Nursing care of children Final
A nurse is caring for a child with cystic fibrosis who has a pulmonary infection. Which of the following findings is the nurse's priority?
Inability to clear secretions
A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus and pertussis (DTaP) vaccine; The measles, mumps, and rubella (MMR) vaccine; and varicella vaccine, which of the following immunizations should the nurse plan to administer
Inactivated poliovirus vaccine (IPV)
A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hour ago and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect?
Inactivity and thumb sucking
A nurse is performing a well-child assessment of a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erickson's stage of psychosocial development
Industry vs. inferiority
A nurse is providing teaching to the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include?
Instruct the child to walk the bike through intersections
A nurse is caring for a 3-year-old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to improve these manifestations?
Knee-chest
A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client?
Longer intestinal tract
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?
Maintain the child on bed rest
A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take?
Measure the infant's head circumference
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?
Minimize physical contact with the child initially
A nurse is assessing a 6-month-old infant. The guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infants visual acuity?
Move a brightly colored toy from side to side in front of the infants face
A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include?
Muscle weakness
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (select all that apply)
Nausea Urticaria Stridor
A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take?
Obtain the adolescent's weight prior to the procedure
A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately?
Oxygen saturation 85%
A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take?
Position the child on a cooling blanket and cover her with a sheet
A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider?
Potassium 2.5 mEq/L
A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take?
Prepare concentrated sucrose for oral administration
A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse take?
Provide thorough skin care
A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids?
Pruritus
A nurse is providing education to the parent of a toddler who is about to receive her first dose of he measles, mumps, and rubella (MMR) immunization. Which of the following statements by the parent indicates an understanding of the teaching?
"I can give my child acetaminophen for discomfort associated with the immunization."
A nurse is teaching the parents of a 4-month-old infant who has gastroesophageal reflex. Which of the following statements by a parent indicates an understanding of the teaching?
"I will add 1 teaspoon of rice cereal per ounce to my baby's formula"
A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which
"My child should consume 1,000 calories per day"
A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further?
"My child spends 4 hours per day using online chat rooms."
A nurse is providing teaching about poisoning prevention top a group of parents with toddlers. Which of the following statements should the nurse make?
"Put all cleaning supplies in a locked cabinet"
A nurse is caring or a child who has bacterial endocarditis. The child is scheduled to receive moderate-term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent?
"The PICC line will last for several weeks with proper care."
A nurse is providing discharge teaching to parents whose infant had a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching?
"We will notify the doctor right away if he has a fever."
A nurse is teaching an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching?
"You should drink 4 ox of orange juice if you experience hypoglycemia
A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching?
"You will be able to participate in physical exercise"
A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make?
"Your baby can start the pneumococcal vaccine now"
A nurse is performing an annual physical assessment of a preschooler. The parent expresses concern about the childs 1.8 kg weight gain over the past year. Which of the following responses should the nurse make?
"Your child's weight change is expected for this age group."
A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). Which of the following pieces of information should the nurse include in the teaching?
Add fortified rice cereal to the infants formula
A nurse is instructing a group of parents and guardians about child development. Which of the following recommendations should the nurse make to promote the developmental task of industry in the school-age child?
Assign the child several small chores
A nurse is assessing a toddler who has AIDS. Which of the following findings is an indication of an opportunistic infection?
Candidiasis
A nurse is discussing the cause of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption?
Celiac disease
A nurse is assessing a child who is postoperative and received a unit of pack RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction?
Chills and flank pain
A nurse is assessing the fine motor skills development of a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities?
Copying a square
A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first?
Demonstrate the injection technique on an orange
A nurse is caring for a 6-year-old child who is experiencing encopresis. Which of the following actions should the nurse take?
Determine if there are any recent stressors in the child's environment
A nurse is an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first?
Determine the child's breathing pattern
A nurse is assessing a 4-year-old child's cognitive development during a well-child visit. Which of the followings should the nurse expect the child to display?
Development of the superego
A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before the child can have corrective surgery. The nurse should explain that the parents should wait no longer than 6-12 months for surgery to prevent which of the following outcomes
Difficulty with language acquisition
A nurse is providing teaching to the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include?
Dry clothing in a hot dryer for at least 20 minutes
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care?
Explain the sounds the child is hearing
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take?
Give the medication at the side of the infants mouth
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well child visit. Which of the following findings should the nurse report to the provider?
Head lagging when the infant is pulled from a lying to a sitting position
A nurse is providing Teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions?
Hip
A nurse is assessing the gross motor skills of a 4-year-old preschooler. The nurse should expect the preschooler to perform which of the following activities?
Hopping on 1 foot
A nurse is reviewing the laboratory value for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect?
Sodium 125 mEq/L - below the expected range for an infant
A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following?
Speech patterns
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions
Supine
An 18-month-old infant has pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors?
The infant's mother is likely HIV positive
A nurse is teaching the parents of an infant about treatment option for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants?
The provide direct stimulation of auditory nerve fiber
A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching?
Toddlers will react to the parents' anxiety and sadness
A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis?
Transposition of the great arteries - reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation
A nurse on a pediatric unit is caring for a preschooler who is prescribed an IV medication. Which of the following actions should the nurse take to prepare the child for the procedure
Use role-play activities with the child
A nurse is caring for a 15-month-old client who requires droplet precautions. Which of the following actions should the nurse take?
Wear a mask when assisting the toddler with meals
A nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include
Withhold the medication if the infant's heart rate is less than 110/min
A nurse is providing postoperative teaching to the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching?
" I will fold my baby's diaper away from the incision"
A nurse is preparing to administer acetaminophen 240 mg PO daily to a child who has a temperature of 38.9. The amount available is 160/5. How many Ml should the nurse administer per done
7.5
A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following examples should the nurse use to illustrate a suggestive finding?
Arm cast for a spiral fracture of the forearm
A nurse is assessing an infant w ho has acute gastroenteritis. Which of the following findings should the nurse identify as the priority?
Capillary refill 5 seconds - Above 4 seconds is s/s severe dehydration
A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications?
Check for pulse in the affected leg every 4 hours
A nurse is planning care for a 3-month-old infant who has ileostomy. Which of the following interventions should the nurse include in the plan?
Check the bag for stool every 4 hours
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take?
Check the child's blood pressure every 4 hr
A nurse is caring for a school-aged child who begins to have a tonic-clinic seizure when leaving the bathroom. Which of the following actions should the nurse take first?
Ease the child to the floor in Sims' position
A nurse is caring for a preschool-age child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take?
Instruct the child to use a soft sponge toothbrush when brushing her teeth
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800 the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hour. Which of the following actions should the nurse take?
Reinforce teaching with the client about how to push the button to deliver the medication
A nurse is providing teaching about home care to the guardian of a school aged child who has seizures. Which of the following statements by the guardian indicates an understanding of the teaching?
" I will turn my child onto her side when a seizure begins"
A nurse is providing teaching to the guardian of an adolescent. The guardian reports that the adolescent sleeps about 10 hour on weekend nights. Which of the following responses should the nurse provide?
"Adolescents need more sleep due to rapid growth."
A nurse teaching the parent of a 3-year-old toddler about promoting sleep. Which of the following pieces of information should the nurse include?
Follow a nightly routine and established bedtime
A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching
" I need to apply paste to the back of the wafer on my child's appliance
A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
" I will add rice cereal to my baby's feedings."
A nurse in the emergency department is caring for an accompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada". The nurse should make which of the following age assessments for this child?
12 months old
A nurse is performing a nutritional screening for a 12-year-old client who weighs 41 kg (90 lb) and has a height of 1.5 m (60 in). Which of the following values is the client's body mass index (BMI)
18.2 - to calculate the clients BMI, the nurse should divide the clients weight in kilograms by the square of the clients height in meters. Therefore, 41 kg divided by the square of 1.5 m gives a correct BMI of 18.2
A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take?
Administer ibuprofen
A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (select all that apply)
Allow 30 minutes to complete each feeding Gradually increase the caloric density of the formula Position the infant semi-upright during feedings Provide gavage feeding if respiratory rate exceeds 80/ min
A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3. Which of the following medications should the nurse administer?
Amoxicillin
A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider immediately?
An infant with a WBC count of 24,000/mm3
A nurse is caring for a child who has episaxis. Which of the following actions should the nurse take?
Apply continuous pressure to the lower part of the childs nose
A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use?
Encourage the child to focus on a recent pleasurable experience
A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority?
Encourage the child to use an incentive spirometer
A nurse is cring for a newborn who has spina bifida. The newborn's parents are upset by the diagnosis. Which of the following action should the nurse take?
Encourage the parents to touch and care for the newborn
A nurse is a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include?
Ensure the child's dietary intake of calcium and iron is adequate
A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take?
Examine the infants throat at the end of the examination
A nurse is assessing a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities?
Fastening buttons on a shirt
A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia?
Patch the unaffected eye
A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use the suction the child's tracheostomy?
Remove the catheter while applying intermittent suction
A nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse. Which of the following actions should the nurse take?
Report the suspected abuse to local authorities
A nurse is assessing a 6-month old infant who was recently admitted with acute votmiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration?
Tachypnea
A nurse is assessing a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect?
Periorbital edema
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
Periorbital edema
A nurse is providing teaching about home safety to the parent of a 2-month-old infant. Which of the following information should the nurse include?
Remove bibs before the infant goes to sleep
A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse provide to foster a rapport and encourage conversation?
Tell me about your favorite video game.
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take?
Test the nasal secretions for glucose
A nurse is assessing a 3-year-old child during a well-child examination. Which of the following findings should the nurse report to the provider?
The child cannot walk on tiptoe
A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examinations
The child prefers to sit on the parent's lap during the examination
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (select all that apply)
The child views death as similar to sleep The child believes his thoughts can cause death The child thinks death is a punishment
A nurse is evaluating the outcome of surgery for an infant who had a bile duct obstruction which of the following findings should indicate to the nurse that the surgery was successful?
The color of the infants stool is yellowish-brown
A nurse is discussing disciplinary techniques with the guardian of a preschooler. Which of the following actions indicates to the nurse that the guardian is using an age-appropriate disciplinary technique?
The guardian places the child in time-out after misbehaving
