Peds

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for FURTHER teaching? A. "I only need to catheterize myself twice every day" B. "I carry a water bottle with me because I drink a lot of water" C. I use a suppository every night to have a BM D. "I do wheelchair exercises while watching TV"

"I only need to catheterize myself twice every day"

Which of the following may be beneficial in reducing the risk of Reye syndrome? a. Immunization against the disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis d. Avoidance of aspirin and ibuprofen for children with varicella or those suspected of having influenza

Avoidance of aspirin and ibuprofen for children with varicella or those suspected of having influenza

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? A. Attempt to stop the seizure B. Restrain the child's arms C. Use a padded tongue blade D. Position the child laterally

Position the child laterally

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority? A. Place a pillow under the child's head B. Position the child side-lying C. Loosen restrictive clothing D. Clear the area of hazards

Position the child side-lying

The nurse is assessing a 3-year-old child at a routine wellness checkup. Which of the following findings should the nurse expect? A.) Skips and hops on one foot b.) Has a vocabulary of 1,500 words c) Walks backward heel to toe d) Stands on one foot for a few seconds

Stands on one foot for a few seconds

Why are chemotherapeutic agents such as methotrexate (Trexall) and cyclophosphamide (Cytoxan) sometimes used to treat juvenile idiopathic arthritis (JIA)? 1. Are effective against cancer-like JIA. 2. Suppress the immune system. 3. Are similar to NSAIDs. 4. Are absorbed into the synovial fluid.

Suppress the immune system

A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis? A. Sweat chloride test B. A sputum culture C. A stool fat content analysis D. Pulmonary function tests

Sweat chloride test

A nurse is assessing a child with suspected osteomyelitis. Which finding would help support this suspicion? A) Swelling and point tenderness B) Decreased erythrocyte sedimentation rate C) Coolness of the affected site D) Increased range of motion

Swelling and point tenderness

The nurse is caring for a child with an epidural hematoma. The nurse should assess for what signs that can indicate Cushing triad? (Select all that apply.) a. Fever b. Flushing c. Bradycardia d. Systemic hypertension e. Respiratory depression

Systemic hypertension Bradycardia Respiratory depression

A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective? a. perform range of motion on the infant's hips b. maintains a dry dressing over the sac c. takes an axillary temperature d. places the infant in a side-lying position

Takes an axillary temperature

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? A. Test the drainage for glucose B. Suction the nostril C. Notify the physician D. Ask the client to blow his nose

Test the drainage for glucose

A nurse is caring for a toddler who has a fractured right femur and is in Bryant traction. When determining that the traction is appropriately assembled, the nurse should observe which of the following? A. Skin straps maintain the leg in an extended position. B. Weights are attached to a pin that is inserted into the femur. C. A padded sling is under the knee of the affected leg. D. The buttocks is elevated slightly off the bed.

The buttocks is elevated slightly off the bed

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make? A. The test will indicate if your child has rheumatic fever B. The test will confirm if your child had a recent streptococcal infection C. The test will indicate if your child has a therapeutic blood level of an aminoglycoside D. This test will confirm if your child has immunity to streptococcal bacteria

The test will confirm if your child had a recent streptococcal infection

Which clinical manifestations would lead the nurse to suspect an infant has hydrocephaly? Select all that apply. a. depressed fontanelle b. headache c. vomiting d. low-pitched cry e. irritability f. pupillary changes g. bulging fontanelle

Vomiting Irritability Pupillary changes

A nurse is providing discharge teaching about nutrition to the parents of a child who has CF. Which of the following responses by the parents indicate and understanding of the teaching? a. We will give our child pancreatic enzymes with snacks and meals b. We will restrict the amount of salt in our child's food c. I will limit my child's fluid intake d. I will prepare low-fat meals with limited protein for my child

We will give our child pancreatic enzymes with snacks and meals

A nurse is caring for a child who is postoperative following a ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client? A. Trendelenburg B. Semi-Fowler's C. Prone D. On the unoperated side

On the unoperated side

A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask? a."has your son had a sore throat recently?" b. "was your son born with this cardiac defect?" c. "has your child had any injuries recently?" d. "have you given your child aspirin in the last 2 weeks?"

"Has your son had a sore throat recently?"

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect? A. Weight loss B. Increased urine output C. Bradycardia D. Orthopnea

Orthopnea

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow? Coarctation of the aorta Patent ductus arteriosus Tetralogy of Fallot Tricuspid atresia

Patent ductus arteriosus

A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will feed my baby on a schedule every 4 hours" B "I will give my baby high calorie formula as directed by the nutritionist" C. "I will allow my baby to take as much time as needed to finish the bottle" D. "I will limit my babies crying to 15 minutes prior to each feeding"

"I will give my baby high calorie formula as directed by the nutritionist"

A nurse is teaching the mother of a child who has cystic fibrosis and is prescribed pancreatic enzymes three times per day. Which of the following statements indicates the mother understands the information? 1. "My child will take the enzymes to improve metabolism" 2. "My child will take the enzymes following meals" 3. "My child will take the enzymes to help digest the fat in foods" 4. "My child will take the enzymes 2 hours before meals

"My child will take the enzymes to help digest the fat in foods"

A 9-year-old is in a spica cast and complains of pain 1 hour after receiving intravenous opioid analgesia. What should the nurse do first? 1. Give more pain medication. 2. Perform a neuromuscular assessment. 3. Call the surgeon for orders. 4. Tell the child to wait another hour for the medication to work.

Perform a neuromuscular assessment.

A nurse is providing discharge instructions to a parent and his school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include? A. Encourage the child to take a 45 min nap daily B. Allow the child to stay at home on days when her joints are painful C. Apply cool compresses for 20 min every hour D. Administer prednisone on an alternate-day schedule

Administer prednisone on an alternate-day schedule

A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary? a. Tachycardia b. Gastrointestinal upset c. Hypotension d. Alteration in level of consciousness

Alteration in level of consciousness

A newborn with a myelomeningocele is being transferred immediately from the birthing room to the neonatal intensive care unit (NICU). What is the initial nursing intervention?

Apply sterile saline dressing to prevent infection

A nurse is caring for a child who is a having a seizure. Which of the following actions should the nurse take? (Select all that apply) A. Assess the client's airway patency B. Place a tongue depressor in the client's mouth C. Remove objects from the client's bed D. Place the client in a side-lying position E. Restrain the client

Assess the client's airway patency Remove objects from the client's bed Place the client in a side-lying position

A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission? A. Auscultating the rate and characteristics of the child's heart sounds B. Using a pain-rating tool to determine the severity of the joint pain C. Identifying the degree of parental anxiety related to the diagnosis D. Assessing the client's erythematous rash

Auscultating the rate and characteristics of the child's heart sounds

A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately? A. A client who is 1 day post op and has a temp of 37.5 C (99.5 F) B. A client who has a burn injury to an estimated 5% his leg and is crying C. A client's BP changes from 112/60 mmHg to 90/54 mmHg when standing D. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation

A client's BP changes from 112/60 mmHg to 90/54 mmHg when standing

A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection? A. A classmate who has fifth disease B. A sibling who has had a sore throat 3 weeks ago C. The father who has gastritis 2 weeks ago D. A neighbor's child who has chickenpox

A sibling who has had a sore throat 3 weeks ago

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take? A. Percuss each lung segment for 15 min. B. Perform CPT immediately after the child eats. C. Administer albuterol prior to CPT. D. Perform vibration during the client's inspirations.

Administer albuterol prior to CPT

A nurse is reviewing data for four children. Which of the following children should the nurse assess first? A. A 10-year-old child who has sickle cell anemia who reports severe chest pain. B. A 7-year-old child who has a diabetes insipidus and a urine specific gravity of 1.016 C. A 1 year old toddler who has roseola and a temperature of 39 C (102.2 F) D. A 4-year-old who has asthma a PCO2 of 37 mm Hg

A 10-year-old child who has sickle cell anemia who reports severe chest pain

A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? 1. administer antibiotics when available 2. reduce environmental stimuli 3. document intake and output 4. maintain seizure precautions

Administer antibiotics when available

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

Blood pressure 156/60, pulse 60, respirations 14

A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis? a. Cardiovascular b. Gastrointestinal c. Integumentary d. Respiratory

Cardiovascular

The parent of a 3-week-old states that the infant was re-casted this morning for clubfoot and has been crying for the past hour. Which intervention should the nurse suggest the parent do first? 1. Give pain medication. 2. Reposition the infant in the crib. 3. Check the neurocirculatory status of the foot. 4. Use a cool blow-dryer to blow into the cast to control itching.

Checking the neurocirculatory status of the foot

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels

Cloudy CSF Elevated protein Decreased glucose levels

The cerebrospinal (CSF) fluid laboratory finding the nurse would expect in a client with bacterial meningitis is a. clear color. b. decreased glucose level. c. decreased protein level. d. negative nitrates.

Decreased glucose level

A nurse is caring for a child who just underwent insertion of a ventriculoperitoneal shunt. Which of the following positions would be appropriate for the client? 1. on the operative side 2. a 45-degree head elevation 3. prone 4. dorsal recumbent

Dorsal recumbent

The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the child's care plan? a. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline. b. Maintain an active, stimulating environment. c. Perform chest percussion and suctioning every 1 to 2 hours. d. Perform active range of motion and nontherapeutic touch every 8 hours.

Elevate the head of the bed 15 to 30 degrees and maintaining the head in a midline position

For how long should a nurse maintain isolation of a child with bacterial meningitis? 1) For 12 hours after admission 2) Until the cultures are negative 3) Until antibiotic therapy is completed 4) For 48 hours after antibiotic therapy begin

For 48 hours after antibiotic therapy begin

A nurse is caring for a 6-month-old infant. Which of the following findings indicate to the nurse that the infant may be experiencing pain? A. Dry palms and feet B. Decreased muscle tone C. Furrowed brow D. Eyes wide open

Furrowed brow

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include? a. Keep the child home for 1 week. b. Give the child acetaminophen for discomfort c. Offer the child clear liquids for the first 12 hr d. Assist the child to take a tub bath for the first 3 days

Give the child acetaminophen for discomfort

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule our meningitis. Which of the following actions should the nurse include in the plan of care? A. Keep the infant NPO for 6 hr prior the procedure B. Apply a eutectic mixture of lidocaine and prilocaine cream optically 15 min prior to the procedure C. Place the infant in an infant seat for 2 hr following the procedure D. Hold the infant's chin to his chest and knees to his abdomen during the procedure

Hold the infant's chin to his chest and knees to his abdomen during the procedure

A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? Select all. A. Hypotension B. Bradycardia C. Clubbing of the nail beds D. Weak pulses E. Murmur

Hypotension Weak pulses Murmur

A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parents indicates an understanding of the teaching? A. I will feed my baby on a schedule every 4 hours B. I will add Polycose to each of my baby's bottles C. I will allow my baby to take as much time as needed to finish the bottle D. I will limit my babies crying to 15 prior to each feedings

I will add Polycose to each of my baby's bottles

Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which problem should receive the highest priority during the acute phase? A. risk for infection due to altered immune system B. ineffective breathing pattern related to neuromuscular impairment C. impaired swallowing related to neuromuscular impairment D. fluid volume deficits related to total urinary incontinence

Ineffective breathing pattern related to neuromuscular impairment

A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care? A. Keep the head of the bed at a 30 degree angle B. Reposition the client by log rolling every 4 hr C. Place the client in protective isolation D. Initiative the use of PCA pump for pain control

Initiative the use of PCA pump for pain control

A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation Which of the following actions should the nurse take? (SATA) A. Keep the client NPO after midnight B. Inspect the electrode pads C. Wash the skin with plain water before placing the electrodes D. Instruct the client not talk during the test E. Administer an analgesic prior to the procedure

Inspect the electrode pads Wash the skin with plain water before placing the electrodes Instruct the client not talk during the test

The nurse knows that young infants are at risk for injury from shaken baby syndrome (SBS) because: 1. The anterior fontanel is open. 2. They have insufficient musculoskeletal support and a disproportionate head-to-body ratio. 3. They have an immature vascular system with veins and arteries that are more superficial. 4. The nurse knows there is immature myelination of the nervous system in a young infant.

Insufficient musculoskeletal support and a disproportionate head size

The nurse is caring for a child who has just been admitted to the pediatric floor with a diagnosis of bacterial meningitis. When reviewing the child's plan of care, which of the following orders would the nurse question? 1. Maintain isolation precautions until 24 hours after receiving intravenous antibiotics. 2. Intravenous fluids at 1 & 1/2 times regular maintenance. 3. Neurological checks every 4 hours. 4. Administer acetaminophen for temperatures higher than 38°C (100.4°F).

Intravenous fluids at 1 & 1/2 times regular maintenance

A nurse is reviewing serum laboratory results for four children. Which of the following values should the nurse report to the provider? 1. WBC 10,000 2. Lead 2mcg/dL 3. RBC 4.9 4. Iron 38 mcg/dL

Iron 38 mcg/dL

The nurse prepares to administer Baclofen into a child with CP who just had her hamstring surgically released the child's parents ask with the medication is for select the nurses best response. a. It is a medication that will help decrease the pain from her surgery b. it is a medication that will prevent her from having seizures c. it is a medication that will help control her spasms d. it is a medication that will help with bladder control

It is a medication that will help control her spasms

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness

Level of consciousness

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Place the client in a semi-Fowler's position B. Admit the client to a private room C. Measure head circumference every shift D. Implement seizure precautions

Measure head circumference every shift

A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering? a. Pneumococcal polysaccharide vaccine b. Bacille Calmette-Guérin (BCG) vaccine c. Meningococcal polysaccharide vaccine d. Influenza vaccine

Meningococcal polysaccharide vaccine

A home health nurse is developing a place of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care? A. Provide respite services for the parents B. Improve the client's communication skills C. Foster self-care activities D. Modify the environment

Modify the environment

A nurse is assessing a toddler who has infective endocarditis. Which of the following findings should the nurse expect? New heart murmur Weight gain Bradycardia Decreased body temperature

New Heart Murmur

What cerebrospinal fluid (CSF) analysis should the nurse expect with viral meningitis? Select all that apply a. Color is turbid. b. Protein count is normal. c. Glucose is decreased. d. Gram stain findings are negative. e. White blood cell (WBC) count is slightly elevated.

Protein is normal Gram stain is negative WBC count is slightly elevated

A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Which of the following interventions should the nurse include in the plan of care? A. Maintain infant in supine position B. Initiate contact precautions C. Provide latex free environment D. Limit visitors to immediate family

Provide a latex free environment

The nurse is to administer digoxin elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should: A. Record the heart rate and call the physician B. Record the heart rate and administer the medication C. Administer the medication and recheck the heart rate in 15 minutes D. Hold the medication and recheck the heart rate in 30 minutes

Record the HR and admin med

A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck extension traction. Which of the following actions should the nurse take? A. Reposition the child every 2 hr B. Remove the traction boot during baths C. Apply antibiotic ointment to pin sites daily D. Reduce fluid intake

Reposition the child every 2 hr.

A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority? A. Respiratory rate B. Burns of the mouth C. Bowel sounds D. Visual Acuity

Respiratory rate

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion? A. Photophobia B. Nuchal rigidity C. Positive Kernig's sign D. Restlessness

Restlessness

Which nursing diagnosis is most relevant in the first 12 hours of life for a neonate born with a myelomeningocele? a) Impaired physical mobility b) Delayed growth and development c) Risk for infection d) Constipation

Risk for infection