NCLEX Peds - Exam 2

In infants with hydrocephalus, the early signs of ventricular shunt malfunction are: a high-pitched cry, colic, and pupillary changes a tense fontanelle, vomiting, and irritability. anorexia, and changes in pulse and respiration. headaches, lethargy, and a loss of appetite.

B. a tense fontanelle, vomiting, and irritability --> these show icp, changes in hr and rr would be a late sign

How should the nurse prepare a suspension before administration? A. By diluting it with normal saline solution B. By diluting it with 5% dextrose solution C. By shaking it so that all the drug particles are dispersed uniformly D. By crushing remaining particles with a mortar and pestle

C. By shaking it so that all the drug particles are dispersed uniformly

The nurse is evaluating a female child with acute post streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement? A. Increased urine output B. Increased appetite C. Increased energy level D. Decreased diarrhea

A. Increased urine output --> classical symptoms of PSGN = hematuria, oliguria, hypertension, and edema

Nurse Nancy is teaching Mr. and Mrs. Diaz about the early signs and symptoms of lead poisoning. Which of the following if stated by the couple would indicate the need for further understanding of the case? A. Anemia B. Seizures C. Irritability D. Anorexia

B. seizures --> seizures usually are associated with encephalopathy, a late sign of lead poisoning --> nurse should start screening a child for lead poisoning at 18mo

Nurse Dorothy is caring for a child with Category A Near Drowning; she should do which of the following? Select all that apply. A. Give furosemide as ordered. B. Check for increased intracranial pressure C. Plan for discharge in 12 to 24 hours. D. Check for electrolyte imbalances. E. Keep mechanical ventilation. F. Provide oxygen as ordered.

Answer: C, D, F --> near-drowning is defined as survival for at least 24 hours from suffocation by submersion. aspiration of water causes the plasma to be pulled into the lungs, resulting in hypoexemia, acidosis, and hypovolemia

Mandy, age 12, is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on the child's nutritional intake, the nurse should ask: A. "What activities do you engage in during the day?" B. "Do you have any allergies to foods?" C. "Do you like yourself physically?" D. "What kinds of food do you like to eat?"

C. "Do you like yourself physically?" --> role and relationship patterns focus on body image and the patient's relationship with others, which are commonly interrelated with food intake

During a well-baby visit, Liza asks the nurse when she should start giving her infant solid foods. The nurse should instruct her to introduce which solid food first? A. Applesauce B. Egg whites C. Rice cereal D. Yogurt

C. Rice Cereal -->first solid food an infant should receive because it is easy to digest and is associated with few allergies

Which of the following organisms is responsible for the development of rheumatic fever? A. Streptococcal pneumonia B. Haemophilus influenza C. Group A beta-hemolytic streptococcus D. Staphylococcus aureus

C. group A beta-hemolytic streptococcus

Nurse Karen is providing postoperative care for Dustin who has cleft palate (CP); she should position the child in which of the following? A. In an infant seat B. In the supine position C. In the prone position D. On his side

C. in the prone position --> postop, children with CP should be placed on the abdomens to facilitate drainage (cleft lip should be positioned on their side or back to keep them from rubbing their face in the bed)

After receiving an immunization for diphtheria, tetanus, and pertussis, a child develops swelling and tenderness at the injection site, a low-grade fever, and malaise. The pediatric ED nurse informs the child's parents that: the reaction is severe enough that they should bring the child to an emergency department they should delay future immunizations until the child is seen by an allergist. this is a mild reaction, and teaches them how to manage it. this is an appropriate reaction, and instructs them to do nothing.

C. this is a mild reaction, and teaches them how to manage it --> A severe reaction would present as Anaphylaxis. An appropriate reaction would be mild warmth over the site. This reaction is moderate and can be managed with Tylenol and Benadryl.

A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect: A. Gross hematuria B. Dysuria C. Nausea and vomiting D. An abdominal mass

D - abdominal mass --> common sign of wilms tumor is a painless, palpable abdominal mass ... typically asymptomatic

When performing a physical examination on an infant, the nurse in charge notes abnormally low-set ears. This finding is associated with: A. Otogenous tetanus B. Tracheoesophageal fistula C. Congenital heart defects D. Renal anomalies

D. Renal anomalies -->ears set below are associated with renal anomalies or mental retardation c- TEF = tracheoesophageal fistual = associated with congenital heart defects

When administering an I.M. injection to an infant, the nurse in charge should use which site? A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis

D. Vastus lateralis

Niklaus was born with hypospadias; which of the following should be avoided when a child has such condition? A. Surgery B. Circumcision C. Intravenous pyelography (IVP) D. Catheterization

B. Circumcision --> hypospadias is a condition in which the urethral opening is located below the glans penis or anywhere along the underside of the penile shaft.

Which of the following parameters would Nurse Max monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)? A. Urine B. Vomiting C. Weight D. Stools

B. Vomiting --> thickened feedings are used with GER to stop the vomiting, therefore the nurse would monitor the child's vomiting to evaluate the effectiveness

A pediatric ED nurse, who is caring for a 12-year-old patient with septic shock, perceives a potential complication of fluid resuscitation upon noting: a heart rate of 50 beats/mina temperature of 102o F (38.8o C). complaints of leg pain. rales and rhonchi by auscultation.

D. rales an rhonchi by auscultation --> pulmonary edema should be monitored closely in septic shock bc fluids can third space and leak into the lungs

Nurse Nancy is assessing a child with pyloric stenosis; she is likely to note which of the following? A. "Currant jelly" stools B. Regurgitation C. Steatorrhea D. Projectile vomiting

D. Projectile Vomiting A-intussusception B-GERD C-celiac disease and malabsorption

An 8 year old is being evaluated in the ER for suspected appendicitis. The physician has then lie on their left side and extend the hip, eliciting pain in the RLQ. What is this test called? Kernig's Sign Rovsing's Sign Brudzinski's Sign Psoas Sign

D. Psoas Sign -Kernig's and Bruszinski's signs are used to evaluate for Meningitis. Rovsing's sign also is a test for appendicitis, but is done by applying deep palpation to the RLQ, causing pain.

Benjamin was rushed to the emergency department with possible increased intracranial pressure (ICP); which of the following is an early clinical manifestation of increased ICP in older children? A. Macewen's sign B. Setting sun sign C. Papilledema D. Diplopia

D. diplopia

Stephen was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder? A. Hypertension, edema, hematuria B. Hypertension, edema, proteinuria C. Gross hematuria, fever, proteinuria D. Poor appetite, edema, proteinuria

D. nephrotic syndrome -->classic NS presentation = edema and then proteinuria and poor appetite