NURS 4331
The parents of a 5-year-old have just found out that their child has head lice. Which statement by the parents would support the nursing diagnosis of deficient knowledge?
"I can't believe it. We're not unclean, poor people."
An extremely thin preadolescent is being assessed by the nurse. Which client statement should the nurse identify as being consistent with that of a person with anorexia nervosa?
"I feel chubby no matter what I wear."
A nurse is assessing a child for possible obsessive-compulsive disorder. Which question would be most helpful for obtaining information from the child?
"Is there anything that you do over and over again and can't resist doing?"
During a complete physical assessment of a preteen boy, the nurse correctly recognizes which finding as being the first change of puberty?
Testicular enlargement
The nurse is educating parents of a child admitted to the hospital with rubella (German measles). Which statement by the parents indicates the further education is needed?
"Antibiotics are needed to help our child recover from rubella."
A nurse is conducting a physical examination of a 12-year-old girl with suspected systemic lupus erythematosus (SLE). How would the nurse best interview the girl?
"Have you noticed any hair loss or redness on your face?"
The nurse is caring for the family of a pediatric client during resuscitative efforts of their child following an accident. Which response by the nurse would be best?
"I am here to answer your questions and be with you during this difficult time."
The nurse is providing teaching about food substitutions when cooking for the child with an allergy to eggs. Which response indicates a need for further teaching?
"I can use the egg white when baking, but not the yolk."
An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?
"SLE is an autoimmune disorder that I will always have, with times of flare- ups and times of minimal to no symptoms."
An 11-year-old boy has recently been prescribed methylphenidate. The mother calls the pediatrician's office to speak with the advanced practice pediatric nurse practitioner. This mother has been extremely resistant to medication and insists that the medication is not working. How should the nurse respond?
"Tell me what makes you think the medication is not working"
Jerry and his mother have come to the office for a routine visit. In the hall away from Jerry, his mother relates to the nurse that she is concerned because Jerry is playing games that girls play, and has noticed that when he plays any role-playing games his character is very feminine. She tells the nurse that she is worried about Jerry's sexual orientation. What is the best response to her concerns?
"This behavior may be exploratory or reflect peer pressure, so avoid making assumptions about his sexual orientation."
The nurse is providing teaching to the parents of a child with varicella. Which statement indicates that the parents have understood the instructions?
"We need to make sure that he washes his hands frequently."
The nurse is teaching the parents of a child with varicella about the disorder. The nurse determines that the teaching was successful when the parents state which of the following?
"We will make sure to remind him not to scratch the lesions."
An infant is brought to the emergency department with acetaminophen poisoning. Which medication should the nurse expect to administer to this child?
Acetylcysteine
The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next?
Administer next dose as ordered in 12 hours.
Which nursing intervention is priority when caring for a child with HIV?
Administer prescribed medications.
A 13-year-old girl tells the nurse during a gynecological visit that a friend of hers developed toxic shock syndrome from tampon use. The client says that tampons work well for her, but she wonders whether they are safe. Which of the following recommendations should the nurse give this client to help prevent toxic shock syndrome?
Alternate use of tampons with sanitary pads
For which child's behavior should the nurse identify as being characteristic of separation anxiety disorder?
An 8-year-old who will not stay overnight at a friend's house
A child with attention deficit hyperactivity disorder (ADHD) is prescribed methylphenidate hydrochloride. What should the nurse instruct the parents regarding an adverse effect of this medication?
Anorexia
A child is brought into the emergency department. After assessing a child's airway, breathing, and circulation (ABCs), which of the following would the nurse do next?
Assess level of consciousness.
The nurse is caring for a child and notes periorbital edema on the left eye with urticaria. Which action by the nurse is priority?
Assess lung sounds bilaterally.
The nurse is called into a toddler's room. The child's mother says "he's having trouble breathing." What should the nurse do first?
Assess patency of the child's airway.
A child presents to the emergency department via ambulance in critical condition following a traumatic motor vehicle crash. What would the first action of the nurse be?
Assess the child's airway and manage airway patency
A child is exhibiting symptomatic bradycardia that has been unresponsive to ventilation and oxygenation. Which of the following would the nurse expect to be administered?
Atropine
A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?
Avoid unattended baths for the toddler.
The nurse is evaluating outcomes for teaching provided to the mother of a school-age child with an itchy rash. Which outcome indicates that teaching has been effective?
Child drinks a glass of water every 1 to 2 hours throughout the day
When assessing a infant born at 32 weeks' gestation, which finding would lead the nurse to suspect to suspect that the newborn has a patent ductus arteriosus (PDA)?
Continuous murmur on auscultation
A 6-month-old child has developed skin irritation due to an allergic reaction. He has been prescribed a topical skin ointment. The nurse will consider which of the following before administering the drug?
That the infant's skin has greater permeability than that of an adult
A school health nurse is supporting a 15-year-old young woman with acne. What is a common myth related to acne in adolescent populations?
Diet plays a significant role in acne production
The nurse is doing an in-service training on clinical manifestations seen in communicable diseases. Which best describes a macule?
Discolored skin spot not elevated at the surface
The nurse is completing the physical assessment of a 12-year-old child who has a series of bruises in various stages of healing. When asked about the bruises the child appears frightened and offers inconsistent accounts about how the child got the bruises. The nurse suspects abuse. Which initial action of the nurse is most appropriate?
Document the bruises and any statements made by the child relating to them.
The nurse is caring for a chronically ill adolescent client. What can the nurse do to maintain stimulation and support the client's sense of identity while hospitalized?
Encourage communicating with friends through social media
A 15-year-old male complains of persistent scrotal pain, edema, and nausea since being hit in the groin by a baseball 3 hours ago. Which is the priority action by the nurse?
Ensuring that the teen is assessed by the physician immediately
An unconscious client is brought to the emergency department after ingesting too much prescribed medication. What is the highest priority nursing intervention?
Establish a patent airway.
A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following would the nurse do first?
Establish a suitable IV site.
The nurse is collecting data on a 5-year-old child admitted with the diagnosis of congestive heart failure. Which clinical manifestation observed during the physical assessment would be consistent with this diagnosis?
Failure to gain weight
The nurse is teaching a group of parents about head lice. Which statement is essential to include during the presentation?
Head lice are becoming very resistant to treatment.
A child with allergic rhinitis is prescribed a nasal antihistamine spray. When advising the parents about the use of the sprays, what should the nurse explain about the rebound phenomenon?
It causes an increase in nasal secretions after an initial decrease
An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse?
It will determine if the heart is enlarged.
The nurse is performing CPR on a child who is a victim of a near-drowning experience. How should the nurse open the child's airway to provide breaths?
Jaw-thrust maneuver
A nurse is reading a journal article about adolescents and major causes of injuries in this age group. The nurse demonstrates understanding of this information by identifying which situation as the major cause of adolescent injuries?
Motor vehicle crashes
A 15-year-old boy visits his primary care physician's office with fever, headache, and malaise, along with complaints of pain on chewing and pain in the jawline just in front of the ear lobe. The boy asks his mother to leave the exam room for a minute and then tells the nurse that he is also experiencing testicular pain and swelling. The nurse recognizes that this client most likely has which condition?
Mumps
A 3-year-old child is brought to the emergency department after swallowing batteries taken from a grandparent's hearing aids. The parents believe that two batteries were swallowed. What should the nurse explain to the parents regarding the care that the child will need at this time?
Preparation for an emergency endoscopy to remove the batteries
The nurse is reviewing the medical record of a child with a mental health disorder and finds that the child is receiving cognitive behavioral therapy. How does the nurse interprets this information?
Process that requires the individual to view a situation from a different perspective
The nurse is doing an in-service training on clinical manifestations seen in communicable diseases. Which skin condition best describes erythema?
Redness of the skin produced by congestion of the capillaries
A 10-year-old boy has just arrived by ambulance at the emergency room following a motor vehicle accident, and a nurse is assessing him. Which three body systems should the nurse evaluate fist?
Respiratory, cardiovascular, and neurologic
The nurse is assessing a child with suspected infective endocarditis. Which assessment finding would the nurse interpret as a sign of extracardiac emboli?
Roth spots
A 17-year-old girl has been diagnosed with bulimia nervosa. Which complication should the nurse carefully assess for in this client?
Severe erosion of teeth
The nurse is conducting an assessment of a 5-year-old client. During the assessment, the nurse notes that the child does not maintain eye contract or speak. The nurse suspects an autism spectrum disorder. Which additional finding would help support the nurse's suspicion?
The child constantly opens and closes the hands.
The nurse is caring for a 12-month-old child diagnosed with an autism spectrum disorder. What information from the mother during the health history should the nurse identify as being consistent with the disorder?
The child constantly stares at a rotating wheel on the crib mobile
An adolescent comes into the emergency department with a foot wound. Upon assessment, the nurse learns that the patient is a runaway and has been living on the streets. Which is the most appropriate care for the nurse to provide to the client at this time?
Treat the wound and provide wound care supplies
A 7-year-old child is rushed into the emergency room after being stung by a yellow jacket. The child is nauseated and vomiting and is experiencing itching and swelling on the arm where stung. The is having trouble breathing. Which type of hypersensitivity response is the child experiencing?
Type I: anaphylaxis
The nurse is caring for a school-age child with varicella. What should the nurse observe about the rash that is associated with this infection?
Various stages of lesions present at the same time
The adoptive parents of a child who is 7 years old and HIV positive are concerned about telling their child about his condition. What information can be provided by the nurse?
When providing health information to a child of this age it should be simplistic and at the child's level of understanding.
The nurse receives the shift report of multiple pediatric clients. Which pediatric client will the nurse see first?
a toddler with tetralogy of Fallot squatting quietly in the corner of the room
Parents usually ask when their child can return to school after having chickenpox. The correct answer would be
as soon as all lesions are crusted.
Nursing students correctly label the group of cells whose job is to ingest, engulf, and neutralize pathogens as:
macrophages
In developing a plan of care for the child diagnosed with rheumatic fever, the nursing intervention that takes highest priority for this child is to:
promote rest periods and bed rest.
The nurse is assessing a 30-month-old child during a routine well-child visit. Which statement by the parent would alert the nurse to further assess for a learning disorder?
"My child does not say more than one or two words and grunts to indicate needs."
The mother of a an 8-year-old boy with mumps tells the nurse that she does not understand how her son could have gotten mumps since he was immunized according to her physician's recommendations. What is the best response by the nurse?
"While immunizations are highly effective they aren't 100% effective at preventing infectious diseases."
An adolescent who is depressed states, "Nothing ever seems to be right in my life." Which would be the most appropriate response by the nurse?
"You are feeling sad right now. It's a hard time."
The nurse is monitoring the CD4 count of an infant who has contracted HIV from the mother in utero. The nurse is concerned that treatment with antiretroviral therapy is not effective when noting which CD4 level?
1300/mm3
A 13-year-old girl has grown rapidly in height over the past 2 years and is taller than most of the boys in her class. She wonders when she will stop growing. What should the nurse tell her as a general guideline for the ages at which most girls stop growing?
16 to 17 years old
A nurse is assessing, Maria, an 11-year-old female. During the assessment, the nurse notices that the girl's breasts have begun to develop. Based on an understanding of adolescent growth and development, the nurse would anticipate that Maria would most likely begin to menstruate within which time period?
2 years
A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. Which of the following would be the priority?
Administering 100% oxygen by mask
The nurse is caring for a 24-month-old child with a fever of 101°F. The child also exhibits a toxic appearance. Which of the following would the nurse expect to implement?
Administering antibiotics as ordered
A young client is admitted to the hospital directly from the clinic. The physician suspects a problem with the child's immune system. What test does the nurse anticipate the physician will order for this client?
Blood analysis
The mother of a 10-year-old child diagnosed with rubella asks what can be done to help her child feel better during her illness. What information can be provided?
Encourage rest and relaxation
Linda, a 14-year-old, and her mother are in the office. As Linda goes to the bathroom, her mother stops the nurse and asks about the changes that Linda is going through. She would like to talk to her about sex and the changes but she is unsure of how to do this. As the nurse, which of the following would be appropriate for you to suggest?
Promote open lines of communication, encourage listening, don't lecture, and share family values.
When interviewed by the school nurse, a 13-year-old adolescent female states she has a boyfriend and that her parents do not talk about sex with her. She says is confused about the facts and wants to know the truth. Which approach would best address this adolescent's concerns?
Sit down with her and openly discuss her concerns and questions in an honest, straightforward manner.
The parent of a child with mumps on one side of the face is concerned that the disease can develop on the other side in the future. How should the nurse respond to the mother about this concern?
The child is immune to further attacks of the disease.
The nurse is educating the parents of a 6-year-old boy about his learning disorder. Which of the following facts would the nurse integrate into the discussion?
The disorder is caused by a difference in brain architecture.
The nurse is providing education to parents of a child with a blood pressure in the 90th percentile. What would be included in the intervention strategies?
The nurse would review the child's 24-hour diet recall.
The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education?
"If we need to use the EpiPen® we will need to notify her physician's office the next business day."
A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning?
Keep cleaning solutions locked up.
When educating parents of preschoolers what is most important to include in your presentation?
Keep chemicals in a locked cabinet.
A child in the clinic has a fever and reports a sore neck. Upon assessment the nurse finds a swollen parotid gland. The nurse suspects which infectious disease?
Mumps
A nurse is conducting a secondary assessment of a child who has experienced multiple trauma. When inspecting the child's back, which of the following would be most appropriate to do?
Logroll the child to the side.
