ATI PN Children Practice 2020B

A nurse is collecting physical data from a 4-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child's skin turgor?

The child's abdomen. The nurse should expect the child who has diarrhea and has been vomiting to exhibit a decrease in skin turgor. To check skin turgor, the nurse should grasp the skin on the child's abdomen, pull it taut, and release it quickly. A child who has been vomiting and had diarrhea for 24 hr will have a prolonged period of tenting.

A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance. Which of the following supplements should the nurse instruct the parent in the child's diet?

Vitamin D Lactose intolerance is managed by eliminating dairy products from the diet. However, this can result in a decrease in bone density because of the lack of calcium and vitamin D in the diet. The nurse should instruct the parent to administer a vitamin D supplement to the child to enhance the absorption of calcium from foods other than those containing lactose.

A nurse is reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetamide. Which of the following instructions should the nurse include?

Instill medication immediately after cleansing the eye

A nurse is caring for a school aged child who has hemophilia A. Which of the following should the nurse recognize as a manifestation of this disorder?

Join pain and stiffness oint pain and stiffness can occur as a result of bleeding into the joint, which is a manifestation of hemophilia A.

A nurse is contributing to the plan of care for a child who is in Buck's traction. Which of the following interventions should the nurse include in the plan?

Maintain the leg in an extended position -decreases the risk for further injury to the extremity and minimizes the occurrence of muscle spasms

A nurse in a pediatric clinic is caring for an infant who has heart failure and a prescription for digoxin. Which of the following statements by the parent indicates desired therapeutic effect of the medication?

My baby is breathing easier than she used to -Digoxin(increases cardiac output and decrease venous pressure and pulmonary edema, which will reduce respiratory demands

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching?

My chid might have a period of irregular movement of the extremities -chorea is temporary lack of coordination

A nurse is providing care to parents immediately following their child;s unexpected death. Which of the following actions should the nurse take?

Offer the parents the opportunity to bathe and dress the child's body -this can facilitate the grieing process and allow them to provide care for their child one last time

A nurse is reinforcing teaching with the parents of a 2 yo toddler at a well child visit. Which of the following should the nurse recommend as an age appropriate activity for the toddler

Putting together a large piece puzzle Puzzles provide the child an opportunity to develop fine motor skills. Other fine motor skill activities include finger painting and coloring with thick crayons.

A nurse is collecting for an adolescent who has asthma and has received an albuterol nebulizer treatment. Which of the following findings indicates an improvement in the adolescent's condition

RR 20/min expected reference

A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats in a motor vehicle. Which of the following instructions should the nurse include in the teaching?

Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt. The nurse should instruct the parents to secure both the child and the booster seat with the shoulder-lap seat belt inside the motor vehicle, because booster seats do not have built-in straps.

A nurse is collecting data from a 10-month-old infant. Which of the following findings should the nurse report to the provider?

Sits with support by leaning on hands bc an infant should be able to sit unsupported by 8months of age

A nurse is contributing to the plan of care for an infant who has bronchiolitis and is tachypneic. Which of the following actions should the nurse include in the plan of care?

Suction nasal passages with a bulb syringe. The nurse should suction the infant's nasal passages using a bulb syringe to clear the nasal passages and decrease respiratory effort.

A nurse is assisting with the development of a health promotion program for the guardians of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program

The leading cause of death in adolescents is physical injury -MVC (motor vehicle crashes) are the leading cause of death in adolescent population.

A nurse is collecting data from an 18month old toddler. Which of the following is a deviation from expected growth and development that the nurse should report to the provider?

The toddler is unable to recognize familiar objects by name The nurse should report that the toddler is unable to recognize familiar objects by name, because this is a deviation from expected growth and development. The toddler should be able to accomplish this task by 12 months of age.

A nurse is reinforcing discharge teaching with the guardians of a 6month old infant following a surgical procedure to repair a hypospadias. Which of the following instructions should the nurse include?

Wait 1 week before giving the infant a tub bath Keep the infants penis as dry as possible until the stent or cather is removed. The nurse should instruct the guardians to keep the infant's penis as dry as possible until the stent or catheter is removed. The parent should provide sponge-baths to the child until the stent or catheter is removed.

A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22lb). The prescription read phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobabrital 20mg/5mL. How many mL should the nurse administer with each dose? (Round answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

2.5mg/kg * 10kg = 25mg 20 mg/5 mL = 25 mg/X mL X mL = 6.25 mL

A nurse is screening a group of school age children for abuse. The nurse should identify that which of the following conditions places a child at risk for physical abuse?

A child who has ADHD due to the increased emotional and physical demands the conditon can place of the child's parents

A nurse is caring for a group of children in an acute care setting. The nurse should identify that which of the following children is at risk for impaired elimation?

A child who has hyperglycemia -A client who has hyperglycemia exhibits manifestations of polyuria, lethargy, confusion, thirst, nausea, vomiting, abdominal pain, signs of dehydration, rapid respiration, and fruity breath. A child who has hyperglycemia is at risk for dehydration

A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For which of the following adverse effects should the nurse monitor?

depression; can experience mental status changes

A nurse is assisting iterm-41n the care of a male child who has acute post-streptococcal glomerulonphritis. For which of the following manifestations should the nurse monitor?

oliguria; retention of sodium and water

A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate?

Droplet precautions The nurse should plan to initiate droplet precautions for this child, because bacterial meningitis caused by Haemophilus influenzae type B is transmitted through the air via large-particle droplets.

A nurse is reinforcing teaching with a guardian whose child was exposed to poison ivy. Which of the following instructions should the nurse provide?

Flush the child's skin within 15 min with cold, running water. The nurse should instruct the guardian to flush the child's skin with cool running water to remove the urushiol, the oil from the poison ivy plant, from the child's skin.

A nurse is reinforcing teaching to the guardian of a toddler who is receiving chemotherapy and has developed stomatitis. Which of the following instructions should the nurse include in the teaching?

Frequently rinse the mouth with chlorihexidine mouthwash The nurse should encourage the guardian to rinse the toddler's mouth frequently with chlorhexidine mouthwash.

A nurse is reinforcing teaching with the parent of an infant who has a new diagnosis of human immunodefiency virus (HIV). Which of the following statements made by the parent indicates an understanding of the teaching?

"I should bring my child in for immunizations on schedule." Immunizations provide protection from communicable diseases

A nurse is reinforcing teaching about interventions for mild hypoglycemia with the parent of a child who has diabetes mellitus. Which of the following statements by the parent indicated that the teaching has been effective?

"I should give my child 4 ounces of orange juice followed by cheese and crackers." The parent should treat mild hypoglycemia with 10 to 15 g of a simple carbohydrate, such as 4 oz of orange juice, and follow it with a starch-protein snack.

A nurse is reinforcing teaching about home care with the guardian of a 14month old toddler who has spatic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will perform daily stretching exercises to my toddler's affected muscles Stretching prevents muscle contractures.

A nurse in a pediatric clinic is talking on the telephone with the parent of a 6-month-old infant who has a urinary tract infection and started taking an oral antibiotic the day before. Listen to the audio clip and determine which of the following responses the nurse should take?

"Mix the medicine with 1 teaspoon of applesauce before giving it to your baby." To enhance acceptance of an oral medication, the parent can mix the medication with a small amount of a sweet, nonessential food item.

A nurse is reinforcing teaching regarding the immunization schedule with the parent of a 6-month-old infant during a well-baby visit. Which of the following statements by the parent indicates an understanding of the teaching?

"My baby will receive his third DTaP vaccine today." The nurse should reinforce with the parent that the infant should receive his third diphtheria, tetanus, and pertussis (DTaP) immunization at 6 months of age.

A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the following statements by the parent requires immediate intervention by the nurse?

"My child has refused to drink any fluids for the past 8 hours." An inadequate fluid intake indicates the child is at greatest risk for dehydration and electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention by the nurse.

A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when the child will no longer be contagious. Which of the following responses should the nurse make?

"Six days after lesions appear if they are crusted." The nurse should inform the guardian that a child will stop being contagious around 6 days after the lesions appeared, as long as they are crusted over.

A nurse is contributing to the plan of care for a child who has type 1 diabetes mellitus and is experiencing an acute illness. Which of the following actions should the nurse include in the plan of care?

- Encourage an increased fluid intake to flush out ketones and prevent dehydration; this can lead to DKA The nurse should encourage an increased fluid intake to flush out ketones and prevent dehydration. Children who have diabetes mellitus and an acute illness are more likely to experience ketonuria and hyperglycemia. Dehydration increases the risk of the child developing diabetic ketoacidosis.

A nurse is caring for a toddler following a tonsillectomy . Which of the following is the priority finding that the nurse should report to the provider?

Continuous swallowing When using the urgent vs. nonurgent approach to client care, the nurse should identify that continuous swallowing is a manifestation of hemorrhage. Therefore, this is the priority finding for the nurse to report to the provider.

A nurse is assisting with the care of a 4-year old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure? (Select all)

Discuss the benefits of the procedure Give the child needleless IV supplies to play Allow the child to perform the procedure with a doll

A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate?

Apical The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line.

A nurse is caring for a 3-year-old female child who is prescribed an indwelling urinary catheter. Which of the following actions should the nurse take when performing this procedure?

Apply 2% lidocaine lubricant into the urethral meatus. The nurse should apply 2% lidocaine lubricant into the urethral meatus to assist in decreasing the discomfort the child might experience during catheterization.

A nurse is reinforcing dietary teaching with the parent of a child who has phenylketonuria. Which of the following foods should the nurse include the best recommendation for a low phenylalanine diet?

Banana A banana is the best food source to recommend because bananas contain low protein and low levels of phenylalanine. The nurse should also reinforce with the parent the importance of a low protein diet for their child. The nurse should determine that foods such as a banana is the best food source to recommend because bananas contain low protein and low levels of phenylalanine. The nurse should also reinforce with the parent the importance of a low protein diet for their child. Yogurt or dairy products contains high levels of protein, which should be restricted or limited in the child's diet. Boiled eggs contain high levels of protein, which should be restricted or limited in the child's diet. A hamburger or other meats contains high levels of protein, which should be restricted or limited in the child's diet.

A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further?

Blood pressure 120/80 mm Hg A blood pressure of 120/80 mm Hg is outside the expected reference range for an 18-month-old toddler and requires further investigation by the nurse. Expected ranges: RR: 25/min, HR: 110/min , T: 37.4° C (99.3° F)

term-40A nurse is assisting with the care of a child who is receiving a blood transfusion. Which of the following findings indicates the child is having a hemolytic reaction?

Chills and flank pain= incompatibility of the transfused blood product Findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify this finding as an indication that the child is having a hemolytic reaction.

A nurse is preparing to leave the room after performing nasal suctioning for an infant who has respiratory syncytial virus (RSV). Identify the sequence in which the nurse should remove the following personal protective equipment (PPE).

Gloves Goggles Gown Mask (The infant is on droplet and contact precautions due to the RSV. First, the nurse should remove his gloves, because these are the most contaminated. Second, the nurse should remove goggles, so they do not interfere with removing the other PPE. The nurse should then remove the gown, and finally the mask, to decrease exposure to the disease.)

A nurse is caring for a child who has type 1 diabetes mellitus and has been receiving insulin via subcutaneous infusion pump. Which of the following laboratory tests would verify the average blood glucose level over the past 2 months?

Glycosylated hemoglobin Glycosylated hemoglobin provides an accurate average of the client's blood glucose level over the past 120 days. This test can be used to determine the effectiveness of, or compliance with, a treatment plan. It can also be used to diagnose diabetes mellitus.

A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect?

Hgb 9 g/dL The nurse should expect a child who has iron deficiency anemia to have an Hgb level below the expected reference range of 10 to 15.5 g/dL. An Hgb of 9.0 g/dL is below the expected reference range.

A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1month old infant. Which of the following statement by the parent indicates an understanding of the teaching?

I will allow my baby to have a pacifier while sleeping -decreases the risk for SIDS

A nurse is reinforcing teaching about liquid oral iron supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching?

I will give this medication to my child with a straw administer this medication with a straw to prevent staining the child's teeth.

A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse, "I'm a bad parent, and I cant deal with this." Which of the following responses should the nurse make?

I'm not sure I follow you. Can you explain? The nurse should use open-ended statements that will allow the parent to share their feelings and emotions. During times of grief, the parent needs to express emotions. The use of an open-ended statement relays the message that it is safe to do so with the nurse.

A nurse is contributing to the plan of care for a 10mo old infant who is postoperative following a cleft palate repair. Which of the following actions should the nurse include in the plan of care?

Place the infant in side lying position promote healing and prevent injury to the surgical site.

A nurse is reviewing the laboratory findings of a school-age child who reports feeling tired and being easily bruised. Which of the following laboratory values should the nurse report to the provider?

Platelets 85,000/mm3 This value is below the expected reference range for a school-age child and should be reported to the provider.

A nurse is assisting with planning dietary needs for a toddler. Which of the following interventions should the nurse include in the plan of care?

Provide 1 Tbsp (15 g) of solid food for each year of age. The nurse should ensure the toddler receives food serving sizes of 1 Tbsp (15 g) of solid food for each year of age of the toddler.

A nurse in a care provider's office is preparing to administer scheduled vaccines to an infant. The infant's parent refuses to allow the nurse to administer the vaccines. Which of the following actions should the nurse take?

Provide the parent with a vaccine information sheet (VIS). The nurse should provide the parent with a copy of the VIS for each of the vaccines to be administered to ensure the parent has the most current information regarding the benefits and risks of the vaccines.

During a well-child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make?

Provide the toddler with a favorite toy at bedtime. providing the toddler with a favorite toy at bedtime will help the toddler to feel more secure and facilitate sleep.

A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend

Yellow corn A client who has celiac disease is unable to process gluten, a protein found in wheat, barley, rye, and oats. The nurse should instruct the family that the client's diet is restricted to foods that are free of gluten, such as corn, rice, and millet.

A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler?

ask the guardian to verify the child's name Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should ask the guardian to verify the identity of the child and use the identification band as the second identifier.

A nurse is assisting with the care of an adolescent following a cardiac catherization. Which of the following is the priority finding the nurse should report to the provider?

bleeding noted on the dressing Bleeding noted on the dressing is an indication that the client is at greatest risk for hemorrhage at the catherization site; therefore, the nurse should identify bleeding on the dressing as the priority finding. The nurse should apply continuous pressure 2.5 cm (1 in) above the site and notify the provider.

A nurse is collecting data from a school-age child. The nurse should identify that which of the following findings is a manifestation of physical abuse?

bruises at various stages of healing a clinical manifestation of physical abuse.

A nurse is preparing to obtain a peak expiratory flow rate from an adolescent. Which of the following actions should the nurse take?

have the client stand during the procedure ; allows to get an accurate reading To obtain the peak expiratory flow rate, the nurse should have the client stand during the procedure, which will allow the nurse to get an accurate reading.

A nurse is caring for a school age child who has hypocalcemia. Which of the following manifestations should the nurse expect?

hypotension hypotension is a manifestation of hypocalcemia.

A nurse is preparing to assist a provider with a lumbar puncture for a school age child. Which of the following actions is the nurse's priority

maintaining the child's position

A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints?

mummy restraint The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the toddler that involves the head and neck. The nurse should always use the least amount of restraint necessary.

A nurse is caring for a 1month old infant who has a nasogasatric tube in place for intermittent feedings. Which of the following actions should the nurse take?

position the head of the crib at 30 angle between feedings place the infant with the head of the crib elevated 30° to 45° to prevent aspiration.