Pediatrics Ass. A
A nurse is performing screening for scoliosis on a school-aged child. Which of the following instructions should the nurse provide?
"Bend forward with your knees straight and your arms dangling." MY ANSWER This position allows for adequate visualization to detect any asymmetry of the spine or rib cage. Wrong "Stand facing me with your hands on your hips." The nurse should inspect the child from behind to note any asymmetry of the hips or shoulders. "Bend your knees and touch your toes." This position does not enable the nurse to inspect the spine for a lateral curvature. "Lie on your stomach with your arms extended over your head." The prone position does not allow adequate visualization of any asymmetry of the spine, hips, or shoulders.
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?
"Give the infant a pacifier at bedtime." MY ANSWER The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping. Wrong "Use a soft mattress in the infant's crib." The nurse should instruct the parent to use a firm mattress and avoid the use of waterbeds, beanbags, or soft mattresses when placing the infant in bed. The use of a soft mattress in the infant's crib is a risk factor for SIDS and can lead to asphyxiation. "Allow the infant to sleep on a large pillow." Placing the infant on a large pillow to sleep can increase the risk of suffocation, asphyxiation, and SIDS. "Place the infant in a prone position to sleep." The nurse should instruct the parent to place the infant in a supine position to sleep. Prone and side-lying positions are risk factors for SIDS.
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?
"I should keep my child indoors when I mow the yard." MY ANSWER The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks. Wrong I should avoid using a wet mop on my floors when I am cleaning." The nurse should instruct the parent to wet mop bare floors weekly because sweeping floors can trigger an asthma attack due to the inhalation of the dust that becomes airborne during sweeping. I will give my child a cough suppressant every 6 hours if he has a cough." The nurse should instruct the parent that cough suppressants are contraindicated for children who have asthma because they need to be able to cough up mucus to keep their airway open. "I will use a humidifier in my child's room at night." The nurse should instruct the parent that dehumidifiers or air conditioners are recommended to control the room temperature because heat and humidification can cause an asthma exacerbation.
A nurse is teaching the guardian of a 6 month old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?
"I should secure the car seat using lower anchors and tethers instead of the seat belt." Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used. Wrong "I should position the car seat harness 1 inch above my baby's shoulders." The car seat harness in rear-facing car seats should be positioned at or just below the infant's shoulders. "I will make sure that the car seat is placed at a 90-degree angle." MY ANSWER The car seat should be positioned at a 45° angle to prevent slumping and injury to the infant. "I will pad my baby's car seat with a blanket for traveling long distances." Padding placed underneath the infant or anywhere in the car seat can compress and/or create space between the infant and the harness. This can increase the risk for injury to the infant and should be avoided.
A nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?
"I will give myself a shot of regular insulin 30 minutes before I eat breakfast." The child should administer regular insulin 30 min before meals so that the onset coincides with food intake. Wrong "I will puncture the pad of my finger when I am testing my blood glucose." The child should avoid puncturing the pads of the fingers because they have fewer blood vessels and more nerve fibers. Instead, the child should puncture the skin on either side of the finger pad to promote blood flow and decrease pain. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." MY ANSWER The child should eat a snack of 10 to 15 g of carbohydrates, such as 120 mL (4 oz) of fruit juice or 66 g (1/2 cup) of ice cream, to rapidly increase the blood glucose level during a mild hypoglycemic reaction. "I will decrease the amount of fluids I drink when I am sick." During acute illness, the child is prone to hyperglycemia and ketonuria and is at risk for dehydration. Therefore, the child's fluid intake should be increased, rather than decreased.
A nurse is teaching the parent of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?
"I will place my infant's diapers under the harness straps." To prevent soiling of the harness, the parent should apply the infant's diaper under the straps. Wrong "I should apply baby powder to my infant's skin twice daily." MY ANSWER The use of powders and lotions should be avoided during treatment with a Pavlik harness because these products, in combination with the harness, can cause skin irritation and breakdown. "I will need to adjust the straps on the harness once each week." The Pavlik harness is designed to maintain the infant's hips in a position of flexion and abduction. The nurse should instruct the parent not to adjust the harness in any way to avoid complications. "I should remove the harness at night to allow my infant to stretch her legs." The harness is to be worn continuously until the hip is stable, which usually occurs within 6 to 12 weeks. Removing the harness frequently or for long periods of time will reduce the effectiveness of the treatment
A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make?
"Let's talk about some of the ways you have handled previous stressors in your life." MY ANSWER This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation. Wrong "I know how you feel. This is an extremely stressful time for your family." This statement is making artificial consolation. These types of statements do not encourage the parent to express their thoughts, concerns, and fears. "You have to do what you feel is best. Everything will turn out fine." This statement offers false reassurance to the parent, which can invalidate the parent's feelings and cause the parent to become defensive. "It is important that you provide emotional support for your family at this time." This statement tells the parent how to behave, which can make them feel as if they must behave as the nurse does and can lead to dependence.
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by a parent indicates an understanding of the teaching?
"My child will receive antibiotics for several weeks." MY ANSWER The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful. Wrong "My child will receive antibiotics for several weeks." MY ANSWER The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful. "My child can return to playing sports once they have been discharged." Bearing weight should be avoided to prevent complications and minimize pain. Therefore, it will be several weeks to months before the child can play contact sports. "My child needs to be in contact isolation." Contact isolation is not necessary because osteomyelitis is not a communicable illness.
A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include?
"Shake the medication prior to administration."The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension. Wrong "Provide the medication through a straw." The nurse should instruct the parent to put the medication directly in the child's mouth and make sure the child swishes it around before swallowing. "Rinse the child's mouth with water immediately after giving the medication." The nurse should instruct the parent to have the child keep the medication in their mouth for as long as possible before swallowing it. Rinsing the mouth can wash some of the medication away and decrease its effectiveness. "Mix the medication with applesauce if the child dislikes the taste." MY ANSWER The parent should not mix the medication with food because this will interfere with the absorption.
A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" Which of the following responses should the nurse make?
"You can sign the consent form because you are married." MY ANSWER The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age. Wrong "Your spouse should sign the consent form for you." The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of their spouse. "Your parent should sign the consent form for you." The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of a parent. "You can appoint a legal guardian to sign the consent form." The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of a legal guardian.
A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?
"Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating. Wrong "Your daddy will be back at 7 p.m." A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words. "Your daddy will be back after he takes care of your brother." MY ANSWER A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words. Also, this response by the nurse does not relate to the child directly. "Your daddy will be back in the morning." A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words.
A nurse is inspecting the throax of an infant. Which finding should the nurse expect?
A barrel-shaped chest in which the anterior-posterior are equal MY ANSWER A barrel-shaped chest is an expected finding in an infant. As the child grows, the lateral diameter will increase more than the posterior diameter. Wrong Primarily thoracic movement during inspiration In an infant, the nurse should expect to observe primarily abdominal movement with respiration. This finding persists until young school-age when children transition to thoracic respirations. Asymmetrical movement of the chest during respirations Asymmetrical chest movement is an unexpected finding at any age and should be reported to the provider. A chest circumference that is twice the measurement of the head circumference During infancy, the chest and head circumferences should be approximately equal in size.
McBurney's point
A is correct. The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness. Wrong B is incorrect. The nurse should identify this area as the left lower quadrant. Structures of this area of the client's abdomen include the sigmoid colon and part of the descending colon. This area does not contain the appendix, and is therefore not associated with McBurney's point. C is incorrect. The nurse should identify this area as the right upper quadrant. Structures of this area of the client's abdomen include parts of the ascending and transverse colon, liver, and gallbladder. This area does not contain the appendix, and is therefore not associated with McBurney's point.
A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first?
A school-age child who has sickle cell anemia and reports decreased vision in the left eye MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first. Wrong A school-age child who has cystic fibrosis and a frequent nonproductive cough A frequent nonproductive cough is an expected and nonurgent finding for a child who has cystic fibrosis. Therefore, the nurse should see another child first. A preschooler who has asthma and a peak flow meter reading in the green zone A peak flow meter reading in the green zone is an expected and nonurgent finding for a child who has asthma. Therefore, the nurse should see another child first. An adolescent who has meningitis and reports a sensitivity to lights and noise A sensitivity to light and noise is an expected and nonurgent finding for a child who has meningitis. Therefore, the nurse should see another child first.
A school nurse is assessing an adolescent who has scoliosis. Which of the following finding should the nurse expect?
A unilateral rib hump When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature. Wrong Lateral flexion of the neck Lateral flexion of the neck is an indication of torticollis as a result of contracture of the sternocleidomastoid muscle. Torticollis can be congenital, the result of intrauterine fetal posturing or abnormality of the cervical spine, or it can be acquired, due to factors such as a traumatic lesion to the sternocleidomastoid muscle. Increased curvature of the thoracic spine MY ANSWER An increased curvature of the thoracic spine is a manifestation of kyphosis. Kyphosis can be a manifestation of a congenital condition or disease process such as rickets, or it can be posture-related. In posture-related kyphosis, the adolescent presents with rounded shoulders and a slouching posture. Increase in anterior convexity of the lumbar spine An increased anterior convexity of the lumbar spine is a manifestation of lordosis, an expected finding in toddlers. Lordosis can indicate a complication of a disease process, such as flexion contractures, congenital dislocation of the hip, or obesity, when seen in older children.
A nurse is preparing to perform a physical exam on a 10 year old child. Which of the following interventions should the nurse implement?
Explain how the equipment works using correct medical terminology. MY ANSWER School-age children are interested in learning and building language skills. Therefore, the nurse should explain the function of the equipment using correct medical terminology. Wrong Allow the child to touch and play with the equipment. This technique is best used with toddlers, preschoolers, and young school-age children. Play games while performing the physical examination. This technique is best used with toddlers and uncooperative preschoolers because it can help decrease the child's anxiety. Discuss the benefits of performing the examination with the child. This technique is best used with adolescents because discussing the benefits and long-term consequences of the examination requires abstract thinking. This developmental skill does not appear until adolescence.
A nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect?
Abdominal distention MY ANSWER The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness. Wrong Hyperactive bowel sounds Hypoactive bowel sounds are a manifestation of peritonitis. The peritoneal inflammation caused by the feces and bacteria released from the perforated appendix results in the development of an ileus and a decrease in bowel motility. Bradycardia Tachycardia is a manifestation of peritonitis, resulting from infection and fluid shifts within the abdomen, which causes hypovolemia. Bloody stool Bloody stool is a manifestation of Meckel diverticulum, not peritonitis. Diarrhea or constipation can be manifestations of appendicitis.
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?
Absence of peristalsis The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning. Wrong Purulent nasogastric drainage Purulent drainage is not an expected finding following a perforated appendix repair. The nurse should expect brown to green-tinged drainage from the NG tube. Passage of dark red stool with mucus MY ANSWER Passage of dark red stool with mucus is not an expected finding immediately following a perforated appendix repair. The nurse should identify this finding as a manifestation of Meckel diverticulum. WBC count 6,000/mm3 The nurse should expect a WBC count greater than 20,000/mm3 in a client who has had a ruptured appendix.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?
Administer an analgesic to the child. MY ANSWER Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder. Wrong Initiate prophylactic antibiotic therapy for the child. Prophylactic antibiotic therapy is not recommended for children who have burns. Place a mesh gauze dressing over the child's wound. A nurse should apply mesh gauze to the child's wound following hydrotherapy to prevent infection. Apply topical antimicrobial ointment to the child's wound. A nurse should apply topical antimicrobial ointment to the child's wound following hydrotherapy to prevent infection.
A nurse in an emergency department is caring for a school age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
Administer epinephrine IM to the child. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart. Wrong Determine the allergen that caused the child's reaction. Determining the allergen that caused the child's reaction is important to prevent any additional episodes of anaphylaxis. However, it is not the priority action the nurse should take. Insert a large bore IV catheter for the child. Inserting a large bore IV catheter is important to facilitate administration of IV fluids and medications. However, it is not the priority action the nurse should take. Elevate the head of the child's bed. Elevating the head of the child's bed is important to facilitate breathing and circulation. However, it is not the priority action the nurse should take.
A nurse is preparing to administer an immunization to a 4 year old child. Which of the following actions should the nurse plan to take?
Administer the immunization using a 24-gauge needle. MY ANSWER The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences. Wrong Place the child in a prone position for the immunization. The nurse should place the child in an upright sitting position for the immunization because this decreases the child's fear and anxiety. Request that the child's caregiver leave the room during the immunization. The nurse should allow the caregiver to stay near the child during the immunization to provide a sense of security and reduce the child's anxiety level. Inject the immunization slowly after aspirating for 3 seconds. The nurse should inject the immunization rapidly and avoid aspiration. These actions decrease the risk of needle displacement and lower the child's fear and anxiety level by decreasing the amount of time it takes to administer the immunization.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?
Apply topical analgesic cream to the site 1 hr prior to the procedure. MY ANSWER The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted. Wrong Place a cardiac monitor on the adolescent prior to the procedure. Cardiac monitoring is not necessary during a lumbar puncture. Keep the adolescent in a semi-Fowler's position for 4 hr following the procedure. The nurse should place the adolescent in the prone position or flat in bed for up to 12 hr following the procedure to prevent postprocedural spinal headache. Restrict fluids for 2 hr following the procedure. The nurse should encourage the adolescent to drink extra fluids following the procedure to replace the cerebrospinal fluid removed during the procedure.
A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take?
Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling. Wrong Change the child's position every 2 hr. MY ANSWER Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should maintain the child in a supine position. Clean the peripheral pin sites with chlorhexidine solution every 4 days. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery and does not involve the use of pins. A child who requires skeletal traction will require pin site care. Ensure that the head of the bed is elevated to a 90° angle.The nurse should maintain the child in a supine position while in Buck's traction. Elevating the head of bed should be implemented for a child who is in cervical traction.
A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take?
Cleanse the affected area with mild soap and water. The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection. Wrong Insert a nasogastric tube. The nurse should be aware that inserting a nasogastric tube to empty the contents of the stomach and maintain decompression is an intervention for major burn management. Initiate prophylactic antibiotic therapy. MY ANSWER The nurse should be aware that antibiotics are not routinely administered for the prevention of infection at the burn site because the decreased circulation in the burned area decreases the distribution of the medication to the deeper tissues. Apply a topical corticosteroid to the affected area. The nurse should apply an antimicrobial ointment to the affected area to prevent infection.
A nurse is assessing a 4 year old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?
Cuts an outlined shape using scissors The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape. Wrong Identifies right from left handIdentifying the right from left hand is an expected developmental milestone of a 6-year-old child. Uses a utensil to spread butter Using a utensil to spread butter is an expected developmental milestone of a 6-year-old child. Draws a stick figure with seven body parts MY ANSWER Drawing a stick figure with seven body parts is an expected developmental milestone of a 5-year-old child.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?
Epinephrine This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs. Wrong Prednisone Prednisone is an anti-inflammatory agent that can treat severe inflammation. Although it will benefit a child who is having an anaphylactic reaction, it is not the first medication the nurse should administer. Diphenhydramine MY ANSWER Even though histamines are not the major mediators of an anaphylactic reaction, administering an antihistamine such as diphenhydramine can help to decrease the allergic reaction. However, it is not the first medication the nurse should administer. Albuterol Albuterol is a beta adrenergic agonist that can treat acute bronchospasms. Although albuterol will improve the child's breathing, it is not the first medication the nurse should administer.
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?
Denies discomfort during assessment of injuries The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury. wrong Describes strong relationships with peers MY ANSWER The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has withdrawn behavior and poor relationships with peers. Provides a detailed description of how the burns occurred The nurse should suspect child maltreatment in the form of physical abuse if the adolescent's description of the injury is vague and inconsistent with the actual wounds. Expresses a reluctance to leave home The nurse should suspect child maltreatment in the form of physical abuse if the adolescent expresses a reluctance to return home or demonstrates a fear of parents.
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
Dry, hacking coughMY ANSWERThe nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night. Wrong Inflamed throat with exudateThe nurse should identify that an inflamed throat with exudate is a manifestation of acute streptococcal pharyngitis. Purulent eye drainageThe nurse should identify that purulent eye drainage is a manifestation of bacterial conjunctivitis. Koplik spots on buccal mucosaThe nurse should identify that Koplik spots on buccal mucosa are a manifestation of rubeola, or measles.
A nurse is inspecting the skin of a toddler. Which of the following findings should the nurse expect to report to the provider?
Ecchymotic area on the abdomen MY ANSWER Although bruising on the extremities is a common finding in children, bruising in other areas, such as the abdomen, should be investigated to determine the cause. Therefore, the nurse should report this finding to the provider. Wrong Mongolian spot across the buttocks Mongolian spots are a variation of skin coloring commonly present on the skin of toddlers from some ethnic backgrounds. This is an expected finding for a toddler. Telangiectatic nevi on the back of the neck Telangiectatic nevi are commonly referred to as stork bites. They are flat and deep pink in coloring and are most commonly observed on the face and head. They are an expected finding for a toddler. Presence of fine hair on the lower arms and legs Fine hair on the arms and legs is an expected finding for a toddler.
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. Wrong Laryngeal edema Laryngeal edema is an indication of an allergic reaction to the blood transfusion. Distended neck veins Distended neck veins are an indication of circulatory overload, which is a complication of a blood transfusion. Muscular weakness MY ANSWER Muscle weakness is an indication of an electrolyte disturbance, which is a complication of a blood transfusion.
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take?
Give morphine 0.05 mg/kg IV. MY ANSWER A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief. Wrong Instill a 500 mL tap water enema. Administering an enema accelerates bowel motility and increases the risk for perforation of the appendix. Administer polyethylene glycol 1g/kg PO. Administering laxatives accelerates bowel motility and increases the risk for perforation of the appendix. Apply a heating pad to the child's abdomen. Applying heat to the child's abdomen increases the risk for perforation of the appendix.
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for a infection control?
Have a designated stethoscope in the infant's room. MY ANSWER The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room. Wrong Have a designated stethoscope in the infant's room. MY ANSWER The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room. Administer palivizumab as prescribed for the infant. Palivizumab is used for prophylaxis in at-risk infants and is not used in the treatment of RSV. Remove gloves after leaving the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. To reduce the risk of transmission, all health care personnel should remove their gloves prior to leaving the infant's room.
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?
Hematocrit 28% MY ANSWER The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity. Wrong Hemoglobin 13.5 g/dL This hemoglobin level is within the expected reference range of 9.5 to 14 g/dL for a school-age child. WBC count 8,000/mm3 This WBC count is within the expected reference range of 5,000 to 10,000/mm3 for a school-age child. Platelets 250,000/mm3 This platelet count is within with expected reference range of 150,000 to 400,000/mm3 for a school-age child.
A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?
Hgb 8.5 g/dL MY ANSWER A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider. Wrong WBC count 9,500/mm3 A child receiving chemotherapy is at risk for infection due to the myelosuppressing effects of the medication used to treat the cancer. The presence of infection can be evaluated through body temperature, redness, edema, warmth, or drainage of wound or IV sites, as well as through measurements of WBC and absolute neutrophil counts. A WBC count of 9,500/mm3 is within the expected reference range of 5,000 to 10,000/mm3 for a 7-year-old child. WBC count 9,500/mm3 A child receiving chemotherapy is at risk for infection due to the myelosuppressing effects of the medication used to treat the cancer. The presence of infection can be evaluated through body temperature, redness, edema, warmth, or drainage of wound or IV sites, as well as through measurements of WBC and absolute neutrophil counts. A WBC count of 9,500/mm3 is within the expected reference range of 5,000 to 10,000/mm3 for a 7-year-old child. Platelets 300,000/mm3 A child receiving chemotherapy is at risk for hemorrhage due to the thrombocytopenic effects of the medications used to treat cancer. The development of thrombocytopenia is diagnosed through laboratory testing of platelet levels. A platelet count of 300,000/mm3 is within the expected reference range of 150,000 to 400,000/mm3 for a 7-year-old child.
A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan?
Implement seizure precautions for the infant. An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child. Wrong Suction the infant's nares to remove secretions. The nurse should avoid suctioning the infant's nares due to the risk of exposure of the suction catheter to the brain through the fracture; however, oral suctioning can be performed. Perform a neurological assessment every 4 hr. MY ANSWER The nurse should perform a neurological assessment as frequently as every 15 min to detect changes in the child's condition and monitor for intracranial pressure. Position the infant side-lying with their head at a 0° to 5° angle.The nurse should position the infant with their head slightly elevated in a midline position to reduce the risk of increased intracranial pressure.
A nurse is reviewing the lumbar puncture results of a school age child suspected of having bacterial meningitis. which of the following results should the nurse identify as a finding associated with bacterial meningitis?
Increased protein concentration MY ANSWER The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis. Decreased cerebrospinal fluid pressureIncreased cerebrospinal fluid pressure is a finding associated with bacterial meningitis. Decreased WBC countAn increased WBC count in the spinal fluid is a finding associated with bacterial meningitis. Increased glucose level A decreased glucose level in the spinal fluid is a finding associated with bacterial meningitis.
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
Initiate droplet precautions for the child. MY ANSWER The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks. Wrong Initiate contact precautions for the child. The nurse should initiate contact precautions for a child who has an illness that can be transmitted by direct contact or contact with the child's items, such as hepatitis A and rotavirus. Place the child in a room with negative-pressure airflow. The nurse should place a child who has an airborne infection, such as measles or varicella, into a room with negative-pressure airflow. Place the child in a room with positive-pressure airflow. The nurse should place a child who has undergone an allogeneic hematopoietic stem cell transplant in a room with positive-pressure airflow to reduce the risk of disease transmission to the child.
A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?
Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider. Wrong Reports a headache as 6 on a 0 to 10 pain scale Headache is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report. Nuchal rigidity MY ANSWER Nuchal rigidity is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report. Positive Kernig's sign Positive Kernig's sign is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 meq/L. Which of the following interventions should the nurse include in the plan?
Initiate seizure precautions for the child. MY ANSWER A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety. Wrong Weigh the child weekly at various times of the day. In the oliguric phase of AKI, the child will have decreased urine output and fluid retention. This can result in water intoxication, which predisposes the child to neurologic alterations such as seizures. To ensure accurate evaluation of fluid balance, the nurse should plan to weigh the child daily, at the same time, in the same clothing, and using the same scale. Assess the child's blood pressure every 8 hr. A child who has AKI is often hypertensive due to fluid volume excess and the activation of the renin-angiotensin system. To prevent complications, such as hypertensive encephalopathy, the nurse should assess the child. Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F). A child who has AKI can develop a fever due to an infection. Because AKI is a contraindication for receiving medications that are nephrotoxic, such as NSAIDs, the nurse should use compensatory measures, such as turning on a fan in the room.
A nurse is performing a cardiac assessment on a preschooler. The nurse should plan to auscultate the apical pulse at which of the following precordial landmarks?
Left of the midclavicular line at the fourth intercostal space MY ANSWER This is the site where the mitral valve is best auscultated in children who are younger than 7 years old. Therefore, the nurse should plan auscultate the child's apical pulse at this site. Wrong At the second intercostal space, to the right of the sternum This site is where the nurse can best auscultate sounds from the pulmonic valve. Along the sternal border at the third intercostal space This site is where murmurs are best auscultated. It is also referred to as Erb's point. At the fifth intercostal space, left of the midclavicular line This is the site where the mitral valve is best auscultated in children who are older than 7 years old. The nurse should use this site to auscultate the apical pulse in an older child.
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
Loud, harsh murmur The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle. Wrong Dysrhythmias Ventricular septal defect does not affect the electrical conduction of the heart. Therefore, the nurse should not expect to hear dysrhythmias when assessing this infant. eak femoral pulses MY ANSWER The nurse should expect weak femoral pulses when assessing an infant who has coarctation of the aorta. High blood pressure The nurse should expect an elevated blood pressure when assessing an infant who has coarctation of the aorta.
A nurse is caring for a 15 year old client following a head injury. Which of the following should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
Mental confusion A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur. Wrong Sodium 148 mEq/LMY ANSWERA sodium level of 148 mEq/L is above the expected reference range of 136 to 145 mEq/L. SIADH is caused by the secretion of excess antidiuretic hormone, which results in a decreased serum sodium level due to increased circulation of free water. Urine specific gravity 1.020 A urine specific gravity of 1.020 is within the expected reference range of 1.005 to 1.030. A child who has SIADH is more likely to have concentrated urine and urine specific gravity above the expected reference range. Weak peripheral pulses A child who has SIADH is more likely to have fluid overload, full, bounding pulses, increased blood pressure, and tachycardia.
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all the apply)
Negative Babinski reflex is incorrect. The nurse should expect a child who has spastic cerebral palsy to exhibit a positive Babinski reflex. Ankle clonus is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed. Exaggerated stretch reflexes is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes. Uncontrollable movements of the face is incorrect. The nurse should expect a child who has nonspastic (dyskinetic) cerebral palsy, rather than spastic (pyramidal) cerebral palsy to exhibit uncontrollable movements of the face and extremities. Contractures is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles.
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?
Oral rehydration solution MY ANSWER A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration. Wrong
A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the following actions should the nurse plant to take?
Perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease. Wrong Obtain a sputum specimen. Sputum specimens are collected to identify the infectious organism in a child who has an acute respiratory tract infection. Therefore, this is not a component of the sickle-turbidity test. Perform an Allen test. MY ANSWER An Allen test determines adequate circulation by observing capillary refill before an arterial puncture. Therefore, this is not a component of the sickle-turbidity test. btain a stool specimen. Stool specimens are collected to identify organisms or parasites that cause diarrhea or to check for the presence of occult blood. Therefore, this is not a component of the sickle-turbidity test.
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?
Place the child in a side-lying position. MY ANSWER The nurse should place the child in a side-lying position to prevent aspiration. Wrong Delay documentation until the child is fully alert. To ensure accurate description of the event, the nurse should document the treatment of the seizure and the postictal period as early as possible. Give the child a high-carbohydrate snack. The child should not be given any foods or liquids until protective reflexes have returned to prevent aspiration. Administer an oral sedative to the child. The child should not be given anything by mouth until protective reflexes have returned to prevent aspiration.
A nurse is preparing to obtain a temperature on an 18 month toddler during a well child exam. Which of the following actions should the nurse take?
Place the thermometer tip in the center of the toddler's axilla against their skin. MY ANSWER The nurse should us the axillary method to obtain a young child's temperature during a screening assessment. Wrong Pull the pinna up and back before placing the tympanic thermometer in the ear canal. A tympanic thermometer should not be used to assess the temperature of a child who is younger than 2 years old due to the small size of the ear canal. Insert the lubricated tip of a rectal electronic thermometer 2.5 cm (1 inch) into the toddler's rectum. Rectal temperature assessment is invasive and upsetting to young children. Therefore, the nurse should not use this method for routine screening. Place the tip of the oral electronic thermometer under the toddler's tongue in a posterior sublingual pocket. The nurse should not use an oral electronic thermometer to assess a toddler's temperature because children younger than 5 years old have difficulty holding the temperature probe under their tongue.
A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
Playing dress-up MY ANSWER The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child. Wrong Creating a scrapbook Creating a scrapbook is a recommended play activity for a school-age child. Using a push-pull toy Using a push-pull toy is a recommended play activity for a toddler. Playing pat-a-cake Playing pat-a-cake is a recommended play activity for an infant.
A nurse is assessing the reflexes of a 6-month old infant. Which of the following reflex findings should the nurse expect?
Positive Babinski reflex MY ANSWER The Babinski reflex is elicited by stroking up the side of the foot and across the ball of the foot. A positive Babinski reflex is present when this action causes the toes to fan outwards. This is an expected finding through the first year of life, after which it begins to fade. Wrong Positive extrusion reflex The extrusion reflex is elicited when the infant's tongue is depressed or touched. A positive extrusion reflex is present when the infant responds by forcing their tongue outwards. This reflex should disappear by 4 months of age. Negative plantar grasp reflex The plantar grasp reflex is elicited by touching the foot at the base of the toes. A positive plantar grasp reflex is present when the toes curl downwards in response to this action. This is an expected finding in a 6-month-old infant. Negative sucking reflex The sucking reflex is elicited by touching the lips. A positive sucking reflex is present when the infant responds to the touch with strong sucking movements if the circumoral area. This is an expected finding throughout the first year of life.
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?
Provide small, frequent meals for the child. MY ANSWER The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy. Wrong Schedule time in the play room for the child.The nurse should restrict play activities to the child's bed to minimize energy expenditure. Weigh the child weekly. The nurse should weigh the child daily. Maintain the child in a supine position. To provide for maximum chest expansion, the nurse should maintain the child's bed in a semi-Fowler's position.
A nurse is assessing a 3 year old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?
Respiratory rate 45/minThe nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider. Wrong Blood pressure 90/50 mm Hg The nurse should identify that a blood pressure of 90/50 mm Hg is within the expected reference range of 86 to 118 mm Hg systolic and 44 to 74 mm Hg diastolic for a 3-year-old toddler. Weight 14.5 kg (32 lb) MY ANSWER The nurse should identify that a weight of 14.5 kg (32 lb) is the average weight for a 3-year-old toddler. Heart rate 110/min The nurse should identify that a heart rate of 110/min is within the expected reference range of 80 to 120/min for a 3-year-old toddler.
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?
Schedule the toddler for a yearly rescreening. The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure. Wrong Refer the family to Child Protective Services. A serum lead level of 4 mcg/dL does not require a report to Child Protective Services because it is not an indicator of child endangerment. Prepare the toddler for chelation therapy. MY ANSWER Chelation therapy is required for a lead level of 45 mcg/dL or greater and, depending on the situation, can be initiated for lead levels over 10 mcg/dL. Instruct the parents to decrease the calcium in their toddler's diet. The nurse should instruct the toddler's parents to provide a diet rich in calcium because calcium, vitamin C, and iron decrease lead absorption.
A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
Screen the child's visitors for indications of infection. MY ANSWER A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection. Wrong Use surgical asepsis when providing routine care for the child. It is not necessary for the nurse to use surgical asepsis when providing direct care. Strict hand hygiene and medical asepsis are recommended to prevent the spread of infection. Administer the measles, mumps, and rubella (MMR) vaccine to the child. The MMR vaccine is contraindicated for a child who is severely immunocompromised because it is a live virus vaccine and the child might not be able to build adequate antibodies to prevent infection with the organism. Infuse packed RBCs. A child who is immunocompromised as a result of chemotherapy will have a decreased neutrophil count. The nurse should plan to infuse packed RBCs for the child who is anemic. However, packed RBCs will not increase the child's neutrophil count.
A nurse is obtaining the blood pressure of a school-aged child. Which of the following actions should the nurse take?
Select a cuff width that covers 40% of the upper arm. MY ANSWER Using a blood pressure cuff that is too large or too small will lead to inaccurate blood pressure measurement. Therefore, the nurse should inspect the limb size of the child and choose a cuff which covers 40% of the upper arm circumference. Wrong Ensure the cuff bladder encircles 50% of the extremity. The cuff bladder length should encircle 80 to 100% of the upper arm. Release the cuff pressure at a rate of 4 to 5 mm Hg per second. The cuff pressure should be released at a rate of 2 to 3 mm Hg per second. Position the arm at the level of the umbilicus while the child is sitting in a chair. The arm should be positioned and supported with the cubital fossa at the level of the heart.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?
Serum creatinine 3.0 mg/dL MY ANSWER Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney. Wrong Negative leukocyte esterase The nurse should identify that a negative leukocyte esterase level is an expected finding and indicates that the adolescent does not have a urinary tract infection. A negative leukocyte esterase does not indicate rejection of the kidney. Negative urine protein The nurse should identify that a negative urine protein is an expected finding and does not indicate rejection of the kidney. Urine output 40 mL/hr The nurse should identify that a urine output of 40 mL/hr is within the average hourly urine output of 33 to 62.5 mL/hr for an adolescent and does not indicate rejection of the kidney.
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?
Sodium 140 mEq/L MY ANSWER The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective. Wrong Potassium 2.9 mEq/L A potassium level of 2.9 mEq/L is below the expected reference range of 4.1 to 5.3 mEq/L and indicates hypokalemia. Urine specific gravity 1.035 A urine specific gravity of 1.035 is above the expected reference range of 1.005 to 1.030 and indicates concentrated urine. BUN 25 mg/dL A BUN level of 25 mg/dL is above the expected reference range of 5 to 18 mg/dL and indicates the kidneys are not excreting BUN as they should be.
The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the inter professional team should the nurse initiate a referral?
Speech therapist MY ANSWER The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation. Wrong Occupational therapist The nurse should initiate a referral for an occupational therapist for a child who has physical disabilities and requires assistance with ADLs. Respiratory therapist The nurse should initiate a referral for a respiratory therapist for a child who requires airway support. Physical therapist The nurse should initiate a referral for a physical therapist for a child who requires assistance with mobility and increasing physical strength.
A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?
Substernal retractions MY ANSWER When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure. Wrong Depressed posterior fontanel The nurse should report a depressed posterior fontanel to the provider. However, there is another finding that is the nurse's priority to report. Multiple capillary hemangiomas The nurse should report the presence of multiple capillary hemangiomas to the provider. However, there is another finding that is the nurse's priority to report. Excoriated scrotal area The nurse should report an excoriated scrotal area to the provider. However, there is another finding that is the nurse's priority to report.
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?
Symmetric burns of the lower extremities MY ANSWER The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron. Wrong Recurrent urinary tract infections Recurrent urinary tract infections are a clinical manifestation that can indicate sexual abuse. Failure to thrive Failure to thrive can be an indication of physical neglect due to malnutrition. Lack of subcutaneous fat Lack of subcutaneous fat can be an indication of physical neglect. This manifestation can be a result of poor health care, infections that were untreated, and/or a lack of or delayed childhood immunizations.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify which of the following sounds?
Tachypnea MY ANSWER The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia. Cheyne-Stokes respiration The nurse should identify Cheyne-Stokes respirations as periods of apnea alternating with periods of hyperventilation. Biot respiration The nurse should identify Biot respirations as periods of apnea alternating with breaths of increased but consistent depth. Biot respiration The nurse should identify Biot respirations as periods of apnea alternating with breaths of increased but consistent depth. Bradypnea The nurse should identify bradypnea as a slow, regular breathing pattern.
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?
Tachypnea When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis. Wrong Hyperpyrexia Toddlers who have gastroenteritis and are dehydrated can exhibit hyperpyrexia, or fever, which is caused by the effect of fluid volume depletion on the hypothalamus. However, there is another finding that is the nurse's priority. Hypotension MY ANSWER Toddlers who have gastroenteritis and are dehydrated can exhibit hypotension because of reduced blood volume. However, there is another finding that is the nurse's priority. Skin breakdown Toddlers who have gastroenteritis and are dehydrated are at increased risk for skin breakdown because of changes in circulation and loss of skin elasticity. However, there is another finding that is the nurse's priority.
A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock?
Temperature 39.1° C (102.4° F) MY ANSWER The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills. Wrong Heart rate 60/min A heart rate of 60/min is within the expected reference range of 60 to 100/min when awake and 50 to 90/min when sleeping for a 10-year-old child. The nurse should expect a child who has early septic shock to have a heart rate above the expected reference range. Blood pressure 130/90 mm Hg A blood pressure of 130/90 mm Hg is above the expected reference range of 97 to 128 mm Hg systolic and 58 to 88 mm Hg diastolic for a 10-year-old child. The nurse should expect a child who has early septic shock to have a blood pressure within the expected reference range. Urinary output 100 mL/hr Urinary output of 100 mL/hr is above the expected reference range of 33 to 58 mL/hr for a 10-year-old child. The nurse should expect a child who has early septic shock to have urinary output within the expected reference range.
A nurse is performing an annual physical exam on an adolescent. Which of the following should the nurse include in the general survey?
The adolescent makes good eye contact. MY ANSWER The nurse should include this information in the general survey. The general survey includes identifying the client's demeanor, mood, and interactions with others. Wrong The adolescent demonstrates fine motor coordination Fine motor coordination, such as moving the fingers rapidly to each touch the thumb, is examined during a neurologic examination. The adolescent is able to read small print at a distance of 14 inches. Visual acuity is examined during an eye examination. The adolescent's deep tendon reflexes are 2+ bilaterally. Deep tendon reflexes are examined during a neurologic examination.
A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?
The toddler received tobramycin during a hospitalization 2 weeks ago. The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment. Wrong The toddler has a vocabulary of 25 words. At the age of 18 months, the toddler should have a vocabulary of at least 10 words. Therefore, a vocabulary of 25 words does not indicate a need to assess the toddler for hearing loss. The toddler developed a mild rash following a recent varicella immunization. Approximately one in 25 people develop a mild rash following administration of the varicella vaccine. This reaction does not indicate a need to assess the toddler for hearing loss. The toddler's Moro reflex is absent. MY ANSWER Primitive reflexes, such as Moro, rooting, and tonic neck, disappear by 5 months of age. Therefore, an absent Moro reflex does not indicate a need to assess the toddler for hearing loss.
A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?
White rice MY ANSWER The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease. Wrong Wheat crackers Wheat crackers contain gluten and should be avoided by children who have celiac disease. Rye bread Rye bread contains gluten and should be avoided by children who have celiac disease. Barley soup Barley soup contains gluten and should be avoided by children who have celiac disease.
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area.
Zinc oxide MY ANSWER Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal. Wrong Antibiotic ointment Diaper dermatitis can be the result of an overgrowth of yeast, such as Candida albicans, on the skin. Treatment for yeast-related dermatitis includes a topical antifungal medication. However, antibiotic ointment is not recommended for the treatment of diaper dermatitis. Talcum powder Diaper dermatitis can be treated with several different products at the same time, including a protective ointment and a protective powder, such as a powder made with karaya or cornstarch. However, talcum powder is not recommended for the treatment of diaper dermatitis because it has been linked to respiratory disorders in infants. Antiseptic solution Infants who have diaper dermatitis should have the affected areas gently washed with water and a mild soap. Antiseptic solution is not recommended because this can cause burning and pain to the infant.