305 Toddler- Preschool-adolescent
A 16-year-old male asks the nurse about the use of condoms. He states, "I've used condoms in the past, but I'm not sure I'm using them correctly." What should be included as part of the teaching plan about condoms?
The condom must be positioned after an erection has occurred
Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit?
pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L
An infant with a seizure disorder is receiving phenobarbital (Luminal) at home. The mother calls the pediatric clinic and states that the infant has become lethargic and sleeps for long periods. How should the nurse respond to ease the mother's anxiety?
"This is a temporary response to the drug; it usually stops after a few weeks."
A 3-month-old infant with tetralogy of Fallot is admitted for a diagnostic workup in preparation for corrective surgery. The morning after cardiac catheterization the infant suddenly becomes cyanotic and begins breathing rapidly. In what position should the nurse immediately place the infant?
Knee-chest
A nurse is caring for a 15-year-old adolescent who was admitted to the hospital after taking an acetaminophen (Tylenol) overdose. The result of which diagnostic study is most important for the nurse to monitor at this time?
Liver function tests
The nurse notes that a 4-year-old child is having difficulty relating to some of the children in the playroom. What does the nurse identify as the reason that this problem is not unexpected?
Exaggerating and boasting to impress others are typical behaviors of preschoolers
The nurse assists the health care provider to perform a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the health care provider to document?
Queckenstedt
A nurse is feeding an infant who recently underwent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding?
Rinse the suture line
An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. What should the nurse tell the girl that may help her wear the bracelet consistently?
Select a bracelet similar to bracelets worn by her peers
A 16-year-old girl has been admitted to the pediatric eating disorders unit with a diagnosis of anorexia and is undergoing behavioral therapy. Unit privileges are based on weight gain and have been explained to the client. What is the most appropriate intervention for the nurse to use when taking the lunch tray to the client's room?
Setting the tray down and say nothing
On admission to the nursery a newborn is found to be experiencing cold stress. What is the nurse's goal at this time?
Prevent metabolism of fat stores
The mother of an adolescent asks the nurse, "What's the best way to remove a tick from the skin?" What is the best response by the nurse?
"Remove the tick carefully with tweezers."
During a routine physical examination a 10-year-old girl is discovered to have scoliosis. The curve is diagnosed as mild and functional, and a daily exercise program is established. The next month, at the follow-up visit, the nurse determines that the child is complying with the exercise program when the girl states:
I think my exercises will make me a better softball and soccer player.
The clinic nurse is teaching an adolescent about lifestyle modifications to prevent hyperlipidemia. Which statement by the adolescent indicates a need for further teaching?
I'll start eating more red meat.
A nurse is discussing insulin needs with an adolescent with recently diagnosed type 1 diabetes. What information is important for the nurse to include concerning insulin administration?
Insulin will be required throughout life
The mother of a 17-year-old adolescent who is going to be a foreign exchange student asks the nurse why her child must have a tetanus toxoid immunization instead of the immune globulin. The nurse responds that the tetanus toxoid immunization provides:
Longer-lasting active immunity
Immediately after being placed in the supine position, an adolescent child experiences shortness of breath and must sit up to breathe. What term should the nurse use to document this clinical phenomenon?
Orthopnea
A 6-week-old infant has just been found to have gastroesophageal reflux. What teaching is most important to discuss with the parents at this time?
Providing formula thickened with cereal
The parents of a 12-year-old child with juvenile idiopathic arthritis ask a nurse why their child is not receiving steroid therapy when it is so effective for adults with rheumatoid arthritis. Which reason that steroids are avoided at this time takes priority in the nurse's explanation?
Steroids could affect growth
A 16-year-old single mother of a 1-month-old infant and the infant's grandmother bring the baby to the emergency department and report that the infant accidentally fell down the stairs. The nurse knows that a consent form for treatment should be signed. Who has the responsibility for signing the consent?
The mother, despite her age
A nurse instructs the parents of an adolescent with asthma how to reduce the allergens in the child's bedroom. The mother tells the nurse what she plans to do to make the room hypoallergenic. Which idea indicates that further teaching is needed?
Using flat outdoor carpeting to cover hardwood floors
A male adolescent with cystic fibrosis (CF) whose parents are both carriers of the disease asks a nurse, "When I have children, could they have cystic fibrosis like me?" On what information about men with CF should the nurse base the response?
Usually they are unable to father children, although sexual function is not affected
A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when teaching the client about health practices that may help decrease future urinary tract infections?
Wear cotton underpants
A 15-year-old girl is grounded for 2 weeks by her parents for smoking in school. The adolescent tells the school nurse, "It's not fair that I get punished when my friends get away with doing the same thing." What is the best response by the nurse?
When errors in judgment are made, people must be prepared to take the consequences for their actions
After 3 months of supplemental oral iron therapy, there is no significant increase in a female adolescent's hemoglobin level. Iron dextran (Imferon) is ordered. What is the best way for the nurse to administer this medication?
With the use of the Z-track method
An adolescent with leukemia is to be given a chemotherapeutic agent that is known to cause nausea and vomiting. When is the best time for the nurse to administer the prescribed antiemetic?
Before each dose
During assessment, the nurse asks a patient about developmental milestones such as the age at which thelarche and menarche occurred. The nurse determines that the patient experienced pubertal delay. Which finding in the patient supports the nurse's conclusion?
Breast development occurred by 15 years of age.
An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do?
Breathe into cupped hands.
An adolescent with type 1 diabetes is brought to the emergency department unconscious. The blood glucose level is found to be 742 mg/dL. What clinical manifestation does the nurse expect the adolescent to exhibit during the initial assessment?
Hyperpnea
Pulse oximetry is prescribed for an adolescent. What should the nurse do to ensure accuracy of the pulse oximeter reading?
Attach the probe to a finger or earlobe
A nurse is assessing an infant for developmental dysplasia of the hip. How does the nurse identify the Ortolani sign?
Audible click on hip manipulation
An adolescent who has just been found to have type 1 diabetes asks a nurse about exercise. What is the best response by the nurse?
"Extra snacks are needed before exercise."
The health care provider has prescribed 700 mL of intravenous fluid, to be infused over 24 hours. At what rate should the nurse set the volume-control device? Express your answer as a whole number. ___ mL/hr
29.1 ml/hr
A nurse in a family planning clinic determines that a client understands the discussion about using a cervical cap with a spermicide when the client states that after intercourse, a cervical cap must be left in place for at least:
6 hours
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. What information about true labor contractions should the nurse include in a response to the client's question?
Accompanied by progressive cervical dilation
An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. What does the nurse identify as the reason that the crisis occurred?
Blockage of small blood vessels as a result of clumping of RBCs
An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How should the nurse respond when the client complains of pain and requests medication?
By acknowledging that the pain is real and administering medication to relieve it
What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for an infant with this diagnosis?
Clubbing of fingers
A client and her partner are working together during the woman's labor. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the partner to do that will alleviate the client's discomfort during contractions?
Deep-breathe slowly
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing?
Metabolic acidosis
A nurse in the clinic is obtaining a health history of a 16-year-old boy with a complaint of a thick urethral discharge. What is the most appropriate nursing action to help confirm a tentative diagnosis of gonorrhea
Obtaining a urethral specimen for a culture
A nurse is teaching parents how to facilitate their 10-week-old infant's optimal growth and development. What type of age-appropriate activity should the nurse encourage?
Placing the baby in an infant seat
An infant with a myelomeningocele is admitted to the pediatric intensive care unit. While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention?
Placing the infant in the prone position
A nurse is caring for an adolescent in the postanesthesia care unit. What action should the nurse take to ensure accuracy of a pulse oximeter reading?
Placing the probe on a finger or earlobe
What is most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation?
Respiratory distress
A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and got a positive result. She confides that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl whether she has told anyone else, she replies, "Yes, but my mother doesn't believe me." Legally, who should the nurse notify?
Child protective services for immediate intervention
A school nurse is teaching a 12-year-old child with recently diagnosed type 1 diabetes about the action of insulin injections. What statement indicates that the child understands how insulin works in the body?
Glucose is carried into cells, where it is burned for energy.
A nurse is assessing a 15-month-old girl at the well-child clinic. The nurse determines that further education about toddler development is necessary when the mother says:
She has a temper tantrum every time I put her on the potty chair.
The parents of an infant with pyloric stenosis ask a nurse many questions about the problem. What information should the nurse communicate when answering these questions?
This is a condition with an excellent prognosis
While assessing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?
Warm the environment
What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?
Warming the newborn
A woman at 40 weeks' gestation is admitted in active labor. After appropriate progress of her labor, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which nursing assessments and interventions should be performed? Select all that apply
-Maintaining intravenous fluid administration -Having oxygen available in case of hypotension -Checking the bladder for distention every 2 hours -Monitoring fetal heart rate and labor progress per hospital protocol
A 2½-year-old toddler arrives at the well-baby clinic for a routine physical examination. The child opens all of the cabinets in the examination room and carefully moves the tongue depressors and other items to different places. What psychosocial developmental stage does the nurse determine that this child is in?
Autonomy
A 14-year-old teenager with type 1 diabetes wants to go out to eat with friends after a volleyball game. The teenager asks the school nurse whether this is permissible on the insulin/diet/exercise regimen that has prescribed. How should the nurse respond?
I'll teach you how to determine the amount of carbohydrates in different fast foods.
A nurse is reviewing the immunization schedule of an 5-month-old infant. What immunizations does the nurse expect the infant to have already received?
Rotavirus, DTaP, Haemophilus influenzae, polio, pneumococcal
An adolescent child is admitted to a pediatric unit with the tentative diagnosis of acute poststreptococcal glomerulonephritis (APSGN). What diagnostic tests does the nurse expect will be performed to confirm this diagnosis?
Serum complement (C3) activity level and urinalysis
A nurse is preparing a preschooler for an elective surgical procedure. How much time should the nurse allow between telling the child about the surgery and the actual surgery?
Several days
After her child's visit to the pediatrician a mother tells the nurse that she is concerned that an antidepressant has been prescribed for her adolescent son. What is the best response by the nurse?
Tell me more about what's bothering you.
A postpartum client intends to breastfeed her infant for the first time. How should the nurse assist the client?
Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
While performing preoperative teaching a nurse explores a young adolescent's concern about changes in appearance after surgery to correct scoliosis. What is the most appropriate statement by the nurse?
"You're concerned about how you'll look after surgery."
A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. Select all that apply.
-Liver and other glandular organ meats -Red meats, such as beef -Enriched whole milk -Chicken broth
A nurse is assessing a 4-year-old child. What age-appropriate language skills does the nurse expect the child to have fulfilled? Select all that apply.
-Uses six- and eight-word sentences -Has a vocabulary of 150 to 200 words
A 17-year-old adolescent with a history of asthma is brought to the emergency department in respiratory distress. A nurse immediately places the client in a bed with the head of the bed elevated and administers oxygen with a facemask. The health care provider performs a physical assessment and admits the adolescent to the pediatric unit. What is the priority nursing intervention in regard to the health care provider's prescriptions?
Administering the nebulizer treatment to facilitate breathing
A woman learning about infant feedings asks a nurse how anyone who is breastfeeding gets anything done with a baby feeding on demand. What is the best response by the nurse?
Babies on demand feedings eventually set a schedule, so there should be time for you to do other things
Loratadine (Claritin), 10 mg by mouth once a day in the morning, is prescribed for a 15-year-old girl with hay fever. The girl tells the school nurse that she is concerned that she will be sleepy for a quiz the next day. How should the nurse respond?
By explaining that this medication rarely causes drowsiness
A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?
Constriction of the peripheral vessels increases the force of flow.
A 5-year-old child is brought to the child health clinic for a routine visit, and the nurse observes the child interacting with other children. What type of play does the nurse expect of the child?
Cooperative
A nurse is caring for an infant with bacterial meningitis. The parents ask how their baby could have contracted the illness. What does the nurse consider as the most likely route of transmission to the central nervous system?
Cranial apertures or sinuses
The nurse should explain to the newly pregnant primigravida that the fetal heartbeat will first be heard with:
Electronic Doppler ultrasonography at 10 to 12 weeks
A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report on the cerebrospinal fluid (CSF) supports this diagnosis?
Increased protein level
The fifth grader whom the school nurse should appoint to be health office monitor is the student who:
Is reserved but is strong academically
