Peds Final Exam
18. What is the priority nursing concern for Terry, who is rubbing at his ears, acting fussy, refusing to suck, and has a temperature of 101.2°F (38.4°C)? 1. Pain 2. Poor nutrition 3. Recurrent ear infections 4. Elevated temperature
Ans: 1 Acute otitis media is painful, and the child is demonstrating behaviors indicative of pain. Symptoms are relieved with acetaminophen and application of a warm, moist towel to the outer ear. Poor nutrition and lack of fluid intake are concerns, but relief of pain will likely improve the child's willingness to suck and improve oral intake. The other concerns are pertinent but less urgent.
8. Which assessment finding for Billy is the most urgent and requires immediate intervention and notification of the pediatrician? 1. Sudden increase in respiratory rate and decreased breath sounds 2. Rattling cough productive of frothy, clear, gelati- nous sputum 3. Crackles auscultated on inspiration in the lower lung fields 4. Restlessness and wheezing auscultated at the end of expiration
Ans: 1 An increased respiratory rate and decreased breath sounds are ominous signs of airway obstruction. Respiratory arrest is imminent. A productive cough warrants close observation because the client is at risk for mucus plugs and bronchial spasm, which can cause an obstruction. Restlessness and wheezing are charac- teristic clinical manifestations of an asthma exacerba- tion and require attention but are not urgent. Crackles are suggestive of pneumonia and need to be monitored but are not the priority in this scenario. Respiratory arrest is the life-threatening event that the nurse must address.
55. A 10-year-old girl has completed a course of amoxicil- lin for a urinary tract infection (UTI). This is the sec- ond UTI the child has had this year. The child is in the 95th percentile for weight and has a history of consti- pation. Her parents ask the nurse for preventive strat- egies for UTIs. Which of the following preventive strategies is best for the nurse to recommend? 1. Increase fiber in the diet. 2. Drink cranberry juice. 3. Increased vitamin C in a diet. 4. Limit fluids at bedtime.
Ans: 1 Based on the history, this child's constipation is the most likely etiology of the UTI, and increasing dietary fiber is the best intervention. Urinary stasis from constipation is the primary cause of UTIs in chil- dren. Stool in the intestine prevents complete empty- ing of the bladder. There is no conclusive evidence to support that cranberry juice and vitamin C prevent UTIs. Limiting fluids at bedtime has not been shown to decrease UTI. Increasing fluids however, helps to flush bacteria out of the bladder.
26. The nurse has just received a change-of-shift report about these pediatric patients. Which patient will the nurse assess first? 1. A 1-year-old patient with hemophilia B who was admitted because of decreased responsiveness 2. A 3-year-old patient with von Willebrand disease who has a dose of desmopressin (DDAVP) scheduled 3. A 7-year-old patient with acute lymphocytic leukemia who has chemotherapy-induced thrombocytopenia 4. A 16-year-old patient with sickle cell disease who reports acute right lower quadrant abdominal pain
Ans: 1 Because decreased responsiveness in a 1-year-old patient with a clotting disorder may indicate intracerebral bleeding, this patient should be assessed immediately. The other patients also require assess- ments or interventions but are not at immediate risk for life-threatening or disabling complications
45. A tearful parent brings a child to the emergency department after the child takes an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the health care provider? 1. The ingested children's chewable vitamins contain iron. 2. The child has been treated previously for ingestion of toxic substances. 3. The child has been treated several times before for accidental injuries. 4. The child was nauseated and vomited once at home.
Ans: 1 Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. The other information needs additional investigation but will not change the immediate diagnostic testing or treatment plan.
30. The nurse is caring for a 3-year-old patient who has returned to the pediatric intensive care unit after insertion of a ventriculoperitoneal shunt to correct hydrocephalus. Which assessment finding is most important to communicate to the surgeon? 1. The child is crying and says, "It hurts!" 2. The right pupil is 1 mm larger than the left pupil. 3. The cardiac monitor shows a heart rate of 130 beats/min. 4. The head dressing has a 2-cm area of bloody drainage.
Ans: 2 Pupil dilation may indicate increased intra- cranial pressure and should be reported immediately to the surgeon. The other data are not unusual in a 3-year-old patient after surgery, although they indicate the need for ongoing assessments or interventions.
9. The pediatric unit charge nurse is working with a new RN. Which action by the new RN requires the most immediate action on the part of the pediatric unit charge nurse? 1. Wearing gloves, gowns, and a mask for a neutropenic child who is receiving chemotherapy 2. Placing a newly admitted child with respiratory syncytial virus (RSV) infection in a room with another child who has RSV 3. Wearing a N95 respirator mask when caring for a child with tuberculosis 4. Performing hand hygiene with soap and water after caring for a child with diarrhea caused by Clostridium difficile
Ans: 1 Protective isolation (wearing gloves, gowns, and mask) revealed no significant differences in infec- tion rates for children who are neutropenic. General standard precautions are advised with routine patient care. Although private rooms are preferred for patients who need droplet precautions, such as patients with RSV infection, they can be placed in rooms with other patients with exactly the same microorganism. An N95 respirator is recommended for tuberculosis. Washing hands with soap and water after caring for a patient
14. An unimmunized 7-year-old child who attends a local elementary school contracts rubeola (measles). The child has two siblings, ages 9 and 11 years, who also attend the elementary school. Which action by the school nurse is a priority? 1. Exclude the child and siblings from attending school for 21 days. 2. Notify all parents of children attending the school of the exposure. 3. Recommend that siblings receive the measles vaccine. 4. Recommend that siblings receive measles immunoglobulin.
Ans: 1 Rubeola is a highly contagious infectious dis- ease with severe consequences that include death. The Centers for Disease Control and Prevention reports that 9 of 10 susceptible persons with close contact to a person with measles will contract the disease. The incubation period is 7 to 21 days. Excluding the infected and exposed children during this period of time is a priority to prevent exposure of healthy chil- dren enrolled in the elementary school. Although it is important to notify the parents of the other children in the school of the exposure, limiting exposure of other children is the priority. Mumps, measles, and rubella vaccine administered within 72 hours of initial measles exposure and immunoglobulin administered within 6 days of exposure may provide some protection or modify the clinical course of the disease in unimmu- nized children; however, the priority is to prevent an epidemic by limiting exposure.
13. While working in the pediatric clinic, the nurse receives a telephone call from the parent of a 13-year-old child who is receiving chemotherapy for leukemia. The patient's sibling has chickenpox (vari- cella). Which action will the nurse anticipate taking next? 1. Administer varicella-zoster immune globulin to the patient. 2. Teach the parent about the correct use of acyclovir. 3. Educate the parent about contact and airborne precautions. 4. Prepare to admit the patient to a private room in the hospital.
Ans: 1 The administration of varicella-zoster immune globulin can prevent the development of varicella in immunosuppressed patients and will typically be pre- scribed. Acyclovir therapy and hospitalization may be required if the child develops a varicella-zoster virus infection. Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child is hospitalized with varicella.
1.. A 3-month-old infant arrives at the health center for a scheduled well-child visit. The parents ask the nurse why the infant extends the arms and legs in response to a loud sound. Which response by the nurse is best? 1. Inform the parents that this is a normal reflex that generally disappears by 4 to 6 months of age. 2. Tell the parents that if the behavior does not change by 6 months, the infant will need further evaluation. 3. Remind the parents that this is a normal response that indicates the infant's hearing is intact. 4. Reassure the parents that the behavior is normal and not an indicator of any problem such as cerebral palsy.
Ans: 1 The infant's behavior is consistent with the Moro and startle reflexes. The Moro reflex usually dis- appears by 6 months of age. The startle reflex usually disappears by 4 months of age. A hearing test is not based on response to loud sounds alone. Although it is true that further evaluation may be needed if the reflexes do not disappear, there is no need for the nurse to discuss this with the parents at this time. The infant's behavior is not consistent with cerebral palsy. Focus: Prioritization; Test Taking Tip: In studying pediatrics, pay attention to developmental milestones. Moro, startle, and Babinski reflexes are three classic examples of what the nurse observes during physical assessment.
49. A 16-year-old patient arrived at the cystic fibrosis (CF) clinic for a routine 3-month visit. The most recent respiratory culture results are negative. Which action is best for the nurse to take? 1. Place the patient in an exam room immediately upon arrival to the clinic. 2. Allow the patient to wait in the reception area until the provider is available to see the patient. 3. Allow the patient to wait in the reception area with a mask until the provider is available to see the patient. 4. Place the patient in a waiting area with other patients who also have negative respiratory cultures.
Ans: 1 This is a CF clinic, so this patient may be exposed to others with CF if he or she remains in the reception area. The CF Foundation recommends all individuals with CF, regardless of respiratory culture results, be separated from others with CF to reduce risk of droplet transmission of CF pathogens. National guidelines indicate that the best solution is that patients with CF not wait in common areas but be placed in a private exam room. However, when patients are in common waiting areas, a minimum distance of 3 feet (1 meter) between patients should be maintained if patients have CF
33. The nurse is caring for a child with a foreign body in the ear canal who has not been evaluated by the health care provider. Which actions should the nurse implement? Select all that apply. 1. Inspect the pinna for trauma. 2. Irrigate the auditory canal with warm water. 3. Obtain a history for the type of object. 4. Attempt to remove the object with forceps. 5. Use an otoscope to check for perforation.
Ans: 1, 3 The nurse should assess the pinna for trauma and obtain history for the type of object as a component of a complete assessment which could determine the course of action by the health care pro- vider. Some foreign bodies may swell when water is used for irrigation, further lodging the object in the auditory canal. Removing the object with forceps could traumatize the tympanic membrane and auditory canal further. Placing an otoscope in the auditory canal could wedge the object further into the canal.
48. The emergency department receives multiple individ- uals, mostly children, who were injured when the roof of a day-care center collapsed because of a heavy snow- fall. Based on physiologic differences in children com- pared with adults, for which injuries and complications will the nurse assess first? Select all that apply. 1. Head injuries 2. Bradycardia or junctional arrhythmias 3. Hypoxemia 4. Liver and spleen contusions 5. Hypothermia 6. Fractures of the long bones 7. Lumbar spines injuries
Ans: 1, 3, 4, 5 Children have proportionately larger heads that predispose them to head injuries. Hypox- emia is more likely because of their higher oxygen demand. Liver and spleen injuries are more likely because the thoracic cages of children offer less protection. Hypothermia is more likely because of children's thinner skin and proportionately larger body surface area. They have strong hearts; therefore, pulse rate will increase to compensate, but other arrhythmias are less likely to occur. Children have relatively flexible bones compared with those of adults. The most likely spinal injury in children is injury to the cervical area.
52. A 2-year-old child arrives at the health center for a rou- tine well-child visit. A complete blood count and lead level are obtained. The lead level is less than 10 mcg/ dL (0.483 μmol/L). The hemoglobin is 8 g/dL (80 g/ L). The hematocrit is 24% (0.24 volume fraction), and the mean corpuscular volume (MCV) is 65μm3 (65 fL). What questions should the nurse ask the par- ent to obtain a more thorough history? Select all that apply. 1. Does your child eat nonfood substances? 2. Is your child more prone to infections? . 3. Has your child experienced hair loss? 4. Does your child frequently have nosebleeds? 5. How much milk does your child drink?
Ans: 1, 5 Iron deficiency anemia is a microcytic anemia. Laboratory findings consistent with iron deficiency anemia include low hemoglobin, hematocrit, and MCV. Additionally, the patient may have thrombocytosis, which is an increase in the number of platelets; so the child will not be more likely to have nosebleeds. The white blood cell count (WBC) and WBC differential are not affected by anemia; there- fore, the child will not be more prone to infections. Children with iron deficiency anemia experience pica, which is a consumption of nonfood items. Excessive cow's milk intake has been found to cause anemia by irritating the intestine and resulting in microscopic blood loss from the gastrointestinal tract.
53. A 2-year-old child arrives at the health center for a rou- tine well-child visit. A complete blood count and lead level are obtained. The lead level is less than 10 mcg/ dL (0.483 μmol/L). The hemoglobin is 8 g/dL (80 g/ L). The hematocrit is 24% (0.24 volume fraction), and the mean corpuscular volume (MCV) is 65μm3 (65 fL). What questions should the nurse ask the par- ent to obtain a more thorough history? Select all that apply. 1. Does your child eat nonfood substances? 2. Is your child more prone to infections? 3. Has your child experienced hair loss? 4. Does your child frequently have nosebleeds? 5. How much milk does your child drink?
Ans: 1, 5 Iron supplementation can stain the teeth and has an unpleasant taste. By administering the iron with a syringe to the back of the throat, it will mask the taste and prevent staining of the teeth. The vitamin C in orange juice increases iron absorption and may mask the unpleasant taste. Chocolate contains caffeine, which interferes with the absorption of iron. Milk and food also interfere with the absorption of iron. Although allowing a child to drink the iron through a straw is feasible for an older child, a 10-month-old child cannot developmentally perform this task.
28. Which laboratory value is consistent with clubbing of Rebecca's finger and toe nails? 1. Elevated white blood cell (WBC) count 2. Elevated red blood cell (RBC) count 3. Decreased hematocrit 4. Decreased mean corpuscular volume
Ans: 2 Clubbing occurs with chronic arterial desaturation. Chronic arterial desaturation can result in polycythemia (increased RBCs). This would result in increased hematocrit, not a decrease. Increased WBCs are indicative of infection. Decreased mean corpuscular volume is associated with diseases that may affect formation of the RBCs such as microscopic anemia resulting from iron deficiency.
An excited mother calls the nurse for advice. "My child got cleaning solution in her eyes, and I rinsed her eyes with water for a few minutes. What should I do? She is still screaming!" What does the nurse instruct the caller to do first? 1. Comfort the child and check her vision. 2. Continue to irrigate the eyes with water. 3. Call the Poison Control Center. 4. Call 911 to request an ambulance.
Ans: 2 Even though the child is screaming, the mother must continue to irrigate the eyes for at least 20 minutes. Another adult, if present, should call the Poison Control Center and 911.
30. Four-year-old Bobby is admitted to the pediatric unit with Kawasaki disease. Today is the 7th day of fever. Laboratory studies reveal C-reactive protein of 3.1 mg/dL (29.5 mmol/L) and a WBC count of 17,000 mm3 (17 109/L). Which pharmacologic intervention should the nurse anticipate at this time? 1. IV methylprednisolone 2. IV immunoglobulin 3. IV ibuprofen 4. IV infliximab
Ans: 2 IV immunoglobulin is the first line of treat- ment for children with Kawasaki disease because it has been demonstrated to reduce the incidence of coronary artery aneurysms (this is life threatening). Methylpred- nisolone and infliximab are indicated for refractory Kawasaki disease. Ibuprofen may be administered for fever, which is a symptom of Kawasaki disease, but does not decrease the incidence of coronary aneurysm. Additionally, it usually is not administered intrave- nously.
16. An adolescent with cystic fibrosis (CF) is admitted to the pediatric unit with increased shortness of breath and pneumonia. Which nursing activity is most important to include in the patient's care? 1. Allowing the adolescent to decide if aerosolized medications are needed 2. Scheduling postural drainage and chest physiotherapy every 4 hours 3. Placing the adolescent in a room with another adolescent with CF 4. Encouraging oral fluid intake of 2400 mL/day
Ans: 2 National guidelines indicate that airway clearance techniques are critical for patients with CF; hence, postural drainage and chest physiotherapy are a priority. National guidelines also indicate that chil- dren and adolescents with CF who are hospitalized with respiratory illnesses should be placed on contact precautions. Furthermore, people with CF should be separated from others with CF to reduce droplet trans- mission of CF pathogens. There is no evidence that increased fluid intake adequately thins respiratory secretions, and chest physiotherapy is the priority.
36. A 2-year-old child who has abdominal pain is diagnosed with intussusception. A hydrostatic reduction has been performed. Which finding should be reported immediately before surgery proceeds? 1. Palpable sausage-shaped abdominal mass 2. Passage of normal brown stool 3. Passage of currant jelly-like stools 4. Frequent nausea and vomiting
Ans: 2 Passage of brown stool indicates resolution of the intussusception, so surgery may not be necessary. The other findings are part of the clinical presentation of this disorder
25. The RN is working with an LPN/LVN to provide care for a 10-year-old patient with severe abdominal, hip, and knee pain caused by a sickle cell crisis. Which action taken by the LPN/LVN requires the RN to intervene immediately? 1. Administering oral pain medication as needed 2. Positioning cold packs on the child's knees 3. Encouraging increased fluid intake 4. Monitoring vital signs every 2 hours
Ans: 2 Sickle cell crisis may include vaso-occlusive crisis, splenic sequestration, and aplastic crisis. The symptoms experienced by this child are indicative of both vaso-occlusive crisis and splenic sequestration. Placing cold packs on the knees of a child with vaso- occlusive crisis results in vasoconstriction, placing the child at risk for thrombosis formation. Encouraging increased fluid intake is advised to prevent thrombosis formation. Monitoring vital signs is a method to assess for life-threatening complications associated with both vaso-occlusive crisis and splenic sequestration. Vaso- occlusive crisis is associated with severe pain and pain medication is recommended
6. Six-year-old Billy woke last night with dyspnea, restlessness, wheezing, and cough. Mother and child spent the night in a reclining chair. His mother declares, "He is having an asthma attack. We are both exhausted. I'm tired of waiting forever to see the doctor!" What is the priority nursing concern? 1. Billy's poor sleep quality and restlessness 2. Billy's ongoing shortness of breath 3. Mother's report of feeling exhausted 4. Mother's frustration with health care system
Ans: 2 The priority is the child's ongoing dyspnea, which indicates poor control of his asthma and pos- sible hypoxemia. Additionally, restlessness is a clinical manifestation of impending respiratory failure. This requires rapid intervention. The mother's exhaustion should improve with treatment for the asthma attack. The mother's frustration with Billy's health care is important to address, but this is not immediately life threatening
3. A 9-month-old child arrives at the health center with his mother for immunizations. The child is fussy with rhinorrhea and has an axillary temperature of 100.4°F (38°C). The pediatrician has determined that the child has nasopharyngitis. What is the priority action? 1. Administer half of the immunizations and reschedule a subsequent appointment for the other half. 2. Advise the mother that fever is a contraindication for immunization and reschedule the appointment. 3. Administer acetaminophen to reduce fever and apply an anesthetic cream to the injection site. 4. Advise the mother that the child will likely need an antibiotic and reschedule the appointment.
Ans: 3 Acetaminophen will reduce the child's fever, and an anesthetic cream will reduce pain at the injec- tion site. By taking this action, the nurse is preparing to give the child the recommended immunizations. Fever and minor illnesses are not a contraindication for immunizations. Nasopharyngitis is a common cold that is caused by a virus, and antibiotics are not indi- cated for viruses. Additionally, antibiotics are not a contraindication for immunizations. Splitting immu- nizations is not recommended because it would result in immunization delay. The scheduling of immuniza- tions is such that it protects children at times when they are most vulnerable to morbidity and mortality related to the natural diseases. Delayed immunization places the child at risk for vaccine-preventable diseases.
7. As the nurse approaches Billy, which presentation would be of most concern and require immediate intervention? 1. Alert and irritable, lying recumbent on the examination table 2. Awake and nervous, sitting upright and crying, skin pale and dry 3. Agitated, sweating, and sitting upright with shoulders hunched forward 4. Asleep in a side-lying position breathing through open mouth
Ans: 3 Agitation and sweating are signs of severe respiratory distress. In addition, the child is attempting to maximize the thoracic cavity and to oxygenate more effectively by sitting upright and hunching forward.
21. The nurse is observing a preschool classroom of children between the ages of 3 to 4 years of age. When planning actions to ensure that each child meets nor- mal developmental goals, which child will require the most immediate intervention? 1. A 3-year-old boy who needs help dressing 2. A 4-year-old girl who has an imaginary friend 3. A 4-year-old girl who engages only in parallel play 4. A 3-year-old boy who draws stick figures
Ans: 3 At 4 years of age, children engage in pretend play. Parallel play is seen in younger children between the ages of 2 and 3 years when they play side by side with limited interaction. The other behaviors are developmentally appropriate. The nurse will plan interventions to ensure that all the children meet devel- opmental goals, but the 4-year-old child engaging only in parallel play will require the most immediate inter- vention.
33. Eight-year-old Charlie had a laparoscopic appendectomy. During surgery, the appendix perforated. Charlie arrives on the pediatric unit from the operating room. His weight on admission was 46 lbs (21 kg). He has a peripheral IV line in the left basilic vein with D5W and 20mEq/L (20 mmol/L) of KCl running at 70 mL/hr. A nasogastric tube (NG) is attached to low suction. Charlie's parents ask the nurse if the NG tube can be removed because it is irritating Charlie's nose. What is the nurse's best response? 1. "The NG tube is necessary to prevent aspiration of the stomach contents into the lungs." 2. "The NG tube is necessary because Charlie will need to have feedings through it." 3. "The NG tube is necessary to keep Charlie's stomach empty, allowing the intestines to rest." 4. "The NG tube is necessary to prevent swallowed air from building up in the stomach."
Ans: 3 Charlie has decreased bowel sounds and per- forated appendix, which places him at risk for ileus. Insertion of a NG tube is recommended for gastric decompression.
22. After receiving the change-of-shift report, which patient should the nurse assess first? 1. An 18-month-old patient with coarctation of the aorta who has decreased pedal pulses 2. A 3-year-old patient with rheumatic fever who reports severe knee pain 3. A 5-year-old patient with endocarditis who has crackles audible throughout both lungs 4. An 8-year-old patient with Kawasaki disease who has a temperature of 102.2°F (38.9°C)
Ans: 3 Crackles throughout both lungs indicate that the child has severe left ventricular failure as a compli- cation of endocarditis. Hypoxemia is likely, so the child needs rapid assessment of oxygen saturation, initiation of supplemental oxygen delivery, and administration of medications such as diuretics. The other children should also be assessed as quickly as possible, but they are not experiencing life-threatening complications of their medical diagnoses.
4. A parent calls in for advice because her 18-month-old toddler has stumbled and bumped his head on the cof- fee table. Which symptom is cause for the greatest concern? 1. A swelling the size of a golf ball that is tender to the touch 2. Two episodes of vomiting a small amount of undigested food 3. Continuous crying that is ,unrelieved by familiar comfort measures 4. Gaping1.5-inch(4-cm )laceration on the forehead, with bleeding controlled by pressure
Ans: 3 Inconsolable crying for 2 hours is excessive, prolonged, and abnormal and may be a sign of increased intracranial pressure (ICP). Instruct the par- ent to call 911. The swelling can be treated with ice packs. Vomiting can be a sign of increased ICP, but fewer than three episodes is usually associated with minor injuries. A laceration on the forehead needs suturing, which should be done within several hours to prevent infection and reduce scarring, but the more pressing issue is to reaffirm with the caller that the bleeding is controlled.
28. A 4-year-old patient with acute lymphocytic leukemia has these medications ordered. Which one is most important to double-check with another licensed nurse? 1. Prednisone 1 mg PO 2. Amoxicillin 250 mg PO 3. Methotrexate 10 mg PO 4. Filgrastim 5 mcg subcutaneously
Ans: 3 Methotrexate is a high-alert drug, and extra precautions, such as double checking with another nurse, should be taken when administering this med- ication. Although many pediatric units have a policy requiring that all medication administration to children be double-checked, the other medications listed are not on the high-alert list published by the Institute for Safe Medication Practices. Focus: Prioritization; Test Taking Tip: For test taking purposes and for safety in the clinical setting, it is worthwhile to memorize medications that are considered "high- alert" drugs.
4. The nurse is caring for several children with cancer who are receiving chemotherapy. The nurse is reviewing the morning laboratory results for each of the patients. Which patient condition combined with the indicated laboratory result would cause the nurse the greatest concern? 1. Nausea and vomiting with a potassium level of 3.3 mEq/L (3.3 mmol/L) 2. Epistaxis with a platelet count of 100,000/mm3 (100 109/L) 3. Fever with an absolute neutrophil count of 450/ mm3 (450 109/L) 4. Fatigue with a hemoglobin level of 8 g/dL (80 g/L)
Ans: 3 National guidelines indicate that rapid treat- ment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the priority. A potassium level of 3.3 mEq/L (3.3 mmol/L) is bor- derline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontaneous hemorrhage is not expected until the platelet count drops below 20,000 mm3 (20 109/L). Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue.
15. The school nurse is performing developmental screen- ings for children who will be entering preschool. A 4-year-old girl excitedly tells the nurse about her recent birthday party. As she relates the details of the event, she frequently stutters. Which action by the nurse is most appropriate at this time? 1. Refer the child to an audiologist. 2. Obtain a detailed birth history from the parents. 3. Document the findings on the child's school record. 4. Refer the child to a speech pathologist.
Ans: 3 Stuttering during the preschool years is a nor- mal variation, particularly when excited or upset. The cause is attributed to preschool children's increased cognitive abilities and imagination such that their speech cannot keep up with their thoughts. Docu- menting this on the child's record is important for con- tinued observation to determine if it extends beyond the preschool years.
40.. A parent calls the emergency department, saying, "I think my toddler might have swallowed a little toy. He is breathing okay, but I don't know what to do." What is the most essential question to ask the caller? 1. "Has he vomited?" 2. "Have you been checking his stools?" 3. "What do you think he swallowed?" 4. "Has he been coughing?"
Ans: 3 Theories about bed-wetting relate it to immature bladder and deep sleep patterns. Although it is true that most children stop bed-wetting by the time they start school, this does not answer the mother's question. Many boys wet the bed until after the age of 5 years. The fourth response is not accurate because often bed-wetting is not within the control of a 5-year-old child.
56. A 16-year-old boy comes into the office of the school nurse complaining of left hip pain that began when playing basketball in gym class. The boy is in the 85th percentile for height and weight. He complains of increased pain with weight bearing. The nurse observes out-toeing of the left leg with ambulation. Which nursing action is a priority? 1. Administer ibuprofen and instruct the boy to rest. 2. Apply heat to the hip and elevate the left leg. 3. Refer the boy to the emergency department. 4. Apply ice to the hip and immobilize it with a splint.
Ans: 3 This boy is presenting with classic symptoms of slipped capital femoral epiphysis (SCFE), which is a slippage of the femoral head at the proximal epiphyseal plate. SCFE is an emergency. A delay in treatment can result in necrosis and death of the femoral head. Although the exact cause of SCFE is unknown, there is an increased incidence in boys. Additionally, obesity is a risk factor for SCFE.
5. A 7-month-old infant arrives at the health center for a scheduled well-child visit. When the nurse approaches the infant to obtain vital signs, the infant cries vigorously and clings fearfully to the mother. Which of the following phenomena provides the best explanation for the infant's behavior? 1. Separation anxiety 2. Disassociation disorder 3. Stranger anxiety 4. Autism spectrum
Ans: 3 This infant is displaying stranger anxiety; the child becomes anxious when exposed to unfamiliar people (strangers). Separation anxiety occurs when the child is separated from the primary caregiver; anxiety and crying are also common behaviors. Stranger anxiety and separation anxiety are concurrent and generally begin at 7 to 8 months of age. Disassociation dis- order is characterized by disconnected thoughts and is not a disorder of infancy. Autism spectrum is characterized by poor social interaction. The age of the child is significant because autism is not usually detected at 7 months of age.
54. Parents of a 6-month-old girl bring the infant to the emergency department because "she has not held any- thing down for the entire day." The nurse obtains a fingerstick blood glucose of 94 (5.22 mmol/L). The infant's rectal temperature is 101°F (38.3°C), heart rate is 198 beats/min, respiratory rate is 40 breaths/ min, and blood pressure 60/38 mm Hg in the left arm. Which nursing action is a priority? 1. Administer an antiemetic rectally. 2. Administer a bolus of D10W. 3. Administer a bolus of normal saline. 4. Administer an antipyretic rectally.
Ans: 3 This infant is experiencing severe dehydra- tion, which is evidenced by tachycardia and hypoten- sion. The child is at risk for hypovolemic shock, which is a life-threatening event. A bolus of normal saline or lactated Ringer's solution of 20 mL/kg is the standard of care to establish hemodynamic stabil- ity. The blood glucose is normal. The safety profile for antiemetics have not been established with infants, and the priority for this patient is to establish hemodynamic stability. Fever can cause increased fluid loss; however, the priority in this life-threatening situation is to estab- lish hemodynamic stability.
42. Parents of a 13-year-old adolescent girl expressed con- cern because she spends "quite a bit of time in her room alone in front of the mirror." The girl's height and weight are in the 50th percentile. In the exam room, the girl is quiet but does answer questions appropriately. What advice should the nurse provide to the parents? 1. "Further evaluation by a psychologist is needed because your daughter spends a lot of time alone in her room." 2. "Limit the amount of time that your daughter is allowed to spend alone in her room." 3. "This behavior is normal. Your daughter is adjust- ing to the physical changes she is experiencing." 4. "This behavior may be associated with depression, and further evaluation by a counselor is advised."
Ans: 3 This is normal behavior in early adolescence. During this time period, adolescents are conscious of their rapid physical changes. As a result, they spend more time in front of the mirror inspecting their bod- ies. Consider that the height and weight are normal; therefore, an eating disorder is not likely. Also, the girl does answer questions appropriately, so mental health issues are not likely. Focus: Prioritization; Test Tak- ing Tip: It will be helpful to know what types of phys- ical and mental health disorders are common at various developmental stages because these issues are likely to be on the NCLEX® Examination and will occur com- monly in a pediatric nursing practice setting.
18. An adolescent with cystic fibrosis (CF) is admitted to the pediatric unit with increased shortness of breath and pneumonia. Which nursing activity is most important to include in the patient's care? 1. Allowing the adolescent to decide if aerosolized medications are needed 2. Scheduling postural drainage and chest physiotherapy every 4 hours 3. Placing the adolescent in a room with another adolescent with CF 4. Encouraging oral fluid intake of 2400 mL/day
Ans: 3 Tracheal deviation suggests tension pneumo- thorax, a possible complication of positive-pressure ventilation. The nurse will need to communicate rap- idly with the health care provider and assist with actions such as chest tube insertion. The heart rate, crackles, and oxygen saturation will be reported to the health care provider but are expected in RDS and do not require immediate intervention.
24. The nurse is obtaining the history and physical information for a child who is recovering from Kawasaki disease and receives aspirin therapy. Which information concerns the nurse the most? 1. The child attends a day-care center 5 days a week. 2. The child's fingers have areas of peeling skin. 3. The child is very irritable and cries frequently. 4. The child has not received any immunizations.
Ans: 4 Children who receive aspirin therapy are at risk for the development of Reye syndrome if they con- tract viral illnesses such as varicella or influenza, so the lack of immunization is the greatest concern for this child. Peeling skin on the fingers and toes and irritabil- ity are consistent with Kawasaki disease but do not require any change in therapy. Because Kawasaki dis- ease is not a communicable disease, there is no risk for transmission to other children in the day care (although assuring that immunizations are up to date before returning to day care is important).
20. The nurse obtains this information when assessing a 3-year-old patient with uncorrected tetralogy of Fallot who is crying. Which finding requires immedi- ate action? 1. The apical pulse rate is 118 beats/min. 2. A loud systolic murmur is heard in the pulmonic area. 3. There is marked clubbing of the child's nail beds. 4. The lips and oral mucosa are dusky in color.
Ans: 4 Circumoral cyanosis indicates a drop in the partial pressure of oxygen that may precipitate seizures and loss of consciousness. The nurse should rapidly place the child in a knee-chest position, administer oxygen, and take steps to calm the child. The other assessment data are expected in a child with congenital heart defects such as tetralogy of Fallot.
37. A parent calls the emergency department, saying, "I think my toddler might have swallowed a little toy. He is breathing okay, but I don't know what to do." What is the most essential question to ask the caller? 1. "Has he vomited?" 2. "Have you been checking his stools?" 3. "What do you think he swallowed?" 4. "Has he been coughing?"
Ans: 4 Even though the caller reports that the child is "breathing okay," additional questions about possible airway obstruction are the priority (e.g., coughing, gag- ging, choking, drooling, refusing to eat or drink). Gas- trointestinal symptoms should be assessed but are less urgent. The type of foreign body, in the absence of symptoms, may dictate a wait-and-see approach, in which case the parent would be directed to check the stools for passage of the foreign body. Focus: Prioriti- zation; Test Taking Tip: In emergency situations, apply the ABCs (airway, breathing, and circulation) before proceeding to other actions.
6. A 6-year-old child who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is the nurse's best response to this behavior? 1. Remind the child that foods tasted good today and will help her or his body to get strong. 2. Allow the mother and child time alone to review and control the behavior. 3. Ask the mother to leave until the child can finish eating and then invite her back. 4. Explain to the mother that the behavior could be a normal expression of anger.
Ans: 4 Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions under- lying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is pre- pared to deal with the behavior in a constructive man- ner. Asking the mother to leave the child suggests that the mother is a source of stress
7. An 18-month-old child has oral mucositis secondary to chemotherapy. Which task should the nurse dele- gate to the unlicensed assistive personnel (UAP)? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Feeding the child a bland, moist, soft diet
Ans: 4 Helping the child to eat is within the scope of responsibilities for a UAP. Assessing ability and will- ingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. An 18-month-old child is not able to swish and spit, which could result in swallowing the mouthwash. Mouth- wash is not intended for swallowing because it can con- tain alcohol and other ingredients not safe for ingestion.
29. Four-year-old Bobby is admitted to the pediatric unit with Kawasaki disease. Today is the 7th day of fever. Laboratory studies reveal C-reactive protein of 3.1 mg/dL (29.5 mmol/L) and a WBC count of 17,000 mm3 (17 109/L). Which nursing assessment is a priority? 1. Obtain a rectal temperature. 2. Auscultate the lungs. 3. Obtain a blood pressure. 4. Auscultate the heart.
Ans: 4 Kawasaki disease is one of the most common causes of vasculitis in children and may result in cardiac complications. Early indications of cardiac involve- ment include tachycardia out of proportion to fever and a gallop rhythm; therefore, auscultating the heart is the priority. It has already been established that this child has a fever; thus, obtaining a rectal temperature is not a priority. Respiratory changes are not characteris- tic of complications of Kawasaki disease. Although shock is a complication of Kawasaki disease, hypoten- sion is a late ominous sign of shock in children. In fact, tachycardia is an earlier sign of shock in children, which further validates the need to auscultate the heart.
29. A 6-year-old child arrives in the emergency department with active seizures. Which assessment is a priority for the nurse to obtain? 1. Heart rate 2. Body mass index (BMI) 3. Blood pressure 4. Weight
Ans: 4 The child will need medication to control the seizures. Medications for children are based on weight in kilograms. Although heart rate and blood pressure may be obtained, the priority is to stop the seizures with medication. There is no clinical indication for BMI for a child with active seizures.
31. The nurse is caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of most concern? 1. Bulging of the sac when the infant cries 2. Oozing of stool from the anal sphincter 3. Flaccid paralysis of both legs 4. Temperature of 101.8°F (38.8°C)
Ans: 4 The elevated temperature indicates possible infection and should be reported immediately to the surgeon so that treatment can be started. The other data are typical in an infant with myelomeningocele.
32. Eight-year-old Charlie had a laparoscopic appendectomy. During surgery, the appendix perforated. Charlie arrives on the pediatric unit from the operating room. His weight on admission was 46 lbs (21 kg). He has a peripheral IV line in the left basilic vein with D5W and 20mEq/L (20 mmol/L) of KCl running at 70 mL/hr. A nasogastric tube (NG) is attached to low suction. Which assessment should be most concerning to the nurse? 1. Oral temperature of 100.4°F (38°C) 2. Decreased bowel sounds in all quadrants 3. Urine output of 160 mL over 4 hours 4. Respiratory rate of 15 breaths per minute
Ans: 4 The respiratory rate is low and indicates possible postoperative atelectasis. It is expected that after a perforated appendix, the client may have a slightly elevated temperature and decreased bowel sounds. A urine output of 160 mL over 4 hours is normal based on 1 to 2 mL/kg/hr.
57. toddler is brought to the health center for a fever of 102°F (39°C) and a sore throat. As the nurse places a toddler and his parents in the exam room, the child experiences a tonic-clonic seizure. Which nursing action is a priority? 1. Assess the child's level of consciousness. 2. Obtain an oxygen saturation. 3. Loosen the child's clothing. 4. Position the child in side-lying position.
Ans: 4 To ensure safety and prevent aspiration the first action by the nurse should be to position the child in side-lying position. Other assessment and actions will follow this initial step.