ATI Questions
A nurse is assessing a toddler for possible hearing loss. Which of the following are clinical manifestationsof a hearing impairment? (Select all that apply.) A. Uses monotone speech B. Speaks loudly C. Repeats sentences D. Appears shy E. Is overly attentive to the surroundings
A, B, D
A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following results indicate viral meningitis? (Select all that apply.) A. Negative gram stain B. Normal glucose content C. Cloudy color D. Decreased WBC count E. Normal protein content
A, B, E
A nurse is caring for an adolescent who has sustained a closed head injury. Which of the following are clinical manifestations of increased intracranial pressure (ICP)? (Select all that apply.) A. Report of headache B. Alteration in pupillary response C. Increased motor response D. Increased sleeping E. Increased sensory response
A, B, D
A nurse is assessing a child. Which of the following are clinical manifestations of myopia? (Select all that apply.) A. Headaches B. Photophobia C. Difficult reading D. Difficulty focusing on close objects E. Poor school performance
A, D, E
A nurse is teaching the parent of a child who has a growth hormone deficiency.Which of the following are complications of untreated growth hormone deficiency? A. delayed sexual development B. premature aging C. advanced bone age D. short stature E. increased epiphyseal closure
A, B, D
The nurse is caring for a child who has a fracture. Which of the following are manifestations of a fracture? (Select all that apply) A. Crepitus B. Ecchymosis C. Fever D. Pain E. Edema
A, B, D, E
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. Provide extra time for ADLs B. Take ibuprofen on an empty stomach C. Apply cool compresses for 20 minutes every hour. D. Remain home during periods of exacerbation E. Preform range of motion exercises
A and E
A nurse is caring for a child who has absence seizures. Which of the following findings can the nurse expect?(Select all that apply.) A. Loss of consciousness B. Appearance of daydreaming C. Dropping held objects D. Falling to the floor E. Having a piercing cry
A, B, C
A nurse is teaching a group of parents about the risk factors for seizures. Which of the following should be included in the teaching? (Select all that apply.) A. Febrile episodes B. Hypoglycemia C. Sodium imbalances D. Low serum lead levels E. Presence of diphtheria
A, B, C
A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? (Select all that apply) A. Edema in the ankles B. Anorexia C. Urine dipsticks +2 protein D. Hyperlipidemia E. Polyuria
A, B, C, D
A nurse is caring for a child who has short stature. Which of the following diagnostic tests should be complete to confirm growth hormone (GH) deficiency? (Select all that apply) A. CT scan of the head B. skeletal x-rays C. GH stimulation test D. Blood IGF-1 E. DNA testing
A, B, C, D
A nurse is reviewing treatment options with the parent of a child who has worsening seizures. Which ofthe following should be included in the discussion? (Select all that apply.) A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection E. Radiation therapy
A, B, C, D
A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A. Maintain in a side-lying position. B. Monitor vital signs. C. Reorient the child to the environment. D. Assess for injuries.
A
A nurse is caring for a child who was admitted to the emergency department after a motor-vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the foreheadthat is bleeding. Which of the following is the priority nursing action at this time? A. Keep the neck stabilized. B. Clean the laceration with soap and water. C. Implement seizure precautions. D. Establish IV access.
A
A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness.Which of the following actions by the nurse is appropriate? A. Place the client on NPO status. B. Prepare the client for a liver biopsy. C. Position the client dorsal recumbent. D. Put the client in a protective environment.
A
A nurse is teaching a child who has type 1 diabetes mellitus about self-care. Which of the following statements by the child indicates understanding of the teaching? A. I should drink a glass of milk when I am feeling irritable. B. I should draw up NPH insulin into the syringe before the regular insulin. C. I should increase my insulin with exercise. D. I should skip breakfast when I am not hungry.
A
An adolescent is found wandering around. The client is confused, sweaty, and pale. Which test will the nurse prepare to perform first? A. blood glucose level B. computed tomography (CT) scan C. blood toxicology D. serum ketone testing
A
The nurse has told the 14-year-old adolescent with diabetes that the doctor would like to have a hemoglobin A1C test performed. Which comment by the client indicates that she understands what this test is for? A. "This will tell my doctor what my average blood glucose level has been over the last 2 to 3 months." B. "The normal level for my hemoglobin A1C is between 60 to 100 mg/dl." C. "That is the test that I take after I have fasted for at least 8 hours." D. "I monitor my own blood glucose every day at home. I don't see why the doctor would want this done."
A
A nurse is caring for a child who has cerebral palsy which of the following medications should the nurse expect to administer to treat painful muscle spasms? (Select all that apply) A. baclofen B. diazepam C. oxybutin D. methotrexate E. prednisone
A and B
A nurse is caring for an infant and notices an audible click in their left hip. Which of the following diagnostic test should the nurse expect the provider to perform? (Select all that apply) A. barlow test B. babinski sign C. manipulation of foot and ankle D. ortolani test E. ponseti method
A and D
A nurse is caring for a child who has a fracture. Which of the following are manifestations of a fracture? A. crepitus B. edema C. pain D. fever E. ecchymosis
A, B, C, and E
A nurse is reviewing sick-day management with a parent of a child with type 1 diabetes mellitus. Which of the following should the nurse include in teaching? (Select all that apply) A. Monitor blood glucose levels every 3 hours. B.Drink 8 ounces of fruit juice every hour. C. Discontinue taking insulin until you feel better. D. Test urine for ketones. E. Call the provider if blood glucose is greater than 240 mg/dL.
A, D, E
A nurse is reviewing sick-day management with a patient of a child who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? A. monitor blood glucose levels every 3 hr B. discontinue taking insulin until feeling better C. drink 8oz of fruit juice every hour D. test urine for ketones E. call the provider if blood glucose if greater than 240 mg/dL
A, D, E
A nurse is assessing a child who has a concussion. Which of the following are clinical manifestations of a minor head injury? (Select all that apply.) A. Amnesia B. Systemic hypertension C. Bradycardia D. Respiratory depression E. Confusion
A, E
A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? A. "The purpose of this device is to immobilize the cervical spine." B. "The purpose of this device is to allow for neck movement during the healing process." C. "Apply talcum powder under the vest to limit friction." D. "Turn the screws on the device once each day."
A. "The purpose of this device is to immobilize the cervical spine."
A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching? A. Drain the bladder with a clean intermittent catheter every hour B. Decrease fluid intake C. Observe the urine for a foul odor D. Keep an indwelling catheter in place at all times
A. Drain the bladder with a clean intermittent catheter every hour
A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Encourage the parents to rock the infant. B. Offer the infant a pacifier. C. Administer ibuprofen as needed for pain. D. Position the infant on her abdomen.
A. Encourage the parents to rock the infant.
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 and 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. Should be done every 3-4 hours to prevent UTIs and bladder stasis
A nurse is preparing to administer the first measles, mumps, and rubella (MMR) immunizations to a 15-month-old toddler. Which of the following findings is a contraindication for this immunization? A. The child has a congenital immunodeficiency. B. The child is currently taking antibiotics for otitis media. C. The child has a cough and a temperature of 37.7° C (99.9" F) D. The child's temperature after the last set of immunizations was 38.3 C(101)
A. The child has a congenital immunodeficiency. Children with congenital immunodeficiencies have compromised immune systems and may not be able to mount an adequate immune response to the vaccine. Administering live vaccines, such as MMR, to these children can potentially cause severe complications.
A nurse is caring for a child who is sustained a fracture. Which of the following actions should the nurse take? (Select all the apply) A. place a heat pack on the site of injury B. elevate the affected limb C. assess neurovascular status frequently D. encourage ROM of the affected limb E. stabilize the injury
B, C, and E
A nurse is preparing to assist with applying a cast to a preschoolers arm. Which of the following actions should the nurse take? A. Wrap the arm of the child doll or a 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 doll or a toy prior to the procedure.
A child with a history of T3 spinal cord injury presents to the emergency department with headache, facial flushing, and cardiac dysrhythmias. Which of the following conditions would the nurses suspect? A. autonomic dysreflexia B. spinal cord shock C. poikilothermia D. spasticity
A. autonomic dysreflexia
A child is admitted to the inpatient unit with Guillain-Barré syndrome. Which assessment should the nurse perform first? A. respiratory B. nutrition C. neurological D. motor
A. respiratory
A 4-year-old diagnosed with diabetes insipidus is being discharged. Which information below is most important to emphasize to the parents? A. Children outgrow this diagnosis over time. B. Diabetes insipidus is different from diabetes mellitus. C. Only one person in the house needs to learn how to give the injections of vasopressin. D. Children younger than 5 do not need to wear medical alert tags.
B
A child has recently been diagnosed with cataracts. The treatment for cataracts is: A. wearing a patch until the cloudiness clears. B. surgery. C. there is no treatment for childhood cataracts. E. eye drops to lower the pressure.
B
A nurse is developing a plan of care for a toddler who has cerebral palsy. Which of the following actions should the nurse take? A. structure interventions according to the toddler's chronological age B. evaluate the toddler's need for an evaluation of hearing ability C. monitor the toddler's pain routinely using a numeric rating scale D. provide total care for daily hygiene activities
B
A nurse is planning care for a child who has a urinary tract infection. Which of the following interventions should the nurse include? A. Evaluate the child's self-esteem B. Encourage frequent voiding C. Restrict fluids D. Administer an antidiuretic
B
A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I should expect him to have frequent diarrhea." B. "I should place a cool mist humidifier in his room." C. "I should avoid the use of lotion on his skin." D. "I should expect him to grow faster in length than other infants."
B
A nurse suspects that a child has developed pneumococcal meningitis based on assessment of which of the following? A, productive cough B. nuchal rigidity C. chills D. otitis media
B
A nurse is caring for a 6-month-old infant. Which of the following findings indicates to the nurse that the infant may be experiencing pain? A Eyes wide open B Furrowed brow C Decreased muscle tone D Dry hands and feet
B Furrowed brow Furrowing of the brow is often associated with discomfort or distress in infants. Other signs of pain in infants can include crying, irritability, increased heart rate, increased respiratory rate, and changes in sleep and feeding patterns. The eyes wide open, decreased muscle tone, and dry hands and feet are not specific indicators of pain and may have other explanations or may be within normal variations for an infant.
A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure? A Increased formula consumption B Increased crying episodes C Decreased respiratory rate D Decreased heart rate
B Increased crying episodes Crying is a common behavioral response to pain in infants, and it serves as an important indicator of discomfort. Infants may cry more intensely, have a high-pitched cry, or exhibit inconsolable crying when they are in pain. It is important for the nurse to assess the infant's pain level and provide appropriate interventions to alleviate the discomfort.
A nurse is assessing the child who has Legg-Calve-Perthes disease. Which of the following findings should the nurse expect? (Select all that apply) A. longer affected leg B. hip stiffness C. back pain D. limited ROM E. limp with walk
B, C, D, and E
A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (Select all that apply) A. Falling to the floor B. Dropping held objects C. Appearance of daydreaming D. Having a piercing cry E. Loss if consciousness
B, C, E
A nurse is caring for a child with type 1 diabetes mellitus. Which of the following are manifestations of diabetic ketoacidosis? (Select all that apply) A. Weight gain B. Fruity breath C. Mental confusion D. Blood glucose 58 mg/dL E. Dehydration
B, C, E
A nurse is caring for a child who is in skeletal traction. Which of the following actions should the nurse take? (Select all the apply) A. remove the weights to reposition the client B. assess the child's position frequently C. assess pin sites every 4 hr D. ensure the weights are hanging frequently E. ensure the rope's knot is in contact with the pulley
B, C, and D
A nurse is caring for a child who has increased intracranial pressure. Which of the following areappropriate actions by the nurse? (Select all that apply.) A. Suction the endotracheal tube every 2 hr. B. Maintain a quiet environment. C. Use two pillows to elevate the head. D. Administer a stool softener. E. Maintain body alignment
B, D, E
A nurse is teaching an adolescent who has diabetes mellitus about manifestations of hypoglycemia. Which of the following should the nurse include in the teaching? (Select all that apply) A. increased urination B. hunger C. poor skin turgor D. irritability E. sweating and pallor F. kussmaul respirations
B, D, E
A 13-year-old adolescent is seen in the office and appears very anxious. For the past 2 weeks, the adolescent has had some muscle twitching; upon examination, the client is found to have a positive Chvostek sign. Which would be an appropriate explanation of a Chvostek sign? A. Pain can be caused by touching the muscles. B. Chvostek sign is a facial muscle spasm demonstrated by tapping the facial nerve. C. Increased intracranial pressure causes this sign. D. Excess intake of vitamin D can cause this sign.
B.
An infant is born with congenital clubfoot and the nurse tells the mother that serial casting should be started soon after birth. The mother asks why treatment must start so early? A. "That's how it's always done." B. "Early treatment allows the bone to be reformed before it hardens." C. "Early treatment allows for the extensive surgical interventions that are required later in life." D. "It's okay to wait if you think that would be best."
B. "Early treatment allows the bone to be reformed before it hardens."
A nurse is teaching a group of caregivers about fractures. Which of the following information should the nurse include in the teaching? A. "Children need a longer time to heal from a fracture than an adult" B. "Epiphyseal plate injuries can result in altered bone growth" C. "A greenstick fracture is a complete break in the bone" D. "Bones are unable to bend, so they break
B. "Epiphyseal plate injuries can result in altered bone growth"
A nurse is administering vaccines at a county health immunization clinic. Which of the following clients should the nurse plan to administer the meningococcal conjugate (MCV4) vaccine? A. a 4-year old preschool child B. An 11-year old school-aged child C. A 4 month old infant D. A 2 year old toddler
B. An 11-year old school-aged child
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
The nurse receives a report on a child admitted with severe muscular dystrophy. The nurse suspects the child has been diagnosed with the most severe form of the disease, known as: A. Limb-girdle B. Duchenne C.Facioscapulohumeral D. Myotonia
B. Duchenne
A nurse is planning to perform a peripheral vision test on a child. Which of the following actions should the nurse take? A. Show a set of cards to the child one at a time. B. Place the child 10 feet away from a Snellen chart. C. Have the child focus on an object while performing the test. D. The nurse should cover the child's eye while performing the test on the other eye.
C
A client with a diagnosis of trigeminal neuralgia reports which of the following manifestations as significantly affecting her quality of life? A. lethargy B. pain C. social withdrawal D. poor hygiene
B. Pain
A nurse is assessing an eight month old infant for cerebral palsy. Which of the following findings is a manifestation of the condition? A. Tracks and object with eyes B. Sits with pillow props C. Smiles when a parent appears D. Uses a pincer grass to pick up a toy
B. Sits with pillow props
A child with a newly diagnosed ulnar fracture has a short-arm cast applied. Which of the following symptoms would be most concerning for the nurse? A. Swelling B. Uncontrolled, severe pain C. Mild pain D. Itching
B. Uncontrolled, severe pain
Which of the following would a provider do to assess vestibular function? A. Have child track eyes with a light B. Whisper a word and observe head movement c. Watch posture and gait
B. Whisper a word and observe head movement
A nurse is providing care to a child who has an allergy to eggs. The nurse should question the prescription for which of the following immunizations? A inactivated poliovirus (PV) B influenza live attenuated (LAV) C Haemophilus influenza type b (Hib) D Hepatitis (Hepi)
B. influenza live attenuated (LAV) The influenza LAV is typically produced using egg-based methods, which may pose a risk for individuals with an allergy to eggs. Although the risk of a severe allergic reaction to the influenza vaccine is low, it is recommended to avoid the influenza LAV in individuals with a known severe allergy to eggs. Inactivated poliovirus (PV), Haemophilus influenza type b (Hib), and Hepatitis (Hepi) vaccines do not contain egg proteins and can generally be safely administered to individuals with an egg allergy.
A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the following findings should the nurse monitor for as an adverse effect of mannitol? A. bradycardia B. weight loss C. confusion D. constipation
C
A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A.Note the time of the postictal period. B. Try to determine the seizure trigger. C. Position the child in a side-lying position. D. Reorient the child to the environment.
C
A nurse is reviewing the medical record of a client who has Reye syndrome. Which of the following findings should the nurse identify as a risk factor for Reye syndrome? A. Recent history of infectious cystitis caused by Candida. B. Recent episode of Haemophilus influenzae meningitis. C. Recent episode of gastroenteritis. D. Recent history of bacterial otitis media.
C
A parent of a school-aged child who has GH deficiency asks the nurse how long the child will need to take injections for growth delay. Which of the following responses should the nurse make? A. "Injections are usually continued until age 10 for girls and age 12 for boys" B. "Injections continue until your child reaches the fifth percentile on the growth chart" C. "Injections might be stopped once your child grows less than 1 inch/year" D. "The injections will need to be administered throughout your child's entire life"
C
Diabetes insipidus is a disorder of the posterior pituitary that results in deficient secretion of which hormone? A. Luteinizing hormone (LH) B. Thyroid stimulating hormone (TSH) C. Antidiuretic hormone (ADH) D. Adrenocorticotropic hormone (ACTH)
C
A nurse is planning care for a 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain? A PANAD scale B OUCHER scale C FLACC scale D FACE Scale
C FLACC scale The appropriate pain rating scale to use for a 2-month-old infant is the FLACC (Face, Legs, Activity, Cry, Consolability) scale. The FLACC scale is commonly used for infants and young children who are unable to self-report their pain. It assesses facial expression, leg movement, activity level, cry, and ability to be consoled. Each category is scored on a scale of 0 to 2, and the total score provides an indication of the infant's pain level. The PANAD scale and OUCHER scale are more commonly used for older children, while the FACE scale is specific to assessing pain in individuals with cognitive impairments.
A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess? (Select all that apply) A. purposeless, involuntary, abnormal movements B. spinal defect and saclike protrusion C. muscular weakness in lower extremities D. unsteady, wide-based or waddling gait E. upward slant to the eyes
C and D
A client has sustained a T4-T5 injury and the nurse suspects he is in neurogenic shock. Which of the following manifestations are consistent with neurogenic shock? Select All that Apply A. hypertension B. rapidly elevating temperature C. bradycardia D. fixed and dilated pupils E. hypotension
C and E A + B are signs of autonomic dysreflexia
A nurse is reinforcing teaching with a group of caregivers about possible manifestations of Down syndrome. Which of the following findings should the nurse include? (Select all that apply.) A. A large head with bulging fontanels B. Larger ears that are set back C. Protruding abdomen D. Broad, short feet and hands E. Hypotonia
C, D, E
A nurse is developing an educational program about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (Select all the apply) A. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) B. Trivalent inactivated influenza vaccine (TIV) C. Pneumococcal conjugate vaccine (PCV) D. Inactivated polio vaccine (IVP) E. Haemophilus influenzae type B (Hib) vaccine
C, E
A nurse is teaching a child who has type 1 diabetres mellitus about self-care. Which of the following statements by the child indicates understanding of the teaching? A. "I should skip breakfast when I am not hungry" B. "I should increase my insulin with exercise" C. "I should drink a glass of milk when I am feeling irritable" D. "I should draw up the NPH insulin into the syringe before the regular insulin"
C. "I should drink a glass of milk when I am feeling irritable"
A nurse is completing preoperative teaching with an adolescent client who is scheduled to receive spinal instrumentation for scoliosis. A. "You will go home the same day as surgery" B. "You will have minimal pain" C. "You will need to receive blood" D. "You will not be able to eat until the day after surgery"
C. "You will need to receive blood"
When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment? A. Urinary output B. Blood Pressure C. Counting respirations D. Bowel sounds
C. Counting respirations
An 8-year-old girl is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. What intervention will help her most in her adjustment to the hospital? A Orient her parents, because she is too young to be in her room and hospital facility. B Explain hospital schedules to her, such as mealtimes. C Explain when parents can visit and why siblings cannot come to see her D Use terms such as "honey and "dear to show a caring attitude.
C. Explain when parents can visit and why siblings cannot come to see her Hospitalization can be a challenging and unfamiliar experience for children, especially when they are separated from their family and siblings. Providing clear information about visitation policies and explaining the reasons for restrictions can help the child understand and cope better with the situation. While orienting her parents and explaining hospital schedules can be beneficial, the focus should be on directly addressing the needs and concerns of the child to support her adjustment. Using caring and comforting language is important, but it should be combined with age-appropriate explanations and addressing specific concerns related to the child's situation.
A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action? A. Unscrew the pins from the cervical tongs B. Ask the client to sit on the edge of the bed C. Gather supplies and at least 3 other people D. Remove the straps from the halo vest
C. Gather supplies and at least 3 other people
When planning care for a client hospitalized with Guillain-Barre Syndrome, which of the following will the nurse report to the physician? A. A report by the client of difficulty sleeping B. Removing the sequential compression device once a shift C. Hypoactive bowel sounds D. Glasgow Coma Score of 15
C. Hypoactive bowel sounds
A nurse is planning care for an infant who has spina bifida and needs to undergo surgical closure of the Myelomeningocele sack. Which of the following interventions should the nurse include in the plan of care? A. Maintain the infant in the supine position. B. Initiate contact precautions. C. Provide a latex free environment. D. Limit visitors to immediate family members.
C. Provide a latex free environment.
A nurse is orienting a newly licensed nurse in the care of an infant who has Myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?A.Performs range of motion on the infants hips. B.Maintains a dry dressing over the sack. C. Takes an axillary temperature. D. Place is the infant and a side lying position
C. Takes an axillary temperature.
A nurse working in a pediatric clinic recognizes the three most common toxins in pediatric care? A. Pesticides B. Air pollution C. Pharmacuetical D. Lead Poisoning
Correct Answer : A,C,D Lead is a toxic metal that can be found in old paint, dust, soil, and certain consumer products. Children are particularly vulnerable to lead poisoning, which can lead to developmental delays, learning difficulties, and other health problems. Pesticides are chemicals used to control pests, such as insects and rodents. Children can be exposed to pesticides through contaminated food, water, or direct contact with treated areas. Pesticide exposure has been linked to various health issues, including neurodevelopmental disorders and respiratory problems. Certain medications can be toxic to children, especially if taken in excessive amounts or without appropriate supervision. Accidental ingestion of medications, including over-the-counter and prescription drugs, is a significant concern in pediatric care. While air pollution is a significant environmental factor that can impact children's health, it is not typically considered one of the most common toxins in pediatric care.
The nurse is assessing the spine of an infant. Which finding requires further follow up by the nurse? A. Mild curvature from anterior to posterior B. Skin is free of dimples C. No lateral curvature D. Tuft of hair present on the lower back
D. Tuft of hair present on the lower back
The primary health care provider has ordered a thyroid scan to confirm the diagnosis of hyperthyroidism. Which would the nurse do before the scan? A. Insert a urinary catheter. b. Give the client a bolus of fluids. c. Tell the client he or she will be asleep d. Assess the client for allergies.
D
A nurse is teaching about neural tube defects to a group of females who are pregnant. Which of the following disease processes should the nurse include as an example of a neural tube defect? A) Cerebral palsy B) Hydrocephalus C) Muscular dystrophy D) Spina bifida
D. Spina bifida
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 parent swings under than any of the affected leg. D. The buttocks is elevated slightly off the bed.
D. The buttocks is elevated slightly off the bed.
A 4-year-old child is brought to the emergency department after being in a motor vehicle accident. The child experienced head trauma in the accident. When assessing the child, which will be the first change noted in the presence of increasing intercranial pressure? A. decline in respiratory rate B. reduction in heart rate C. increase in heart rate D. change in level of consciousness
D
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room? A. A two-bed room in the middle of the hall B. A room with an 8-month-old infant with failure to thrive C. A room with a 12-month-old infant with a urinary tract infection D. A private room near the nurses' station
D
A nurse is assessing a child who has short stature. Which of the following findings would indicate a growth hormone deficiency? A. Height proportionally greater than weight B. Early-onset puberty C. Oversized jaw D. Proportional height to weight
D
A nurse is caring for a 4-month-old infant who has meningitis. Which of the following findings isassociated with this diagnosis? A. Depressed anterior fontanel B. Constipation C. Presence of the rooting reflex D. High-pitched cry
D
A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take? A. Put the client in a protective environment. B. Prepare the client for a liver biopsy. C. Position the client dorsal recumbent. D. Place the client on nothing by mouth, NPO, status.
D
A nurse is caring for an infant who has a myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care? A. assist the caregiver in cuddling the infant B. assess the infant's temperature rectally C. place the infant in a supine position D. apply a sterile, moist dressing on the sac
D
A nurse is planning to perform a peripheral vision test on a child. Which of the following is an appropriate action for the nurse to take? A. Place the child 10 feet away from the chart. B. Show a set of cards to the child one at a time. C. Cover the child's eye while performing the test on the other eye. D. Have the child focus on an object while performing the test.
D
A nurse is providing teaching to the parents of a newborn. Which of the following information should the nurse include? A "Your baby should receive the measles, mumps, rubella vaccine at 6 months. B "Your baby will receive the first diphtheria, tetanus, pertussis vaccine at the 2 week well-baby visit C "Your baby should receive the pneumococcal conjugate vaccine on his first birthday." D "Your baby will receive a hepatitis B vaccine prior to discharge
D "Your baby will receive a hepatitis B vaccine prior to discharge The hepatitis B vaccine is typically administered to newborns shortly after birth, usually within 24 hours. The measles, mumps, rubella (MMR) vaccine is typically given between 12 and 15 months of age, not at 6 months. The first dose of the diphtheria, tetanus, pertussis (DTaP) vaccine is usually given at 2 months of age, not at the 2-week visit. The pneumococcal conjugate vaccine (PCV) is typically given in a series, starting at 2 months of age, and is completed by the age of 12-15 months. It is not given specifically on the first birthday.
A nurse is caring for a child who is in a plaster spica cast. Which of the following actions should the nurse take? A. use a heat lamp to facilitate drying B. avoid turning the child until the cast is dry C. assist the client with crutch walking after the cast is dry D. apply moleskin to the edges of the cast
D apply moleskin to the edges of the cast
A nurse is caring for a toddler who has hip dysplasia and has been placed in a hip spica cast. The child's guardian asked the nurse why a Pavlik harness is not being used. Which of the following responses should the nurse make? A. "The Pavlik harness is used for children with scoliosis, not hip dysplasia" B. "The Pavlik harness is used for school-aged children" C. "The Pavlik harness cannot be used for your child because her condition is too severe" D. "The Pavlik harness is used for infants less than 6 months of age"
D. "The Pavlik harness is used for infants less than 6 months of age"
A nurse is teaching a school-age child who has diabetes mellitus about insulin administration. Which of the following should the nurse include in the teaching? A. "You should inject the needle at a 30-degree angle" B. "You should combine your glargine and regular insulin in the same syringe" C. "You should aspirate for blood before injecting the insulin" D. "You should give four to six injections in one area before switching sites"
D. "You should give four to six injections in one area before switching sites"
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 an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation which of the following intervention should the nurse include in the plan of care? A. Keep the head of the bed at a 30° angle. B. Reposition the client by logrolling every four hours. C. Place the client in protective isolation. D. Initiate the use of a PCA pump for pain control.
D. initiate the use of a PCA pump for pain control.
A nurse is caring for a child who is suspected of having Legg-Calve-Perthes disease. The nurse should prepare the child for which of the following diagnostic procedures? A. bone biopsy B. genetic testing C. CT scan D. radiographs
D. radiographs
Which of the following manifestations can the nurse expect in a client with upper motor neuron deficit related to a spinal cord injury? A. leakage B. anuria C. flaccid bladder, inability to voluntarily void D. spastic, involuntary voiding
D. spastic, involuntary voiding
A newborn was admitted to the hospital with vomiting and dehydration. The newborn's heart rate is 170, respiratory rate is 44, blood p 85/52, and temperature is 99 Degree F (37.2 Degree C). What is the nurse's best response to the parents who ask if the vital signs are normal? A. "The blood pressure is elevated, but the other vital signs are within normal limits" B. "The heart rate is elevated, but the other vital signs are within normal limits" C. "The temperature is elevated, but the other vital signs are within normal limits" D. "The respiratory rate is elevated, but the other vital signs are within normal limits"
The Correct Answer is B While the newborn's heart rate of 170 bpm is elevated, the respiratory rate of 44 breaths/min, blood pressure of 85/52 mmHg, and temperature of 99°F (37.2°C) are within the normal range for a newborn. It is important for the nurse to explain to the parents that the newborn's heart rate may be elevated due to the vomiting and dehydration and that healthcare providers will monitor the vital signs closely to ensure the newborn's stability.
A nurse is assisting with a routine physical 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. Torticollis. B. Kyphosis. C. Scoliosis. D. Lordosis.
The Correct Answer is C Scoliosis is a condition characterized by sideways curvature of the spine or backbone.A lateral curvature of the spine is called scoliosis. Choice A, Torticollis, is not the correct answer because it is a condition in which the head becomes persistently turned to one side, often associated with painful muscle spasms. Choice B, Kyphosis, is not the correct answer because it refers to an excessive outward curvature of the spine, causing hunching of the back. Choice D, Lordosis, is not the correct answer because it refers to an excessive inward curvature of the spine.
A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother? A. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines.". B."Sleep apnea is the main cause of SIDS.". C. "Placing your child on her back when sleeping will decrease the risk of SIDS.". D."SIDS rates have been rising over the last 10 years.".
The Correct Answer is C The American Academy of Pediatrics recommends that infants be placed on their backs to sleep to reduce the risk of SIDS1. Choice A is not an answer because there is no direct correlation between SIDS and diphtheria, tetanus, and pertussis vaccines
