NU 413 Ch 19

Which intervention for a 5 year old who still wets the bed would be best assigned to the UAP? 1. Reminding the child to use the bathroom before going to bed 2. Teaching the mother about moisture alarm devices 3. Administering the prescribed dose of imipramine 4. Discussing research related to the use of hypnosis with the mother

1. Reminding the child to use the bathroom before going to bed (Reminding is within the scope of a UAP)

The nurse is providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal continuous positive airway pressure ventilation. Which assessment finding is most important to report to the HCP? 1.Apical pulse rate of 156 bpm 2. Crackles audible in both lungs 3. Tracheal deviation to the right 4. Oxygen saturation of 93%

3. Tracheal deviation to the right (Suggests tension pneomothorax, a possible complication of positive pressure ventilation)

A tearful parent brings a child to the ED after the child takes an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What info should be immediately reported to the HCP? 1. The ingestion children's chewable vitamins contain iron 2. The child has been treated previously for ingestion of toxic substances 3. The child has been treated several times before for accidental injuries 4. The child was nauseated and vomited once at home

1. The ingestion children's chewable vitamins contain iron

The nurse is assisting with the delivery of a 31 week gestation age premature newborn who required intubation for respiratory distress syndrome. Which medication does the nurse anticipate will be needed first for this infant? 1. Theophylline 2. Surfactant 3. Dexamethasone 4. Albuterol

2. Surfactant (Admin of synthetic surfactant improves respiratory status and decreases incidence of pneuomothorax in premature infants with RDS)

The nurse is caring for a child with a foreign body in the ear canal who has not been evaluated by the HCP. Which actions should the nurse implement? Select all that apply. 1. Inspect the pinna for trauma 2. Irrigate the auditory canal with warm water 3. Obtain a history for the type of object 4. Attempt to remove the object with forceps 5. Use an otoscope to check for perforation

1, 3 1. Inspect the pinna for trauma 3. Obtain a history for the type of object

The nurse is preparing to care for a 6 year old child who has just undergone allogenic stem cell transplantation. Which nursing tasks should the nurse delegate to the UAP? Select all that apply 1. Stocking the child's room with standard PPE items 2. Teaching the child to perform thorough hand washing after using the bathroom 3. Reminding the child to wear a face mask outside of the hospital room 4. Assessing the child's oral cavity for signs and symptoms of infection 5. Talking to the family members about the methods to reduce risk of infection

1, 3 1. Stocking the child's room with standard PPE items 3.Reminding the child to wear a face mask outside of the hospital room

The ED receives multiple individuals, mostly children, who were injured when the roof of a daycare center collapsed because of heavy snow fall. Based on physiologic differences in children compared with adults, for which injuries and complications will the nurse assess first? Select all that apply 1. Head injuries 2. Bradycardia or junctional arrhythmias 3. Hypoxemia 4. Liver and spleen contusions 5. Hypothermia 6. Fracture of long bones 7. Lumbar spine injuries

1, 3, 4, 5 1. Head injuries 3. Hypoxemia 4. Liver and spleen contusions 5. Hypothermia (Children have larger heads, higher oxygen needs (become hypoxic easier), have spleens and livers that are less protected by thoracic cage; and become more hypothermic because of thinner skin and larger body surface areas)

A 6 year old girl arrives in the emergency department with her parents. She hit her head when she fell from the jungle gym in the school playground. Which questions are appropriate for the nurse to ask to assess the child's neurological status? Select all that apply. 1. What is your home address? 2.What time does your family eat dinner? 3. What grade are you in? 4. What is your teacher's name? 5. What time did you fall? 6. What is the name of your school?

1, 3, 4, 6 1. What is your home address? 3. What grade are you in? 4. What is your teacher's name? 6.What is the name of your school? (Children in this age group may have trouble differentiating times)

Liquid supplemental iron is prescribed for a 10 month old with iron deficiency anemia. The parents tell the nurse that their child hates the tase of the medicine. Which of the following instructions should the nurse provide to the patients? Select all that apply 1. Give the iron orally with a syringe 2. Mix the iron in a little bit of chocolate syrup 3. Give the iron with food or milk 4. Let the child drink the iron through a straw 5. Give the iron with orange juice

1, 5 1. Give the iron orally with a syringe 5. Give the iron with orange juice (Iron can stain teeth and leave bad taste, admin with syringe to back of throat to mask the unpleasantness. OJ increases iron absorption)

The nurse is caring for a 3year old patient who has returned to the pediatric intensive care unit after insertion of a ventriculoperitoneal shunt to correct hydrocephalus. Which assessment finding is most important to communicate to the surgeon? 1. The child is crying and says "It hurts!" 2. The right pupil is 1 mm larger than the left pupil 3. The cardiac monitor shows a HR of 130 bpm 4. The head dressing has a 2 cm area of bloody drainage

2. The right pupil is 1 mm larger than the left pupil (Pupil dilation may indicate increased ICP and should be reported to HCP immediately)

A 2 year old arrives at the health center for a routine well child visit. A CBC and lead level are obtained. The lead level is less than 10 mcg/dL. The hemoglobin is 8 g/dL. The hematocrit is 24% and the mean corpuscular volume is 65. which questions should the nurse ask the parents to obtain a more thorough history? Select all that apply. 1. Does your child eat nonfood substances? 2. Is your child more prone to infections? 3. Has your child experienced hair loss? 4. Does your child frequently have nosebleeds? 5. How much milk does your child drink?

1, 5 1. Does your child eat nonfood substances? 5. How much milk does your child drink? (Iron deficiency anemia is a micocytic anemia, children with iron deficiency anemia may be more prone to pica (eating non food objects); patient may also experience more nosebleeds from thrombocytosis)

The nurse has just received a change of shift report about these pediatric patients. Which patient will the nurse asses first? 1. A 1 year old patient with hemophilia B who was admitted because of decreased responsiveness 2. A 3 year old with von Willebrand disease who has a dose of desmopressin (DDAVP) scheduled 3. A 7 year old with acute lymphocytic luekemia who has chemotherapy induced thromocytopenia 4. A 16 year old patient with sickle cell disease who reports acute right lower quadrant abdominal pain

1. A 1 year old patient with hemophilia B who was admitted because of decreased responsiveness (DECREASED LOC)

The pediatric charge nurse is working with a newly graduated RN who has been on orientation in the unit for 2 months. Which patient should the charge nurse give to the new RN? 1. A 2 year old patient with a ventricular septal defect for whom digoxin 90 mcg PO has been prescribed 2. A 4 year old patient who had a pulmonary artery banding and has just been transferred in from ICU 3. A 9 year old with mitral valve endocarditis who parents need teaching about IV antibiotic administration 4. A 16 year old with a heart transplant who was admitted with a low grade fever and tachycardia

1. A 2 year old patient with a ventricular septal defect for whom digoxin 90 mcg PO has been prescribed (Patient requires least complex assessments and interventions)

While working in the pediatric clinic, the nurse receives a telephone call from the parent of a 13 year old child who is receiving chemotherapy for leukemia. The patient's sibling has chickenpox. Which action will the nurse anticipate taking next? 1. Administer varicella zoster immune globulin to the patient 2. Teach the patient about the correct use of acyclovir 3. Educate the parent about contact and airborne precautions 4. Prepare to admit the patient to a private room in the hospital

1. Administer varicella zoster immune globulin to the patient

An unimmunized 7 year old child who attends a local elementary school contracts rubeola (measles). The child has 2 siblings, 9 and 11 years old, who also attend the elementary school. Which action by the school nurse is a priority? 1. Exclude the child and siblings from attending school for 21 days 2. Notify all parents of children attending the school of the exposure 3. Recommend that siblings receive the measles vaccine 4. Recommend that the siblings receive measles immunoglobulin

1. Exclude the child and siblings from attending school for 21 days (Measles is HIGHLY infectious and the incubation period is 7-21 days. Children must be excluded during entire incubation period to prevent further spread of the disease)

The nurse has obtained this assessment information about a 3 year old patient who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow up? 1. Frequent swallowing 2. Hypotonic bowel sounds 3. Reports of a sore throat 4. Heart rate of 112 BPM

1. Frequent swallowing (May indicate bleeding after tonsillectomy)

The nurse is teaching a group of day care workers about how to avoid transmission of Hep A in day care settings. What is the single most effective measure to emphasize? 1. Hand hygiene should be performed often to prevent and control the spread of infections 2. Children in whom hepatitis has been diagnosed should not share toys with others 3. Children with episodes of fecal incontinence should be isolated from others 4. Immunizations are recommended before children are admitted into day care settings

1. Hand hygiene should be performed often to prevent and control the spread of infections

A 10 year old girl has completed a course of amoxicilin for a UTI. THis is the second UTI the child has had this year. The child is in the 95th percentile for weight and has a history of constipation. Her parents ask the nurse for preventative strategies for UTI. Which of the following preventative strategies is best for the nurse to recommend? 1. Increase fiber in the diet 2. Drink cranberry juice 3. Increased vitamin C in the diet 4. Limit fluids at bedtime

1. Increase fiber in the diet (Constipation may be cause for patient UTI's so increasing fiber and decreasing occurrence of constipation may lower her chances of getting another UTI)

A 3 month old infant arrives at the health center for a scheduled well-child visit. The parents ask the nurse why the infant extends the arms and legs in response to a loud noise. Which response by the nurse is best? 1. Inform the parents that this is a normal reflex that generally disappears by 4-6 months of age 2. Tell the parents that if the behavior does not change by 6 months, the infant will need further evaluation 3. Remind the parents that this is a normal response that indicates the infant's hearing is intact 4. Reassure the parents that the behavior is normal and not an indicator of any problem such as cerebral palsy

1. Inform the parents that this is a normal reflex that generally disappears by 4-6 months of age

A 16 year old arrived at the cystic fibrosis clinic for a routine 3 month visit. The most recent respiratory culture results are negative. Which is best for the nurse to take? 1. Place the patient in the exam room immediately upon arrival to the clinic 2. Allow the patient to wait in the reception area until the provider is available to see the patient 3. Allow the patient to wait in the reception area with a mask until the provider is able to see the patient 4. Place the patient in a waiting area with other patients who also have negative respiratory cultures

1. Place the patient in the exam room immediately upon arrival to the clinic (All CF patients should be separated from others regardless of infection status in order to reduce risk of droplet transmission of CF pathogens)

The pediatric unit charge nurse is working with a new RN. Which action by the new RN requires the most immediate action on the part of the charge nurse? 1. Wearing gloves, gowns, and a mask for a neutropenic child who is receiving chemotherapy 2. Placing a newly admitted child with respiratory syncytial virus (RSV) infection in a room with another child who has RSV 3. Wearing a N95 respiratory mask when caring for a child with tuberculosis 4. Performing hand hygiene with soap and water after caring for a child with diarrhea caused by C. diff

1. Wearing gloves, gowns, and a mask for a neutropenic child who is receiving chemotherapy (PPE has revealed no significant differences in infection rates for children who are neutropenic)

A newborn infant with tracheoesophageal fistula. Which nursing interventions should be implemented in the preoperative period? Select all that apply. 1. Provide small frequent feedings 2. Elevate the HOB 3. Prepare a tracheostomy tray 4. Set up suctioning 5. Administer antibiotics

2,4, 5 2. Elevate the HOB 4. Set up suctioning 5. Administer antibiotics (Infant is at high risk for aspiration so elevate HOB and set up suction; preoperative period demands pre op antibiotics)

Which pediatric pain patient should be assigned to a newly graduated RN? 1. An adolescent who has sickle cell disease and was recently weaned from morphine via PCA device to an oral analgesic; he has been continually asking for an increased dose 2. A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch of the arm or other procedures 3. A child who is receiving palliative end-of-life care; the child is receiving opioids around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. A child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful

2. A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch of the arm or other procedures (Least complicated case so it should go to the new RN)

The HCP has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task will the nurse delegate to the UAP? 1. Providing explanations of the nursing actions to the family 2. Assisting the child to remove the outer clothing 3. Advising the parent to use acetaminophen instead of aspirin 4. Monitoring the child's level of consciousness and orientation level

2. Assisting the child to remove the outer clothing

An excited mother calls you for advice. "My child got cleaning solution in her eyes and I rinsed her eyes with water for a few minutes. What should I do? She is still screaming!" What do you instruct the caller to do first? 1. Comfort the child and check her vision. 2. Continue to irrigate the eyes with water. 3. Call the Poison Control Center. 4. Call 911 to request an ambulance.

2. Continue to irrigate the eyes with water. (Must continue to wash eyes for 20 min with water, if another adult is present they should call poison control for additional guidance)

Which action will the public health nurse take to have the most impact on the incidence of infectious diseases in the school? 1.Make soap and water readily available in the classrooms 2. Ensure that students are immunized according to national recommendations 3. Provide written information about infection control to all parents 4. Teach students how to cover their mouths when they cough or sneeze

2. Ensure that students are immunized according to national recommendations

A teenager arrives in the triage area alert and ambulatory but his clothes are covered with blood. His friends are yelling "We were goofing around and he got poked in the abdomen with a stick!" Which comment would be of most concern? 1. There was a lot of blood and we used three bandages 2. He pulled the stick out just now because it was hurting him 3. The stick was really dirty and covered with mud 4. He has diabetes so he needs attention right away

2. He pulled the stick out just now because it was hurting him (Removal can precipitate sudden hemodynamic decompensation)

The nurse is reviewing a CBC for a 3 year old with idiopathic thrombocytopenic purpura (ITP). Which info should the nurse report immediately to the HCP? 1. Prothrombin time (PT) of 12 seconds 2. Hemoglobin of 6.1 g/dL 3. Platelet count of 40,000/mm3 4. Leukocyte count of 5600/mm3

2. Hemoglobin of 6.1 g/dL (Low Hgb may signify bleeding, therefore alerting the HCP is recommended)

A 2 year old who has abdominal pain is diagnosed with intussusception. A hydrostatic reduction has been performed. Which findings should be reported immediately before surgery proceeds? 1. Palpable sausage shaped abdominal mass 2. Passage of normal brown stool 3. Passage of currant jelly like stools 4. Frequent nausea and vomiting

2. Passage of normal brown stool (Passage of brown stool indicates resolution of the issue so surgery may not be necessary)

An adolescent who was hospitalized for anorexia nervosa is following the prescribed treatment plan. Her self esteem and weight have gradually improved, but she continues to refer to herself as fatty. She is able to verbalize an appropriate diet and exercise plan. At this point what is the priority concern? 1. Patient needs to continue to gain weight 2. Patient has an unrealistic body image 3. Patient needs more information about nutrition 4. Patient lacks motivation to adhere to therapy

2. Patient has an unrealistic body image

THe RN is working with an LPN to provide care for a 10 year old with severe abdominal, hip and knee pain caused by sickle cell crisis. Which action taken by the LPN requires the RN to intervene immediately? 1. Administering oral pain meds as needed 2. Positioning cold packs on the child's knees 3. Encouraging increased fluid intake 4. Monitoring vital signs every 2 hours

2. Positioning cold packs on the child's knees (Ice packs during a vaso-occlusive crisis results in further vasoconstriction, placing the child at risk for thrombis formation)

An adolescent with cystic fibrosis is admitted to the pediatric unit with increase shortness of breath and pneumonia. Which nursing activity is most important to include in the patients care? 1. Allowing the adolescent to decide if aerosolized medications are needed 2. Scheduling postural drainage and chest physiotherapy every 4 hours 3. Placing the adolescent in a room with another adolescent with CF 4. Encouraging oral fluid intake of 2400 mL/day

2. Scheduling postural drainage and chest physiotherapy every 4 hours (Guidelines indicate that airway clearance is critical for patients with CF)

The pediatric unit charge nurse is making patient assignments for the evening shift. Which patient is most appropriate to assign to an experienced LPN? 1. A 1 year old patient with severe combined immunodeficiency disease who is scheduled to receive chemotherapy in preparation for a stem cell transplant 2. A 2 year old patient with WIskott-ALdrich syndrome who has orders for a platelet transfusion 3. A 3 year old patient who has chronic graft-versus-host disease and is incontinent of loose stool 4. A 6 year old patient who received chemotherapy 1 week ago and is admitted with increasing lethargy and temparature of 101 °F

3. A 3 year old patient who has chronic graft-versus-host disease and is incontinent of loose stool (Chronic diseases are most stable and should be given to the LPN)

The nurse is observing a preschool classroom of children between ages 3 to 4 year old. When planning actions to ensure that each child meets normal developmental goals, which child will require the most immediate intervention? 1. A 3 year old boy who needs help dressing 2. A 4 year old girl who has an imaginary friend 3. A 4 year old girl who engages only in parallel play 4. A 3 year old boy who draws stick figures

3. A 4 year old girl who engages only in parallel play (Should be done with parallel play after 3 years of age, should be engaging in pretend play by age 4)

After receiving the change of shift report, which patient should the nurse assess first? 1. An 18 month old patient with coarctation of the aorta who has decreased pedal pulses 2. A 3 year old with rheumatic fever who reports of severe knee pain 3. A 5 year old with endocarditis who has crackles audible throughout both lungs 4. An 8 year old with Kawasaki disease who has a temp of 102.2°F

3. A 5 year old with endocarditis who has crackles audible throughout both lungs (Crackles in both lungs indicate severe Left ventricular failure as a complication of endocarditis. Hypoxemia is likely)

Parents of a 6 month old girl bring the infant to the ED because "she has not held anything down for the entire day" The nurse obtains a blood glucose of 94. The infants rectal temp is 101°F, heart rate 198 bpm, RR of 40 breaths per min,and BP 60/38 mmHg in the left arm. Which nursing action is a priority? 1. Administer an antiemetic rectally 2. Administer a bolus of D10W 3. Administer a bolus of normal saline 4. Administer an antipyretic rectally

3. Administer a bolus of normal saline (Infant is experiencing severe dehydration, at risk for hypoglycemic shock)

The school nurse is performing developmental screenings for children who will be entering preschool. A 4 year old girl excitedly tells the nurse about her recent birthday party. As she relates the details of the event, she frequently stutters. Which action by the nurse is most appropriate at this time? 1. Refer the child to an audiologist 2. Obtain a detailed birth history from the parents 3. Document the findings on the child's school record 4. Refer the child to a speech pathologist

3. Document the findings on the child's school record (Stuttering in preschool years is a normal variation especially when excited or upset)

The nurse is caring for several children with cancer who are receiving chemotherapy. The nurse is reviewing the morning laboratory results for each of the patients. Which patient condition combined with the indicated lab result would cause the nurse the greatest concern? 1. Nausea and vomiting with a K+ level of 3.3 mEq/L 2. Epistaxis with a platelet count of 100,000 3. Fever with an absolute neutrophil count of 450 4. Fatigue with a hemoglobin level of 8 g/dl

3. Fever with an absolute neutrophil count of 450 (fever is sign of infection -- in a neutropenic patient could lead to sepsis quickly)

The nurse is caring for a 5 year old whose mother asks why he still wets the bed. What is the best response? 1. He is old enough that he should no longer be wetting the bed 2. Most children outgrow the bed wetting by the time they start school 3. His bed wetting may be due to an immature bladder or deep sleep pattern 4. He will probably stop once he realizes how embarrassing it is to wet the bet

3. His bed wetting may be due to an immature bladder or deep sleep pattern

These medications have been prescribed for a 9 year old with deep partial and full thickness burns. Which medication is most important to double check with another licensed nurse before administration? 1. Silver sulfadiazine ointment 2. Famotidine 20 mg IV 3. Lorazepam 0.5 mg PO 4. Multivitamin 1 tablet PO

3. Lorazepam 0.5 mg PO (BZD and other sedation agents are considered high alert especially for children)

A 4 yaer old with acute lymphocytic leukemia has these medications ordered. Which one is most important to double check with another licensed nurse? 1. Prednisone 1 mg PO 2. Amoxicillin 250 mg PO 3. Methotrexate 10 mg PO 4. FIlgrastim 5 mcg subcutaneously

3. Methotrexate 10 mg PO (High alert drug so extra precautions should be taken)

A 16 year old boy comes into the office of the school nurse complaining of left hip pain that began when playing basketball in gym class. The boy is in the 85th percentile for height and weight. He complains of increased pain with weight bearing. The nurse observes out-toeing of the left leg with ambulation. Which nursing action is a priority? 1. Administer ibuprofen and instruct the boy to rest 2. Apply heat to the hip and elevate the left leg 3. Refer the boy to the emergency department 4. Apply ice to the hip and immobilize it with a splint

3. Refer the boy to the emergency department (Slipped capital femoral epiphysis, which is slippage of femoral head. Exact cause of SCFE is unknown but it occurs more in boys. It is an emergency as tissue necrosis may occur)

A child with Hirschsprung disease arrives on the pediatric unit from the operating room with a temporary colostomy. Which task should the nurse delegate to the UAP? 1. Assess the frequency and consistency of stool 2. Instruct the parents on skin care 3. Stock the room with ostomy supplies 4. Assess the patient for pain

3. Stock the room with ostomy supplies

A 7 month old infant arrives at the health center for a scheduled well child visit. When the nruse approaches the infant to obtain vital signs, the infant cries vigorously and clings fearfully to the mother. Which of the following phenomena provides the best explanation for the infant's behavior? 1. Separation anxiety 2. Disassociation disorder 3. Stranger anxiety 4. Autism spectrum

3. Stranger anxiety

The nurse is preparing a child for an IV moderate conscious sedation before repair of a facial laceration. What information should the nurse immediately report to the HCP? 1. The parent is unsure about the child's tetanus immunization status 2. THe child is upset and pulls out the IV 3. The parent declines the IV moderate sedation 4. The parent wants information about the IV moderate/conscious sedation

3. The parent declines the IV moderate sedation (Parental refusal is an absolute contraindication; therefore physicial must be notified)

The nurse caring for a 3 year old child plans to assess the child's pain using the Wong-Baker FACES pain rating scale. Which accompanying assessment question would be the most useful? 1. If number 0 were no pain and number 10 were a big pain, what number would your pain be? 2. Can you point to the face picture with one finger and tell me what the pain feels like inside of you? 3. The smiling face has no hurting, the crying face has a really big hurting. Which face is most like your hurting? 4. If you look at these faces and I give you a paper and pencil can you draw for me the face that looks most like your pain?

3. The smiling face has no hurting, the crying face has a really big hurting. Which face is most like your hurting?

Parents of 13 year old adolescent girl expressed concern because she spends quite a lot of time in her room alone in front of the mirror. The girls height and weight are in the 50th percentile. In the exam room the girl is quiet but does answer questions appropriately. What advice should the nurse provide to the parents? 1. Further evaluation by a psychologist is needed because your daughter spends a lot of time alone in her room 2. Limit the amount of time that your daughter is allowerd to spend alone in her room 3. This behavior is normal. Your daughter is adjusting to physical changes she is experiencing 4. This behavior may be associated with depression, and further evaluation by a counselor is advised.

3. This behavior is normal. Your daughter is adjusting to physical changes she is experiencing

A 16 year old female adolescent arrives at the health center. She tells the nurse that she's sexually active for 6 months "but only with my boyfriend". Her immunizations are up to date. Screening for which STD will be most important for this patient? 1. Syphilis 2. Genital herpes simplex 3. Human papillomavirus 4. Chlamydia

4. Chlamydia (CDC recommends chlamydia screenings for all sexually active women under 25 d.t being most prevalent STD in US)

A 6 year old child who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is the nurse's best response to this behavior? 1. Remind the child that foods tasted good today and will help her or his body to get strong 2. Allow the mother and child time alone to review and control the behavior 3. Ask the mother to leave until the child can finish eating and then invite her back 4. Explain to the mother that the behavior could be a normal expression of anger

4. Explain to the mother that the behavior could be a normal expression of anger (Child may be angry about being left in a hospital or about being sick in general, help the mother understand what they child may be feeling)

An 18 month old child has oral mucosities secondary to chemotherapy. Which task should the nurse delegate to the UAP? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Feeding the child a bland, moist, soft diet

4. Feeding the child a bland, moist, soft diet (assisting with feeding is appropriate for UAP

A parent calls the ED saying "I think my toddler might have swallowed a little toy. He is breathing okay but I don't know what to do" What is the most essential question to ask the caller? 1. Has he vomited? 2. Have you been checking his stools? 3. What do you think he swallowed? 4. Has he been coughing?

4. Has he been coughing? (Even if he has been "breathing ok" other signs of airway complications include couging, drooling, refusing to eat or drink, etc.)

A 4 month old infant boy is brought to the emergency department by his parents. He had been vomiting and fussy for the past 24 hrs. On exam, there are circular bruises on his back. What priority assessment does the nurse anticipate? 1. Chest x ray examination 2. Ultrasonography of the head 3. Electrocephalography 4. Ophtalmologic examination

4. Ophtalmologic examination (H and P suggests shaken baby syndrome. Ophthalmic exam is indicated to determine if baby has retinal hemorrhages often seen in shaken baby syndrome)

A toddler is brought to the health center for a fever of 102°F and a sore throat. As the nurse places a toddler and his parents in the exam room the client experiences a tonic clonic seizure. Which nursing action is a priority? 1. Assess the childs level of consciousness 2. Obtain an oxygen saturation 3. Loosen the child's clothing 4. Position the child in side lying position

4. Position the child in side lying position (prevent aspiration)

The nurse is caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of most concern? 1. Bulging of the sac when the infant cries 2. Oozing of stool from the anal sphincter 3. Flaccid paralysis of both legs 4. Temperature of 101.8°F

4. Temperature of 101.8°F (Indicates possible infection, notify HCP so potential treatment may be started)

The nurse is obtaining the H&P information for a child who is recovering from Kawasaki disease and receives aspirin therapy. Which information concerns the nurse the most? 1. The child attends a day care center 5 days a week 2. The child's fingers have areas of peeling skin 3. The child is very irritable and cries frequently 4. The child has not receive any immunizations

4. The child has not receive any immunizations (Children who receive aspirin therapy are at risk for development of Reyes syndrome if they contract viral illnesses such as varicella or influenza)

The nurse obtains this information when assessing a 3 year old patient with uncorrected tetralogy of Fallot who is crying. Which finding requires immediate action? 1. The apical pulse rate is 118 bpm 2.A loud systolic murmur is heard in the pulmonic area 3. There is marked clubbing of the child's nail beds 4. The lips and oral mucosa are dusky in color

4. The lips and oral mucosa are dusky in color (Indicates a drop in the partial pressures of oxygen that may precipitate seizures and loss of consciousness

A 6 year old arrives in the ED with active seizures. Which assessment is a priority for the nurse to obtain? 1. Heart rate 2. Body mass index (BMI) 3. Blood pressure 4. Weight

4. Weight (drug doses by weight)