Peds 1
Nurse in ED is performing physical assessment on 2 week old male newborn. Which findings is priority for nurse to report to HCP? Excoriated scrotal area Multiple capillary hemangiomas Depressed posterior fontanel Substernal retractions
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. 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. 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. ANS: Substernal retractions: - When using the ABC 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.
Nurse is planning care for toddler with serum lead 4 mcg/dL. Which actions should the nurse plan to take? Instruct the parents to decrease the calcium in their toddler's diet. Prepare the toddler for chelation therapy. Refer the family to Child Protective Services. Schedule the toddler for a yearly rescreening.
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. Prepare the toddler for chelation therapy: - 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. Refer the family to Child Protective Services: - A serum lead level of 4 mcg/dL does not require a report to CPS bc it is not an indicator of child endangerment. ANS: 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.
Nurse teaching parents of infant with Pavlik harness for tx of hip dysplasia. Nurse should ID which statements by parent indicating understanding of teaching? "I should remove the harness at night to allow my infant to stretch her legs." "I will need to adjust the straps on the harness once each week." "I should apply baby powder to my infant's skin twice daily." "I will place my infant's diapers under the harness straps."
"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. "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 apply baby powder to my infant's skin twice daily.": - 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. ANS: "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.
Nurse is teaching school age child with new dx of T1DM. Which statements by child indicates an understanding of teaching? "I will puncture the pad of my finger when I am testing my blood glucose." "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." "I will decrease the amount of fluids I drink when I am sick."
"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. ANS: "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. "I will eat a snack of 5 grams of carbohydrates if my BG is low.": - 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 BG 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.
Nurse auscultates lungs of adolescent with asthma. Nurse should ID sound as what? Biot respiration Cheyne-Stokes resp Tachypnea Bradypnea
Biot respiration: - periods of apnea alternating with breaths of increased but consistent depth. Cheyne-Stokes respiration: - periods of apnea alternating with periods of hyperventilation. ANS: Tachypnea: - a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia. Bradypnea: - slow, regular breathing pattern.
Nurse cares for preschooler receiving IV fluids via peripheral IV catheter. When preparing to discontinue IV fluids and catheter, which actions should the nurse plan to take?
First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.
Nurse in ugent care clinic is assessing adolescent with URTI. Which findings should the nurse ID as manifestation of pertussis? Inflamed throat with exudate Purulent eye drainage Dry, hacking cough Koplik spots on buccal mucosa
Inflamed throat with exudate: - a manifestation of acute streptococcal pharyngitis. Purulent eye drainage: - a manifestation of bacterial conjunctivitis. ANS: Dry, hacking cough: - The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an URTI, which includes a dry, hacking cough that is sometimes more severe at night. Koplik spots on buccal mucosa: - a manifestation of rubeola, or measles.
Nurse caring for school age child receiving blood transfusion. Which manifestation should alert the nurse to possible hemolytic transfusion reaction? Laryngeal edema Flank pain Distended neck veins Muscle weakness
Laryngeal edema: - an indication of an allergic reaction to the blood transfusion. ANS: 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. Distended neck veins: - an indication of circulatory overload, which is a complication of a blood transfusion. Muscular weakness: - an indication of an electrolyte disturbance, which is a complication of a blood transfusion.
Nurse is providing teaching about play activities for social development to parents of preschooler. Which play activities should nurse recommend for child? Playing pat-a-cake Using a push-pull toy Creating a scrapbook Playing dress-up
Playing pat-a-cake: - a recommended play activity for an infant. Using a push-pull toy: - a recommended play activity for a toddler. Creating a scrapbook: - a recommended play activity for a school-age child. ANS: Playing dress-up: - 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.
Nurse assesses school age child with meningitis. Which findings is priority for the nurse to report to HCP? Reports a headache as 6 on a 0 to 10 pain scale Petechiae on the lower extremities Nuchal rigidity Positive Kernig's sign
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. ANS: 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. Nuchal rigidity: - an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report. Positive Kernig's sign: - an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report.
Nurse caring for adolescent with severe abd. pain due to appendicitis. Which location should the nurse ID 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.
Nurse reviews lumbar puncture results of school-age child with suspected bacterial meningitis. Which findings should the nurse ID as an indication of bacterial meningitis? Decreased cerebrospinal fluid pressure Decreased WBC count Increased protein concentration Increased glucose level
Decreased cerebrospinal fluid pressure: - Increased cerebrospinal fluid pressure is a finding associated with bacterial meningitis. Decreased WBC count: - An increased WBC count in the spinal fluid is a finding associated with bacterial meningitis. ANS: Increased protein concentration: - The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis. Increased glucose level: - A decreased glucose level in the spinal fluid is a finding associated with bacterial meningitis.
Nurse cares for preschooler whose father is going home for a few hours while another relative stays with child. Which statements should the nurse make to explain to child when their father will return? "Your daddy will be back at 7 p.m." "Your daddy will be back after he takes care of your brother." "Your daddy will be back in the morning." "Your daddy will be back after you eat."
"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.": - *, Also, this response by the nurse does not relate to the child directly. "Your daddy will be back in the morning.": - * ANS: "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.
Nurse assesses 3 y/o toddler at a well-child visit. Which manifestations should the nurse report to HCP? BP 90/50 RR 45/min Weight 14.5 (32 lbs) HR 110/min
Blood pressure 90/50 mm Hg: - 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. ANS: Respiratory rate 45/min: - 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. Weight 14.5 kg (32 lb): - average weight for a 3-year-old toddler. Heart rate 110/min: - within the expected reference range of 80 to 120/min for a 3-year-old toddler.
Nurse assesses school age child with peritonitis. Which findings should the nurse expect? Hyperactive bowel sounds Abdominal distention Bradycardia Bloody stool
Hyperactive bowel sounds: - Hypoactive BS = 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. ANS: Abdominal distention: - 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. 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.
Nurse reviews lab report of an infant receiving tx for servere dehydration. Nurse should ID that which lab value indicates effectiveness of current Tx? Potassium 2.9 mEq/L Sodium 140 mEq/L Urine specific gravity 1.035 BUN 25 mg/dL
Potassium 2.9 mEq/L: - below the expected reference range of 4.1 to 5.3 mEq/L and indicates hypokalemia. ANS: Sodium 140 mEq/L: - 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. Urine specific gravity 1.035: - above the expected reference range of 1.005 to 1.030 and indicates concentrated urine. BUN 25 mg/dL: - above the expected reference range of 5 to 18 mg/dL and indicates the kidneys are not excreting BUN as they should be.
Nurse provides dietary teaching to parent of school age child with celiac disease. Nurse should recommend parent offer which foods to child? Wheat crackers Rye bread Barley soup White rice
Wheat crackers: - contain gluten and *should be avoided by children who have celiac disease. Rye bread: - Rye bread contains gluten * Barley soup: - Barley soup contains gluten * ANS: White rice: - 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.
Nurse teaches parent of preschooler about ways to prevent acute asthma attacks. Which statements by parent indicates understanding of teaching? "I will use a humidifier in my child's room at night." "I will give my child a cough suppressant every 6 hours if he has a cough." "I should avoid using a wet mop on my floors when I am cleaning." "I should keep my child indoors when I mow the yard."
"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. "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 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. ANS: "I should keep my child indoors when I mow the yard.": - 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.
Nurse cares for preschooler scheduled for hydrotherapy tx for wound debridement following burn injury. Which actions should the nurse take prior to procedure? Apply topical antimicrobial ointment to the child's wound. Place a mesh gauze dressing over the child's wound. Administer an analgesic to the child. Initiate prophylactic antibiotic therapy for the child.
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. 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. ANS: Administer an analgesic to the child: - 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. Initiate prophylactic antibiotic therapy for the child: - Prophylactic antibiotic therapy is not recommended for children who have burns.
Nurse in ED is caring for school age child experiencing anaphylacitic reaction. Which priority action should be done by the nurse? Elevate the head of the child's bed. Insert a large bore IV catheter for the child. Determine the allergen that caused the child's reaction. Administer epinephrine IM to the child.
Elevate the head of the child's bed: - important to facilitate breathing and circulation. However, it is not the priority action the nurse should take. Insert a large bore IV catheter for the child: - important to facilitate admin of IV fluids and med. However, it is not the priority action the nurse should take. Determine the allergen that caused the child's reaction: - important to prevent any additional episodes of anaphylaxis. However, it is not the priority action the nurse should take. ANS: 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.
Nurse is preparing to collect sample from toddler for sickle-turbidity test. Which actions should the nurse plan to take? Obtain a sputum specimen. Perform an Allen test. Perform a finger stick. Obtain a stool specimen
Obtain a sputum specimen: - to identify the infectious organism in a child who has an acute resp tract infection. Therefore, this is not a component of the sickle-turbidity test. Perform 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. ANS: 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. Obtain 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.
Nurse teaches parent of school age child with new prescription for oral nystatin for tx of oral candidiasis. Which instructions should the nurse include? "Shake the medication prior to administration." "Provide the medication through a straw." "Rinse the child's mouth with water immediately after giving the medication." "Mix the medication with applesauce if the child dislikes the taste."
ANS: "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. "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.": - The parent should not mix the medication with food because this will interfere with the absorption.
Nurse cares for adolescent who received kidney transplant. Which findings should the nurse ID as indication adolescent is rejecting the kidney? Negative leukocyte esterase Serum creatinine 3.0 mg/dL Negative urine protein Urine output 40 mL/hr
Negative leukocyte esterase: - an expected finding and indicates that the adolescent does not have a UTI. A negative leukocyte esterase does not indicate rejection of the kidney. ANS: Serum creatinine 3.0 mg/dL: - 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. Negative urine protein: - an expected finding and does not indicate rejection of the kidney. Urine output 40 mL/hr: - within the average hourly UO of 33 to 62.5 mL/hr for an adolescent and does not indicate rejection of the kidney.
Nurse teaches parents of school age child with new Dx of osteomyelitis of tibia. Which statements by parent indicates an understanding of teaching? "My child will have a cast until healing is complete." "My child will receive antibiotics for several weeks." "My child can return to playing sports once they have been discharged." "My child needs to be in contact isolation."
"My child will have a cast until healing is complete.": - Bearing weight must be avoided with osteomyelitis. Therefore, the child should be placed in a comfortable position with the limb supported. There is no indication for a cast. ANS: "My child will receive antibiotics for several weeks.": - 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.
Nurse caring for school age child experienced a tonic-clonic seizure. Which actions should the nurse take during the immediate postictal period? Place the child in a side-lying position. Delay documentation until the child is fully alert. Give the child a high-carbohydrate snack. Administer an oral sedative to the child.
ANS: Place the child in a side-lying position: - The nurse should place the child in a side-lying position to prevent aspiration. 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.
Nurse caring for toddler experiencing acute diarrhea and moderate dehydration. Which nutritional items should the nurse offer to toddler? Apple juice Peanut butter Chicken broth Oral rehydration solution
Apple juice: - A toddler who has acute diarrhea should not drink apple juice because it is high in carbohydrates and osmolarity and low in electrolytes. Peanut butter: - A toddler who has acute diarrhea should not eat peanut butter because it is high in carbohydrates and fiber. The high sugar content can result in prolonging the diarrhea and worsening of the dehydration, because water is pulled into the bowel lumen in response to the increased osmolality caused by the sugar. The fiber content further stimulates the bowel, worsening the diarrhea. Chicken broth: - A toddler who has acute diarrhea should not consume chicken broth because it is high in sodium and is not nutrient-dense. ANS: Oral rehydration solution: - 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.
Nurse teaches the guardian of 6 month/old infant about care seat use. Which statements by guardian indicates understanding of teaching? "I should secure the car seat using lower anchors and tethers instead of the seat belt." "I should position the car seat harness 1 inch above my baby's shoulders." "I will make sure that the car seat is placed at a 90-degree angle." "I will pad my baby's car seat with a blanket for traveling long distances."
ANS: "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. "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." - 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.
Nurse reviews lab report of 7 y/o receiving chemo. Which lab result should the nurse report to provider? Hgb 8.5 g/dL WBC count 9,500/mm3 Prealbumin 18 mg/dL Platelets 300,000/mm3
ANS: Hgb 8.5 g/dL: - A child receiving chemotherapy is at risk for anemia due to the chemo effects on the blood-forming cells of the bone marrow. The development of anemia is Dx through lab testing of Hb and Hct levels. The nurse should recognize that a Hb 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. 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 ANC. 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. Prealbumin 18 mg/dL: - A child receiving chemo is at risk for malnutrition as a result of N/V, stomatitis, and pain. Nutritional status can be evaluated through prealbumin, albumin, and transferrin levels. A prealbumin level of 18 mg/dL is within the expected reference range of 15 to 33 mg/dL for a 7-year-old child. Platelets 300,000/mm3: - A child receiving chemo 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.
Nurse in provider's office prepares to admin immunizations to toddler during well-child visit. Which actions should the nurse plan to take? Exhibit: Tuberculin skin test (TST), Measles, mumps, and rubella (MMR) vaccine, Inactivated influenza vaccine, Diphtheria, tetanus, and pertussis (DTaP) vaccine, RR 24/min, HR 115/min, Temp 36.9° C (98.4° F), Age 15 months, Height 71.1 cm (28 in), Allergies Neomycin (anaphylactic reaction), Caregiver reports rhinitis with clear nasal drainage for 2 days, Occasional nonproductive cough for 2 days, History of asthma Withhold the measles, mumps, and rubella (MMR) vaccine. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine. Withhold the influenza vaccine. Withhold the tuberculin skin test (TST).
ANS: Withhold the measles, mumps, and rubella (MMR) vaccine: - The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine: - It is safe to administer the DTaP vaccine at the same time as the MMR vaccine and tuberculin skin test (TST). DTaP vaccines are not contraindicated for children who have mild acute illness or asthma. Withhold the influenza vaccine: - A child who has asthma can receive the inactivated influenza vaccine. Withhold the tuberculin skin test (TST): - It is safe to perform a TST at the same time as administering MMR and varicella vaccines. A TST is not contraindicated for children who have mild acute illness or asthma.
Nurse in ED is caring for school age child with appendicitis and rates abd. pain 7/10. Which actions should the nurse take? Instill a 500 mL tap water enema. Give morphine 0.05 mg/kg IV. Administer polyethylene glycol 1g/kg PO. Apply a heating pad to the child's abdomen.
Instill a 500 mL tap water enema: - Administering an enema accelerates bowel motility and increases the risk for perforation of the appendix. ANS: Give morphine 0.05 mg/kg IV: - 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. 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.
Charge nurse in ED is preparing an inservice for a group of newly licensed nurses about manifestations for child maltreatment. Which manifestations should the charge nurse include as potential indications of physical abuse? Recurrent urinary tract infections Symmetric burns of the lower extremities Failure to thrive Lack of subcutaneous fat
Recurrent UTI: - Recurrent UTIs are a clinical manifestation that can indicate sexual abuse. ANS: Symmetric burns of 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. Failure to thrive: - indication of physical neglect due to malnutrition. Lack of subcutaneous fat: - 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.
Nurse assessing toddler with gastroenteritis and exhibits manifestations of dehydration. Which findings is the nurse's priority? Skin breakdown Hypotension Hyperpyrexia Tachypnea
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. Hypotension: - 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. 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. ANS: Tachypnea: - When using the ABC 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.
Nurse caring for 15 y/o client following head injury. Which findings should the nurse ID as indication that child's developing SIADH? Sodium 148 mEq/L Urine specific gravity 1.020 Mental confusion Weak peripheral pulses
Sodium 148 mEq/L: - 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: - 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. ANS: 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 UO, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur. Weak peripheral pulses: - A child who has SIADH is more likely to have fluid overload, full, bounding pulses, increased blood pressure, and tachycardia.
Nurse interviews parent of 18 month old toddler during well-child visit. Nurse should ID which findings that indicates a need to assess toddler for hearing loss? The toddler has a vocabulary of 25 words. The toddler developed a mild rash following a recent varicella immunization. The toddler's Moro reflex is absent. The toddler received tobramycin during a hospitalization 2 weeks ago.
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: - 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. ANS: 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.
Nurse assesses 4 y/o child at well-child visit. Which developmental milestone should the nurse expect to observe? Identifies right from left hand Uses a utensil to spread butter Cuts an outlined shape using scissors Drawing a stick figure with seven body parts
Identifies right from left hand: - 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. ANS: 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. Draws a stick figure with seven body parts: - an expected developmental milestone of a 5-year-old child.
Nurse assessing school age child immediately following perforated appendix repair. Which findings should the nurse expect? Purulent nasogastric drainage Absence of peristalsis Passage of dark red stool with mucus WBC count 6,000/mm3
Purulent nasogastric drainage: - not an expected finding following a perforated appendix repair. The nurse should expect brown to green-tinged drainage from the NG tube. ANS: Absence of peristalsis: - The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning. Passage of dark red stool with mucus: - 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 >20,000/mm3 in a client who has had a ruptured appendix.
Nurse in ED is caring for toddler with partial thickness burns on right arm. Which actions should the nurse take? Insert a nasogastric tube. Initiate prophylactic antibiotic therapy. Cleanse the affected area with mild soap and water. Apply a topical corticosteroid to the affected area.
Insert a NG 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: - 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. ANS: 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. Apply a topical corticosteroid to the affected area: - The nurse should apply an antimicrobial ointment to the affected area to prevent infection.
Nurse reviews lab report of school age child experiencing fatigue. Which findings should the nurse recognize as an indication of anemia? Hematocrit 28% Hemoglobin 13.5 g/dL WBC count 8,000/mm3 Platelets 250,000/mm3
ANS: Hematocrit 28%: - 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. Hemoglobin 13.5 g/dL: - within the expected reference range of 9.5 to 14 g/dL for a school-age child. WBC count 8,000/mm3: - within the expected reference range of 5,000 to 10,000/mm3 for a school-age child. Platelets 250,000/mm3: - within with expected reference range of 150,000 to 400,000/mm3 for a school-age child.
Nurse prepares to admin an immunization to 4 yo child. Which actions should the nurse plan to take? Place the child in a prone position for the immunization. Request that the child's caregiver leave the room during the immunization. Administer the immunization using a 24-gauge needle. Inject the immunization slowly after aspirating for 3 seconds.
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. ANS: Administer the immunization using a 24-gauge needle: - 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. 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.
Nurse is caring for school age child receiving chemotherapy and severely immunocompromised. Which actions should the nurse take? Use surgical asepsis when providing routine care for the child. Administer the measles, mumps, and rubella (MMR) vaccine to the child. Screen the child's visitors for indications of infection. Infuse packed RBCs.
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. ANS: Screen the child's visitors for indications of infection: - 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. 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.
School nurse assesses adolescent with multiple burns in various stages of healing. Which behaviors should the nurse ID as possible indication of physical abuse? Expresses a reluctance to leave home Provides a detailed description of how the burns occurred Denies discomfort during assessment of injuries Describes strong relationships with peers
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. 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. ANS: 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. Describes strong relationships with peers: - The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has withdrawn behavior and poor relationships with peers.
Nurse is preparing an adolescent for lumbar puncture. Which actions should the nurse take? Place a cardiac monitor on the adolescent prior to the procedure. Apply topical analgesic cream to the site 1 hr prior to the procedure. Keep the adolescent in a semi-Fowler's position for 4 hr following the procedure. Restrict fluids for 2 hr following the procedure.
Place a cardiac monitor on the adolescent prior to the procedure: - Cardiac monitoring is not necessary during a lumbar puncture. ANS: Apply topical analgesic cream to the site 1 hr prior to the procedure: - 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. 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.
Hospice nurse is caring for preschooler with terminal illness. One parent of patient tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which statement should the nurse make? "It is important that you provide emotional support for your family at this time." "You have to do what you feel is best. Everything will turn out fine." "I know how you feel. This is an extremely stressful time for your family." "Let's talk about some of the ways you have handled previous stressors in your life."
"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. "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. "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. ANS: "Let's talk about some of the ways you have handled previous stressors in your life.": - 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.
nurse teaching the parent of an infant about ways to prevent SIDS. Which instructions should the nurse include? "Place the infant in a prone position to sleep." "Allow the infant to sleep on a large pillow." "Use a soft mattress in the infant's crib." "Give the infant a pacifier at bedtime."
"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. "Allow the infant to sleep on a large pillow.": - Placing the infant on a large pillow to sleep can increase risk of suffocation, asphyxiation, and SIDS. "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. ANS: "Give the infant a pacifier at bedtime." - The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.
Nurse caring for 15 y/o who's married and scheduled for surgical procedure. Client asks " Who should sign my surgical consent?" Which responses should the nurse make? "You can sign the consent form because you are married." "Your spouse should sign the consent form for you." "Your parent should sign the consent form for you." "You can appoint a legal guardian to sign the consent form."
ANS: "You can sign the consent form because you are married.": - 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. "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.": - *, do not require the consent of a parent. "You can appoint a legal guardian to sign the consent form.": - *, do not require the consent of a legal guardian.
Nurse receives change of shift report for 4 children. Which children should nurse see first? A school-age child who has sickle cell anemia and reports decreased vision in the left eye A school-age child who has cystic fibrosis and a frequent nonproductive cough A preschooler who has asthma and a peak flow meter reading in the green zone An adolescent who has meningitis and reports a sensitivity to lights and noise
ANS: A school-age child who has sickle cell anemia and reports decreased vision in the left eye: - 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 ASAP. Therefore, the nurse should see this child first. A school-age child who has cystic fibrosis and a frequent nonproductive cough: - an expected and nonurgent finding for a child who has cystic fibrosis. A preschooler who has asthma and a peak flow meter reading in the green zone: - an expected and nonurgent finding for a child who has asthma. An adolescent who has meningitis and reports a sensitivity to lights and noise: - an expected and nonurgent finding for a child who has meningitis.
Nurse caring for toddler with spastic (pyramidal) cerebral palsy. Which findings should the nurse expect? (SATA) Negative Babinski reflex Ankle clonus Exaggerated stretch reflexes Uncontrollable movements of the face Contractures
ANS: 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. ANS: Exaggerated stretch reflexes is correct: - The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes. ANS: Contractures is correct: - The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles. Negative Babinski reflex is incorrect: - The nurse should expect a child who has spastic cerebral palsy to exhibit a positive Babinski reflex. 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.
Nurse is caring for infant with resp syncytial virus (RSV). Which actions should the nurse implement for infection control? Have a designated stethoscope in the infant's room. Place the infant in a room equipped with negative airflow. Administer palivizumab as prescribed for the infant. Remove gloves after leaving the infant's room.
ANS: Have a designated stethoscope in 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. Therefore, designated equipment, such as a BP cuff and a stethoscope, should be placed in the infant's room. Place the infant in a room equipped with negative airflow: - The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. A room equipped with negative airflow is not necessary and is only initiated for infants who need airborne precautions. 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.
Nurse assesses infant with ventricular septal defect. Which findings should the nurse expect? Loud, harsh murmur Dysrhythmias Weak femoral pulses High blood pressure
ANS: 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. 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. Weak femoral pulses: - 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 BP when assessing an infant who has coarctation of the aorta.
Nurse is creating POC for school age child with heart disease and has developed heart failure. Which interventions should the nurse include in plan? Provide small, frequent meals for the child. Schedule time in the play room for the child. Weigh the child weekly. Maintain the child in a supine position.
ANS: Provide small, frequent meals for the child: - 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. 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.
Nurse is providing teaching to parent of infant with diaper dermatitis. Nurse should instruct parent to apply what to the affected areas? Zinc oxide Antibiotic ointment Talcum powder Antiseptic solution
ANS: Zinc oxide: - 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. 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.
Nurse is planning care for school age child in oliguric phase of AKI and has sodium level 129 mEq/L. Which interventions should the nurse include in plan? Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F). Assess the child's blood pressure every 8 hr. Weigh the child weekly at various times of the day. Initiate seizure precautions for the child.
Administer ibuprofen to the child for a temperature >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, i.e. turning on a fan in the room. Assess the child's BP 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, nurse should assess child's BP Q 4 - 6 hr. Weigh the child weekly at various times of the day: - In the oliguric phase of AKI, the child will have decreased UO 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. ANS: Initiate seizure precautions for child: - 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.
Nurse is assessing VS of 10 y/o following burn injury. Nurse should ID that which findings is an indication of early septic shock? Blood pressure 130/90 mm Hg Heart rate 60/min Temperature 39.1° C (102.4° F) Urinary output 100 mL/hr
Blood pressure 130/90 mm Hg: - above the expected reference range of 97 - 128 mm Hg systolic and 58 to 88 mm Hg diastolic for a 10 y/o child. The nurse should expect a child who has early septic shock to have a BP within the expected reference range. Heart rate 60/min: - 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. ANS: Temperature 39.1° C (102.4° F): - 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. Urinary output 100 mL/hr: - 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.
Nurse caring for school age child in Buck's traction following a leg fracture 24 hrs ago. Which actions should the nurse take? Change the child's position every 2 hr. Clean the peripheral pin sites with chlorhexidine solution every 4 days. Assess peripheral pulses once every 4 hr. Ensure that the head of the bed is elevated to a 90° angle.
Change the child's position Q 2 hr: - 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. ANS: 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. 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.
School nurse assesses an adolescent with scoliosis. Which findings should the nurse expect? Increase in anterior convexity of the lumbar spine Increased curvature of the thoracic spine Lateral flexion of the neck A unilateral rib hump
Increase in anterior convexity of the lumbar spine: - 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. Increased curvature of the thoracic spine: - 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. 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. ANS: 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.
Nurse gives discharge teaching to parent of child 1 week postop following cleft palate repair. Which members of interprofessional team should the nurse initiate a referral? Occupational therapist Speech therapist Respiratory therapist Physical therapist
Occupational therapist: - for a child who has physical disabilities and requires assistance with ADLs. ANS: Speech therapist: - 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. Respiratory therapist: - for a child who requires airway support. Physical therapist: - for a child who requires assistance with mobility and increasing physical strength.
Nurse admits a school age child with pertussis. Which actions should the nurse take? Place child in room with positive pressure airflow Place child in room with negative pressure airflow Initiate contact precautions for child Initiate droplet precautions for child
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. 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. 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. ANS: Initiate droplet precautions for the child: - 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.
Nurse creating POC for infant with epidural hematoma from head injury. Which interventions should the nurse include in plan? Position the infant side-lying with their head at a 0° to 5° angle. Perform a neurological assessment every 4 hr. Suction the infant's nares to remove secretions. Implement seizure precautions for the infant.
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 IICP. Perform a neurological assessment Q 4 hr: - perform a neurological assessment as frequently as Q 15 min to detect changes in the child's condition and monitor for ICP. Suction the infant's nares to remove secretions: - 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. ANS: 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.
Nurse cares for school age child receiving cefazolin via intermittent IV bolus. Child suddenly develops diffuse flushing skin and angiodema. After discontinuing med infusion, which meds should the nurse admin first? Prednisone Epinephrine Diphenhydramine Albuterol
Prednisone: - 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. ANS: Epinephrine: - This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to EBP, the nurse should first admin 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. Diphenhydramine: - 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: - 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.