Children Practice A
A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parent asks the nurse why it is necessary to check the child's urine for protein. Which of the following explanations should the nurse offer?
"A decrease in urine protein indicates that treatment is effective." The desired outcome of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.
A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parent asks the nurse why it is necessary to check the child's urine for protein. Which of the following explanations should the nurse offer? "A decrease in urine protein indicates that treatment is effective." "Protein in the urine indicates your child's protein intake is adequate." "Protein in the urine indicates a need to begin dialysis." "An increase in urine protein indicates your child has a secondary infection."
"A decrease in urine protein indicates that treatment is effective." The desired outcome of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.
A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death? "Your child will likely exhibit fear of the impending death with verbal uncooperativeness." "At this age, your child will understand that death is irreversible." "Your child will likely be curious about what happens to the body after death." "At this age, your child likely believes his thoughts can cause another person's death."
"At this age, your child likely believes his thoughts can cause another person's death." The nurse should reinforce that, at this age, the preschooler might believe that his thoughts can cause another person's death, which can make him feel guilty or responsible for the death.
A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death? "Your child will likely exhibit fear of the impending death with verbal uncooperativeness." "At this age, your child will understand that death is irreversible." "Your child will likely be curious about what happens to the body after death." "At this age, your child likely believes his thoughts can cause another person's death."
"At this age, your child likely believes his thoughts can cause another person's death." The nurse should reinforce that, at this age, the preschooler might believe that his thoughts can cause another person's death, which can make him feel guilty or responsible for the death.
A nurse is monitoring a child who is receiving a transfusion of packed RBCs. Which of the following responses by the child is an indication of a transfusion reaction? "My nose is runny. Can I have a tissue?" "I am hungry. Can I get a snack?" "I am sleepy. I might take a nap after this." "I am cold. Can I have an extra blanket?"
"I am cold. Can I have an extra blanket?" The nurse should identify that being cold and having chills is an indication of a transfusion reaction.
A nurse is reinforcing teaching about injury prevention with the guardian of an infant. Which of the following statements by the guardian indicates an understanding of the teaching?
"I should make sure my baby's clothing does not have buttons on it." The nurse should instruct the guardian to avoid dressing the infant in clothing with buttons to reduce the risk of choking and aspiration.
A nurse is reinforcing teaching about injury prevention with the guardian of an infant. Which of the following statements by the guardian indicates an understanding of the teaching? "I should lightly shake talcum powder on my baby's skin after each diaper change." "I should use a drop-side crib after my baby is 6-months-old." "I should make sure my baby's clothing does not have buttons on it." "I should ensure the crib slats are no more than 3 inches apart."
"I should make sure my baby's clothing does not have buttons on it." The nurse should instruct the guardian to avoid dressing the infant in clothing with buttons to reduce the risk of choking and aspiration.
A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile idiopathic arthritis (JIA). Which of the following statements by the parent indicates an understanding of the teaching? "I will have my child sleep in knee, wrist, and hand splints." "I will encourage my child to take an afternoon nap." "I will apply topical hydrocortisone to my child's joints as needed." "I will administer opioids to my child for the next several months to control the pain."
"I will have my child sleep in knee, wrist, and hand splints." The nurse should reinforce with the guardian that splinting the child's joints at night will decrease pain and enhance joint function.
A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea. Which of the following findings should the nurse identify as a risk factor for this disorder? (Select all that apply.) 1. Hypothyroidism 2. Obesity 3. Cannabis use 4. Oral contraceptive use 5. Emotional stress
1. Hypothyroidism The nurse should identify that hypothyroidism and other endocrine disorders are risk factors for primary amenorrhea. 3. Cannabis use The nurse should identify that cannabis use is a risk factor for primary amenorrhea. 4. Oral contraceptive use The nurse should identify that oral contraceptive use affects the estrogen and progesterone cycle and is a risk factor for primary amenorrhea. 5. Emotional stress The nurse should identify that emotional stress causes hypothalamic suppression and is a risk factor for primary amenorrhea.
A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of following actions should the nurse take first? Open the sterile dressing tray. Administer pain medication to the client. Assist the client into the left lateral position. Remove the previous dressing to inspect the wound.
Administer pain medication to the client. According to evidence-based practice, the nurse should first provide pain medication to the client to reduce discomfort during the procedure.
A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of the following actions should the nurse take first? Open the sterile dressing tray. Administer pain medication to the client. Assist the client into the left lateral position. Remove the previous dressing to inspect the wound.
Administer pain medication to the client. According to evidence-based practice, the nurse should first provide pain medication to the client to reduce discomfort during the procedure.
A nurse is caring for a preschooler who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the parent to administer for an acute asthma attack? Albuterol Fluticasone Cromolyn sodium Montelukast
Albuterol The nurse should inform the parent to administer albuterol, a short-acting beta2 agonist, to the preschooler for acute asthma attacks. Cromolyn sodium for the long-term management of asthma. Fluticasone, a corticosteroid, for the long-term management of asthma. Montelukast, a leukotriene modifier, for the long-term management of asthma.
A nurse is reinforcing teaching with the parents of a child who has cystic fibrosis and is taking pancrelipase as a pancreatic enzyme replacement. The nurse should plan to inform the child's parents that the therapeutic effects of this medication can be evaluated by which of the following? Blood glucose levels Amount and consistency of stools Chloride sweat tests BUN and creatinine clearance tests
Amount and consistency of stools Recording the amount and consistency of the child's stools will help determine the effectiveness of pancrelipase, which is taken to decrease the bulk of feces.
A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who is recovering from acute glomerulonephritis. Which of the following food choices by the parents indicates an understanding of the teaching? Pretzels Apples Canned corn Peanut butter
Apples The nurse should instruct the parents that apples are low in sodium and supply the child with energy needed for recovery.
A nurse is preparing to administer ophthalmic drops to a child. Which of the following actions should the nurse take? Position the child with his head flexed while administering the medication. Apply pressure to the lacrimal punctum for 1 min following administration. Hold the dropper 5 cm (2 in) above the eye to administer the medication. Wipe the excess medication toward the inner canthus with a cotton swab
Apply pressure to the lacrimal punctum for 1 min following administration. The nurse should apply pressure to the lacrimal punctum to prevent the medication from entering the nasopharynx.
A nurse is collecting data from a 12-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? Heart rate 130/min Respiratory rate 30/min BP 115/70 mm Hg Temperature 37.5° C (99.5° F)
BP 115/70 mm Hg The nurse should identify that this blood pressure is above the expected reference range for a 12-month-old infant and report this finding to the provider.
A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening? Clasping hands while arms are raised above the head Bending forward with back parallel to the floor Standing with feet shoulder-width apart Bending knees while placing hands on hips
Bending forward with back parallel to the floor The nurse should observe for asymmetry and prominence of the rib cage by having the students bend forward with the back parallel to the floor.
A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening? Clasping hands while arms are raised above the head Bending forward with back parallel to the floor Standing with feet shoulder-width apart Bending knees while placing hands on hips
Bending forward with back parallel to the floor The nurse should observe for asymmetry and prominence of the rib cage by having the students bend forward with the back parallel to the floor.
A nurse is collecting data from a 12-month-old infant during a well-child visit. The nurse should identify which of the following findings as a deviation from expected growth and development? Vocabulary of three words Negative Babinski reflex Birth weight doubled Unable to build a two-block tower
Birth weight doubled The nurse should identify this finding as a deviation from expected growth and development. The infant's birth weight should triple by 12 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is collecting data from a toddler who has gastroesophageal reflex disease (GERD). Which of the following findings should the nurse expect? Abdominal distention Constipation Chronic cough Decreased bowel sounds
Chronic cough The nurse should identify that a chronic cough is an expected finding in a child who has GERD. Abdominal distention is an expected finding in a child who has Hirschsprung's disease. Constipation is an expected finding in a child who has Hirschsprung's disease. Identify that decreased bowel sounds are an expected finding in a child who has appendicitis.
A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of actions the nurse should recommend to the parent.
Determine if the child is breathing. Empty the child's mouth of remaining pills and residue. Identify the medication and dosage strength. Call a poison control center. The child's respiratory and cardiovascular status should be checked first to determine if CPR is necessary. Then, the child's mouth should be emptied of pills and residue to prevent additional exposure to the medication. Next, the parent should identify the medication and dosage strength by looking at the medication container. Lastly, the parent should contact a poison control center for advice on the next course of action.
A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis? Dry cough Abdominal pain Muscle stiffness Swollen eyelids
Dry cough The nurse should identify that a dry cough is an early manifestation of pertussis. Abdominal pain-Abdominal pain is a manifestation of scarlet fever, rather than pertussis. Muscle stiffness-Muscle stiffness is a manifestation of poliomyelitis, rather than pertussis. Swollen eyelids-Swollen eyelids are a manifestation of bacterial conjunctivitis, rather than pertussis
A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the following should the nurse recognize as an early manifestation of increased intracranial pressure? Fixed and dilated pupils Increased irritability Decorticate posturing Cheyne-Stokes respirations
Increased irritability The nurse should recognize that increased irritability, fatigue, vomiting, and headache are early signs of increased intracranial pressure.
A nurse is contributing to the plan of care for an adolescent client who has human immunodeficiency virus (HIV). Based on the adolescent's diagnosis, which of the following actions should be included in the plan of care? Instruct visitors to wear gowns and masks when entering the client's room. Contact the dietary department to request that foods be delivered on disposable dishes. Prepare a negative-pressure airflow room for the client. Inform the client regarding routes of transmission
Inform the client regarding routes of transmission. The nurse should inform the client about the transmission of HIV and how to prevent its spread.
A nurse is reinforcing teaching with the parent of a child who has hemophilia and is experiencing acute hemarthrosis. Which of the following instructions should the nurse include in the teaching? Provide the child with a high-calorie diet. Apply warm compresses to affected joints. Administer ibuprofen for reports of pain. Keep the affected joints immobilized.
Keep the affected joints immobilized The nurse should reinforce with the parent to keep the child's affected joints elevated and immobilized to minimize bleeding. After the acute episode, the child should begin active range-of-motion exercises.
A nurse is collecting data from a toddler at a well-child visit. Which of the following findings should the nurse identify as a possible indication of child maltreatment? Diaper dermatitis Bruise on the front of the lower leg Inflamed unilateral conjunctiva Laceration on the side of the torso
Laceration on the side of the torso A laceration on the side of the torso is not an injury that occurs due to the typical clumsiness of a toddler. This finding indicates the need to further investigate for suspected child maltreatment.
A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory results should the nurse report to the provider? Potassium 4.2 mEq/L Lead 14 mcg/dL Fasting blood glucose 75 mg/dL Hematocrit 40%
Lead 14 mcg/dL This lead level is above the expected reference range for a preschooler. Therefore, the nurse should report this result to the provider.
A nurse is caring for a preschooler who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the parent to administer for an acute asthma attack? Levalbuterol Fluticasone Omalizumab Montelukast
Levalbuterol The nurse should inform the parent to administer levalbuterol, a short-acting beta2 agonist, to the preschooler for acute asthma attacks.
A nurse is assisting with the care of a 3-year-old child who is prescribed a lumbar puncture. Which of the following actions should the nurse take to prevent complications? Stabilize the child in a prone position during the procedure. Apply temporary elbow restraints during the procedure. Implement NPO status for 12 hr after the procedure. Maintain the child in a flat position after the procedure.
Maintain the child in a flat position after the procedure. After a lumbar puncture, the optimal position for the client is flat and supine to prevent headaches.
A nurse is reinforcing teaching with the parent of a child who has a new prescription for ferrous sulfate. The nurse should reinforce that the parent should administer the medication with which of the following fluids to enhance the medication absorption? Orange juice Water Milk Unsweet tea
Orange juice The nurse should reinforce with the parent that administering ferrous sulfate with orange juice will enhance medication absorption.
A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which of the following actions should the nurse take? Place the infant in semi-Fowler's position for 1 hr after the feeding. Flush the tube with 30 mL of normal saline before the feeding. Warm the feeding in the microwave immediately prior to administration. Auscultate over the infant's epigastric area to ensure proper tube placement.
Place the infant in semi-Fowler's position for 1 hr after the feeding. The nurse should elevate the head of the infant's bed by 30º to 45º for 30 min to 1 hr after the feeding.
A nurse is reviewing the laboratory report of a preschooler who has a Wilm's tumor and is scheduled to begin treatment with an antineoplastic medication regimen. Which of the following laboratory results should the nurse report to the provider? BUN 16 mg/dL WBC count 5,500/mm3 Serum glucose 98 mg/dL Platelet count 70,000/mm3
Platelet count 70,000/mm3 This platelet count is below the expected reference range for a preschooler and increases the risk for spontaneous bleeding. The nurse should hold the medication and report this finding to the provider immediately.
A nurse is assisting with the care of a school-age child who has congestive heart failure and is receiving digoxin. Which of the following manifestations should the nurse report to the provider? Potassium 3 mEq/L Decreased edema Heart rate 90/min Peripheral pulses 3+
Potassium 3 mEq/L The nurse should report a potassium level of 3 mEq/L to the provider. A decreased potassium level can place the child at risk for digoxin toxicity.
A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to include in the plan? Promote oxygen utilization. Administer antibiotics. Encourage fluid intake. Apply a warm compress to the joints
Promote oxygen utilization The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is promoting oxygen utilization to prevent further sickling of the red blood cells and promote adequate oxygenation of the tissue. Should encourage fluid intake to prevent dehydration and clumping of the red blood cells. Apply a warm compress to the joints to reduce pain and inflammation.
Expected Pulse rate and respiration by age. Newborn (birth to 2 days) Infants (2 days to 1 year) Toddler (1 to 3 years) preschoolers (3 to 5 years) School aged (6 to 12 years) Adolescence (13 to 18 years)
Pulse. Respiration Newborn (birth to 2 days) 110 to 160/min. 30 to 60/min Infants (2 days to 1 year) 90 to 160/min. 25 to 30/min Toddler (1 to 3 years) 80 to 140/min. 25 to 30/min preschoolers (3 to 5 years) 70 to 120/min. 20 to 25/min School aged (6 to 12 years) 60 to 110/min. 20 to 25/min Adolescence (13 to 18 years) 50 to 100/min. 16 to 20/min
A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg to repair a femur fracture. Which of the following findings is the priority for the nurse to report to the provider? Report of tingling in the right foot Pain rating of 7 on a scale of 0 to 10 Decrease in food intake Increase in crusting at pin sites
Report of tingling in the right foot The nurse should identify that the greatest risk to the child is nerve injury. Therefore, tingling in the right foot, which can indicate nerve damage or compartment syndrome, is the priority finding for the nurse to report to the provider.
A nurse is collecting data from an adolescent who has manifestations of physical abuse. Which of the following actions should the nurse take? Conduct the admission process with the adolescent's parent at bedside. Report the suspected abuse to the authorities. Use closed-ended questioning when speaking with the adolescent. Encourage the adolescent to enroll in family psychotherapy.
Report the suspected abuse to the authorities. Nurses are required mandatory reporters of child abuse. It is the nurse's responsibility to report any type of abuse to the appropriate agencies. This action will assist with ensuring a safe environment for the adolescent.
A nurse is contributing to the plan of care for a school-age child who has acute poststreptococcal glomerulonephritis (APSGN) and is mildly hypertensive. Which of the following actions should the nurse include in the plan of care? Restrict the child's sodium intake. Weigh the child every other day. Monitor the child's blood pressure every 12 hr. Place the child on bed rest.
Restrict the child's sodium intake. The nurse should limit the sodium intake for a child who has APSGN and is hypertensive or who has a decreased urine output to help prevent water retention and edema.
A nurse is auscultating heart sounds on an infant. The nurse should identify this sound as which of the following? (Audio clip) Sinus rhythm Ventricular septal defect Pulmonic stenosis Atrial septal defect
Sinus rhythm The nurse should identify this heart sound as sinus rhythm. The nurse should auscultate heart sounds at the apical impulse, which is at the left midclavicular line and fifth intercostal space. The expected heart sounds include S1, which is the closure of the atrioventricular valves, and S2, which is the closure of the semilunar valves.
A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone. Which of the following laboratory results should the nurse report to the provider? Fasting blood glucose 74 mg/dL Sodium 150 mEq/L Potassium 4.2 mEq/L WBC count 9,400/mm3
Sodium 150 mEq/L Hypernatremia is an adverse effect of prednisone. This level is above the expected reference range for a school-age child. Therefore, the nurse should report this value to the provider.
A nurse is collecting data from an infant who is receiving IV therapy for fluid replacement. Which of the following findings indicates the infant's status is improving? WBC count 19,000/mm3 Sodium level 145 mEq/L Capillary refill greater than 3 seconds Dry mucous membranes
Sodium level 145 mEq/L The nurse should identify that a sodium level of 145 mEq/L is within the expected reference range of 134 to 150 mEq/L and is an indication that the infant's status is improving.
A nurse is reinforcing teaching with the guardians of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child? Exaggerate the pronunciation of each word. Keep hands still when speaking. Speak at the child's eye level. Avoid facial expressions when speaking
Speak at the child's eye level. The nurse should instruct the guardian to speak at the child's eye level and ensure that there is adequate lighting on the speaker's face to facilitate lipreading and communication.
A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of enterobiasis. The nurse should advise the guardian to take which of the following actions to prevent infection? Dress the child in two-piece sleeping outfits. Trim the child's fingernails short. Have the child take a tub bath daily. Repeat treatment in 4 weeks.
Trim the child's fingernails short. The nurse should instruct the guardian to trim the child's fingernails short to reduce the collection of eggs under her nails and prevent reinfection. Guardian to have the child wear one-piece sleeping outfits to minimize scratching of the perianal area. Child take showers, instead of tub baths, because tub baths can increase the incidence of reinfection. Treatment with antiparasitic medication should be repeated in 2 weeks to prevent reinfection.
A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The nurse should identify which of the following as an indication that the preschooler experienced an allergic reaction to the contrast dye? Jaundice Hematuria Urticaria Petechiae
Urticaria The nurse should monitor the child for an allergic reaction to the contrast dye. Manifestations of the allergic reaction include urticaria, itching, flushing of the skin, and possible anaphylaxis.
A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following instructions should the nurse include to decrease the child's risk of an upper respiratory infection? Rinse the infant's mouth with water before feeding. Limit the infant's fluid intake. Use a cool mist vaporizer in the infant's room. Avoid applying lip balm to the infant's lips.
Use a cool mist vaporizer in the infant's room. The nurse should reinforce that a cool mist vaporizer should be used to help thin respiratory secretions and decrease the infant's risk for an upper respiratory infection.
A nurse is reinforcing teaching with the guardians of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child? Exaggerate the pronunciation of each word. Keep hands still when speaking. Stand away from child when speaking. Use facial expressions when speaking.
Use facial expressions when speaking. The nurse should instruct the guardians to use facial expressions when speaking to assist in conveying the message being spoken.
A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin. Which of the following manifestations should the nurse identify as an indication of digoxin toxicity and report to the provider? Irritability Diaphoresis Vomiting Tachycardia
Vomiting The nurse should identify that vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider.
A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin. Which of the following manifestations should the nurse identify as an indication of digoxin toxicity and report to the provider? Irritability Diaphoresis Vomiting Tachycardia
Vomiting The nurse should identify that vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider.
A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect? Capillary refill of 2 seconds Flushed skin Weight loss of 10% Bulging anterior fontanel Decrease heart rate
Weight loss of 10% The nurse should expect an infant who has severe dehydration to experience weight loss of 10% or greater. Other signs of sever dehydration is Capillary refill greater than 4 seconds, increase heart rate, and sunken anterior fontanel.
A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child's diet? 1) White rice 2) While wheat bread 3) Graham crackers 4) French fries
White rice The nurse should reinforce to the guardian that celiac disease is a genetic autoimmune disorder in which eating gluten, even in very small amounts, can damage the child's small intestine. Currently, the only treatment for the disease is a lifelong, strict adherence to a gluten-free diet. The nurse should stress the importance of avoiding foods containing wheat, rye, barley, and oats. The child should consume foods that are gluten-free, such as milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh poultry, meats, fish, and dried beans.
A nurse is reinforcing teaching about tracheostomy care with the parent of a toddler who has a temporary tracheostomy. Which of the following instructions should the nurse include in the teaching? Ensure one finger fits between the ties and the neck. Clean around the stoma with isopropyl alcohol. Perform necessary tube changes immediately after meals. Change the tracheostomy tube every other week.
Ensure one finger fits between the ties and the neck. The nurse should instruct the parent that one finger should fit between the ties and the neck to ensure the tube is held securely in place. Clean around the stoma with soap and warm water. The parent can also use hydrogen peroxide to remove secretions that have adhered to the tube. Parent to perform necessary tube changes before meals or 2 hr after meals. Instruct the parent to change the tracheostomy tube once each week.
A nurse is caring for a child who has a fractured tibia and is in Buck's traction. Which of the following actions should the nurse take? Ensure the weights are hanging freely. Allow the child to change positions frequently. Use palms of hands when handling the traction boot. Check the pin site every 8 hr
Ensure the weights are hanging freely. The nurse should ensure that the weights are hanging freely for a child who is in Buck's traction.
A nurse is reinforcing teaching with the parents of a toddler who has strabismus. Which of the following treatments should the nurse plan to include in the teaching? Corrective biconcave lenses Laser surgery Eye patch Artificial tears
Eye patch Treatment of strabismus includes covering the strong eye to strengthen the muscles in the weak eye. Strabismus surgery is performed to improve visual stimulation to the weak eye. Biconcave lenses are used to correct myopia
A nurse is collecting data from a child who has iron deficiency anemia. Which of the following data signifies that adherence to ferrous sulfate therapy has occured? Occasional vomiting and nausea Green, tarry stools Tolerates milk Weight gain
Green, tarry stools Green, tarry stools are an expected outcome of ferrous sulfate therapy. Therefore, this is an indication of adherence to the prescribed medication regimen. Occasional vomiting and nausea are adverse effects of ferrous sulfate.
A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following actions should the nurse take? Ensure the availability of soft extremity restraints. Place a padded tongue blade at the bedside. Have a suction canister and tubing available in the room. Keep the child's bed in the highest position.
Have a suction canister and tubing available in the room. The nurse should have a suction canister and tubing available in the child's room to keep the child's airway patent during a seizure.
A nurse is caring for an adolescent client who is experiencing sickle cell crisis. Which of the following laboratory values should the nurse report to the provider? Total bilirubin 0.5 mg/dL Reticulocyte count 1% WBC count 8,000/mm3 Hgb 6 g/d
Hgb 6 g/dL The expected reference range for an adolescent's Hgb level is 10 to 15.5 g/dL. Therefore, an Hgb of 6 g/dL is below the expected reference range and should be reported to the provider.
A nurse is assisting with the care of an infant who has spina bifida and recently had a ventriculoperitoneal shunt placed for hydrocephalus. Which of the following findings should the nurse identify as an indication of increased ICP? High-pitched cry Ataxia Depressed anterior fontanel Nuchal rigidity
High-pitched cry The nurse should identify that a high-pitched cry is an indication of increased intracranial pressure. Ataxia is an expected finding in an infant who has cerebral palsy. Bulging anterior fontanel is a sign of increased intracranial pressure. Nuchal rigidity is an expected finding in an infant who has bacterial meningitis.
A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM antibiotic to a child 5 min ago. Which of the following manifestations should the nurse expect to observe first? Wheezing Angioedema Hives Hypotension
Hives The nurse should observe for hives first because this is an early manifestation of an anaphylactic reaction.
A nurse is collecting data about a 4-year-old preschooler's gross motor skills. The nurse should expect the preschooler to be able to perform which of the following activities? Hopping on one foot Skipping on alternate feet Jumping rope Roller skating
Hopping on one foot The nurse should expect to find that a 4-year-old preschooler is able to hop on one foot.
A nurse is reinforcing discharge teaching with the guardian of a school-age child who has a new prescription for home oxygen therapy. Which of the following statements by the guardian indicates an understanding of the teaching? "I will restrict the length of the oxygen tubing to no longer than 3 feet." "I will place the extra oxygen tanks in a horizontal position for storage." "I will check the oxygen delivery equipment once every week." "I will make sure that electrical devices in the house are grounded."
"I will make sure that electrical devices in the house are grounded." This response by the guardian indicates an understanding of the nurse's instructions. Due to the combustible nature of oxygen, all pieces of electrical equipment in the home should be grounded to decrease the risk of a fire caused by an electrical spark. Oxygen tanks should be stored vertically, not horizontally. Placing a full oxygen tank on its side can cause the tank to rupture, which can lead to serious injuries of individuals in the home. Guardian should check the child's oxygen equipment and oxygen delivery at least once each day.
A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following parent statements indicates an understanding of the teaching? "I will keep my hearing aid batteries in my bedside table." "I will place a screen in front of the fireplace." "I will keep my medication in my purse." "I will use a steam vaporizer when my child has a cold."
"I will place a screen in front of the fireplace." The nurse should instruct the parent to place a screen in front of a fireplace or other heating appliances to prevent burns.
A nurse is reinforcing discharge teaching with the guardian of a school-age child who has acute lymphocytic leukemia and an absolute neutrophil count of 450/mm3. Which of the following instructions should the nurse include? "Allow your child to receive the varicella immunization." "Take your child's rectal temperature twice per day." "Increase your child's intake of fresh fruits and vegetables." "Keep your child away from crowded areas."
"Keep your child away from crowded areas." The nurse should instruct the guardian to keep the child away from crowds and visitors who have an illness to decrease the risk for infection.
A nurse is caring for an adolescent client who is a practicing Jehovah's Witness and is scheduled for surgery for a ruptured appendix. The adolescent tells the nurse that based on her religious beliefs, she cannot receive a blood transfusion. Which of the following responses should the nurse make? "Why do members of your faith believe this?" "You'll only receive blood during the procedure if you need it." "I will let the surgical team know your wishes." "Let's discuss the possible need for a transfusion with your parents
"Let's discuss the possibility of you needing a blood transfusion with your parents." The nurse should offer to involve the child's parents to understand the family's beliefs about blood transfusions.
A nurse is reinforcing teaching regarding the immunization schedule of a newborn. Which of the following statements made by the parent should the nurse recognize as an understanding of the newborn's immunization schedule? "My baby should not have a hepatitis B vaccine if I test negative." "My baby will receive his first varicella vaccine at 6 months." "My baby will receive his next immunization when he is 2 months old." "I will need to start my baby's immunizations when I put him in day care."
"My baby will receive his next immunization when he is 2 months old." Newborns should receive the next scheduled immunization 2 months after birth
A nurse is reinforcing teaching regarding the immunization schedule of a newborn. Which of the following statements made by the parent should the nurse recognize as an understanding of the newborn's immunization schedule?
"My baby will receive his next immunization when he is 2 months old." Newborns should receive the next scheduled immunization 2 months after birth.
A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a preschooler. The nurse should recognize which of the following statements by the parent as a contraindication to receiving the immunization? "My child is allergic to latex." "My child is allergic to baker's yeast." "My child received amoxicillin recently." "My child received an immunoglobulin last month."
"My child received an immunoglobulin last month." The nurse should identify that a preschooler who received an immunoglobulin less than 1 month ago should not receive the MMR vaccine on this day. The nurse should instruct the parent to reschedule the immunization after 3 months have elapsed, since the child received passive immunity via administration of an immunoglobulin. Allergy to latex is a contraindication for receiving the rotavirus or meningococcal vaccine. allergy to baker's yeast is a contraindication for receiving the HPV vaccine.
A nurse is caring for a school-age girl who is being treated for frequent, severe UTI's. The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTI's? "My daughter has bowel movements every 4 to 5 days." "I taught her to wipe from front to back after going to the bathroom." "She urinates every 2 to 3 hours during the day." "I don't let her wear nylon underwear."
"My daughter has bowel movements every 4 to 5 days." The nurse should recognize that this frequency indicates the child is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection.
A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching? "Press the platform of the lancet firmly against your child's finger." "Obtain the blood sample from the center of your child's finger pad." "Put your child's finger under warm, running water prior to collecting blood." "Steady the finger against a hard surface while puncturing the skin."
"Put your child's finger under warm, running water prior to collecting blood." The nurse should instruct the parent that placing the child's finger under warm, running water increases the blood flow to the finger, which will make it easier to obtain the sample.
A nurse is reinforcing teaching with the guardian of a child who has scabies and a new prescription for permethrin 5% cream. Which of the following information should the nurse include? "Apply the cream to only the affected areas twice daily." "Wash off the cream 4 to 6 hours after application." "The provider will monitor for liver toxicity while your child is taking the medication." "The medication will eliminate your child's itching within 2 to 3 weeks."
"The medication will eliminate your child's itching within 2 to 3 weeks." The nurse should instruct the guardian that, although the medication kills the mites, itching can continue for 2 to 3 weeks following application of the medication.
A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the following parent statements indicates an understanding of the teaching? "We will keep our child out of the sun between 3 p.m. and 5 p.m." "We will transition our child to a toddler bed when he is 2 feet tall." "We will purchase a toy storage box with a lightweight lid." "We will provide a healthy snack of peanuts."
"We will purchase a toy storage box with a lightweight lid." The nurse should instruct the parents to avoid toy boxes with heavy, hinged lids. Toddlers may suffocate or have the lid close on their head or neck, causing injury.
A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the following parent statements indicates an understanding of the teaching? "We will keep our child out of the sun between 3 p.m. and 5 p.m." "We will transition our child to a toddler bed when he is 2 feet tall." "We will turn the pot handles toward the back of the stove." "We will provide a healthy snack of peanuts."
"We will turn the pot handles toward the back of the stove." The nurse should instruct the parents to turn pot handles toward the back of the stove to prevent the toddler from pulling a pot off the stove, resulting in a burn.
A nurse is reinforcing teaching with an adolescent female client who has acne vulgaris and a new prescription for isotretinoin. Which of the following information should the nurse include? "You should apply this medication to the affected skin twice daily." "You will need to have two negative pregnancy tests prior to starting this medication." "Your provider will monitor your kidney function while you are taking this medication." "Your provider will prescribe a vitamin A supplement to take with each dose of this medication."
"You will need to have two negative pregnancy tests prior to starting this medication." The nurse should reinforce with the client that isotretinoin is teratogenic. Pregnancy must be ruled out prior to administration and before each subsequent refill. The client should use two effective forms of contraception while taking this medication.
A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. What area should the nurse observe when monitoring for manifestations of splenic sequestration 1) Liver 2) Spleen 3) Kidney
2) Spleen The nurse should observe the loaction over the infant's spleen when monitoring for manifestations of splenic sequestration. Splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood.
A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of actions the nurse should recommend to the parent. (Place them in order of performance. All steps must be used.) 1. Identify the medication and dosage strength. 2. Determine if the child is breathing. 4. Empty the child's mouth of remaining pills and residue. 5. Call a poison control center.
2. Determine if the child is breathing. 4. Empty the child's mouth of remaining pills and residue. 1. Identify the medication and dosage strength. 5. Call a poison control center. The child's respiratory and cardiovascular status should be checked first to determine if CPR is necessary. Then, the child's mouth should be emptied of pills and residue to prevent additional exposure to the medication. Next, the parent should identify the medication and dosage strength by looking at the medication container. Lastly, the parent should contact a poison control center for advice on the next course of action.
A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child's oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 oz of gelatin, and drank 7 oz of water. What is the child's oral intake for this shift in milliliters? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL
690 mL
A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child's oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 oz of gelatin, and drank 7 oz of water. What is the child's oral intake for this shift in mL?
690 mL 1 oz = 30 mL
A nurse has just received change-of-shift report for four children in a pediatric unit. Which of the following children should the nurse collect data from first? A child who is 2 days postoperative following an appendectomy and reports incisional pain A child who has a new diagnosis of diabetes mellitus and an HbA1c level of 7.5% A child who has a fever and nuchal rigidity A child who experienced a seizure 1 hr ago and is resting
A child who has a fever and nuchal rigidity A client who has a fever and nuchal rigidity is unstable. This finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. Therefore, the nurse should collect data from this child first.
A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which of the following areas should the nurse observe when monitoring for manifestations of splenic sequestration? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A is incorrect. The nurse should observe the location over the infant's liver when monitoring for manifestations of liver sequestration, or an enlarged liver. B is correct. The nurse should observe the location over the infant's spleen when monitoring for manifestations of splenic sequestration. Splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood. C is incorrect. The nurse should check the location over the kidney in an infant who is experiencing a sickle cell crisis for manifestations of a kidney infarction. Other manifestations of sickle cell anemia include dilute urine, hematuria, and enuresis.
A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a nasogastric tube. Which of the following actions should the nurse take? Administer 20 mL/min of formula by gravity. Refrigerate the formula for 30 min prior to administration. Confirm that the pH of the stomach contents is 5 or less. Flush the tube with 5 to 15 mL of 0.9% sodium chloride.
Confirm that the pH of the stomach contents is 5 or less. The nurse should test the pH of the stomach contents prior to administering the tube feeding in order to confirm tube placement in the stomach. The nurse should identify that a pH of 5 or less indicates gastric placement. The nurse should not exceed 5 mL every 5 to 10 min in premature or infants who are small for gestational age and 10 mL/min in older infants and children. A feeding should take 15 to 30 min to complete to prevent nausea and regurgitation. The nurse should ensure that the formula is at room temperature prior to feeding to avoid abdominal cramping. The nurse should flush the tube with 1 to 15 mL of sterile water to maintain patency.
A nurse is reinforcing teaching with the parents of a 7-year-old female child about behavioral expectations. Which of the following behaviors should the nurse include in the teaching? Spends a lot of time by herself Exhibits a decline in self-esteem Selectively chooses a best friend Shows a competitive nature with others
Spends a lot of time by herself Spending time alone is an expected characteristic of a 7-year-old female child. When they do spend time with others, children in this age group prefer to socialize with children of the same sex and age. Decline of self-esteem-ages 11 to 14 years of age exhibit a decline in self-esteem because they measure social status by acceptance or rejection by peers. Selectively chooses a best friend- ages 10 to 12 years of age are expected to be selective in their choices of friends and typically have a best friend. Shows a competitive nature with others- Children who are 8 to 9 years of age are expected to be competitive with others.
A nurse is assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding? Walks backward with heel to toe Stands on one foot for several seconds Uses scissors to cut out shapes Prints letters with a pencil
Stands on one foot for several seconds Standing on one foot for several seconds is an expected behavior for a toddler
A nurse is assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding? Walks backward with heel to toe Stands on one foot for several seconds Uses scissors to cut out shapes Prints letters with a pencil
Stands on one foot for several seconds Standing on one foot for several seconds is an expected behavior for a toddler.
A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse plan to administer? Haemophilus influenza type b (Hib) Rotavirus (RV) Polio (IPV) Tetanus, diphtheria toxoids, and acellular pertussis (Tdap)
Tetanus, diphtheria toxoids, and acellular pertussis (Tdap) The Tdap vaccine is recommended between the ages of 11 and 12 years. Therefore, this adolescent should receive the Tdap vaccine now.
A nurse is collecting data about the dietary habits of an adolescent female client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits? The client chooses to eat more vegetables than fruits. The client consumes approximately 2,000 calories a day. The client fasts twice a week to manage dietary intake. The client increases their dietary intake during track season
The client fasts twice a week to manage dietary intake. The nurse should identify that adolescents are often at risk for developing poor eating habits. Regular fasting puts this client at risk for nutritional deficits.
A nurse is collecting data about the dietary habits of an adolescent client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits?
The client skips eating dinner for track practice three times per week. The nurse should identify that adolescents are often at risk for developing poor eating habits. Skipping dinner twice each week puts this client at risk for nutritional deficits.
A nurse is collecting data about the dietary habits of an adolescent client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits? The client chooses to eat more vegetables than fruits. The client chooses fast food for lunch once each week. The client skips eating dinner for track practice three times per week. The client eats breakfast on the way to school.
The client skips eating dinner for track practice three times per week. The nurse should identify that adolescents are often at risk for developing poor eating habits. Skipping dinner twice each week puts this client at risk for nutritional deficits.
A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which of the following areas should the nurse observe when monitoring for manifestations of splenic sequestration?
The nurse should observe the location over the infant's spleen (LUQ of abdomen) when monitoring for manifestations of splenic sequestration. Splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood. The nurse should check the location over the kidney in an infant who is experiencing a sickle cell crisis for manifestations of a kidney infarction. Other manifestations of sickle cell anemia include dilute urine, hematuria, and enuresis.