Ill child
An infant is brought to the clinic with a possible diagnosis of Wilms' tumor. When obtaining the health history, which question should the nurse consider a priority to ask the parent? "Does your baby have projectile vomiting after feeding?" "Did the healthcare provider find a mass in the abdominal area?" "Does your baby have a pulsating anterior fontanel?" "Did your baby have a reddish jelly-like bowel movement?"
"Did the healthcare provider find a mass in the abdominal area?"
A 16-year-old adolescent is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on the client's nutritional intake, the nurse should ask: "Do you like yourself physically?" "What kinds of foods do you like to eat?" "What activities do you engage in during the day?" "Do you have any allergies to foods?"
"Do you like yourself physically?"
A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the parent indicates the need for further teaching? "I hope this cast will cure the feet in the next several weeks." "Immunizations will have to be delayed until the casts come off." "I know I will have to be careful when changing the diapers." "I will have to be careful how I hold the baby."
"Immunizations will have to be delayed until the casts come off."
The parents of a child who requires skeletal traction are unable to visit their child for more than 1 hour a day because there are five other children at home and both parents work outside of the home. The nurse recognizes expressions of guilt in both parents. To help alleviate this guilt, the nurse should make which statement? "Not all parents can stay all the time." "Perhaps you could take turns visiting for a bit longer." "I am sure you feel guilty about not being able to visit often." "It is important that you visit even for 1 hour."
"It is important that you visit even for 1 hour."
A nurse is caring for a 14-year-old adolescent who states, "No one understands me." Which statement by the nurse best demonstrates empathy? "Explain why you think no one understands you. How can adults help?" "Tell me about a time you felt your parents were understanding." "It's difficult to be a teenager. Tell me more about your experiences." "Let's talk about your future plans and which courses you enjoy."
"It's difficult to be a teenager. Tell me more about your experiences."
An adolescent child is admitted to the nursing unit after an attempted suicide. The nurse is discussing the attempted suicide with the parents. Which of the following statements by the parents indicate to the nurse that the parents need more teaching? Select all that apply. "Our child is just trying to get attention." "Our child needs to learn new coping skills." "Our child will be fine in a couple of days." "Our child would not do this again." "Our child doesn't understand how this affects the family."
"Our child is just trying to get attention." "Our child will be fine in a couple of days." "Our child would not do this again."
The nurse teaches the mother of a child newly diagnosed with insulin dependent diabetes about the principles of a healthy eating plan. Which statement by the mother indicates effective teaching? "Most children find it difficult to eat all the calories required by their diets in three main meals." "Snacks are used to offset the desire for sweets and to keep the meals smaller so my child can eat better." "By spreading the calories throughout the day in small, frequent meals, the risk of hyperglycemia is eliminated." "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks."
"Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks."
The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse? "Oliguria is common after a barbiturate overdose." "There is not enough blood circulating to the kidneys." "Dialysis is needed to clear the toxins from the blood." "The body is conserving fluids to dilute the barbiturates."
"There is not enough blood circulating to the kidneys."
A nurse is providing health teaching to a group of adolescent girls. The focus is on urinary tract infections. One of the girls tells the nurse that she wants to know more about cystitis. Which statement by the nurse is the most appropriate response? "This condition happens frequently in young women and is not harmful." "This is a serious condition that occurs after intercourse or vaginal cleanses." "This is a minor bacterial infection of the bladder that can occur at anytime." "This condition can result from irritation and inflammation from sexual activity."
"This condition can result from irritation and inflammation from sexual activity."
The unlicensed assistive personnel (UAP) obtained vital signs on a 7-month-old infant and recorded the peripheral pulse as 85 beats/minute. The RN immediately reassesses the child's pulse and discovers the pulse is 115 beats/minute. What should the nurse teach the UAP about obtaining an accurate heart rate in an infant? "To assess a pulse in children, always assess the apical pulse." "Always assess the pulse rate after you take the blood pressure." "Here is a copy of normal heart rates in children so you can report abnormal findings." "To assess a pulse under age 1, you should check the brachial artery."
"To assess a pulse in children, always assess the apical pulse."
An adolescent client with a history of muscular dystrophy is admitted with aspiration pneumonia. The nurse asks the parents if the adolescent has an advance directive. Which response by the parents indicates to the nurse that the parents need additional teaching? "We are going to take time to discuss our options." "I am afraid a feeding tube will be necessary soon." "We know what our child desires but have not made it formal." "We can make decisions about care as they are needed."
"We can make decisions about care as they are needed."
The nurse is caring for an adolescent client. The parents inform the nurse that the client has lost interest in activities, has experienced falling grades, and sleeps all day. All symptoms have become worse over the past 2 years. Which statement by the parents is of most concern to the nurse? "We can't be supportive when we are always pushed away." "We feel that this is just a case of the blues." "We do not know what else to do to help with whatever this is." "We have other family members with depression."
"We feel that this is just a case of the blues."
The parent of a preschool-age child tells the nurse that the child is hyperactive and something needs to be done. Which response by the nurse would be most appropriate initially? "Does the preschool teacher think your child is hyperactive?" "What do you think needs to be done?" "What makes you think your child is hyperactive?" "How does your child behave normally?"
"What makes you think your child is hyperactive?"
An athletic teenager who is diagnosed with infectious mononucleosis is told to avoid contact sports for 3 to 4 weeks. The teenager protests to the nurse and demands to know why sports must be avoided for so long. What is the best response by the nurse? "Vigorous activity can further weaken your immune system." "Your spleen is enlarged from your illness and could easily rupture with an injury." "Your illness causes fatigue and it's best for you to rest while recovering." "This helps prevent transmission of the infection to your teammates."
"Your spleen is enlarged from your illness and could easily rupture with an injury."
The nurse is educating parents of first graders about child sexual abuse. What is the most critical information the nurse should convey to the parents? Parents are usually the first people to see the signs of sexual abuse. Children often keep the contact a secret to avoid getting into trouble. An adult who sexually abuses a child is usually known to the child. Most cases of child sexual abuse are committed by neighbors.
An adult who sexually abuses a child is usually known to the child.
An adolescent with abdominal pain and a fever is being seen in the clinic. In what order should the nurse assess the abdomen? All options must be used. 1Percuss 2Inspect 3Auscultate 4Palpate
2Inspect 3Auscultate 1Percuss 4Palpate
An adolescent sustains a head injury and develops diabetes insipidus. The healthcare provider orders desmopressin, 10 mcg subcutaneously. When does the nurse assess the client to determine the need for an additional dose? 4 to 7 hours 30 minutes to 2 hours 2 to 4 hours 15 to 30 minutes
4 to 7 hours
A 5-year-old preschooler suspected of having leukemia is admitted to the hospital for diagnosis and treatment. The physician orders a bone marrow aspiration. Place the interventions below in ascending chronological order according to their importance. 1Assure the child that the pain will go away. 2Act out the procedure using a doll and biopsy kit. 3Check the biopsy site for hemorrhage and infection. 4Discuss the procedure with the parents. 5Explain the discomforts the child will feel.
4Discuss the procedure with the parents. 2Act out the procedure using a doll and biopsy kit. 5Explain the discomforts the child will feel. 1Assure the child that the pain will go away. 3Check the biopsy site for hemorrhage and infection.
Which measure would be most effective in helping the infant with a cleft lip and palate to retain oral feedings? Burp the infant at frequent intervals. Feed the infant small amounts at one time. Place the end of the nipple far to the back of the infant's tongue. Maintain the infant in a supine position while feeding.
Burp the infant at frequent intervals.
A nurse is teaching the parents of a 6-month-old infant about usual growth and development. Which statements about infant development are true? Select all that apply. Stranger anxiety usually peaks at 12 to 18 months. A teething ring is appropriate for a 6-month-old infant. A 6-month-old infant can usually roll from prone to supine and supine to prone positions. A 6-month-old infant has difficulty holding objects. Head lag is commonly noted in infants at age 6 months. Lack of visual coordination usually resolves by age 6 months.
A teething ring is appropriate for a 6-month-old infant. A 6-month-old infant can usually roll from prone to supine and supine to prone positions. A teething ring is appropriate for a 6-month-old infant. A 6-month-old infant can usually roll from prone to supine and supine to prone positions.
A nasogastric tube is prescribed to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next? Test the gastric aspirate for blood. Attempt to place the tube into the duodenum. Ask for the prescription to be changed to an oral gastric tube. Use extra lubrication when inserting the nasogastric tube.
Ask for the prescription to be changed to an oral gastric tube.
The nurse is providing nutrition counseling for an obese adolescent. What is the most effective way for the nurse to obtain a nutrition history from this client? Ask her what she knows about good nutrition. Tell her to list what she plans to eat for the next 24 hours. Telephone her mother and ask her what she ate yesterday. Ask her what she ate yesterday if it was a typical day.
Ask her what she ate yesterday if it was a typical day.
The nurse is caring for a 5-year-old child in pain. What is the best method to assess the child's pain? Ask the child to rate the pain intensity on a scale of 1 to 10. Ask the child to describe the way the pain feels. Ask the child to point to a face drawing that indicates pain intensity. Observe the child for behaviors such as crying and restlessness.
Ask the child to point to a face drawing that indicates pain intensity.
When developing the teaching plan for the mother and a child with insulin-dependent diabetes about sick-day management, which of the following instructions should the nurse include? Take the child to the emergency department for immediate care. Immediately call the physician for information about what to do. Adhere to the same schedule and type and amount of insulin. Adjust insulin based on more frequent testing of blood glucose levels.
Adjust insulin based on more frequent testing of blood glucose levels.
The nurse is caring for an infant diagnosed with thrush. Which instruction would the nurse give to a client's mother who will be administering nystatin oral solution? Mix the drug with small amounts of formula in bottle. Administer the drug right after meals by dabbing the solution to the sites. Administer the drug right before meals by using a gauze pad. Administer half the dose before and half after a feeding.
Administer the drug right after meals by dabbing the solution to the sites.
The nurse is developing a community disaster plan. Which information does the nurse apply when planning the care of children in a disaster involving a chemical attack? Children are more susceptible to the effects of a chemical attack because they have a smaller body surface area in relation to weight than adults. Children are less susceptible to the effects of a chemical attack because they have a lower fluid reserve than adults. Children are less susceptible to the effects of a chemical attack because they breathe at a faster rate than adults. Children are more susceptible to the effects of a chemical attack because they have thinner skin than adults.
Children are more susceptible to the effects of a chemical attack because they have thinner skin than adults.
The nurse is interviewing a pediatric client and family in a clinic after the client had a fever at home. The parent said she gave the client one adult acetaminophen earlier in the day because she ran out of children's acetaminophen. What is the nurse's next action? Select all that apply. Report the parent to the state welfare agency. Continue to complete the physical assessment of the client. Inform the healthcare provider of the acetaminophen dose. Teach the parent not to use adult medications with children. Document that the parent administered adult acetaminophen.
Continue to complete the physical assessment of the client. Inform the healthcare provider of the acetaminophen dose. Teach the parent not to use adult medications with children. Document that the parent administered adult acetaminophen.
A nurse is assessing the chest of a 4-month-old infant. The nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:2. Which actions should the nurse take next? Auscultate for adventitious lung sounds. Document the findings in the client's medical record. Observe for substernal retractions. Obtain an order for a chest X-ray.
Document the findings in the client's medical record.
The nurse is caring for a young child on the oncology unit who has developed thrombocytopenia after cancer treatment. What is the priority action for the nurse to implement when caring for this client? Plan for extra nap times. Ensure a safe environment. Assess for signs of infection. Encourage high-protein foods.
Ensure a safe environment.
Which action(s) should the nurse take prior to administering an oral medication to an infant? Select all that apply. Ensure that it is the correct medication. Verify that it is the correct dose. Have the mother hold the infant. Check the infant's pulse. Verify the infant's name.
Ensure that it is the correct medication. Verify that it is the correct dose. Verify the infant's name.
When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information? Fifth disease is transmitted by stool. Fifth disease is transmitted by respiratory secretions. Fifth disease has an unknown transmission mode. Fifth disease is transmitted by respiratory secretions, stool, and urine.
Fifth disease is transmitted by respiratory secretions.
The nurse is instructing young parents of infants at a community health clinic. When instructing on mealtime activity, which activity is most recommended to prevent foreign body aspiration in children during meals? Cut foods into bite size portions. Have a calm conversation. Have the parents eat beside the children. Insist that children are seated.
Insist that children are seated.
Which nursing action would be most successful in gaining a preschooler's cooperation in preparing for surgery? Have the child remove their own underwear. Let the child choose which parent can accompany the child to the preoperative waiting area. Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon. Encourage the child to use the hospital blanket as a transition object to make the child feel more secure.
Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.
An adolescent presents with a large round ring with a swollen border on the left arm. The adolescent often plays ball games in a field behind the school. What condition does the nurse suspect? cellulitis impetigo actinic keratosis Lyme disease
Lyme disease
A 3-year-old client is admitted to the pediatric unit with pneumonia. The child has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the child has not been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should the nurse include in the care plan? Select all that apply. Maintain humidification with a cool mist humidifier. Keep the head of the bed flat. Limit fluid intake. Perform postural drainage. Encourage coughing and deep breathing. Perform chest physiotherapy as ordered.
Maintain humidification with a cool mist humidifier. Perform postural drainage. Encourage coughing and deep breathing. Perform chest physiotherapy as ordered.
Which action should the nurse take when providing postoperative nursing care to a child after insertion of a ventriculoperitoneal shunt? Administer narcotics for pain control. Check the urine for glucose and protein. Monitor for increased temperature. Test cerebrospinal fluid leakage for protein.
Monitor for increased temperature.
An adolescent client is hospitalized with bacterial meningitis. At 1730, the client's mother reports her child is "burning up." The nurse is reviewing the client's medication administration records in the medical record. The health care provider (HCP) has prescribed ibuprofen 325 mg every 3 to 4 hours for temperature over 99°F (37.2°C). The child's temperature at 1730 is 102.5°F (39.1°C). What should the nurse do first? Notify the HCP. Initiate tepid sponge bath. Institute seizure precautions. Administer another dose of ibuprofen.
Notify the HCP.
A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse's best response to this situation? Continue to observe the behavior of the child. Discuss the child's behavior with the parents. Notify the local Child Protective Services. Advise the child that the inappropriate behavior must stop.
Notify the local Child Protective Services.
After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of parental role conflict related to child's hospitalization. Which defining characteristic suggests this diagnosis? Parents express feelings of inadequacy in caring for child. Parents make negative statements about health care provider. The parents are expressing desire for more information. The parents are questioning the nursing plan of care.
Parents express feelings of inadequacy in caring for child.
The nurse formulates a plan of care to address negative feeding patterns for a 5-month-old infant diagnosed with failure to thrive. To meet the short-term outcomes of the infant's plan of care, the nurse should expect to implement which intervention? Give the infant high-calorie formula. Allow the infant to sit in a high chair during feedings. Instruct the parents in proper feeding techniques. Provide consistent staff to care for the infant.
Provide consistent staff to care for the infant.
A preschool-age child presents to the emergency department. His father tearfully reports that his son was on his shoulders in the driveway playing when he began to fall. When the child began to fall, the father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which action should the nurse take? Record the father's story in the medical record. Restrict the father's visitation. Notify the police immediately. Refer the father for parenting classes.
Record the father's story in the medical record.
The nurse is assessing a 5-year-old client and wants to gain the client's cooperation. Which actions are appropriate for the nurse? Perform a head to toe assessment, just as for an adult. Tell the child not to be afraid because it will not hurt. Save the more intimidating or intrusive parts of the assessment, such as eyes, ears, and genitalia, until the end of the assessment. Tell the child that prizes are given for good behavior.
Save the more intimidating or intrusive parts of the assessment, such as eyes, ears, and genitalia, until the end of the assessment.
Parents of a 5-year-old child call the clinic to tell the nurse that they think their child has been abused by the daycare provider. What should the nurse advise them to do first? Make an appointment to speak with the daycare provider. Schedule an immediate appointment with their healthcare provider. Call Child Protective Services to file a complaint. Talk to their attorney to file charges against the accused.
Schedule an immediate appointment with their healthcare provider.
An adolescent female with polycystic ovarian syndrome (PCOS) is extremely upset, saying, "I'm so embarrassed by hair on my face. I just don't fit in." Which intervention is most needed? Refer the client to a hair removal specialist. Screen the client for depression. Provide more information on causes and treatment options. Suggest the client join a support group.
Screen the client for depression.
A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl? Check the color of the child's urine every day. Sew thick padding into the elbows and knees of the child's clothing. Administer one-half of a children's aspirin for a temperature higher than 101° F (38.3° C). Expect the eruption of the primary teeth to produce moderate to severe bleeding.
Sew thick padding into the elbows and knees of the child's clothing.
An elementary school nurse is conducting a program for parents on attention deficit hyperactivity disorder (ADHD). What is the most important information for the nurse to include in the program? Sleep disturbances are common for children with ADHD. Diagnosis usually occurs before the child reaches school age. Boys with ADHD show more aggression than girls with ADHD. The child will have fatigue from the increased activity level.
Sleep disturbances are common for children with ADHD.
A nurse is caring for a 16-year-old male client who needs an appendectomy. His parents are not present at the hospital. Prior to the surgery, the nurse needs to ensure that informed consent is obtained. Which situations allows the healthcare provider to obtain an informed consent from an adolescent? The adolescent has a power-of-attorney document. The adolescent is the appropriate age to sign an informed consent. The adolescent is under the protection of a court guardian. The adolescent has declared himself emancipated.
The adolescent has declared himself emancipated.
A child is brought to the emergency department experiencing severe right lower quadrant pain. The child's pulse and respirations are elevated, and there are localized tenderness and sluggish bowel sounds. Shortly after the initial assessment, the child states that the pain has suddenly resolved. Which of the following would the nurse suspect? The child has signs that the appendix has ruptured. The child was experiencing symptoms of a food allergy. The child had a bowel obstruction that has now resolved. The child is recovering from a mild case of gastroenteritis.
The child has signs that the appendix has ruptured.
A nurse is planning care for a hospitalized school-age child and is delegating care to a pediatric care assistant. When a nurse delegates a task to an unlicensed assistive personnel (UAP), which factor is most important? The task is appropriate for that individual's preparation. The UAP has previously performed the task. The nurse has observed the UAP perform the task. The child and UAP have established a positive relationship.
The task is appropriate for that individual's preparation.
When an infant with pyloric stenosis is admitted to the hospital, which aspect of the plan of care should the nurse implement first? Orient the mother to the hospital unit. Weigh the infant. Begin an intravenous infusion. Switch the infant to an oral electrolyte solution.
Weigh the infant.
When preparing to give a child with insulin-dependent diabetes his dose of regular insulin and isophane insulin suspension, which of the following actions is most appropriate? Withdrawing the regular insulin first, then withdrawing the isophane insulin suspension into one syringe. Using two syringes, one for each type of insulin, and giving two injections. Withdrawing the isophane insulin suspension first, then withdrawing the regular insulin into one syringe. Taking the premixed insulin out of the refrigerator, then withdrawing the amount into one syringe.
Withdrawing the regular insulin first, then withdrawing the isophane insulin suspension into one syringe.
Intraosseous infusion of a medication would be most appropriate for which client? a 4-year-old client with celiac disease a 5-year-old client with status asthmaticus a 2-year-old client with a ruptured spleen and hypovolemia an 18-month-old client with cystic fibrosis
a 2-year-old client with a ruptured spleen and hypovolemia
The charge nurse on the adolescent unit must decide which nurse should admit a new client. Based on the present client care assignments, who is the best candidate to admit the client? a nurse whose patient with asthma has decreasing oxygen saturation levels a nurse caring for a client who is paralyzed and has no visiting family a nurse who is about to start a complicated wet-to-damp dressing change a nurse who was reassigned from another ward at the beginning of the shift
a nurse who was reassigned from another ward at the beginning of the shift
Which intervention is the highest priority for the therapeutic management of a child with congestive heart failure (CHF) resulting from pulmonary stenosis? administering furosemide to decrease systemic venous congestion administering enoxaparin to improve left ventricular contractility educating the family about the signs and symptoms of CHF assessing heart rate and blood pressure every 2 hours
administering furosemide to decrease systemic venous congestion
A 4-year-old, 40-lb (18.1-kg) child is brought to the pediatrician's office. The child has upper respiratory symptoms and has had a fever for 2 days. The health care provider diagnoses a viral illness, and the parent is instructed to treat the child with rest, fluids, and antipyretics. The nurse is reviewing the orders and questions which of the following instructions? acetaminophen 181 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 181 mg (10 mg/kg/dose) q6h for temperature higher than 102.5° F (39.2° C) aspirin 294 mg (65 mg/kg/24 hours) q6h with intermittent doses of acetaminophen 217 mg q4h acetaminophen 235 mg (10 to 15 mg/kg/dose) q4h for a temperature lower than 102.5° F (39.2° C) acetaminophen 253 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 181 mg (10 mg/kg/dose) q6h for a temperature higher than 102.5° F (39.2° C)
aspirin 294 mg (65 mg/kg/24 hours) q6h with intermittent doses of acetaminophen 217 mg q4h
When assessing a child's cultural background, the nurse should keep in mind that heritage dictates a group's shared values. behavioral patterns are passed from one generation to the next. cultural background usually has little bearing on a family's health practices. physical characteristics mark the child as part of a particular culture.
behavioral patterns are passed from one generation to the next.
The nurse reviews the laboratory report of a child with leukemia (see exhibit). What does the nurse determine is the priority problem for this client? WBC 6.5 Plt 40 HCT 41.2% activity intolerance bleeding impaired tissue perfusion risk for infection
bleeding
The nurse assesses a child with acute glomerulonephritis. Which finding should the nurse should report immediately to the health care provider? temperature of 100.2° F (37.9° C) serum sodium level of 135 blood pressure of 140/92 mm Hg weight loss of 1 lb (0.45 kg)
blood pressure of 140/92 mm Hg
When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which teaching and learning principle should the nurse address first? building the teaching on the child's current level of knowledge presenting the information in order from simplest to most complex organizing information to be taught in a logical sequence arranging to use actual equipment for demonstrations
building the teaching on the child's current level of knowledge
When planning counseling sessions with adolescents, the nurse must incorporate measures to consider which abilities? capacity to deal with abstract possibilities conservation problem solving representational thought assimilation and accommodation
capacity to deal with abstract possibilities
A home care nurse is visiting a family with a chronically ill 9-year-old child. What is a priority of client care when working with a family caring for their chronically ill child at home? social isolation lack of knowledge anxiety caregiver role strain
caregiver role strain
When assessing a child diagnosed with rheumatic fever, the nurse should determine if the child has which manifestations? Select all that apply. chorea pericardial friction rub vomiting seizures diarrhea arthralgia
chorea pericardial friction rub arthralgia
The nurse is attempting to reduce the risk for impaired skin integrity related to immobility in a toddler. Which actions does the nurse include in the plan of care? Select all that apply. clean skin only when soiled wipe pressure points with alcohol wipes promote good nutrition massage skin with a lubricating substance change position frequently
clean skin only when soiled promote good nutrition change position frequently
A client is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the client has a ventricular septal defect. coarctation of the aorta. patent ductus arteriosus. truncus arteriosus.
coarctation of the aorta.
A nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent? fear related to altered body image anxiety related to separation from parents fear related to the unknown ineffective coping related to activity restrictions
fear related to altered body image
The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship? the mother's feelings of loss of control over her child the mother's fear that the staff do not respect her communication barriers between the mother and staff lack of knowledge about the child's illness and treatment
communication barriers between the mother and staff
When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which factor for the parents? affection for their child responsibility for their child's welfare understanding of their child's disability confidence in their ability to care for their child
confidence in their ability to care for their child
On the second postoperative day after repair of a cleft palate, what should the nurse use to feed a toddler? cup straw large-holed nipple rubber-tipped syringe
cup
The nurse plans care for a child with sickle cell disease in vasoocclusive crisis. The nurse includes increasing fluid intake in the list of interventions because the nurse understand that: decreased blood viscosity prevents the sickling process. increasing fluid intake increases hemolysis. children with sickle cell disease lose more water than is normal through diaphoresis. hemodilution increases normal red blood cell life span.
decreased blood viscosity prevents the sickling process.
A nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement? decreased hematuria increased appetite decreased diarrhea increased energy level
decreased hematuria
A child with diabetes insipidus receives desmopressin acetate. When evaluating for therapeutic effectiveness, the nurse should interpret which finding as a positive response to this drug? relief of nausea decreased urine output decreased blood pressure increased urine glucose level
decreased urine output
The nurse assesses a child with ketoacidosis. What manifestations are supportive of the diagnosis of ketoacidosis? slow, bounding pulse rate. deep, rapid respirations. diaphoretic, warm skin. elevated blood pressure.
deep, rapid respirations.
An adolescent with ulcerative colitis who is taking corticosteroids is at risk for which complication? jaundice perianal lesions decreased bowel sounds delayed sexual maturation
delayed sexual maturation
When instilling ear drops on a 2-year-old child, the nurse should pull the pinna in which directions? up and back up and forward down and back down and slightly forward
down and back
A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can prepare the child by positive self-talk. hold and rock the child and give the child a security object. establish a time limit to get ready for the procedure. count and sing with the child.
hold and rock the child and give the child a security object.
When assessing a child for impetigo, the nurse expects which assessment findings? honey-colored, crusted lesions small, brown, benign lesions circular lesions that clear centrally linear, threadlike burrows
honey-colored, crusted lesions
The nurse is caring for a 15-year-old adolescent mother after birth. The adolescent lives at home with her parents and has a boyfriend who is also 15 years old. Neither is currently working, and they both have plans for higher education. When addressing the psychosocial issues that may occur after the birth of the child, which of the following would be the most important for the nurse to include in client teaching? increased stress for new mothers inability to achieve educational goals potential rejection by the boyfriend dependence on parents after birth
increased stress for new mothers
According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? identity versus role confusion initiative versus guilt industry versus inferiority trust versus mistrust
industry versus inferiority
The administration of medications during infancy is often necessary. The nurse needs to be concerned about the metabolism of these drugs. What concern regarding metabolism should the nurse consider when administering medications to an infant? increased tubular secretion reduced protein-binding ability decreased glomerular filtration inefficient liver function
inefficient liver function
A child, age 5, is to have potassium added to his I.V. fluid. Before initiating this therapy, the nurse first should measure the blood pressure. assess respiratory rate and depth. assess the child's apical pulse rate. monitor fluid intake and output.
monitor fluid intake and output.
Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin? tachycardia weight gain seizures nausea and vomiting
nausea and vomiting
A 17-year-old adolescent with a history of muscular dystrophy is admitted with aspiration pneumonia. The client's medical history reveals that this is the third time in the past 6 months that the client has been diagnosed with pneumonia. Which topics should the nurse plan to address for teaching? need for good hand hygiene need to avoid crowds and large gatherings need for an advance directive need for a feeding tube
need for a feeding tube
A hospitalized 5-year-old is pulseless, and after verifying the child is not breathing, the nurse begins chest compressions. Where should the nurse apply pressure? on the lower sternum with the heel of one hand over the apex of the heart with the heel of one hand on the upper sternum with the heels of both hands midway on the sternum with the tips of two fingers
on the lower sternum with the heel of one hand
A child with leukemia has petechiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which laboratory test results should the nurse correlate with these findings? serum calcium level of 5 mg/dL(1.25 mmol/L) fibrinogen level of 75 mg/dL (2.21 µmol/L) platelet count of 80 x 103/mm3 (80 X 109/L) partial thromboplastin time of 38 seconds
platelet count of 80 x 103/mm3 (80 X 109/L)
A 3-year-old boy has arrived in the emergency department. The nurse documents the following assessment findings in the client's chart, knowing that they are consistent with which disease process? T 103.6 HR 100 RR 24 respirations shallow breath sounds decreased rales discolored productive cough pneumonia bronchiolitis asthma cystic fibrosis
pneumonia
A nurse is caring for a 2-year-old child with tetralogy of Fallot (TOF) who is scheduled for surgery in 24 hours. What intervention is the most important for the nurse to include in the plan of care? meperidine for pain positioning the child with knees to the chest oxygen at 2 L/nasal cannula encouraging activity in the playroom
positioning the child with knees to the chest
When positioning a neonate with an unrepaired myelomeningocele, which position is most appropriate? supine with the hips at 90-degree flexion prone with hips in abduction right side-lying position with the knees flexed supine in semi-Fowler's position with chest and abdomen elevated
prone with hips in abduction
An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate? administering digestive enzymes before meals as ordered administering antibiotics with meals as ordered providing small, frequent meals providing high-fiber snacks
providing small, frequent meals
An adolescent is brought to the facility by friends after accidentally ingesting gasoline while siphoning it from a car. Based on the nurse's knowledge of petroleum distillates, which system should be the priority assessment? cardiovascular system GI system respiratory system neurologic system
respiratory system
An adolescent client who is being seen by the crisis nurse after making several superficial cuts on her wrist states that all her friends are siding with her ex-boyfriend and will not talk to her anymore. She says she knows that the relationship is over, but "If I can't have him, no one else will." Which client problem takes the highest priority? risk-prone health behavior risk for other-directed violence risk for suicide situational low self-esteem
risk for other-directed violence
A 4-year-old child is admitted to the hospital for surgery. The nurse applies interventions to address what major stressor for a child of this age? separation from family fear of bodily injury loss of control fear of pain
separation from family
A 12-year-old boy has depression and post-trauma response. The boy's father is now in jail for molesting him from ages 6 to 9. Given the typical reactions of incest victims, the nurse should assess the child for which behavior? Select all that apply. sexualized play isolation at home aggression running away truancy
sexualized play aggression running away truancy
The nurse is assessing an adolescent who has been diagnosed with aplastic anemia. Which should be the priority assessment for the nurse? paresthesia and gait disturbances inability to perform self-care activities signs and symptoms of nutritional deficit signs and symptoms of infection
signs and symptoms of infection
When discussing an infant's motor skill development with the mother, the nurse should explain that by age 7 months, an infant most likely will be able to perform which skill? walking with one hand held eating successfully with a spoon standing while holding onto furniture sitting alone using the hands for support
sitting alone using the hands for support
A 14-year-old is admitted to the hospital with a diagnosis of acute rheumatic fever. The nurse should assess the client for which signs and symptoms? Select all that apply. skin rash fatigue peripheral edema sore throat migraine headaches
skin rash fatigue sore throat
A child is diagnosed with pituitary dwarfism. Which pituitary agent will the primary care provider most likely order to treat this condition? desmopressin acetate vasopressin synthetic ACTH somatotropin
somatotropin
A child, age 5, takes amoxicillin trihydrate orally three times per day to treat otitis media. For the most accurate calculation of a safe dosage, the nurse should use the child's body surface area. the child's weight in kilograms. Clark's rule based on the child's weight in pounds. Young's rule based on the child's age.
the child's body surface area.
A mother brings her 18-month-old child to the clinic because the child eats ashes, crayons, and paper. Which information would be most important to obtain about this toddler? whether the toddler is currently cutting large teeth whether the toddler is eating a soft, low-roughage diet whether the toddler is experiencing a growth spurt whether the toddler is experiencing changes in the home environment
whether the toddler is experiencing changes in the home environment
