Peds #3

An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply. 1. Administer oxygen. 2. Place the child in knee-chest position. 3. Administer morphine and propranolol intravenously as ordered. 4. Draw blood for a serum hemoglobin. 5. Administer diphenhydramine (Benadryl) as ordered.

1. Administer oxygen. 2. Place the child in knee-chest position. 3. Administer morphine and propranolol intravenously as ordered.

Which clinical manifestations should the nurse expect when conducting an assessment for a child who is diagnosed with autism spectrum disorder (ASD)? Select all that apply. 1. Arm flapping 2. Language delays 3. Ritualistic behavior 4. Impulsive behavior 5. Sleep disturbances

1. Arm flapping 2. Language delays 3. Ritualistic behavior

Which actions should the nurse implement when assessing the physical growth for a child who is diagnosed with chronic renal failure? Select all that apply. 1. Asking the child to step on the scale 2. Measuring the child's height 3. Measuring the child's head circumference 4. Using the Denver II with the child 5. Monitoring the child's blood pressure

1. Asking the child to step on the scale 2. Measuring the child's height 3. Measuring the child's head circumference

The nurse is providing information to an adolescent newly diagnosed with diabetes. Which clinical manifestations of diabetic ketoacidosis (DKA) should the nurse include in the teaching session? Select all that apply. 1. Change in mental status 2. Tachycardia 3. Fruity breath odor 4. Rapid, shallow respirations 5. Abdominal pain

1. Change in mental status 3. Fruity breath odor 5. Abdominal pain

Which is the priority nursing action when preparing a neonate born with a gastroschisis defect for transport to a pediatric hospital for corrective surgery? 1. Covering the exposed intestines with sterile moist gauze 2. Wrapping the newborn warmly in two or three blankets 3. Providing a sterile water feeding to maintain hydration during transport 4. Allowing the parents of the newborn to see their child prior to transport

1. Covering the exposed intestines with sterile moist gauze

Which information should the nurse include in the teaching plan for the parents of a child who is diagnosed with autism spectrum disorder (ASD) as methods to increase the child's socialization? 1. Create a reward system when the child interacts with a person. 2. Punish the child when the child's social behaviors are inappropriate. 3. Use dolls to demonstrate appropriate social interactions to the child. 4. Enroll the child in a day care facility to encourage interaction with other children.

1. Create a reward system when the child interacts with a person.

A 5-year-old child with a history of hypopituitarism presents with complaints of right hip and leg pain. Which prescribed medication for the diagnosis should the nurse identify as the cause for the current symptoms? 1. Daily growth hormone 2. Insulin before meals and bedtime 3. DDAVP (desmopressin) at bedtime 4. Cortisone injections

1. Daily growth hormone

Which injury prevention strategies should the nurse include in the plan of care for a pediatric client who is diagnosed with muscular dystrophy? Select all that apply. 1. Develop a home fire evacuation plan. 2. Provide information regarding oxygen safety. 3. Recommend the use of portable generator. 4. Teach safe transfer methods. 5. Perform neurovascular checks every 2 hours.

1. Develop a home fire evacuation plan. 2. Provide information regarding oxygen safety. 3. Recommend the use of portable generator. 4. Teach safe transfer methods.

The nurse is teaching the caregiver of a child who is newly diagnosed with type 1 diabetes mellitus how to minimize pain with insulin injections. Which interventions should the nurse include in the teaching session? Select all that apply. 1. Do not reuse needles. 2. Remove all bubbles from the syringe before injecting. 3. Have the child flex the muscle during injection. 4. Inject insulin when it is cold. 5. Do not change the direction of the needle during insertion or withdrawal.

1. Do not reuse needles. 2. Remove all bubbles from the syringe before injecting. 5. Do not change the direction of the needle during insertion or withdrawal.

Which interventions should the nurse include in the plan of care for an adolescent client who is on complete bed rest after spinal fusion surgery secondary to scoliosis to prevent complications associated with immobility? Select all that apply. 1. Encouraging use of the spirometer every 2 hours while the child is awake 2. Log-rolling the client every 2 hours while awake 3. Increasing intake of milk to maintain bone calcium 4. Increasing fruit and grains in the diet 5. Limiting fluid intake to reduce the need to void

1. Encouraging use of the spirometer every 2 hours while the child is awake 2. Log-rolling the client every 2 hours while awake 4. Increasing fruit and grains in the diet

The nurse is assessing a 4-year-old child with a possible alteration in mental health. Which findings indicate a need for further investigation? Select all that apply. 1. Fails to make eye contact 2. Flinches when touched on the arm 3. History of limited prenatal care and precipitate delivery 4. Head circumference has not changed in over 1 year 5. Flat facial expressions

1. Fails to make eye contact 2. Flinches when touched on the arm 3. History of limited prenatal care and precipitate delivery 5. Flat facial expressions

A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby? 1. Hypotonia and muscle instability 2. Hypertonia and persistence primitive reflexes 3. Tremors and exaggerated posturing 4. Hemiplegia and hypertonia

1. Hypotonia and muscle instability

Which is the priority nursing diagnosis when planning care for a pediatric client who is diagnosed with bacterial meningitis? 1. Impaired Gas Exchange 2. Risk for Infection 3. Anxiety (parental) 4. Acute Pain

1. Impaired Gas Exchange

Which should the nurse include in the plan of care for a hospitalized school-age child with myelodysplasia? Select all that apply. 1. Implementing interventions for a client of normal intelligence 2. Using latex precautions when providing client care 3. Allowing the client to self-catheterize 4. Ensuring that the client has a low-fiber diet 5. Encouraging the client to shift positions hourly when in the wheelchair

1. Implementing interventions for a client of normal intelligence 2. Using latex precautions when providing client care 3. Allowing the client to self-catheterize 5. Encouraging the client to shift positions hourly when in the wheelchair

Which changes should the school nurse implement to decrease the risk for the development of type 2 diabetes mellitus for a population who is identified as being at risk? Select all that apply. 1. Increase the amount of daily physical activity. 2. Meet with all parents and explain the risk that is associated with obesity. 3. Test each child's urine monthly. 4. Teach the parents to avoid administering aspirin to their children. 5. Work with the cafeteria to decrease the amount of fat in the foods served.

1. Increase the amount of daily physical activity. 2. Meet with all parents and explain the risk that is associated with obesity. 5. Work with the cafeteria to decrease the amount of fat in the foods served.

The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question? 1. Passive range-of-motion exercises to promote hip flexion 2. Oxygen at 2 L nasal cannula to keep saturation above 95% 3. Hourly vital signs and neurologic checks 4. Elevate head of bed 30 degrees

1. Passive range-of-motion exercises to promote hip flexion

A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate based on the current data? 1. Placing the newborn on a radiant warmer 2. Placing the newborn in an open crib 3. Preparing the newborn for phototherapy 4. Preparing the newborn for a bottlefeeding

1. Placing the newborn on a radiant warmer

The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate? 1. Position the newborn in semi-Fowler position. 2. Allow the newborn to be taken to the mother's room for bonding. 3. Offer the newborn formula feeding instead of breastfeeding. 4. Wrap the newborn in blankets and place in a crib by the viewing window.

1. Position the newborn in semi-Fowler position.

Which interventions should the nurse include in the plan of care for a child who is diagnosed with an intellectual disability? Select all that apply. 1. Providing emotional support to the family 2. Maintaining a safe environment for the client 3. Educating the family that maintenance of activities of daily living (ADL) is impossible to achieve 4. Participating in the individualized education program (IEP) process 5. Recommending permanent institutionalization

1. Providing emotional support to the family 2. Maintaining a safe environment for the client 4. Participating in the individualized education program (IEP) process

A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN) and is admitted to the hospital. Which is the priority nursing diagnosis for this child? 1. Risk for Injury related to hypertension. 2. Altered Growth and Development related to a chronic disease. 3. Risk for Infection related to hypertension. 4. Fluid Volume Excess related to decreased plasma filtration.

1. Risk for Injury related to hypertension.

When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother? 1. The mother leaves the filled mop bucket on the floor while in another room. 2. The mother turns all pan handles to the back of the stove. 3. The mother fills the bath tub before bringing the baby into the bathroom. 4. When riding in a car, the child is in a car seat in the middle of the back seat.

1. The mother leaves the filled mop bucket on the floor while in another room.

The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which parental statement indicates the need for further education? 1. "I will not use carbonated beverages to dilute his medication." 2. "I will give his medicine on an empty stomach so he will absorb it better." 3. "I will not let him chew his tablet." 4. "I will bring him to the physician's office for regular blood work to check bleeding times."

2. "I will give his medicine on an empty stomach so he will absorb it better."

Which parental statements regarding precipitating factors for sickle-cell disease indicate correct understanding of the discharge information presented by the nurse? Select all that apply. 1. "My child should avoid regular exercise." 2. "We should provide acetaminophen or ibuprofen to treat fever." 3. "Our child needs to drink lots of fluid to avoid dehydration when playing sports." 4. "High altitudes can cause exacerbation and should be avoided." 5. "Fluid restriction is necessary to avoid exacerbations from occurring."

2. "We should provide acetaminophen or ibuprofen to treat fever." 3. "Our child needs to drink lots of fluid to avoid dehydration when playing sports." 4. "High altitudes can cause exacerbation and should be avoided."

Which clinical manifestations should the nurse expect when assessing a pediatric client who is diagnosed with congenital hip dysplasia (CHD)? Select all that apply. 1. Limited adduction of the affected hip 2. Asymmetry of thigh fat folds 3. Telescoping of the thigh 4. Muscle weakness 5. Atrophy of the muscles

2. Asymmetry of thigh fat folds 3. Telescoping of the thigh

Which laboratory tests should the nurse prepare to draw when admitting a pediatric client with possible obstructive uropathy? Select all that apply. 1. Platelet count 2. Blood urea nitrogen (BUN) 3. Partial thromboplastin time (PTT) 4. Blood culture 5. Creatinine

2. Blood urea nitrogen (BUN) 5. Creatinine

An infant returns to the unit following surgical correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The nurse notes that the toes on both feet are edematous, but there is color, sensitivity, and movement to them. Which action by the nurse is the priority? 1. Apply a warm, moist pack to the feet. 2. Elevate the legs on pillows. 3. Encourage movement of the toes. 4. Call the surgical provider to report the edema.

2. Elevate the legs on pillows.

Which complications should the nurse monitor for when providing care to a child who is having hemodialysis for the treatment of kidney failure? Select all that apply. 1. Migraines 2. Hypotension 3. Infections 4. Fluid overload 5. Shock

2. Hypotension 3. Infections 5. Shock

Which assessment finding would require an immediate nursing action when providing care to an adolescent who is postoperative for spinal fusion surgery? 1. Sleeps when not bothered but arouses easily with stimuli 2. Impaired color, sensitivity, and movement to lower extremities 3. Nausea relieved by antiemetics 4. Pain relieved by analgesics

2. Impaired color, sensitivity, and movement to lower extremities

The home health nurse is visiting a 3-month-old infant who is diagnosed with congenital hypothyroidism and is prescribed daily levothyroxine. Which should the nurse include in the infant's continued plan of care? 1. Stopping the medication as long as the child continues to grow 2. Preventing hypothermia with appropriate clothing 3. Changing formula because it is contraindicated with prescribed medication 4. Monitoring growth and development without any other prescribed interventions

2. Preventing hypothermia with appropriate clothing

Which clinical manifestations should the nurse monitor for when conducting a scoliosis screening for a school-age child? Select all that apply. 1. Lordosis 2. Prominent scapula 3. Pain 4. A one-sided rib hump 5. Uneven shoulders and hips

2. Prominent scapula 4. A one-sided rib hump 5. Uneven shoulders and hips

Which is the appropriate nursing intervention when providing care to a child, diagnosed with nephrotic syndrome, who is edematous and on bed rest? 1. Monitor blood pressure every 30 minutes. 2. Reposition every 2 hours. 3. Limit visitors. 4. Encourage fluids.

2. Reposition every 2 hours.

The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes. Which additional assessment data indicates to the nurse that the infant is experiencing an early to moderate stage of dehydration? 1. Bradycardia 2. Tachycardia 3. Increased blood pressure 4. Normal fontanels

2. Tachycardia

Which instructions should be provided to the parents of a 4-year-old girl who has experienced chronic urinary tract infections (UTIs) in the last 2 years? Select all that apply. 1. Wear only nylon underwear for better air flow. 2. Teach the child to wipe from front to back. 3. Encourage the child to take long baths by allowing the child bubbles and toys in the tub. 4. Encourage the child to drink additional fluids throughout the day. 5. Plan potty breaks every 2 hours throughout the day.

2. Teach the child to wipe from front to back. 4. Encourage the child to drink additional fluids throughout the day. 5. Plan potty breaks every 2 hours throughout the day.

Which teaching topic is the priority for the nurse who is teaching the family of an infant diagnosed with osteogenesis imperfecta? 1. Cast care 2. Trunk and extremity support during everyday care 3. Postoperative spinal surgery care 4. Traction care

2. Trunk and extremity support during everyday care

An adolescent client reports recurrent abdominal pain with diarrhea and bloody stools. Which type of inflammatory bowel disease does the nurse suspect based on these data? 1. Necrotizing enterocolitis (NEC) 2. Ulcerative colitis (UC) 3. Crohn disease 4. Appendicitis

2. Ulcerative colitis (UC)

Which statement from the parent of a child diagnosed with attention deficit/hyperactivity disorder (ADHD) indicates the need for further education by the nurse? 1. "I will develop a reward system for desired behaviors." 2. "I will take my child to the physician every 3 months for a weight and height check." 3. "I will let him do his homework while he is watching his favorite television show." 4. "I will stick to the same routine each day after school."

3. "I will let him do his homework while he is watching his favorite television show."

The nurse is giving discharge instructions to the parents of a child whose adrenal glands have been removed due to a tumor. Which parental statement indicates the need for further education? 1. "I will call the doctor if my child has restlessness and confusion." 2. "If my child has any gastric irritation, I will give him antacids." 3. "If my child has vomiting and diarrhea, I will hold his hydrocortisone." 4. "I will give my child his hydrocortisone in the morning."

3. "If my child has vomiting and diarrhea, I will hold his hydrocortisone."

Which parental statement indicates correct understanding of discharge instructions for a pediatric client after a tonsillectomy? 1. "We will call the healthcare provider for any indication of ear pain." 2. "We will be sure to give our child adequate amounts of citrus juices." 3. "We will plan on administering acetaminophen (Tylenol) for pain." 4. "We will keep our child on bed rest for 10 days after the surgery."

3. "We will plan on administering acetaminophen (Tylenol) for pain."

Which is the priority nursing diagnosis when planning care for a newborn who is born with esophageal atresia and tracheoesophageal fistula? 1. Ineffective Tissue Perfusion 2. Ineffective Infant Feeding Pattern 3. Acute Pain 4. Risk for Aspiration

3. Acute Pain

A child diagnosed with autism spectrum disorder (ASD) is admitted to the hospital with dehydration. Which should the nurse include in the plan of care for this child? 1. Discourage the parents from bringing favorite toys from home that might be lost. 2. Take the child on a tour of the pediatric unit. 3. Assign the child to a single-bed hospital room. 4. Take the child to the playroom for arts and crafts.

3. Assign the child to a single-bed hospital room.

Which finding, noted during the newborn admission assessment, would lead the nurse to suspect unilateral congenital hip dysplasia? 1. Lordosis 2. Trendelenburg sign 3. Asymmetry of the gluteal and thigh fat folds 4. Telescoping of the affected limb

3. Asymmetry of the gluteal and thigh fat folds

Which activities should the nurse include in the plan of care for a child diagnosed with attention deficit/hyperactivity disorder (ADHD) to improve behavior and learning? Select all that apply. 1. Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child 2. Placing the child's desk at the back of the room to reduce distractions 3. Developing a consistent routine for the classroom 4. Limiting the decorations in the classroom 5. Determining areas where the child performs well and using these areas to promote self-esteem

3. Developing a consistent routine for the classroom 4. Limiting the decorations in the classroom 5. Determining areas where the child performs well and using these areas to promote self-esteem

An adolescent presents in the emergency department (ED) with confusion. The healthcare provider suspects diabetic ketoacidosis (DKA). A stat serum glucose is done, and the result is 7l5 mg/dL. Which clinical manifestations does the nurse anticipate upon assessment for this client? 1. Tachycardia, dehydration, and abdominal pain 2. Sweating, photophobia, and tremors 3. Dry mucous membranes, blurred vision, and weakness 4. Dry skin, shallow rapid breathing, and dehydration

3. Dry mucous membranes, blurred vision, and weakness

A school-age child is diagnosed with a learning disorder that is characterized by problems with manual dexterity and coordination. Which term should the nurse use when documenting this child's disorder in the medical record? 1. Dysgraphia 2. Dyscalculia 3. Dyspraxia 4. Dyslexia

3. Dyspraxia --> Children with dyspraxia have problems with manual dexterity and coordination.

The nurse is caring for a 9-month-old infant who just returned from the postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which healthcare provider prescription should the nurse question? 1. Vital signs and neurologic checks hourly 2. Small, frequent formula feedings 3. Elevate head of bed 4. Daily head circumference

3. Elevate head of bed --> The 9-month-old should be placed in a flat position so that cerebrospinal fluid drainage is not too rapid.

Which data, noted by the nurse during the physical assessment, would indicate the need to refer an adolescent client for further treatment due to possible depression? Select all that apply. 1. Agoraphobia 2. Somatic complaints 3. Focus on violence 4. Poor self-care 5. Poor school performance

3. Focus on violence 4. Poor self-care 5. Poor school performance

Which gastrointestinal defects, often diagnosed shortly after birth, should the nurse include in the assessment process of all newborns? Select all that apply. 1. Pyloric stenosis 2. Biliary atresia 3. Hirschsprung disease 4. Umbilical hernia 5. Diaphragmatic hernia

3. Hirschsprung disease 5. Diaphragmatic hernia

Which assessment data would cause the nurse to suspect that a 3-year-old child has Hirschsprung disease? 1. Clay-colored stools and dark urine 2. History of early passage of meconium in the newborn period 3. History of chronic, progressive constipation and failure to gain weight 4. Continual bouts of foul-smelling diarrhea

3. History of chronic, progressive constipation and failure to gain weight

Which clinical data noted by the nurse during the shift assessment indicate the pediatric client may be experiencing compartment syndrome? Select all that apply. 1. Pink, warm extremity 2. Dorsalis pedis pulse present 3. Prolonged capillary refill time 4. Pain not relieved by pain medication 5. Paresthesia of the leg

3. Prolonged capillary refill time 4. Pain not relieved by pain medication 5. Paresthesia of the leg

Which urinalysis result should the nurse anticipate for a child who is admitted with acute glomerulonephritis? 1. Bacteriuria and increased specific gravity 2. Hematuria and proteinuria 3. Proteinuria and decreased specific gravity 4. Bacteriuria and hematuria

3. Proteinuria and decreased specific gravity

A school-age client presents to the pediatric clinic with a history of abdominal pain 3 to 4 mornings per week over the last 2 months. The mother states the child usually complains on school days and always seems to be better by afternoon. Which mental health disorder does the nurse suspect? 1. Separation anxiety 2. Depression 3. School phobia 4. Bipolar disorder

3. School phobia

Which clinical manifestations should the nurse anticipate when providing care to an adolescent client who presents with untreated Graves disease? 1. Hyperglycemia, ketonuria, and glucosuria 2. Weight gain, hirsutism, and muscle weakness 3. Tachycardia, fatigue, and heat intolerance 4. Dehydration, metabolic acidosis, and hypertension

3. Tachycardia, fatigue, and heat intolerance

A child with croup has an increased PCO2, a decreased pH, and a normal HCO3 blood gas value. Which does the nurse report to the healthcare provider based on these data? 1. Uncompensated metabolic alkalosis 2. Uncompensated metabolic acidosis 3. Uncompensated respiratory acidosis 4. Uncompensated respiratory alkalosis

3. Uncompensated respiratory acidosis

Which clinical manifestations should the nurse anticipate upon assessment for a preschool-age child with a urinary tract infection (UTI)? 1. Headache, hematuria, and vertigo 2. Foul-smelling urine, elevated blood pressure (BP), and hematuria 3. Urgency, dysuria, and fever 4. Severe flank pain, nausea, and headache

3. Urgency, dysuria, and fever

The nurse is providing care to a pediatric client, diagnosed with inflammatory bowel disease, who is prescribed daily prednisone. Which parental statement regarding administration of this drug indicates correct understanding of the teaching provided by the nurse? 1. "I will administer this medication between meals." 2. "I will administer this medication at bedtime." 3. "I will administer this medication one hour before meals." 4. "I will administer this medication with meals."

4. "I will administer this medication with meals."

Which parental statement would cause the nurse to include further education related to the care required for a child who is diagnosed with congenital clubfoot? 1. "We're getting a special car seat to accommodate the casts." 2. "We'll watch for any swelling of the feet while the casts are on." 3. "We'll keep the casts dry." 4. "We're happy this is the only cast our baby will need."

4. "We're happy this is the only cast our baby will need."

A nurse is taking care of four different pediatric clients. Which child is at greatest risk for dehydration? 1. 7-year-old child with migraine headaches 2. 4-year-old child with a broken arm 3. 2-year-old child with cellulitis of the left leg 4. 18-month-old child with tachypnea

4. 18-month-old child with tachypnea

Which children should the nurse identify as exhibiting a delay in meeting developmental milestones? Select all that apply. 1. An 18-month-old toddler who is unable to speak in sentences 2. A 2-year-old child who is unable to cut with scissors 3. A 2-year-old child who cannot recite her phone number 4. A 6-year-old child who is unable to sit still for a short story 5. A 5-year-old child who is unable to button his shirt

4. A 6-year-old child who is unable to sit still for a short story 5. A 5-year-old child who is unable to button his shirt

Which action by the nurse is appropriate for a child who presents in the emergency department with an ankle injury? 1. Avoid compressing the area to allow tissue swelling as necessary. 2. Perform passive range-of-motion to the extremity. 3. Lower the extremity below the level of the heart. 4. Apply ice to the extremity.

4. Apply ice to the extremity.

The nurse is planning care for a school-age client who is postoperative for the surgical removal of the appendix. In addition to pharmacologic pain management, which should the nurse include in the plan of care to address pain? 1. Applying a warm, moist pack every 4 hours 2. Applying EMLA cream to the incision site prior to ambulation 3. Applying a cold, moist pack every 2 hours 4. Applying a pillow against the abdomen to splint the incision site when coughing

4. Applying a pillow against the abdomen to splint the incision site when coughing

During a 4-month-old infant's well-child checkup, the nurse discusses introduction of solid foods into the infant's diet. Although the nurse recommends delaying the introduction of many foods into the diet, which food(s) will the nurse discuss delaying because they increase the risk for food allergy? 1. Honey 2. Carrots, beets, and spinach 3. Pork 4. Cow's milk, eggs, and peanuts

4. Cow's milk, eggs, and peanuts

A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse anticipate based on these data? 1. Decreased protein count 2. Clear, straw-colored fluid 3. Positive for red blood cells (RBCs) 4. Decreased glucose level

4. Decreased glucose level

Which clinical manifestations should the nurse expect when conducting an assessment for a child who is diagnosed with attention deficit/ hyperactivity disorder (ADHD)? Select all that apply. 1. Arm flapping 2. Language delays 3. Ritualistic behavior 4. Impulsive behavior 5. Sleep disturbances

4. Impulsive behavior 5. Sleep disturbances

Which prescription regarding an oral hydrocortisone for a toddler-age client diagnosed with congenital adrenal insufficiency should the nurse anticipate when the client is admitted to the hospital with pneumonia? 1. It will be discontinued. 2. It will be reduced. 3. It will be continued as previously prescribed. 4. It will be increased.

4. It will be increased.

The nurse is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate? 1. Measuring the girth just below the umbilicus 2. Measuring the girth just below the sternum 3. Measuring the girth just above the pubic bone 4. Measuring the girth around the portion of the stomach

4. Measuring the girth around the portion of the stomach

A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate? 1. Applying a diaper to prevent contamination of sac 2. Positioning the newborn in a side-lying position 3. Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery 4. Positioning the newborn in a prone position

4. Positioning the newborn in a prone position

A child weighing 18.2 kg with a history of diabetes insipidus (DI) has been admitted to the hospital. Which healthcare provider prescription should the nurse question? 1. Stat electrolytes 2. Urine specific gravity with each void 3. DDAVP (desmopressin) PO 4. Restrict oral fluids to 500 mL every 24 hours

4. Restrict oral fluids to 500 mL every 24 hours

Priority nursing care with ezema (4)

Hydrate and lubricate skin Reduce pruitis (itching) Minizme inflammatory triggers and determine triggers Apply topical corticosteroids

What endocrine disorder causes a short stature?

Hypothyroidism

Nursing care for candida albicans in diapers (7)

- change as soon as wet or Q2 - barrier methds and remove 1-2x/day to reapply fresh medication - mineral oil or soft cloth removes medication - return in one week if not improving - wash perineal area with warm water - pat skin dry - avoid baby powder or corn starch

Which items noted in a pediatric client's medical record indicate the child may be experiencing a learning disability? Select all that apply. 1. Dyslexia 2. Dysphagia 3. Dyspraxia 4. Scoliosis 5. Hypotonia

1. Dyslexia 3. Dyspraxia

Which preventative strategies should the nurse include in a teaching session for a mother whose infant is at risk for febrile seizures? Select all that apply. 1. Increasing oral intake of fluids 2. Administering dose-appropriate aspirin 3. Providing a sponge bath with cold water 4. Decreasing oral fluid intake 5. Patting the child dry after a tepid bath

1. Increasing oral intake of fluids 5. Patting the child dry after a tepid bath

Which is the priority action by the school nurse for an adolescent who drops to the ground and is unresponsive during a high school basketball game? 1. Initiating cardiopulmonary resuscitation (CPR) 2. Calling 911 3. Offering the parents comfort 4. Assessing for hemorrhage

1. Initiating cardiopulmonary resuscitation (CPR)

The nurse is planning a teaching session for the parents of a child who is diagnosed with simple partial seizures. Which causes should the nurse include when teaching the parents? Select all that apply. 1. Lesions 2. Cysts 3. Tumor 4. Brain abscesses 5. Brain trauma

1. Lesions 2. Cysts 3. Tumor 4. Brain abscesses

Which assessment finding would cause the nurse to question whether a preschool-age boy, diagnosed with phenylketonuria shortly after birth, is following the prescribed dietary restrictions? 1. The child's body has a musty odor. 2. This child is a blue-eyed blond. 3. The child appears sleepy and uninterested in the surroundings. 4. The child has a sunburn over his entire body.

1. The child's body has a musty odor.

Which assessment finding for a 4-month-old infant would require further action by the nurse? 1. The posterior fontanel is open. 2. The infant has good head control when held upright. 3. The infant is able to roll only from abdomen to back. 4. The anterior fontanel is open and soft.

1. The posterior fontanel is open.

Which nursing actions are appropriate to assess growth and development for an adolescent client diagnosed with chronic renal failure? Select all that apply. 1. Using the Denver II during a health maintenance visit 2. Educating parents on normal milestones 3. Monitoring for delayed sexual maturation 4. Comparing blood pressure values from previous visit 5. Plotting height and weight measurements

1. Using the Denver II during a health maintenance visit 3. Monitoring for delayed sexual maturation 5. Plotting height and weight measurements

Which should the nurse include in a teaching session for the parents of an infant who will be placed in a Pavlik harness for the treatment of congenital developmental dysplasia? 1. Apply lotion or powder to minimize skin irritation. 2. Check at least 2 or 3 times a day for red areas under the straps. 3. Put clothing over the harness for maximum effectiveness of the device. 4. Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper

2. Check at least 2 or 3 times a day for red areas under the straps.

The nurse is providing care to a newborn who is suspected of having Turner syndrome. Which should the nurse assess the newborn for based on the current diagnosis? 1. Club foot (talipes equinovarus) 2. Congenital heart anomalies 3. Hyperbilirubinemia due to liver abnormalities 4. Diaphragmatic hernia

2. Congenital heart anomalies

The nurse is assessing a child with Down syndrome. Which illness should the nurse monitor for due to the increased risk for children with Down syndrome? 1. Rheumatic heart disease 2. Glomerulonephritis 3. Leukemia 4. Hepatitis

3. Leukemia

The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). Which healthcare provider prescription should the nurse question? 1. Neurologic checks hourly 2. Insert urinary catheter and measure output hourly 3. NPH insulin IV at 0.1 unit/kg per hour 4. Stat serum electrolytes

3. NPH insulin IV at 0.1 unit/kg per hour

Which factor, noted by the nurse during the pediatric health history portion of the assessment process, would indicate the child is at risk for attention deficit/hyperactivity disorder (ADHD)? 1. Measles, mumps, and rubella vaccine 2. Advanced parental age 3. Prenatal exposure to smoke 4. Immune response

3. Prenatal exposure to smoke

A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the nurse suspect? 1. Appendicitis 2. Bowel obstruction 3. Urinary tract infection 4. Kidney stones

4. Kidney stones

A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action? 1. Take vital signs. 2. Establish an intravenous line. 3. Perform rapid neurologic assessment. 4. Maintain patent airway.

4. Maintain patent airway.

Priority nursing diagnosis for child sustaining a burn (4)

Hyperthermia Disturbed body image Anxiety Risk for infection

When should cortisol be administered? Why?

In the morning to mimic normal diurnal pattern of cortisol secretion

Cellulitis nursing care (4)

- Administer oral or IV abx as prescribed - warm compressed 4x/day - elevate limb - bed rest

What complications with pt with burn (4)

Infections Pneumonia Renal failure Loss of function to burned area

Look of snake bite (3)

Puncture marks White wheal Burning sensation

Plan of care for burns (6)

Tx and promote healing Prevent complications Promote comfort, wound care (wound mx, analgesic, fluid mx) Provide emotional support 1st: airway management 2nd: hypovolemic shock

When does separation anxiety begin?

~ 4-8 months

Hydrocortisone administration teaching (5)

- always give as prescribed - never abruptly discontinue - wear medical alert ID band - if child vomiting or diarrhea, give injection - have hydrocortisone available at home, school, travel (emergency kit)

Assessment on a 9 month old (2)

- babbling - finger foods

A neonate is born with a bilateral cleft lip that was not detected during the pregnancy. The parents are distressed about the appearance of their infant. Which nursing actions are appropriate to assist the parents to bond with their newborn? Select all that apply. 1. Calling the newborn by the chosen name 2. Keeping the newborn's lower face covered with the blanket 3. Smiling and talking to the newborn in the parents' presence 4. Showing the parents before and after pictures of other children with cleft lips 5. Discussing positive features of the baby

1,3,4,5

Which assessment questions should the nurse include in the psychosocial assessment to determine the effects of chronic renal failure treatments on the growth and development of a school-age child? Select all that apply. 1. "How does it make you feel to have to follow a special diet?" 2. "Do you take your medications every day?" 3. "How does it make you feel to undergo dialysis treatments?" 4. "Do you attend school each day?" 5. "How does it make you feel when your parents come home late from work?"

1. "How does it make you feel to have to follow a special diet?" 3. "How does it make you feel to undergo dialysis treatments?"

Which child should the nurse refer for further assessment due to a probable diagnosis for autism spectrum disorder (ASD)? 1. A 4-year-old girl who doesn't make eye contact with mother and resists the mother's touch 2. A 3-year-old boy who joins one group of children, then moves to another group of children without joining their activities 3. An 18-month-old child who walks around the area using the furniture to provide balance 4. A 6-year-old boy who chatters constantly to anyone who will listen

1. A 4-year-old girl who doesn't make eye contact with mother and resists the mother's touch

Tinea captius (on the scalp)- 3

Mild tiching, broken hairs, looksl ike cradle cap kind of Tx: give med with a fatty meal Shampoo 2-3x week with selenium ketoconazole

Snake bite nursing care (5)

Mobilize extremity Cold compress (not ice) Contact posion control Elevate hand Avoid NSAIDS for 2 weeks