ati pediatric
A nurse is collecting data for an adolescent who presents with manifestations of appendicitis. Which of the following manifestations should the nurse expect?
. A rigid abdomen is an expected manifestation of appendicitis.
A nurse is caring for a preschooler who has a vesicular, honeycolored, crusty region around the nose and mouth and has been diagnosed with impetigo contagiosa. Which of the following instructions should the nurse plan to reinforce with the parents?
. Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on reinforcing teaching about applying an antibacterial ointment, washing the child's bed linens daily in hot water, and washing hands before and after contact with the affected area to decrease the risk of reinfection or transmission to others.
A nurse is reviewing laboratory ndings of an adolescent who has acute renal failure. Which of the following ndings should the nurse expect?
. Metabolic acidosis is an expected nding for clients who have acute renal failure
A nurse in a pediatric clinic is reinforcing teaching with the parent of a school-aged child who has type 1 diabetes mellitus and an upper respiratory infection. Which of the following statements by the parent indicates an understanding of the instructions?
. The nurse should identify that a child who has type 1 diabetes mellitus has an increased risk of diabetic ketoacidosis during an illness. Therefore, the nurse should instruct the parent to monitor the child's blood glucose level every 3 hours.
A nurse is reinforcing dietary teaching with the parent of a toddler who has phenylketonuria. Which of the following foods should the nurse recommend? .
. The nurse should instruct the parent to offer the toddler foods that are low in protein such as cooked carrots and fruits.
A nurse is reinforcing teaching with the parent of a toddler who is undergoing the insertion of tympanostomy tubes. Which of the following statements should the nurse include?
. Tympanostomy tubes allow for drainage from and ventilation to the middle ear. They usually fall out on their own within 6 to 12 months after insertion.
A nurse is reinforcing teaching with a 17-year-old client about managing manifestations of polycystic ovary syndrome (PCOS). Which of the following client statements indicates an understanding of the teaching?
. Weight loss and diet modications improve the body's insulin use and normalize hormone levels. A reduced-carbohydrate diet and exercise increase the cells' sensitivity to insulin and helps normalize testosterone secretions, ultimately reducing PCOS manifestations.
A nurse is caring for a toddler who is postoperative following a cleft palate repair. Which of the following actions should the nurse take?
. When caring for a toddler who is postoperative following a cleft palate repair, the nurse should apply elbow restraints (unless prescribed otherwise) to prevent the toddler from rubbing or disrupting the sutured area.
A nurse is caring for a preschool-aged child who presents with manifestations of epiglottitis. Which of the following actions is the nurse's priority to perform?
. When using the airway, breathing, and circulation (ABC) approach to client care, the nurse's priority is to place resuscitation equipment and suction equipment at the bedside. Children with epiglottitis may develop sudden respiratory obstruction.
A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take rst?
. When using the urgent vs. nonurgent approach to client care, the nurse should rst administer an antipyretic to decrease the toddler's body temperature
A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include?
A 6-year-old child should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands.
A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the nurse administer?
A child who has acute otitis media should take an antibiotic to help alleviate the infection.
A nurse is reinforcing teaching with the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicate an understanding of the teaching?(Select all that apply.)
A child who is diagnosed with Kawasaki disease will likely be irritable for up to 2 months. Clients with this condition receive high doses of gamma globulin during the initial phase, which might result in the inability to produce adequate antibodies in response to a live vaccine; therefore, these vaccines should be delayed for 11 months. The temperature of a child with Kawasaki disease should be recorded until she has been afebrile for several days
A nurse is assisting with the plan of care for a child who has hyperthermia. Which of the following actions should the nurse take?
A cooling blanket will lower the temperature of the blood circulating at the skin's surface. This cool blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated to the skin and dispensed to the cooler outside surface.
A nurse on a pediatric unit is assisting with the plan of care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan due to which of the following benets?
A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging the child to touch the equipment, the nurse will help decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people
A nurse is collecting data from a child who has type 1 diabetes mellitus. Which of the following ndings should the nurse identify as a manifestation of hypoglycemia? .
A rapid heart rate is a manifestation of hypoglycemia. Other manifestations the nurse should expect the child to exhibit include tremors, difculty concentrating, dizziness, hunger, and irritability
A nurse is applying EMLA cream to a child's hand prior to the insertion of an intravenous catheter. Which of the following interventions should the nurse perform?
A. EMLA cream is a topical anesthetic that should be applied at least 60 minutes prior to a procedure. Procedures requiring deeper penetration such as a bone marrow aspiration may require application 2 to 3 hours prior to the scheduled procedure
A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization?
Age-appropriate playtime objects for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, nger paints, modeling clay, and musical toys. These toys allow manipulation and exploration and meet the child's developmental and diversional activity needs.
A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor?
Alcohol consumption is a maternal risk factor for the development of congenital heart disease.
A nurse is reinforcing teaching with a 12-year-old child who is recovering from an acute bleeding episode of hemophilia A. Which of the following statements should the nurse make?
Although the child still needs to be seen by a health care provider, applying pressure and ice to the site of the bleeding can help control the bleeding and prevent the need for hospitalization.
A nurse working on a maternal-newborn unit is assisting with planning an in-service training session for staff about assisting new mothers with breastfeeding. Which of the following infant conditions should the nurse recommend including in the teaching as a contraindication for breastfeeding?
An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes.
A nurse in a provider's ofce is collecting data from a client. The nurse determines the client's body mass index (BMI) is 21.2. This nding is classied as which of the following?
Body mass index is a measure of an individual's weight relative to height. A BMI from 18.5 to 24.9 is in the healthy range. Therefore, this client's weight is considered healthy.
A nurse is collecting data from a toddler who has AIDS. The nurse should identify which of the following ndings as an indication of an opportunistic infection?
Candidiasis (oral thrush) results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS
A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy?
Correct Answer: B. The nurse should insert the catheter without suction and then withdraw the catheter while applying intermittent suction.
A nurse is caring for a child who has electrical burns on her lower arms and hands. Which of the following ndings indicates the child is experiencing a complication of the injury?
Dark urine can be an indication of myoglobinuria. It results from elimination of waste products from muscle damage and can cause renal failure.
A nurse is collecting data from an infant who has diabetes insipidus (DI). Which of the following ndings should the nurse expect?
Diabetes insipidus is characterized by a decreased secretion of ADH, which results in an increased production of urine.
A nurse is reinforcing teaching about exercise with an adolescent client who has type 1 diabetes mellitus. Which of the following points should the nurse reinforce?
Eating additional carbohydrates or decreasing the regular insulin injection according to an established protocol before exercise is sometimes necessary to prevent hypoglycemia.
The nurse is reinforcing teaching for the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching?
Explanation: Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become prolonged.
A nurse is assisting with the immediate postoperative care of an 8-month-old infant who had a cleft palate repair. Which of the following actions should the nurse perform?
Following a cleft palate repair, infants should be positioned side-lying to allow the drainage of blood and secretions and to minimize the risk of aspiration.
A school nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take?
Immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint.
A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take?
Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference can help determine any increase
A nurse is caring for an infant who has neonatal abstinence syndrome (NAS). Which of the following interventions should the nurse perform?
Infants with NAS should be snugly swaddled with their arms in a exed position to place the hands near the mouth. This position allows self-soothing behaviors and decreases irritability
A nurse is assisting with the care of an infant who has pertussis. Which of the following actions should the nurse take?.
Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidied oxygen and suction equipment should be used as needed
A nurse is reinforcing teaching about baclofen with the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include?
Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea
A school nurse is assisting a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following ndings should the nurse expect if the child develops anaphylaxis?(Select all that apply.
Nausea and hives are common responses to excessive histamine release. A serious, lifethreatening response to excessive histamine release is airway narrowing, which presents with dyspnea and stridor
A nurse is assisting with the care of a child who has paralytic poliomyelitis. Which of the following actions should the nurse take?.
Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause discomfort.
A nurse is caring for an infant receiving phototherapy for hyperbilirubinemia. Which of the following should the nurse recognize as an indication of increased bilirubin excretion?
Phototherapy promotes bilirubin excretion by changing the structure of bilirubin into a form which can be excreted through the bowel. The presence of loose green stools indicates accelerated bilirubin excretion.
A nurse is reinforcing teaching with a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching?.
Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided.
A nurse is assisting with the care of a school-aged child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take?
Placing the child on a pressure-reduction mattress will reduce the pressure on bony prominences, which decreases the risk of skin breakdown.
A nurse is reinforcing teaching about prevention with the parents of a 3-year-old child who has persistent otitis media. Which of the following statements by the parents indicates an understanding of the teaching?
Preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inammation of the respiratory tract.
During a well-child visit, the guardian of a toddler expresses a concern that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make?
Providing the toddler with a favorite toy at bedtime can help the toddler to feel more secure and facilitate sleep
A nurse is contributing to the plan of care for a 6- month-old infant who has respiratory syncytial virus (RSV). Which of the following interventions should the nurse plan to include?
Respiratory syncytial virus is a highly contagious virus that is spread through contact with respiratory secretions and via large droplets. Therefore, both forms of isolation are indicated for a client with this infection.
A nurse is caring for an 8-year-old child in the acute care setting. Which of the following actions should the nurse take?
School-aged children are in Erikson's stage of Industry versus Inferiority. They are willing to accept and thrive when assigned the responsibility to perform simple tasks.
A nurse in an acute pediatric unit is caring for a 2- year-old child who has separation anxiety when her parents leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair?
Separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stage of despair
A nurse is collecting data for a school-aged child who has cystic brosis. Which of the following manifestations should the nurse expect?
Steatorrhea (large, bulky, greasy bowel movements) is a manifestation of cystic brosis. It is the result of an absence of pancreatic enzymes in the duodenum, which causes an inability to digest protein, fat, and some sugars. The resulting increase in intestinal ora and fat leads to bulk and a foul odor.
A nurse is assisting with the care of a school-aged child who had a tonsillectomy. Which of the following interventions should the nurse take?
Straws should be avoided because they can accidently damage the surgical site and cause excessive bleeding
A nurse is caring for a 4-month-old child who is hospitalized. Which of the following playtime objects should the nurse provide for the child?
The 4-month-old infant can recognize himself/herself and will also try to play with "the baby in the mirror." A mirror is a bright object that provides appropriate visual stimulation for this age group. For the infant's safety, however, the mirror must be unbreakable.
A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? . .
The FACES pain rating scale presents the client with various images of faces that represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels
A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make?
The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator
A nurse is caring for a 2-year-old child who has a history of frequent urinary tract infections. When reinforcing teaching with the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include?
The child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra.
A nurse is collecting data during a well-child assessment of a 7- year-old child who takes great pride in bringing school papers home. This behavior demonstrates which of the following of Erikson's stages of psychosocial development? B.
The developmental task of industry vs. inferiority is reected by a child's level of motivation in relation to personal achievements that build good character during the school-aged years (6 to 12 years)
A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take rst?
The greatest risk to the child is an injury resulting from a fall; therefore, the nurse should gently ease the child onto the oor to decrease the chance of injury and turn the child on her left side to prevent aspiration.
A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make?
The infant can receive the rst dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age.
A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take?
The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic
A nurse is collecting data about the visual acuity of a group of school-aged children. Which of the following actions should the nurse take?
The nurse should allow each child to wear his or her glasses during a screening for visual acuity
A nurse is caring for a child who has an exacerbation of cystic brosis. Which of the following laboratory ndings should the nurse report to the provider immediately?
The nurse should apply the ABC prioritysetting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efciently carrying oxygen to them. Therefore, the nurse should report this nding to the provider immediately Oxygen saturation 85% Back Next A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEq/L immediately.
A nurse is caring for an infant who is experiencing dehydration. Which of the following data related to hydration status is the nurse's priority to collect?
The nurse should apply the urgent versus non-urgent priority-setting framework. Using this framework, the nurse should consider urgent ndings to be the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which nding is the most critical. Daily weights are the most sensitive indicator of uid balance in clients of all ages. Daily weights are especially critical for infants and children because uid accounts for a greater portion of body weight.
A nurse in a pediatric clinic is preparing to assist with a sweat chloride test for a toddler who is suspected to have cystic brosis. Which of the following actions should the nurse plan to take?
The nurse should ensure that the examination room is warm. A warm environment promotes the toddler's ability to produce sweat for the sweat chloride test. To further promote sweating, the nurse should apply blankets to maintain the toddler's body heat during the test.
A nurse is collecting data from a 3-year-old preschooler. Which of the following developmental milestones should the nurse expect the preschooler to demonstrate?
The nurse should expect a 3-year-old preschooler to have the ne motor ability to stack 10 blocks.
A nurse is collecting data from a 4-year-old preschooler about his gross motor skills. The nurse should expect the preschooler to perform which of the following activities?
The nurse should expect to nd that a 4-year-old preschooler is able to hop on 1 foot
A nurse is caring for a 4-month-old infant who has tetralogy of Fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse take?
The nurse should identify that a hypercyanotic spell occurs when a vascular spasm reduces pulmonary blood ow and forces blood to shunt from the right ventricle to the left ventricle through the ventricular septal defect. The nurse should place the infant in a knee-chest position to increase systemic vascular resistance, which will help force more blood through the pulmonary artery.
A nurse is reinforcing teaching with the guardian of a schoolaged child who has diabetes mellitus about how to recognize diabetic ketoacidosis (DKA). Which of the following ndings should the nurse describe as a manifestation of this complication? . .
The nurse should identify that deep and rapid respirations are Kussmaul respirations, which is a manifestation of DKA. This respiratory pattern results from the body's attempt to rid itself of the excess carbon dioxide that results from the presence of ketones. The child's breath can be sweet-smelling due to the body's attempt to eliminate ketones through the respiratory system
A nurse in a pediatric clinic is collecting data from a preschooler during a well-child visit. Which of the following ndings should the nurse report to the provider?
The nurse should identify that this blood pressure measurement indicates signicant hypertension, which requires further assessment to conrm. Therefore, the nurse should report this nding to the provider immediately
A hospice nurse is assisting with a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse reinforce in the teaching?
The nurse should identify that toddlers have very little understanding of death. Their reaction is related to changes in routine and parents' emotions.
A nurse on a pediatric unit is assisting with the admission of 4 children. For which of the following children should the nurse initiate droplet precautions? .
The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to other children on the unit. Pertussis is a bacterial infection that is transmitted via direct contact with or exposure to respiratory secretions from an infected child. Manifestations include a fever, sneezing, and a severe cough.
A newly licensed nurse in an urgent care center is caring for a child who has bruises that raise suspicion for child abuse. Which of the following actions should the nurse take?
The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement.
A nurse is reinforcing teaching about home care with the guardian of an adolescent who has hemophilia. Which of the following pieces of information should the nurse provide?
The nurse should instruct the guardian that the adolescent should be allowed to participate in noncontact sports such as walking, bowling, and golf. Contact sports may be allowed if the adolescent wears protective gear and receives routine recombinant factor VIII infusions.
A nurse is reinforcing teaching with the guardian of a toddler about preventing burn injuries. Which of the following pieces of information should the nurse include?
The nurse should instruct the guardian to use a cool-mist vaporizer rather than a steam vaporizer in the home because the steam from a steam vaporizer can cause scalding.
A nurse is reinforcing teaching about injury prevention with the parent of an infant. Which of the following statements by the parent indicates an understanding of the teaching?
The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration
A nurse is reinforcing teaching about home safety with the parent of a 2-month-old infant. Which of the following information should the nurse include? .
The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation.
A nurse is teaching the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following pieces of information should the nurse include in the teaching?
The nurse should instruct the parent to weigh the child 2 to 3 times per week to monitor for weight loss, which is an adverse effect of methylphenidate. The parent should report weight loss to the provider
A nurse is reinforcing discharge teaching with the parents of a school-aged child who has nephrotic syndrome and a prescription for corticosteroid therapy. Which of the following home-care instructions should the nurse include?
The nurse should instruct the parents to keep the child away from others who have or might have an infection. Children who have nephrotic syndrome are prescribed corticosteroids, which impair the immune system. Therefore, the child is at an increased risk of contracting an infection.
A nurse is caring for a school-aged child who has epilepsy and is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? .
The nurse should loosen any clothing that is conning (e.g. around the child's neck) to reduce the risk of injury during a seizure.
A nurse is preparing to administer an oral liquid medication to a 6-month-old infant. Which of the following interventions should the nurse plan to perform?
The nurse should plan to administer small amounts of the medication into the side of the infant's mouth and allow swallowing before administering additional medication.
A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTaP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer?
The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The rst 3 doses are administered between 2 months and 18 months of age.
A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse prepare to administer?
The nurse should prepare to administer albuterol to a child who is experiencing an acute exacerbation of asthma and requires a rescue medication. Albuterol is a betaadrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs.
A nurse working in the emergency department is caring for a 6-month-old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse,"My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take?
The nurse should prepare to assist with the administration of intravenous uids for an infant who has RSV because this condition can cause dehydration as a result of the presence of a fever and the infant's inability to nish a bottle of formula. Also, uids will help loosen congestion, which typically occurs with RSV
A nurse working in the emergency department is caring for a 6-month-old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse,"My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take?
The nurse should prepare to assist with the administration of intravenous uids for an infant who has RSV because this condition can cause dehydration as a result of the presence of a fever and the infant's inability to nish a bottle of formula. Also, uids will help loosen congestion, which typically occurs with RSV.
A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse include?
The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection
A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption?
The nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. Other malabsorption conditions include short-bowel syndrome, lactose intolerance, and congenital enzyme deciency
A nurse is contributing to the plan of care for a preschooler who was admitted for the treatment of measles. Which of the following activities should the nurse recommend for the child?
The nurse should recommend putting together a puzzle with large pieces for a hospitalized preschooler. Other recommended activities for preschoolers on airborne precautions include playing pretend and dress up, painting, and looking at illustrated books
A nurse is reinforcing teaching with an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching?
The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs
A nurse on a pediatric mental health unit is caring for a school-aged child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation?
The nurse uses the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication.
A nurse is reinforcing discharge teaching with the parent of a newborn who has been prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching?
The parent should lightly massage the skin under the harness daily to promote circulation.
A nurse is assisting the provider with a preschooler's annual exam. The parent expresses concern about the child's 1.8 kg (4 lb) weight gain over the past year. Which of the following responses should the nurse make?
The preschooler should gain about 2 to 3 kg (4.4 to 6.6 lb) each year. Therefore, the nurse should reassure the parent that this child's weight gain is an expected nding for the age group
A nurse is reinforcing teaching with the guardian of a toddler who has fth disease. Which of the following statements should the nurse include in the teaching?
The toddler is no longer contagious once a red rash appears on his cheeks. Initial manifestations of fth disease can last for 7 to 10 days and include a fever, a headache, and malaise. Following the rash on the cheeks, a maculopapular rash can appear on the arms, thighs, and buttocks. Treatment for fth disease is primarily symptomatic to promote comfort.
A nurse is collecting data from an infant who is experiencing respiratory distress, absence of breath sounds on a side, and deviation of the trachea away from the affected side. The nurse should identify that the infant is experiencing which of the following conditions?
These manifestations indicate the infant is developing a tension pneumothorax. The infant might also become cyanotic and show asymmetry of the thorax.
A nurse is reinforcing teaching with the parents of a 1-year-old infant regarding appropriate play activities for this age group. Which of the following activities should the nurse include?
This is an appropriate toy for a 12-month-old infant. Beads that are too large to pass through a toilet paper tube do not present a choking hazard. This toy would provide visual and tactile stimulation for a 1-year-old infant
A nurse is inspecting the eyes of a 5-day-old infant. Which of the following is the correct technique for the nurse to use?
To inspect the eyes of an infant, the nurse should lay the infant in a supine position and lift the head. This maneuver usually causes the infant to open the eyes.
Results of enzyme-linked immunosorbent assay (ELISA) testing for an 18-month-old infant who has Pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors?
Transmission of HIV from a woman to her infant can occur during pregnancy, delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants.
A nurse is caring for a 3-year-old toddler who has Haemophilus inuenzae type b meningitis. Which of the following actions should the nurse take?
Using a pillow when in a supine position will cause exion of the neck, which increases discomfort in most children due to nuchal rigidity.
A nurse is reinforcing teaching with a 10-year-old child who requires crutches for a 2-point gait. Which of the following instructions should the nurse reinforce?
Using the crutch opposite the foot provides a wider base of support than using the crutch next to the foot. This is the correct way to use the 2-point gait with crutches.
A nurse in an urgent care clinic is collecting data from an infant who recently started taking digoxin for a supraventricular arrhythmia. Which of the following ndings should the nurse identify as a possible indication of digoxin toxicity?
Vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider immediately
A nurse is reinforcing care instructions with the parent of a child who has a newly placed gastrostomy tube. Which of the following statements demonstrates an understanding of the instructions?
When administering multiple medications at the same time through the gastrostomy tube, the tube should be ushed with clear water in between each medication.
A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room?
When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority item to have in the child's room is suction equipment. If the child experiences a tonicclonic seizure, the child is at risk for aspiration and airway occlusion due to secretions, food, or uids. The nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bag valve mask if needed.
A nurse is assisting with the care of a child who has epilepsy and just experienced a tonic-clonic seizure. Which of the following actions should the nurse take rst? .
When using the airway, breathing, and circulation (ABC) approach to client care, the rst action the nurse should take after a tonic-clonic seizure is to turn and maintain the child in a side-lying position. During tonic-clonic seizures, the tongue is hypotonic, the swallowing reex is diminished or lost, and the amount of saliva increases. These ndings exacerbate the child's risk of aspiration and occlusion of the airway. Therefore, placing the child in a side-lying position is the nurse's priority because it promotes drainage of the increased saliva and retains a patent airway.
A nurse is contributing to the plan of care for a preschool-aged child who has Wilms tumor. Which of the following items should the nurse include in the plan of care prior to surgery?
Wilms tumor is an encapsulated tumor typically involving only 1 of the child's kidneys. Palpation or pressure on the abdomen could cause the cancerous cells to spread to other parts of the body. The nurse should use extreme care when bathing and handling the child pre-operatively.
A nurse is reinforcing discharge teaching with the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider?
manifestation of hemorrhage following a tonsillectomy is the constant clearing of blood that is draining in the back of the throat. Therefore, the provider should be notied if the adolescent begins constantly clearing her throat following a tonsillectomy
