Exam 3 ATI
A nurse is caring for a 2 year old child who has had three ear infections in the past 5 months. which of the following long-term complications is the child at risk for developing? a. balance difficulties b. prolonged hearing loss c. speech delays d. mastoiditis
C
A nurse is caring for a child following an above the knee left leg amputation. which of the following actions should the nurse take? a. avoid discussing the amputation b. administer aspirin for phantom pain c. prepare the child for a prosthesis fitting d. maintain the affected limb in the dependent position
C
A nurse is caring for a child who is postoperative following surgical removal of a Wilm's tumor. which of the following assessments is an indication to continue NPO status? a. abdominal girth 1 cm larger than yesterday b. report of pain at the operative site c. absent bowel sounds d. passing of flatus every 30 minutes
C
A nurse is caring for an adolescent who has a new dx of osteosarcoma. which of the following actions should the nurse take? a. ensure that the adolescent has a referral for psychiatrist visit b. prepare a teaching plan to educate the adolescent in detail about his diagnosis and treatment c. spend time with the adolescent to answer any question he can have d. perform a mental status examination to assess the thought patterns
C
A nurse is completing preoperative teaching with an adolescent client who is scheduled to receive spinal instrumentation for scoliosis. which of the following information should the nurse include in the teaching? a. you will go home the same day of surgery b. you will have minimal pain c. you will need to receive blood d you will not be able to eat until the day after surgery
C
A nurse is planning care for an infant who is scheduled to have a lumbar puncture. which of the following actions should the nurse include in the plan of care? a. cleanse the thoracic area of the infants back with an antiseptic solution b. apply a eutectic mixture of local anesthetic cream just before the procedure begins c. restrain the infant during the procedure to prevent movement d. position the infant with his head extended and chin raised
C
A nurse is teaching a child who has type 1 diabetes about self-care. Which of the following statements by the child indicates understanding of the teaching? a. "I should skip breakfast when I am not hungry." b. "I should increase my insulin with exercise." c. "I should drink a glass of milk when I am feeling irritable." d. "I should draw up the NPH insulin into the syringe before the regular insulin."
C
A nurse is assessing a child who has short stature. Which of the following findings would indicate a growth hormone deficiency? a. Proportional height to weight b. Height proportionally greater than weight c. Weight proportionally greater than height d. BMI greater than height/weight ratio
A
A nurse is caring for a 10 year old child who has nephrotic syndrome. which of the following findings should the nurse report to the provider? a. protein 5.0 b. Hgb 14.5 c. Hit 40% d. platelet 200,000
A
A nurse is caring for a child who is suspected to have Enterobius vermicularis (pinworm). Which of the following actions should the nurse take? a. Perform a tape test b. Collect stool specimen c. Test the stool for occult blood d. Initiate IV fluids
A
A nurse is providing teaching about the management of epistaxis to a child and his family. which of the following position should the nurse instruct the child to take when experiencing a nosebleed? a. sit up and lean forward b. sit up and tilt the head up c. lie in a supine position d. lie in a prone position
A
A nurse is providing teaching to the parent of a child who has a neuroblastoma. which of the following statements should the nurse include in the teaching? (Select all that apply.) a. half of the children who has neuroblastoma have metastatic disease b. your child will need a bone marrow biopsy c. your child will be paralyzed because of this tumor d. most children are diagnosed around age 12 e. your child will need surgery for resection of the tumor
A B E
A nurse is caring for a child who has Meckel's diverticulum. which of the following manifestations should the nurse expect? (Select all that apply.) a. Abdominal pain b. Fever c. Mucus, bloody stools d. Vomiting e. Rapid, shallow breathing
A C
A nurse is providing teaching about epistaxis to the parent of a school ge child. which of the following should the nurse include as an appropriate action to take when managing an episode of epistaxis? (Select all that apply.) a. press the nares together for at least 10 minutes b. breathe through the nose until bleeding stops c. pack cotton or tissue into the naris that is bleeding d. apply a warm cloth across the bridge of the nose e. insert petroleum into the saris after the bleeding stops
A C
A nurse is admitting a child who has severely symptomatic HIV. which of the following findings should the nurse expect? (Select all that apply. a. kaposi's sarcoma b. hepatitis c. wasting syndrome d. pulmonary candidiasis e. cardiomyopathy
A C D
A nurse is caring for a child who is experiencing neuropathy due to chemotherapy. which of the following are manifestations of neuropathy? (Select all that apply.) a. constipation b. skin breakdown c. foot drop d. jaw pain e. hemorrhage cystitis
A C D
A nurse is caring for a male infant who has epispadias. which of the following findings should the nurse expect? (Select all that apply.) a. Bladder exstrophy b. Inability to restrict foreskin c. Widened pubic symphysis d. Broad, spade-like penis e. Pain
A C D
A nurse is teaching a group of parents about E coli. which of the following information should the nurse include in the teaching? (Select all that apply.) a. Severe abdominal cramping occurs b. Watery diarrhea is present for more than 5 days c. It can lead to hemolytic uremia syndrome d. It is a food borne pathogen e. Antibiotics are given for treatment
A C D
A nurse is teaching a parent of a child who has HIV. which of the following information should the nurse include? (Select all that apply.) a. obtain yearly influenza vaccination b. monitor a fever for 24 hours before seeking medical care c. avoid individuals who have colds d. provide nutritional supplements e. administer aspirin for pain
A C D
A nurse is assessing a child who has rhabdomyosarcoma of the upper arm. which of the following findings should the nurse expect? (Select all that apply.) a. pain b. discoloration c. lymph node enlargement d. easy bruising e. palpable mass
A C E
A nurse is caring for a child who has thrombocytopenia. which of the following actions should the nurse take? (Select all that apply.) a. monitor for signs up bleeding b. administer routine immunizations c. obtain rectal temperatures d. avoid peripheral venipuncture e. limit visitors
A D
A nurse is reviewing sick-day management with a parent of a child who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? (Select all that apply.) a. Monitor blood glucose levels every 3 hr b. Discontinue taking insulin until feeling better c. Drink 8 oz of fruit juice every hour d. Test urine for ketones e. Call the provider if blood glucose is greater than 240 mg/dL
A D E
A nurse is caring for a school age child who has juvenile idiopathic arthritis. which of the following home care instructions should the nurse include in the teaching? (Select all that apply.) a. provide extra time for completion of ADLs b. use cold compresses for joint pain c. take ibuprofen on an empty stomach d. remain home during periods of exacerbation e. perform ROM exercises
A E
A parent of a school-age child who has GH deficiency asks the nurse how long the child will need to take injections for growth delay. Which of the following responses should the nurse make? a. "Injections are usually continued until age 10 for girls and age 12 for boys." b. "Injections continue until your child reaches the fifth percentile on the growth chart." c. "Injections should be continued until there is evidence of epiphyseal closure." d. "The injections will need to be administered throughout your child's entire life."
C
A nurse is assessing a child who has chronic renal failure, which of the following findings should the nurse expect? a. flushed face b. hyperactivity c. weight gain d. delayed growth
D
A nurse is caring for a child who has AIDS. which of the following isolation precautions should the nurse implement? a. contact b. airborne c. droplet d. standard
D
A nurse is caring for a child who is in a plaster spic cast. which of the following actions should the nurse take? a. use a heat lamp to facilitate drying b. avoid turning the child until the cast is dry c. assist the client with crutch walking after the cast is dry d. apply moleskin to the edges of the cast
D
A nurse is caring for a child who is suspected of having Legg-calve-perthes disease. the nurse should prepare the child for which of the following diagnostic procedures? a. bone biopsy b. genetic testing c. MRI d. radiographs
D
A nurse is caring for a toddler who has acute otitis media. which of the following is the priority action for the nurse to take? a. provide emotional support to the family b. educate the family on care of the child c. prevent clinical complications d. administer analgesics
D
A nurse is caring for a toddler who is diagnosed with hip dysplasia and has been placed in a hip spica cast. the child's mother asks the nurse why Pavlik harness is not being used. which of the following responses should the nurse make? a. that is used for children with scoliosis, not hip dysplasia b. that is used for school aged children c. that cannot be used for you child because her condition is too severe d. that is used for infants less than 6 months of age
D
A nurse is caring for an infant who has myelomeningocele. which of the following actions should the nurse include in the preoperative plan of care? a. assist the mother with cuddling the infant b. assess the infant's temperature rectally c. place the infant in a supine position d. apply a sterile, moist dressing on the face
D
A nurse is planning care of a child who has a UTI. which of the following should the nurse include? a. Administer an antidiuretic b. Restrict fluids c. Evaluate the child's self esteem d. Encourage frequent voiding
D
A nurse is providing teaching to the parent of a child who has a new prescription for liquid oral iron supplements. which of the following statements by the parent indicates an understanding of the teaching? a. I should take my child to the emergency department if his stools become dark b. my child should avoid eating citrus fruits while taking supplements c. I should give the iron with milk to help prevent an upset stomach d. my child should take the supplement through a straw
D
A nurse is teaching a group of parents about communicable disease. the nurse should include that which of the following is the best method to prevent a communicable disease? a. hand washing b. avoiding person who have active disease c. covering your cough d. obtaining immunizations
D
A nurse is teaching a school-age child who has diabetes mellitus about insulin administration. Which of the following should the nurse include in the teaching? a. "You should inject the needle at a 30-degree angle." b. "You should combine your glargine and regular insulin in the same syringe." c. "You should aspirate for blood before inducting the insulin." d. "You should give four or five injections in one area before switching sites."
D
A nurse in an outpatient facility is caring for an infant who has manifestations of acute otitis media. which of the following factors places the infant at risk for otitis media? (Select all that apply.) a. breastfeeding without formula supplementation b. attends daycare 4 days per week c. immunizations are up to date d. history of cleft palate repair e. parents smoke cigarettes outside
B D E
A nurse is assessing a child who has Legg-calve-perthes disease. which of the following findings should the nurse expect? (Select all that apply.) a. longer affected leg b. hip stiffness c. intense pain d. limited ROM e. limp with walking
B D E
A nurse is assessing an infant who has suspected UTI. which of the following are anticipated findings? (Select all that apply.) a. increase in hunger b. irritability c. decrease in urination d. vomiting e. fever
B D E
A nurse is teaching an adolescent who has diabetes mellitus about manifestations of hypoglycemia. Which of the following findings should the nurse include in the teaching? (Select all that apply.) a. Increased urination b. Hunger c. Signs of dehydration d. Irritability e. Sweating and pallor f. Kussmaul respirations
B D E
A nurse is caring for an infant who has obstructive uropathy. which of the following findings should the nurse expect? (Select all that apply.) a. Decrease urine flow b. UTI c. Metabolic alkalosis d. Concentrated urine e. Hydronephrosis
B E
A nurse is caring for a child who has cerebral palsy. which of the following medications should the nurse expect to administer to treat painful muscle spasms? (Select all that apply.) a. baclofen b. diazepam c. oxybutynin d. methotrexate e. prednisone
A B
A nurse is assessing a child who has a rotavirus infection. which of the following are expected findings? (Select all that apply.) a. Fever b. Vomiting c. Watery stools d. Bloody stools e. Confusion
A B C
A nurse is assessing a client who has pertussis. which of the following findings should the nurse expect? (Select all that apply.) a. runny nose b. mild fever c. cough with whooping sound d. swollen salivary glands e. red rash
A B C
A nurse is providing home care instructions to a parent of a child who is receiving chemotherapy. which of the following instructions should the nurse include in the teaching? (Select all that apply.) a. manifestations of infection b. bleeding precautions c. hand hygiene d. homeschooling e. airborne precautions
A B C
A nurse is caring for a child who has short stature. Which of the following diagnostic tests should be completed to confirm growth hormone (GH) deficiency? (Select all that apply.) a. CT scan of the head b. Bone age scan c. GH stimulation test d. Serum IGF-1 e. DNA testing
A B C D
A nurse is providing teaching for an adolescent client who has mononucleosis. the client has a fever, fatigue, swollen lymph nodes, sore throat and a sore upper abdomen. which of the following instructions should the nurse include in the teaching? (Select all that apply.) a. take antibiotics until symptoms subside b. drink plenty of liquids c. avoid participating in strenuous activities d. allow for periods of rest e. take aspirin as needed for fever and discomfort e. gargle with salt water every 2-3 hours
A B C D F
A nurse is caring for a child who has a fracture. which of the following are manifestations of a fracture? (Select all that apply.) a. crepitus b. edema c. pain d. fever e. ecchymosis
A B C E
A nurse is assessing a child who has rhabdomyosarcoma of the nasopharynx. which of the following are manifestation of rhabdomyosarcoma? (Select all that apply.) a. enlarged neck lymph nodes b. pain c. vomiting d. epistaxis e. diplopia
A B D
A nurse is teaching a parent of an infant about gastrointestinal reflux disease. which of the following should the nurse include in the teaching? (Select all that apply.) a. Offer frequent feedings b. Thicken formula with rice cereal c. Use a bottle with a one-way valve d. Position baby upright after feedings e. Use a wide-based nipple for feedings
A B D
A nurse is teaching the parent of a child who has growth hormone deficiency. Which of the following are complications of untreated growth hormone deficiency? (Select all that apply.) a. Delayed sexual development b. Premature aging c. Advanced bone age d. Short stature e. Increased epiphyseal closure
A B D
A nurse is caring for an infant who has ambiguous genitalia. which of the following actions should the nurse take? (Select all that apply.) a. Prepare the child fro surgery b. Obtain a detailed family history c. Gather supples for a circumcision d. Refer the family for genetic counseling e. Explain the needs for a chromosomal analysis
A B D E
A nurse is assessing an infant who has hypertrophic pyloric stenosis. which of the following findings should the nurse expect? (Select all that apply.) a. Projectile vomiting b. Dry mucus membranes c. Currant jelly stools d. Sausage-shaped abdominal mass e. Constant hunger
A B E
A nurse is assessing a preschool-age child for developmental dysplasia of the hip. which of the following assessment should the nurse include? a. Barlow test b. trendelenburg sign c. manipulation of foot and ankle d. ortolani test
B
A nurse is caring for a 10-year old child who has acute glomerulonephritis. which of the following findings should the nurse report to the provider? a. BUN 8 b. creatinine 1.3 c. blood pressure 100/74 d. urine output 550 in 24 hours
B
A nurse is caring for a child who has Hirschsprung's disease. which of the following actions should the nurse take? a. Encourage a high fiber, low portion, low calorie diet b. Prepare the family for surgery c. Place an NG tube for decompression d. Initiate bed rest
B
A nurse is caring for a child who has enuresis. which of the following is a complication of enuresis? a. UTI b. Emotional problems c. Urosepsis d. Progressive kidney disease
B
A nurse is caring for a child who has watery diarrhea for the past 3 days. Which of the following is an appropriate action for the nurse to take? a. Offer chicken broth b. Initiate oral rehydration therapy c. Start hypertonic IV solution d. Keep NPO until diarrhea subsides
B
A nurse is caring for a toddler who has Wilm's tumor. which of the following actions should the nurse take? a. palpate the child's abdomen to identify the size of the tumor b. prepare the child for surgery c. teach the parents about dialysis d. obtain a 24 hours urine specimen form the child
B
A nurse is caring for a toddler who has rhinitis, cough, diarrhea for 2 days. upon assessment, it is noted that the tympanic membrane has an orange discoloration and decreased movement. which of the following statements should the nurse to make? a. you child has an ear infection that requires antibiotics b. you child could experience transient hearing loss c. you child will need to be on a decongestant until this clears up d. you child will need to have a myringotomy
B
A nurse is caring for an infant who is postoperative following cleft lip and palate repair. which of the following actions should the nurse take? a. Remove the packing in the mouth b. Place the infant in an upright position c. Offer a pacifier with sucrose d. Assess the mouth with a tongue blade
B
A nurse is caring for an infant whose screening test reveals that he might have sickle cell disease. which of the following tests should be performed to distinguish if the infant has the trait or the disease? a. sickle solubility test b. hemoglobin electrophoresis c. complete blood count d. transcranial doppler
B
A nurse is developing a plan of care for a toddler who has cerebral palsy. which of the following actions should the nurse include? a. structure interventions according to the toddlers chronological age b. evaluate the toddler's need for an evaluation of hearing ability c. monitor the toddler's pain level routinely using a numeric rating scale d. provide total care for daily hygiene activities
B
A nurse is preparing to administer iron dextran IM to a school age child who has an iron deficiency anemia. which of the following actions by the nurse is appropriate? a. administer the dose in the deltoid muscle b. use the z track method when administering the dose c. avoid injecting more than 2 ml with each dose d. massage the injection site for 1 minute after administering the dose
B
A nurse is teaching a group of adolescents about HIV/AIDS. which of the following statements should the nurse include in the teaching? a. you can contract HIV through casual kissing b. HIV is transmitted through IV substance use c. HIV is now curable if caught in the early stages d. medications inhibit transmission of the HIV virus
B
A nurse is teaching a group of parents about fractures. which of the following information should the nurse include in the teaching? a. children need a longer time to heal from a fracture than an adult b. epiphyseal plate injuries can result in altered bone growth c. a greenstick fracture is a complete break in the bone d. bones are unable to bend, so they break
B
a nurse is caring for an infant who has hydrocele. which of the following actions should the nurse take? a. prepare the child for surgery b. explain to the parents that the issue will self-resolve c. restrict the foreskin and cleanse several times daily d. refer the family for genetic counseling
B
A nurse is caring for a child who is in skeletal traction. which of the following actions should the nurse take? (Select all that apply.) a. remove the weights to reposition the client b. assess the child's position frequently c. asses pins sites every 4 hours d. ensure the weights are hanging freely e. ensure the ropes knot is in contact with the pulley
B C D
A nurse is teaching a group of parents about complications of communicable disease. which of the following communicable disease can lead to pneumonia? (Select all that apply.) a. rubella b. rubeola c. pertussis d. varicella e. mumps
B C D
A nurse is teaching a group of parents about salmonella. which of the following information should the nurse include in the teaching? (Select all that apply.) a. Incubation period is nonspecific b. It is a bacterial infection c. Bloody diarrhea is common d. Transmission can be from house pets e. Antibiotics are used for treatment
B C D
A nurse is teaching a parent of a child who has a UTI. which of the following should the nurse include in the teaching? (Select all that apply.) a. Wear nylon underpants b. Avoid bubble baths c. Empty bladder completely with each void d. Provide information about manifestations of infectious e. Wipe perineal area back to front
B C D
A nurse is assessing a child who has neuroblastoma of the adrenal gland. which of the following are indications of metastasis from the primary site? (Select all that apply.) a. weight gain b. bone pain c. periorbital eccymoses d. proptosis e. ill appearance
B C D E
A nurse is assessing a child who has a UTI. which of the following are manifestations of a UTI? (Select all that apply.) a. night sweats b. swelling of face c. pallor d. pale-colored urine e. fatigue
B C E
A nurse is assessing a child who has leukemia. which of the following are early manifestations of leukemia? (Select all that apply.) a. hematuria b. anorexia c. petechiae d. ulcerations in the mouth e. unsteady gait
B C E
A nurse is assessing an infant. which of the following findings are clinical manifestations of acute otitis media? (Select all that apply.) a. decreased pain in the supine positions b. rolling head side to side c. loss of appetite d. increase sensitivity to sound e. crying
B C E
A nurse is caring for a child who has post streptococcal glomerulonephritis. which of the following manifestations should the nurse expect? (Select all that apply.) a. frothy urine b. periorbrial edema c. ill appearance d. decrease creatinine e. hypertension
B C E
A nurse is caring for a child who sustained a fracture. which of the following action should the nurse take? (Select all that apply.) a. place heat pack of the site of injury b. elevate the affected limb c. assess neuromuscular status frequently d. encourage ROM of the affected limb e. stabilize the injury
B C E
a nurse is assessing a child who has nephrotic syndrome. which of the following findings should the nurse expect? (Select all that apply.) a. dipstick protein of 1+ b. edema in the ankles c. hyperlipidemia d. weight loss e. anorexia
B C E
A nurse is caring for a child who has muscular dystrophy. for which of the following findings should the nurses assess? (Select all that apply.) a. purposeless, involuntary, abnormal movements b. spinal defect and saclike protrusion c. muscular weakness in lower extremities d. unsteady, wide-based or waddling gait e. upward slant to the eyes
C D
A nurse is admitting a child who has HIV. the nurse should identify which of the following findings as an indication that the child is in the mild symptomatic category of HIV? (Select all that apply.) a. herpes zoster b. anemia c. dermatitis d. hepatomegaly e. lymphadenopathy
C D E
A nurse is caring for a child who has oral mucositis. which of the following actions should the nurse take? (Select all that apply.) a. swab the mucosa with lemon glycerin swabs b. apply viscous lidocaine. c. offer soft foods d. use a soft, disposable toothbrush for oral care e. encourage gargling with a warm saline mouthwash
C D E
A nurse is caring for a child who has type 1 diabetes mellitus. Which of the following are manifestations of diabetic ketoacidosis? (Select all that apply.) a. Blood glucose 58 mg/dL b. Weight gain c. Dehydration d. Mental confusion e. Fruity breath
C D E
A nurse is teaching the parent of a child who has a Wilm's tumor. which of the following statements should the nurse include in the teaching? (Select all that apply.) a. your child will need to have chemotherapy for 12 months b. wilm's tumor are typically genetic in nature c. surgery is done usually within 48 hours of diagnosis d. palpating the tumor could cause spread of the cancer e. further treatments will start immediately after surgery
C D E