which is much more than room air (21%) and at this time the baby should not be moved from under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant (B). Holding sick babies benefits the infant and the parents (A). The first consideration now has to be the infant's oxygenation. The nurse should not take the baby out from under the hood without a prescription from the healthcare provider, as this could severely compromise the infant (C). A PO2 of 35% cannot be readily achieved with "blow by" oxygen (D).

To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? Use a happy-face/sad-face pain scale. Ask the mother if she thinks the analgesic is working. Assess for changes in the child's vital signs. Teach the child to point to a numeric pain scale.

Use a happy-face/sad-face pain scale. A 4-year-old can readily identify with simple pictures (A) to show the nurse how he/she is feeling. (B) could be used to validate what the child is telling the nurse via the "faces" pain scale, but it is best to elicit the child's assessment of his/her pain level. (C) may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables, such as fear. (D) requires abstract number skills beyond the level of a 4-year-old.

The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother? Paddle him gently as soon as the behavior is initiated. Immediately put him in "time-out." Quietly remind him that others are watching him. Walk away from him and ignore the behavior.

Walk away from him and ignore the behavior. The best approach for a toddler is to ignore the attention-seeking behavior (D). The parent should be somewhat nearby, within view of the child but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs. (A, B, and C) would all provide attention for the inappropriate behavior.

At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first? Give the client her 9 a.m. prescription for an oral diuretic early. Administer PRN prescription of nifedipine (Procardia) sublingually. Notify the healthcare provider and inform the nursing supervisor of the client's condition. Attempt to calm the client and retake the blood pressure in thirty minutes.

Administer PRN prescription of nifedipine (Procardia) sublingually. Sublingual Procardia (B) lowers blood pressure very quickly, and this should be done first. (A) may also be done, but oral diuretics do not work as rapidly as the sublingual antihypertensive. When notifying the healthcare provider, the first thing he/she will want to know is if the PRN antihypertensive has been administered (C). (D) does not consider the seriousness of this finding. The nurse should stay with the client until the blood pressure is reduced.

A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? Children need to retain a sense of initiative without impinging on the rights and privileges of others. Negative feelings of doubt and shame are characteristic of 4-year-old children. Role conflict is a common problem of children this age. She is just wondering where she fits into society. At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.

Children need to retain a sense of initiative without impinging on the rights and privileges of others. Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others (A). (B) describes the "Autonomy vs. Shame and Doubt," stage (1 to 3 years of age). (C) describes an adolescent (12 to 18 years of age), the "Identity vs. Role Confusion" stage. (D) describes a child 6 to 12 years of age, the "Industry vs. Inferiority" stage.

Which restraint should be used for a toddler after a cleft palate repair? Clove hitch. Mummy. Elbow. Jacket.

Elbow Elbow restraints prevent children from bending their arms and bringing their hands to the oral surgical site. (A) restrains the hands, but the child can bend and bring their head to their hands. (B) is used during procedures. (D) restrains the body torso and is not appropriate.

The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate? 3 to 6 months. 12 to 15 months. 18 to 24 months. 4 to 6 years.

12 to 15 months. The first measles, mumps, and rubella (MMR) vaccine should be given no sooner than 12 months of age, and ideally between 12 and 15 months of age (B). (A) should not receive the MMR vaccine due to the presence of maternal antibodies. MMR is not routinely administered at (C), but other immunizations, such as DTaP and Hepatitis B may be given at that time. The second dose of MMR is routinely administered at (D), provided that at least 4 weeks have elapsed since the first dose, and if both doses were administered beginning at or after 12 months.

A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan? Use sunscreen when lying by the pool. Cleanse the skin at least 4 times a day. Take the medication with a glass of milk. Menstrual periods may become irregular.

Use sunscreen when lying by the pool. Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) therapy. Severe sunburn can occur with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen (A). (B and D) are not related to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy products interfere with the absorption of tetracyclines.

The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider? Pale bluish coloration of the toes. Skin is warm and dry to the touch. Toes are wiggled upon command. Capillary refill less than 3 seconds.

Pale bluish coloration of the toes. Russell's skin traction is used for fractures of the femur in young children and adolescents whose growth plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can compress the peroneal nerve and arteries that supply the foot. Assessment of adequare circulation, movement, and sensation of the toes and skin distal to the application is made to identify compromised blood flow, so cyanosis (A) should be reported immediately. (B, C and D) are normal findings.

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? Remove all blackheads and follow with an alcohol scrub. Use medicated cosmetics only to help hide the blemishes. Wash the hair and skin frequently with soap and hot water. Encourage her to see a dermatologist as soon as possible.

Wash the hair and skin frequently with soap and hot water. Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at a later time, if healthcare recommendations are not successful.

The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take? Pass the information on in the report. Notify the healthcare provider because the value is high. Repeat the lab study because the value is too high. Hold the next dose of theophylline.

Pass the information on in the report. The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report (A). (B, C, and D) would be inappropriate actions in view of the laboratory finding.

The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family? Polyuria and polydipsia. Lethargy and fatigue. Increased facial hair. Facial bone structure changes.

Polyuria and polydipsia. Signs and symptoms of diabetes or hyperglycemia (A) need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance. (B) is associated with any number of heath alterations, but is not associated with the growth hormone therapy. (C and D) are normal changes that occur with 12-year-old males.

The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction? Tell children they should not taste anything but food. Store all toxic agents and medicines in locked cabinets. Provide special play areas in the house and restrict play in other areas. Punish children if they open cabinets that contain household chemicals.

Store all toxic agents and medicines in locked cabinets. The only reliable way to prevent poisonings in young children is to make them inaccessible (B). Teaching children not to taste is important (A), but ineffective for young children. (C and D) will not control a child's curiosity.

A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take? Tell the student to proceed directly to his regularly scheduled class. Call the parent and suggest re-taking the student's temperature at home. Give the student a glass of cool fluids, then retake his temperature. Send the student to class, but re-verify his temperature after lunch.

Tell the student to proceed directly to his regularly scheduled class. This student has just completed football practice, and increased muscle activity increases body heat production. A temperature of 100° F is normal for this student at this time. The student should attend class (A) since no further nursing action is required. (B) would alarm the parents unnecessarily. (C) would provide a false reading of body temperature. (D) is unnecessary since these findings are within normal limits.

The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching? I will give this antibiotic to my child until it is finished. Using a teaspoon will help me measure this correctly. I will call the clinic if my child develops a rash or itching. My baby should begin to feel better within a few days.

Using a teaspoon will help me measure this correctly. The prescribed medication is 4 ml per dosage and is measured with the most accuracy using a syringe, so if the parent uses a teaspoon (B), which is equivalent to 5 ml, further teaching is indicated. (A, C, and D) indicate correct understanding and require no further intervention by the nurse.

During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next? No action required, as this is an expected finding for a school-aged child. Ask the child if he/she has had a cold, runny nose, or any ear pain lately. Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible. Call the parents and have them take the child home from school for the rest of the day.

Ask the child if he/she has had a cold, runny nose, or any ear pain lately. More information is needed to interpret these findings (B). The tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of history and related signs and symptoms is indicated for accurate interpretation of the findings. (A, C, and D) are inappropriate actions based on the data obtained from the otoscope examination.

When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children? Hyperactive behavioral traits. Delay in the eruption of permanent teeth. Slow sexual development, but within normal range. Cessation of growth in a child that had been normal.

Cessation of growth in a child that had been normal. Since the thyroid gland is responsible for metabolism, cessation of growth (D) which was previously within normal range, is the most common sign for hypothyroidism in children. The child with hypothyroidism is likely to be HYPOactive, not (A). Although (B and C) may occur with hypothyroidism, they are late signs (not early indications) and are signs more often associated with a lack of growth hormone.

A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? Invite other children home to share meals. Accept that he will eat when he is hungry. Reward the child with a nap after eating. Consistently follow a set mealtime routine.

Consistently follow a set mealtime routine. A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-year-olds may participate in parallel activities with other children but are too young to feel comfort and support by the presence of other children when anxious or afraid. (B) may or may not be true and does not address the child's fears. The child with reflux should remain upright at least two hours after eating (C) to reduce symptoms.

A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide? Refer the adolescent to the healthcare provider for a pregnancy screen. Schedule a conference with her parents to recommend hormone therapy. Explain that menarche varies and occurs between the ages of 12 and 18 years. Suggest that she use diversions to help her not worry about delayed menarche.

Explain that menarche varies and occurs between the ages of 12 and 18 years. The nurse should provide a factual and reassuring explanation that focuses on individual variations of menarche, which can normally occur between 12 and 18 years of age (C). (A) does not address the adolescent's concern and is judgmental. Menarche is influenced by hereditary, general health, and nutritional status, so (B) is not indicated. (D) dismisses the adolescent's concerns and does not offer factual information.

The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? I will read all the literature you gave me before surgery. I have had surgery before when I broke my wrist in a bike accident, so I know what to expect. All the things people have told me will help me take care of my back. I understand that I will be in a body cast and I will show you how you taught me to turn.

I understand that I will be in a body cast and I will show you how you taught me to turn. Outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration (D). A 14-year-old may or may not follow through with (A), and there is no measurement of that learning. Having previous surgery (B) may help the client understand the surgical process, but wrist surgery is very different from spinal surgery and emergency surgery is different from elective surgery. In (C), the client may be saying what the nurse wants to hear, without expressing any real understanding of what to do after surgery.

The nurse is planning the care of a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis? Obtain gloves for the child's hands. Apply finger cots on the child's fingers. Place elbow restraints on the child's arms. Apply soft restraints to the child's wrists.

Place elbow restraints on the child's arms. Elbow restraints (C) prevent arm flexion and scratching of involved areas, but do not inhibit use of the hands for play activities. (A and B) can be easily removed by the child and would restrict hand movement. (D) would be ineffective in preventing the child from scratching because the upper body could be moved within reach of restrained hands, and would also create the greatest restriction of hand movement.

A 6-month-old boy and his mother are at the healthcare provider's office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today? The routine immunizations and schedule another appointment to administer the influenza vaccine. Incorrect All the immunizations with the influenza vaccine given at a separate site from any other injection. The influenza vaccine and schedule another appointment to administer the immunizations. The influenza vaccine and the polio vaccine and schedule another appointment to administer the remaining immunizations.

All the immunizations with the influenza vaccine given at a separate site from any other injection. At 6-months of age, the routine immunizations include Hepatitis B, DTaP, Hib (Haemophilus influenza type b), PCV (Pneumococcal), IPV (inactivated poliovirus) and influenza. The influenza vaccine should be given at a separate site from any other injection (B). Scheduling a return visit (A, B, or C) increases the risk that the mother will not bring the child back for the immunizations.