Peds

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

A nurse is assessing a client who has spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? A. Apply downward pressure while the client shrugs his shoulders upward B. Apply resistance while the client lifts his legs from the bed C. Ask the client to grasp an object and form a first D. Apply resistance while the client flexes his arms

A. Apply downward pressure while the client shrugs his shoulders upward

A nurse is instructing the caregiver of a toddler who has bacterial conjuctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide? A. Apply the ointment in a thin line into the conjunctival sac B. Ask the child to look down before applying the ointment C. Always wipe from the outer to the inner canthus when wiping away secretions D. Use a sterile glove and applicator to apply the antibiotic ointment

A. Apply the ointment in a thin line into the conjunctival sac

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

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

A nurse is caring for an 8 year old who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission? A. Auscultating the rate and the 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

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

A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this disease? A. Cardiovascular B. Gastrintestinal C. Integumentary D. Respiratory

A. Cardiovascular

A nurse is a provider's office is assessing a client who has a rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition? A. Anorexia B. Knuckle deformity C. Low-grade fever D. Weight loss

B. Knuckle deformity

A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of the following warnings over the child's bed? A. Do not palpate abdomen B. No venipuncture or blood pressure in left arm C. Contact precautions D. Collect all urine

A. Do not palpate abdomen

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching? A. Eating a high fiber will reduce my risk for developing skin cancer B. I should check my skin monthly for any changes C. I should avoid the use of tanning booths D. I should use suncreen even on cloudy days

A. Eating a high fiber will reduce my risk for developing skin cancer

A nurse is caring for a client who has an ankle sprain. Which of the following actions should the nurse take? (Select all that apply) A. Encourage rest B. Perform passive range-of-motion exercises to the ankle C. Apply heat to the ankle D. Place a compression bandage on the ankle E. Elevate the ankle

A. Encourage rest D. Place a compression bandage on the ankle E. Elevate the ankle

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 recent? 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 past 2 weeks?

A. Has your son had a sore throat recent?

A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor? A. Headache B. Dependent edema C. Polyuria D. Photosensitivity

A. Headache

A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply) A. Hypotension B. Polyuria C. Hyperthermia D. Absence of bowel sounds E. Weakened gag reflex

A. Hypotension D. Absence of bowel sounds E. Weakened gag reflex

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

A. Hypotension D. Weak pulses E. Murmur

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 bowel movement D. I do wheelchair exercises while watching TV

A. I only need to catheterize myself twice every day

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions? A. I'll apply ice to my ankle today and tomorrow B. I'll rewrap my ankle starting from the knee down C. I'll bear weight on my ankle for 10 minutes every hour D. I'll put a heating pad on my ankle at bedtime tonight

A. I'll apply ice to my ankle today and tomorrow

A nurse is caring for a client who has increased intracranial pressure (ICP) following a close-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe B. Place the client in a supine position C. Place a warming blanket on the client D. Use log rolling to reposition the client

A. Instruct the client to cough and deep breathe

A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take? A. Log roll the client every 2 hr B. Assist the client to sit upright in a chair for 4 hr at a time C. Expect clear drainage on the spinal dressing D. Elevate the client's legs when he is sitting in a chair

A. Log roll the client every 2 hr

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply)0 A. Loosen restrictive clothing B. Insert a bite stick into the client's mouth C. Place the client into a supine position D. Place a pillow under the client's head E. Apply restraints

A. Loosen restrictive clothing D. Place a pillow under the client's head

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? A. Maintain the integrity of the sac B. Promote maternal-infant bonding C. Educate the parents about the defect D. Provide age-appropriate stimulation

A. Maintain the integrity of the sac

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? A. Paresthesia B. Hemiplegia C. Quadriplegia D. Paraplegia

D. Paraplegia

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply) A. Monitor peripheral pulses in the affect extremity B. Position weights against the foot of the bed C. Adjust the prescribed weights every shift D. Examine the skin under the traction splint E. Assess the temperature of the affected extremity

A. Monitor peripheral pulses in the affect extremity D. Examine the skin under the traction splint E. Assess the temperature of the affected extremity

A nurse working on a medical unit is caring for client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? A. Obtain IV access B. Keep the lights on when the client is sleeping C. Place the client's bed in the high position D. Keep a padded tongue blade available at the client's bedside

A. Obtain IV access

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is a priority action for the nurse to take? A. Perform a neurovascular assessment B. Explain the discharge instructions to the client and parents C. Provide reassurance to the client and parents D. Apply an ice pack to the casted leg

A. Perform a neurovascular assessment

A nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning the client? (Select all that apply) A. Remove pillows prior to repositioning B. Elevate the bed to waist height C. Position the client towards the edge of the bed on the side the client will face after turning D. Stand with feet wide apart E. Face the direction of movement when positioning the client

A. Remove pillows prior to repositioning B. Elevate the bed to waist height D. Stand with feet wide apart E. Face the direction of movement when positioning the client

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 antiobiotic ointment to pin sites daily D. Reduce fluid intake

A. Reposition the child every 2 hr

A nurse is assisting with a routine examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders? A. Scoliosis B. Kyphosis C. Lordosis E. Torticollis

A. Scoliosis

A nurse is reviewing laboratory values for a client who has systemic lupus erythematous (SLE). Which of the following values should give the nurse the best indication of the client's renal function? A. Serum creatinine B. Blood urea nitrogen (BUN) C. Serum sodium D. Urine-specific gravity

A. Serum creatinine

A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following instructions should the nurse include? A. Take this medication with food if nausea develops B. Monitor for muscle pain C. Expect to have increased bruising D. Increase your intake of grapefruit juice

B. Monitor for muscle pain

A nurse is caring for a 2-year-old child who has seizure and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose? A. Shake the container vigorously B. Be sure the child has not eaten within the hour C. Perform mouth care D. Check the child's blood pressure

A. Shake the container vigorously

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply) A. Slight pain at the insertion site B. Serous drainage on the dressing C. Movement of the pin at the insertion site D. Elastic bandages secure around the traction ropes E. Minimal edema around the pin

A. Slight pain at the insertion site B. Serous drainage on the dressing E. Minimal edema around the pin

A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation? A. Tachypnea B. Hypertension C. Bradycardia D. Swollen calf

A. Tachypnea

A nurse is caring for a child who has a fracture of the forearm. The parent tells the nurse that the provider said it was a greenstick fracture and asks what that means. Which of the following statements should the nurse make? A. The bone is broken on one side and bent on the other side. B. Fragments of bone have splintered into the surrounding tissue. C. The bone ends have been forced toward each other. D. The sharp edge of the bone has broken through the skin.

A. The bone is broken on one side and bent on the other side.

A nurse is an urgent care center is caring for a client who has a greenstick fracture of the forearm. The nurse should explain that which of the following injuries has occurred with a greenstick fracture? A. The bone is cracked lengthwise but did not break all the way through B. Fragments of bone have splintered into the surrounding tissue C. The bone ends have been forced toward each other D. Sharp edge of the bone has broken through the skin

A. The bone is cracked lengthwise but did not break all the way through

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side B. Check the client's motor strength C. Loosen the clothing around the client's waist D. Document the time the seizure began

A. Turn the client's head to the side

A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take? A. Wrap the arm of the child's doll or toy prior to the procedure B. Tell the child, This will make your arm feel better C. Place a heated fan at the bedside to facilitate drying D. Support the casted arm with a firm grasp

A. Wrap the arm of the child's doll or toy prior to the procedure

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? A. Place the wheelchair at a 90 degree angle to the bed B. Lock the wheels of the bed and the wheelchair C. Acquire the help of several people to life the client D. Elevate the bed to a position of comfort for the nurse

B. Lock the wheels of the bed and the wheelchair

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? A. A grey-colored, non-purpuric papular rash B. A dry, red rash across the bridge of the nose and on the cheeks C. Pitting edema of the hands and fingers D. Subcutaneous nodules on the ulnar side of the arm

B. A dry, red rash across the bridge of the nose and on the cheeks

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

B. A sibling who has had a sore throat 3 weeks ago

A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching? A. Drying time is prolonged with a synthetic cast B. A synthetic cast is weighs less C. A plaster cast requires expensive equipment for application D. A synthetic case immobilizes bone fractures more effectively

B. A synthetic cast is weighs less

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? A. Sleep on the abdomen to facilitate wound healing B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week C. Bend at the waist to pick objects up from the floor D. Notify the surgeon if white drainage develops on the eyelids

B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week

A nurse is teaching a client who has a new prescription for aspirin to treat rheumatoid arthritis. The nurse should include to monitor for which of the following adverse effects of this medication? A. Constipation B. Bleeding C. Blurred vision D. Insomnia

B. Bleeding

A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction? A. Identity crisis B. Body image changes C. Feelings of displacement D. Loss of privacy

B. Body image changes

A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that is disease is caused by which of the following types of hypersensitivities? A. Immediate B. Cytotoxic C. Immune complex-mediated D. Delayed

B. Cytotoxic

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply) A. Short attention span B. Delayed language development C. Spinning a toy repetitively D. Ritualistic behavior E. Consistent limit testing

B. Delayed language development C. Spinning a toy repetitively D. Ritualistic behavior

A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which of the following changes is an early manifestations of RA? A. Morning stiffness B. Fatigue C. Temporomandibular joint pain C. Baker's cysts

B. Fatigue

A nurse is providing discharge instructions to the parents 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 24 hr D. Assist the child to take a tub bath for the first 3 days

B. Give the child acetaminophen for discomfort

A nurse is caring for a female client who has rheumatoid arthritis and asks the nurse if it is safe for her to take aspirin. The nurse should recognize which of the following findings in the client's history is a contraindication to this medication? A. Report of recent migraine headaches B. History of gastric ulcers C. Current diagnosis of glaucoma D. Prior reports of amenorrhea

B. History of gastric ulcers

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider? A. My eye really itches, but i'm not trying to rub it B. I need something for the pain in my eye. I can't stand it. C. It's hard to see with a patch on one eye. I'm afraid of failing. D. The bright light in this room is really bothering me.

B. I need something for the pain in my eye. I can't stand it.

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

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

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure? A. Brisk pupillary reaction to light B. Increased sleeping C. Tachycardia D. Depressed fontanels

B. Increased sleeping

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan? A. Instruct the client to flex and extend the ankle twice daily B. Monitor the client's pedal pulses every hour C. Remove the weights every four hours D. Evaluate pressure points daily

B. Monitor the client's pedal pulses every hour

A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make? A. The blood supply to the bone is disrupted B. Normal bone growth can be affected C. Bone marrow can be lost through the fracture D. The younger the child the longer the healing process will take

B. Normal bone growth can be affected

A nurse is caring for a 17 year old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take? A. Initiative the IV per the patient's request B. Notify the provider of the situation C. Administer a sedative to calm the client D. Offer the client an antiemetic

B. Notify the provider of the situation

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first? A. Administered an opioid analgesic B. Obtain a prescription to adjust the weight amount C. Offer a muscle relaxant to the client D> Realign the client's position

B. Obtain a prescription to adjust the weight amount

A nurse is caring for an infant who has a cogenital heart defect. Which of the following defects is associated with increased pulmonary blood flow? A. Coarctation of the aorta B. Patent ductus arterosus C. Teralogy of Fallot D. Tricuspid atresia

B. Patent ductus arterosus

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? A. Insert a tongue blade in the client's mouth B. Place the client on his side C. Hold the client's arms and legs from moving D. Place the client back in bed

B. Place the client on his side

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care? A. Obtain rectal temperatures B. Place the newborn in the prone position C. Cover the lesion with a dry dressing D. Apply snug, clean diapers

B. Place the newborn in the prone position

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

B. Position the child side-lying

A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint? A. Apply lotion to the skin under the edges of the splint B. Reposition the client to keep him from staying in the same position in bed C. Remove the weights for a few minutes each hour D. Apply a foot plate to the bed

B. Reposition the client to keep him from staying in the same position in bed

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A. Electrical cords are placed along the walls B. Scatter rugs are present in the kitchen C. Handrails are present in the bathroom D. Uses a microwave for cooking

B. Scatter rugs are present in the kitchen

A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition? A. Tracks an object with eyes B. Sits with pillow props C. Smiles when a parent appears D. Uses a pincer grasp to pick up a toy

B. Sits with pillow props

A nurse is caring for a client who is to start therapy with ibuprofen for hip pain. Which of the following information should the nurse provide about ibuprofen? A. Take the medication with an aspirin to increase effectiveness B. Take the medication with food C. Taking the maximum dose will offer stroke prevention D. Sustained-release forms may be crushed for easier administration

B. Take the medication with food

A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply) A. The preschooler stutters when speaking B. The preschooler mispronounces words C. The preschooler speaks in three word sentences D. The preschooler talks to himself when reading E. The preschooler speaks in a nasally tone

B. The preschooler mispronounces words E. The preschooler speaks in a nasally tone

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

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

A nurse is caring for a client who has chemotherapy-induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? A. Extremities that turned blue when exposed to cold B. Tingling feeling in the extremities C. Jerking movements of the extremities D. Spasms of the extremities

B. Tingling feeling in the extremities

A nurse is caring for a client whose right leg is in Buck's traction. Which of the following interventions should the nurse implement to promote the client's mobility? A. Log rolling every 2 hr B. Isometric exercises of both legs C. Active range of motion exercises of the left leg D. Passive range of motion to the right leg

C. Active range of motion exercises of the left leg

A clinic nurse is giving instructions to a mother on the proper technique of applying ophthalmic ointment to her preschool-age child who has conjunctivitis. Which of the following should the nurse include in the instructions? A. Warm the ointment by placing the tube in glass of hot tap water B. Cleanse the eye with a wet cotton ball in a direction towards the inner canthus before applying the ointment C. Discard the first bead of ointment before each application D. Instruct your child to squeeze his eyes shut following application

C. Discard the first bead of ointment before each application

A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take? A. Apply pressure to the bridge of the nose after administration B. Wipe the eye from the outer canthus to the inner canthus before instillation C. Drop prescribed amount of medication into the conjunctival sac D. Protect the distal portion of the eyedropper using clean technique

C. Drop prescribed amount of medication into the conjunctival sac

A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect? A. Expressive affect B. Associative looseness C. Echolalia D. Ambivalence

C. Echolalia

A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect? A. Negative Babinski reflex B. Increased appetite C. Hyporeflexia D. Tachycardia

C. Hyporeflexia

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

C. Measure head circumference every shift

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client? A. Short peripheral catheter B. Implanted infusion port C. Peripherally inserted central catheter D. Arteriovenous fistula

C. Peripherally inserted central catheter

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? A. Client report of feelings of depression B. Dry, raised rash of the face C. Presence of peripheral edema D. Joint pain in hands and knees

C. Presence of peripheral edema

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching? A. Use a blow dryer on a moderate heat setting to dry the cast after showering B. Use a cotton swab to relieve itching under the cast C. Report any worsening or unrelieved pain D. Avoid moving the affected leg

C. Report any worsening or unrelieved pain

A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide? A. The medication is to be applied when the client is experiencing eye pain B. The medication will be used until the client's intraocular pressure returns to normal C. The medication should be applied on a regular schedule for the rest of the client's life D. The medication is to be used for approximately 10 days, followed by a gradual tapering off

C. The medication should be applied on a regular schedule for the rest of the client's life

A nurse in a special education program is planning care of the child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care? A. Allow for adjustment of rules to correlate with the child's behavior B. Provide a flexible schedule that adjusts to the child's interests C. Allow for imaginative play with peers without supervision D. Establish a reward system for positive behavior

D. Establish a reward system for positive behavior

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Prepare the child for a lumbar puncture B. Administer an intravenous antibiotic C. Obtain blood cultures D. Place the child in isolation

D. Place the child in isolation

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

D. Position the child laterally

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? A. Intracranial pressure B. Serum electrolytes C. Temperature D. Respiratory status

D. Respiratory status

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

D. Restlessness

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 opically 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

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

A nurse is performing discharge teaching for a client who has seizures and has a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? A. I will notify my doctor before taking any other medications B. I have made an appointment to see my dentist next week C. I know that I cannot switch brands of this medication D. I'll be glad when I can stop this medicine

D. I'll be glad when I can stop this medicine

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

D. Initiative the use of PCA pump for pain control

A home health nurse is developing a place of care for a child who has hemiplegic cerebral palsy. Which of the following foals 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

D. Modify the environment

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

D. On the unoperated side

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

D. Orthopnea

A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A. A room adjacent to the nursing station B. A room without a window C. A room with dim lighting D. A room containing personal belongings

D. A room containing personal belongings

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

D. Administer prednisone on an alternate-day schedule

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development? A. The colorful latex balloons to the side of the crib B. Provide a small electronic toy C. Change the infant's diaper as as soiling occurs D. Allow the infant to stand in the crib

D. Allow the infant to stand in the crib

A nurse is assessing a client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should identify which of the following as a cutaneous manifestation of SLE? A. Facial pallor B. Muscle atrophy C. Foot ulcers D. Butterfly rash on face

D. Butterfly rash on face

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? A. Testing visual acuity B. Observing for facial symmetry C. Eliciting the gag reflex D. Checking the pupillary response to light

D. Checking the pupillary response to light

A nurse is teaching a class about providing emergency care for clients who has a sports-related injury. Which of the following information should the nurse include? A. Apply heat to the injury during the first 12 hr B. Maintain the affected extremity in a dependent position C. Perform passive range of motion (ROM) to an injured join D. Compress the injury for 24 hr

D. Compress the injury for 24 hr

A nurse is teaching a client who starting to take methotrexate to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching? A. Avoid eating foods high in vitamin K B. Use an alcohol-based mouthwash after each meal C. Take the medication daily D. Drink at least 2 liters of water daily

D. Drink at least 2 liters of water daily

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medications? A. White blood cell (WBC) count B. Rheumatoid factor (RF) C. Antinuclear antibody (ANA) D. Erythrocyte sedimentation rate (ESR)

D. Erythrocyte sedimentation rate (ESR)

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy B. Limit visiting hours until the client begins to participate in therapy C. Allow the client to control the timing and frequency of the therapy D. Establish a plan of care with client that sets attainable goals

D. Establish a plan of care with client that sets attainable goals

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 of the bed

D. The buttocks is elevated slightly off of the bed

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands B. The client is unable to make vocal sound C. The client unconscious D. The client opens his eyes when spoken to

D. The client opens his eyes when spoken to