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A nursing student is caring for an infant with a respiratory infection and is monitoring for signs of dehydration. The nursing instructor asks the student to identify the most reliable method of determining fluid loss. Which statement by the student indicates an understanding of the method to determine fluid loss?1.Monitor body weight.2.Obtain a temperature.3.Monitor intake and output.4.Assess the mucous membranes.

1 Body weight is the most reliable method of measuring body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. Options 2, 3, and 4 are also appropriate measures to assess for dehydration, but the most reliable method is to monitor body weight.

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply.1.Pallor2.Edema3.Anorexia4.Proteinuria5.Weight loss6.Decreased serum lipids

1, 2, 3, 4Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight.

The nurse is educating the parents of a 2-month-old infant regarding the immunizations that the child will receive that day. The nurse should educate the parents that which of the following immunizations will protect the child form a serious GI infection?1. Rotavirus (RV)2.. Diphteria, tetanus, and acellular pertussis3. Hib vaccine4. Pneumococcal conjugate (PCV13)

1. Rotavirus is the only vaccine that would protect the child form a GI infection.

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms?1.Watery diarrhea2.Projectile vomiting3.Increased urine output4.Vomiting large amounts of bile

2 In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration including a decrease in urine output.

The mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. What should the nurse tell the mother about the disease?1.It is complete small intestinal obstruction.2.It is congenital aganglionosis or megacolon.3.It is severe inflammation of the gastrointestinal tract.4.It is condition that causes the pyloric valve to remain open.

2Hirschsprung's disease is also known as congenital aganglionosis or megacolon. It is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. The remaining options are incorrect descriptions.

child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?1.Diarrhea2.Metabolic acidosis3.Metabolic alkalosis4.Hyperactive bowel sounds

3 Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not associated with vomiting.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?1.Hold the next dose of insulin.2.Come to the clinic immediately.3.Encourage the child to drink liquids.4.Administer an additional dose of regular insulin.

3When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

The nurse recognizes that clinical manifestations of nephrotic syndrome include which findings?1.Hematuria, bacteriuria, weight gain2.Gross hematuria, albuminuria, fever3.Hypertension, weight loss, proteinuria4.Massive proteinuria, hypoalbuminemia, edema

4 Nephrotic syndrome is a kidney disorder. Clinical manifestations of nephrotic syndrome include edema, proteinuria, hypoalbuminemia, and hypercholesterolemia in the absence of hematuria and hypertension. No fever, bacteriuria, or weight loss would be noted with this syndrome.

The mother of a child with hepatitis A tells the home care nurse that she is concerned because the child's jaundice seems worse. Which response should the nurse make to the mother?1."You need to change the child's diet."2."The child probably is infectious again."3."You need to call the health care provider."4."In many situations, the jaundice worsens before it resolves."

4The parents of the child should be told that jaundice may appear to worsen before it resolves. Options 1, 2, and 3 are incorrect and inappropriate

A nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit data associated with the cause of this disease?1."Has your child had any nausea or diarrhea?"2."Have you noticed any rashes on your child?"3."Did your child recently complain of a sore throat?"4."Did your child sustain any injuries to the kidney area?"

3 Group A beta-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, the child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The questions to the mother in options 1, 2, and 4 are unrelated to a diagnosis of glomerulonephritis.

The nurse is caring for a 7-year-old child with glomerulonephritis and is preparing to discuss the plan of care with the parents. In anticipating this encounter, the nurse recognizes that which is a common reaction of parents to the diagnosis of glomerulonephritis?1.Fear of the complicated treatment regimen2.Anger at the child for requiring hospitalization3.Guilt that they did not seek treatment more quickly4.Depression that the child may not be able to play sports

3 Guilt is a common reaction of the parents of a child diagnosed with glomerulonephritis. Parents blame themselves for not responding more quickly to the child's initial symptoms, or they may believe they could have prevented the development of glomerular damage. Options 1, 2, and 4 may be associated with the parents' reaction to the diagnosis, but they are not common parental reactions.

A nurse is caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. Which assessment finding requires the need to notify the health care provider?1.Weight increase of 0.5 kg2.Temperature of 100.8° F rectally3.A decrease in urine output to 0.5 mL/kg/hr4.Blood pressure (BP) unchanged from baseline

3 The priority assessment is to assess the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. A slight elevation in temperature would be expected in a child with dehydration. A weight increase of 0.5 kg is relatively insignificant. A BP that is unchanged is a positive indicator unless the baseline was abnormal. However, there is no information in the question to support such data.

A 4-year-old child sustains a fall at home and after an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction?1."The cast may feel warm as the cast dries."2."I can use lotion or powder around the cast edges to relieve itching."3."A small amount of white shoe polish can touch up a soiled white cast."4."If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."

2 eaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements.

The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?1.Hypotension2.Brown-colored urine3.Low urinary specific gravity4.Low blood urea nitrogen level

2 Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or brown-colored urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?1.The nail beds2.The skin in the sacral area3.The skin in the abdominal area4.The membranes in the ear canal

1 Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice appears in the skin throughout the body. Option 3 is an inappropriate area to assess for the presence of jaundice.

The nurse is reviewing the laboratory test results for an infant suspected of having hypertrophic pyloric stenosis. The nurse should expect to note which value as the most likely laboratory finding in this infant?1.Blood pH of 7.502.Blood pH of 7.303.Blood bicarbonate of 22 mEq/L4.Blood bicarbonate of 19 mEq/L

1Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis due to vomiting. These include increased blood pH and bicarbonate level, decreased serum potassium and sodium levels, and a decreased chloride level. The normal pH is 7.35 to 7.45. The normal bicarbonate is 22 to 27 mm Hg.

A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the assessment findings and expects to note documentation of which sign of this disorder?1.Diarrhea2.Malaise and anorexia3.Nausea and vomiting4.Evidence of soiled clothing

4Encopresis is defined as fecal incontinence and is a major concern if the child is constipated. Signs include evidence of soiled clothing, scratching or rubbing the anal area because of irritation, fecal odor without apparent awareness by the child, and social withdrawal.

The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome?1.Hypertension2.Generalized edema3.Increased urinary output4.Frank, bright red blood in the urine

2Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased.

A 4-year-old child with acute glomerulonephritis is admitted to the hospital. The nurse identifies which client problem in the plan of care as the priority?1.Infection related to hypertension2.Injury related to loss of blood in urine3.Excessive fluid volume related to decreased plasma filtration4.Retarded growth and development related to a chronic disease

3 Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. The child with acute glomerulonephritis will have an excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume would be a focus for this disease process. No risk for infection is associated with this disease; it is a postinfectious process, usually from a pneumococcal, streptococcal, or viral infection. Hematuria is present, but the loss of blood is not enough to constitute a risk for injury. The disease is acute as opposed to chronic, and almost all children recover completely.

The parents of a child with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond?1.Cleft lip cannot be repaired.2.Cleft-lip repair is usually performed by 6 months of age.3.Cleft-lip repair is usually performed during the first weeks of life.4.Cleft-lip repair is usually performed between 6 months and 2 years.

3Cleft-lip repair is usually performed during the first few weeks of life. Early repair may improve bonding and makes feeding much easier. Revisions may be required at a later age. All other options are incorrect.

The nurse understands that which information collected during the assessment of a child recently diagnosed with glomerulonephritis is most often associated with the diagnosis?1.Child fell off a bike onto the handlebars2.Nausea and vomiting for the last 24 hours3.Urticaria and itching for 1 week before diagnosis4.Streptococcal throat infection 2 weeks before diagnosis

4 Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A b-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The assessment data in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

The mother of an 18-month-old child tells the clinic nurse that the child has been having some mild diarrhea and describes the child's stools as "mushy." The mother tells the nurse that the child is tolerating fluids and solid foods. The most appropriate suggestion regarding the child's diet would be to give the child which items?1.Jell-O, strained cabbage, and custard2.Fluids only until the "mushy" stools stop3.Rice and mashed potatoes diluted with skim milk4.Applesauce, strained bananas, and strained carrots

4If mild diarrhea occurs in a child younger than 2 years, a soft diet is advised as long as the child is tolerating solids. The ABCs (applesauce, strained bananas, and strained carrots), rice, potatoes, and other bland foods without dairy products are advised. Extra fluids may also be needed and may be given by adding 1 to 2 oz of additional water to each bottle of formula or juice.

A child is brought to the hospital emergency department for an injury to the lower right arm that occurred in a fall off a bicycle. On assessment the nurse notes that the skin at the site of the injury is intact. A fracture is suspected, and a radiograph is taken. The nurse can see on the radiograph viewer that the fracture of the bone is across the entire bone shaft with some possible displacement. What type of fracture should the nurse determine that this child has?1.Simple fracture2.Greenstick fracture3.Compound fracture4.Comminuted fracture

A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture that occurs through only a part of the cross section of the bone; one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or a complex fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone. A comminuted fracture is a complete fracture across the shaft of the bone with splintering of the bone fragments.

he clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment?1.Reports of frothy stools and diarrhea2.Reports of foul-smelling ribbon stools3.Reports of profuse, watery diarrhea and vomiting4.Reports of diffuse abdominal pain unrelated to meals or activity1

1Lactose intolerance causes frothy stools and diarrhea. Abdominal distention, crampy abdominal pain, and excessive flatus also may occur. Foul-smelling ribbon stool is a clinical manifestation of Hirschsprung's disease. Profuse, watery diarrhea and vomiting are clinical manifestations of celiac disease. Diffuse abdominal pain is a clinical manifestation of irritable bowel syndrome.

A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen?1.Catheterizing the infant using the smallest available Foley catheter2.Attaching a urinary collection device to the infant's perineum for collection3.Obtaining the specimen from the diaper by squeezing the diaper after the infant voids4.Noting the time of the next expected voiding and then preparing a specimen cup for the urine

2 Although many methods have been used to collect urine from an infant, the most reliable method is the urine collection device. This device is a plastic bag that has an opening lined with adhesive so that it may be attached to the perineum. Urinary catheterization is not to be done unless specifically prescribed because of the risk of infection. Urine for certain tests, such as specific gravity, may be obtained from a diaper by collection of the urine with a syringe. It is not reasonable to try to identify the time of the next voiding to attempt to collect the specimen.

A child sustains a fall at home and is brought to the hospital emergency department by the child's mother. After a radiographic examination, the child is determined to have a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding neurocirculatory assessment and function. Which statement by the mother indicates a need for further instruction?1."I'll need to check her skin twice a day at the cast edges."2."If her hand gets real cool and pale, I can apply the heating pad to it."3."For the first couple of days, I should try to keep her hand higher than her heart most of the time, using pillows."4."If she seems way too fussy and her arm is painful even after I've given her the pain medication, it might be a problem, and I should call you for help to decide on what is happening."

2 The mother needs to understand that compartment syndrome is a complication of fracture and casting and can result in permanent limb damage as a result of pressure-related tissue necrosis. The extremity is elevated to prevent swelling, and the health care provider is notified immediately if any signs of neurovascular impairment develop. Cold fingers could indicate neurovascular impairment and should be reported. A heating pad is not applied to the cast or fingers. Skin edges are checked to monitor for irritation and skin breakdown.

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?1.Provide less frequent, larger feedings.2.Burp the infant less frequently during feedings.3.Thin the feedings by adding water to the formula.4.Thicken the feedings by adding rice cereal to the formula.

4 Gastroesophageal reflux is backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter. Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required.

The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom most likely led the mother to seek health care for the infant? 1.Diarrhea 2.Projectile vomiting 3.Regurgitation of feedings 4.Foul-smelling ribbon-like stools

4 Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul-smelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction especially in the neonatal period, abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not associated specifically with this disorder.

The nurse is reviewing the health care provider's prescriptions for a child hospitalized with nephrotic syndrome. Which dietary prescription should the nurse expect to be prescribed for the child?1.A high-protein, high-salt diet2.A full liquid diet for 1 month3.A low-fat, high carbohydrate diet4.A normal protein, mild sodium diet

4 For the child with nephrotic syndrome, a diet that is normal in protein, with a mild sodium restriction (to reduce fluid retention), is normally prescribed. Options 1, 2, and 3 are incorrect diets for this child.

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which symptom of this disorder documented?1.Watery diarrhea2.Ribbon-like stools3.Profuse projectile vomiting4.Bright red blood and mucus in the stools

4 Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder.

The nurse is developing a plan of care for a 6-year-old child diagnosed with acute glomerulonephritis. The nurse should include which priority intervention in the plan of care?1.Encourage limited activity and provide safety measures.2.Catheterize the child to monitor intake and output strictly.3.Encourage the child to talk about feelings related to illness.4.Encourage classmates to visit and to keep the child informed of school events.

1 Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. In glomerulonephritis, activity is limited, and most children, because of fatigue, voluntarily restrict their activities during the active phase of the disease. Catheterization may cause infection. A 6-year-old should not be encouraged to talk about feelings and may not understand the illness. The child should be allowed to express feelings in other ways, such as play. Visitors should be limited to allow for adequate rest.

The clinic nurse is assessing a child for dehydration. The nurse determines that the child is moderately dehydrated if which finding is noted on assessment?1.Oliguria2.Flat fontanels3.Pale skin color4.Moist mucous membranes

1 In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be dry, and the skin color would be dusky. Also, oliguria would be present.

A child with cerebral palsy (CP) is in a management program to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse works with the child to meet these goals by performing which action?1.Placing the child on a wheeled scooter board2.Removing ankle-foot orthoses and braces once the child arrives at school3.Keeping the child in a special education classroom with other children with similar disabilities4.Placing the child in the supine position with a 30-degree elevation of the head of the bed to facilitate feeding

1 The correct option provides the child with maximum potential in locomotion, self-care, and socialization. While lying on the abdomen, the child can move around independently anywhere the child wants to go and can interact with others as desired. In option 2, orthoses need to be used all the time to aid locomotion. Option 3 does not provide for maximum socialization and normalization; rather, children with CP need to be mainstreamed as much as cognitive ability permits. Not all children with CP are intellectually challenged. Option 4 does not provide for normalization in self-care. Just as children without CP sit up and use assistive devices when eating, so should children with CP.

A child has been diagnosed with Hirschsprung's disease. Which of the following findings would the nurse expect the parents to report in the child's history? SATA1. Ribbon-like stools2. Chronic constipation3. Black and tarry stools4. Distended abdomen5. Delayed meconium passage

1,2,4 & 5These are all indicative of Hirschsprung's disease.

A nurse is assigned to care for a child who is scheduled for an appendectomy. Select the prescription(s) that the nurse anticipates will be prescribed. Select all that apply.1.Initiate an IV line.2.Maintain an NPO status.3.Administer a Fleet enema.4.Administer intravenous antibiotics.5.Administer preoperative medications.6.Place a heating pad on the abdomen to decrease pain.

1,2,4,5Appendicitis is an inflammation of the appendix. When the appendix becomes inflamed or infected, perforation may occur within a matter of hours, leading to peritonitis, sepsis, septic shock, and potential death. IV fluids would be started, and the child would be NPO while awaiting surgery. Usually antibiotics are administered because of the risk of perforation. Prescribed preoperative medications most likely would be administered on call to the operating room. In the preoperative period, enemas or laxatives should not be administered. Additionally, heat is not applied to the abdomen. Any of these interventions can cause rupture of the appendix and resultant peritonitis.

A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful?1."Special cells are not present in the rectum, which caused the disease."2."The protein part of wheat, barley, rye, and oats is not being digested fully."3."The disease occurs from increased bowel motility that leads to spasm and pain."4."The disease occurs because of inability to tolerate sugar found in dairy products."

1Hirschsprung's disease also is known as congenital aganglionosis or megacolon. It results from the absence of ganglion cells in the rectum and, to various degrees, up into the colon. Option 2 describes celiac disease. Option 3 describes irritable bowel syndrome. Option 4 describes lactose intolerance.

A 6-year-old child with diabetes mellitus and the child's mother come to the health care clinic for a routine examination. The nurse evaluates the data collected during this visit to determine if the child has been euglycemic since the last visit. Which information is the most significant indicator of euglycemia?1.Daily glucose monitor log2.Glycosylated hemoglobin (hemoglobin A1c)3.Dietary history for the previous week4.Fasting blood glucose performed on the day of the clinic visit

2 The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs are useful if they are kept regularly and accurately. However, they reflect only the blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time-limited in its scope, as is the dietary history.

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.1.Use the fingertips to lift the cast while it is drying.2.Keep small toys and sharp objects away from the cast.3.Use a padded ruler or another padded object to scratch the skin under the cast if it itches.4.Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.5.Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.6.Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity.

2, 5, 6While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified.

An infant is seen in the health care provider's office for complaints of projectile vomiting after feeding. Findings indicate that the child is fussy and is gaining weight but seems to never get enough to eat. Pyloric stenosis is suspected. Which prescription would the nurse anticipate having the highest priority in the care of this child?1.Administer predigested formula.2.Prepare the family for surgery for the child.3.Administer omeprazole (Prilosec) before feeding.4.Instruct the parents to keep a log of feedings and any reflux present.

2Infants with projectile vomiting after feeding that are fussy should be suspected of pyloric stenosis. The treatment for this diagnosis is surgery. The other options are treatment measures that may be prescribed for gastroesophageal reflux.

The nurse is reviewing the laboratory results for an infant with suspected hypertrophic pyloric stenosis. What should the nurse expect to note as the most likely finding in this infant?1.Metabolic acidosis2.Metabolic alkalosis3.Respiratory acidosis4.Respiratory alkalosis

2Laboratory findings in an infant with hypertropic pyloric stenosis include metabolic alkalosis as a result of the vomiting that occurs in this disorder. Additional findings include decreased serum potassium and sodium levels, increased pH and bicarbonate level, and decreased chloride level. Options 1, 3, and 4 are incorrect

The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?1.Polyuria2.Weight gain3.Hypotension4.Grossly bloody urine

2Massive edema resulting in dramatic weight gain is a characteristic finding in nephrotic syndrome. Urine is dark, foamy, and frothy, but only microscopic hematuria is present; frank bleeding does not occur. Urine output is decreased, and hypertension is likely to be present.

An infant is seen in the health care provider's office for complaints of projectile vomiting after feeding. Findings indicate that the child is fussy and is gaining weight but seems to never get enough to eat. Pyloric stenosis is suspected. Which prescription would the nurse anticipate having the highest priority in the care of this child?1.Administer predigested formula.2.Prepare the family for surgery for the child.3.Administer omeprazole (Prilosec) before feeding.4.Instruct the parents to keep a log of feedings and any reflux present. 2Infants with projectile vomiting after feeding that are fussy should be suspected of pyloric stenosis. The treatment for this diagnosis is surgery. The other options are treatment measures that may be prescribed for gastroesophageal reflux. A 2-year-old child with acute diarrhea has been diagnosed with mild dehydration. Which rehydration methods would the nurse expect the health care provider to prescribe?1.Increase intake of water with a diet high in carbohydrates.2.Consume oral rehydration fluid, advancing to a regular diet.3.Begin the BRAT diet (bananas, rice, apples, and toast or tea).4.Begin fluid replacement immediately with intravenous fluids.

2Mild dehydration is usually treated at home and consists of age-appropriate diet along with oral rehydration fluids. The BRAT diet does not provide the rehydration needed in a child who is dehydrated. Water does not provide electrolyte fluid replacement, a need during dehydration. Hospitalization is not required with mild dehydration.

Which is a priority problem for a child with severe edema caused from nephrotic syndrome?1.Risk for constipation2.Risk for skin breakdown3.Inability to regulate body temperature4.Consumption of more calories or nutrients than the body requires

2Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia (hypoproteinemia), and edema. A child with edema from nephrotic syndrome is at high risk for skin breakdown. Skin surfaces should be cleaned and separated with clothing to prevent irritation and resultant skin breakdown. The child will be anorexic, so "taking in more calories or nutrients than the body requires" is not a concern. A risk for constipation or inability to regulate body temperature is not a concern with nephrotic syndrome.

A home care nurse is teaching an adolescent with type 1 diabetes mellitus about insulin administration and rotation sites. Which statement, if made by the adolescent, would indicate effective teaching?1."I should use only my stomach and my thighs for injections."2."I need to use a different major site for each insulin injection."3."I need to use one major site for 2 to 3 weeks before changing major sites."4."I need to use the same major site for 1 month before rotating to another site."

3 To help decrease variations in absorption from day to day, the adolescent should use one major site for injections for 2 to 3 weeks before changing major sites. The injections are rotated to different locations within that major site. All other options are incorrect. The most efficient rotation plan involves giving about four to six injections in one area, each injection about 2.5 cm (1 inch) apart, or the diameter of the insulin vial from the previous injection, and then moving to another area.

A child is admitted to the pediatric unit. While the nurse was taking the nursing history, the chid regurgitated vomitus that looked like coffee grounds and smelled like feces. Which of the following communications would it be appropriate for the nurse to report to the primary health-care provider? "After assessing the vomitus, it appears that the child:1. has an obstruction proximal to the stomach."2. has a perforated duodenal ulcer."3. is vomiting blood from the lower bowel."4. is exhibiting signs of ruptured esophageal varices."

3. The vomitus does appear to included blood and feces from the lower bowel.Vomitus proximal to the stomach would appear as completely undigested food.Vomitus from a perforated duodenal ulcer would appear bile colored and mixed with blood.Blood-tinged vomitus from ruptured esophageal varies would appear bright red.

A 12-year-old girl is admitted to the hospital with suspected appendicitis. What nursing interventions should be implemented preoperatively?1.Applying a heating pad for 5-minute intervals as prescribed2.Administering acetaminophen (Tylenol) as needed for pain, as prescribed3.Placing the adolescent in a fetal position, side-lying with legs drawn up to chest4.Inserting a nasogastric tube and attaching it to low intermittent suction; measuring drainage as prescribed

3A client with appendicitis is more comfortable when lying in what is traditionally known as the fetal position, with the legs drawn up toward the chest. This flexed positioning assists in decreasing the pain that comes with appendicitis by decreasing the pressure on the abdominal area. Option 1 describes an intervention that is contraindicated because heat can lead to a ruptured appendix. Option 2 is incorrect. Pain medications are not given to the client with acute appendicitis because they may mask the symptoms that accompany a ruptured appendix. Option 4 describes a nursing intervention that may be necessary postoperatively.

A mother brings her child to the well-child clinic and expresses concern to the nurse because the child has been playing with another child diagnosed with hepatitis. The nurse performs an assessment on the child, knowing that which finding is unassociated with hepatitis?1.Hepatomegaly2.The presence of jaundice3.The presence of left upper abdominal quadrant pain4.The presence of dark-colored, frothy urine in the urine specimen

3Assessment findings in a child with hepatitis include right upper quadrant tenderness and hepatomegaly. The stools will be pale and clay-colored, and urine will be dark and frothy. Jaundice may be present and will be best assessed in the sclerae, nail beds, and mucous membranes.

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?1."Treatment needs to be started as soon as possible."2."I realize my infant will require follow-up care until fully grown."3."I need to bring my infant back to the clinic in 1 month for a new cast."4."I need to come to the clinic every week with my infant for the casting.

3Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

A nurse is reviewing the health care provider's documentation in the record of a child admitted with a diagnosis of intussusception. The nurse expects to note that the health care provider has documented which manifestation?1.Scleral jaundice2.Projectile vomiting3.Currant jelly stools4.Pale-colored and hard stools

3In the child with intussusception, bright red blood and mucus are passed through the rectum, resulting in what is commonly described as currant jelly stools. The child classically presents with severe abdominal pain that is crampy and intermittent, causing the child to draw the knees in to the chest. Vomiting may be present, but not projectile. Options 1 and 4 are not manifestations of this disorder.

A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition?1."Are the stools ribbon-like and is the infant eating poorly?"2."Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?"3."Does the vomit contain sour undigested food without bile, and is the infant constipated?"4."Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?"

3Option 3 presents classic symptoms of pyloric stenosis. Stools that are ribbon-like and a child who is eating poorly are signs of congenital megacolon (Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and draws the legs up to chest is demonstrating physical signs of intussusception. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic.

The parent of a 6-month-old calls the child's primary health-care provider and states "My child has had 5 loose stools since she woke up this morning. What should I do?" The other is exclusively breastfeeding her baby. Which of the following responses by the nurse is appropriate?1. "Let's figure out what you may have eaten during the last day that could have caused the diarrhea."2. "Continue to feed the baby breast milk and give oral rehydration therapy after each feeding."3. "That's not that unusual for babies who are breast fed but do call again if the stools turn a green color."4. "Bring the baby in for an appointment with the doctor so that we can weigh and check over the baby."

4. The baby does need to be weighed to determine whether the baby is dehydrated.

A 2-year old child has just been diagnosed with type 1 diabetes. The nurse is providing education to the parents regarding signs of hypoglycemia. Which of the following information should the nurse include in her teaching session?1. Child's breath will smell like fruit.2. Child will complain of excessive thirst.3. Child will complain of sleepiness and will appear fatigued.4. Child's behavior will resemble a burst of anger or a temper tantrum.

4. The child's behavior will resemble a burst of anger or a temper tantrum is the child is hypoglycemic.The other choices are indicative of hyperglycemia.

An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder?1."Does the child have any food allergies?"2."What do the bowel movements look like?"3."Has the child eaten any food in the last 24 hours?"4."Can you describe the type of pain that the child is experiencing?"

4A report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. Options 1, 2, and 3 are important aspects of a health history but are not specific to the diagnosis of intussusception.

The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action?1.Withhold oral fluids for 8 hours.2.Sponge the child with cold water.3.Plan to administer salicylate (aspirin) in 4 hours.4.Remove excess clothing and blankets from the child.

4After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?1.Potassium infusion2.NPH insulin infusion3.5% dextrose infusion4.Normal saline infusion

4Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?1.Sweating and tremors2.Hunger and hypertension3.Cold, clammy skin and irritability4.Fruity breath odor and decreasing level of consciousness

4Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

An infant is seen in the health care provider's office for complaints of frequent vomiting and spitting up after feedings. Findings indicate that the infant is not gaining weight and gastroesophageal reflux is suspected. Which would the nurse anticipate being prescribed initially in the care of this child?1.Place in prone position after each feeding.2.Administer omeprazole (Prilosec) before feeding.3.Instruct parents to keep a log of feedings and any reflux present.4.Change the formula to predigested formula and feed small, frequent feedings.

4For infants with frequent vomiting and spitting up, the diagnosis of gastroesophageal reflux should be considered. The initial action is to alter the formula. After the formula is changed, the family will be instructed to keep a log of feedings and any reflux with the new formula. Medication is not started until after the formula is changed. A prone position increases the risk of reflux and thus aspiration.

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do?1.Eat twice the amount normally eaten at lunchtime.2.Take half the amount of prescribed insulin on practice days.3.Take the prescribed insulin at noontime rather than in the morning.4.Eat a small box of raisins or drink a cup of orange juice before soccer practice.

4Hypoglycemia is a blood glucose level less than 70 mg/dL and results from too much insulin, not enough food, or excessive activity. An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice would prevent hypoglycemia. A small box of raisins or a cup of orange juice provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?1.Obtains a weight2.Takes the temperature3.Takes the blood pressure4.Checks the amount of urine output

4In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hour, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride.

A child is diagnosed with intussusception. On performing an assessment of the child, the nurse keeps in mind which finding as a characteristic of this disorder?1.The presence of fecal incontinence2.Incomplete development of the anus3.The infrequent and difficult passage of dry stools4.Invagination of a section of the intestine into the distal bowe

4Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children aged 3 months to 6 years. The presence of fecal incontinence describes encopresis. Encopresis generally affects preschool and school-aged children. Incomplete development of the anus describes imperforate anus, and this disorder is diagnosed in the neonatal period. The infrequent and difficult passage of dry stools describes constipation. Constipation can affect any child at any time, although the incidence peaks at age 2 to 3 years.

A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the nurse to describe the disorder. Which statement is correct about intussusception?1."It is an acute bowel obstruction."2."It is a condition that causes an acute inflammatory process in the bowel."3."It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel."

4Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is not an acute bowel obstruction, but it is a common cause in infants and young children. It is not an inflammatory process.

The nurse is initiating nasogastric tube feedings in a child. When initiating this procedure the nurse should perform which action?1.Microwave the formula.2.Place the child in a prone position.3.Encourage the child to point the head downward.4.Position the child so that the head is slightly hyperflexed.

4When initiating nasogastric tube feedings a child, he or she should be positioned so that the head is slightly hyperflexed or in a sniffing position with the nose pointed toward the ceiling. The formula should be warmed to room temperature, and a microwave should not be used.

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.1.Administer regular insulin.2.Encourage the child to ambulate.3.Give the child a teaspoon of honey.4.Provide electrolyte replacement therapy intravenously.5.Wait 30 minutes and confirm the blood glucose reading.6.Prepare to administer glucagon subcutaneously if unconsciousness occurs.

PLAY Match Gravity A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? 3, 6 Hypoglycemia is defined as a blood glucose level less than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.