Lipincott Q&A Review for NCLEX (Billing)

A 7-year-old has been diagnosed as mentally retarded. Which of the parents' expectations for their child is realistic? Select all that apply. ■ 1. Diffi culty learning. ■ 2. An IQ below 70. ■ 3. Defi cits in adaptive behavior. ■ 4. Normal intellectual capacity. ■ 5. Behavioral problems.

. 1, 2, 3. The defi nition of mental retardation includes defi cits in intellectual functioning and behavior. The child's IQ will be 70 or less and he will have diffi cult learning. The client cannot adapt to situations in a manner consistent with children with higher IQs. The client does not have a normal intellectual capacity to learn and develop from his experiences. The client may have behavioral problems but these are not considered a result of mental retardation.

A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fl uid intake and output? Select all that apply. ■ 1. Weighing and recording all wet diapers. ■ 2. Obtaining a urine specifi c gravity measure. ■ 3. Obtaining an accurate daily weight. ■ 4. Restricting fl uids prior to weighing the child. ■ 5. Obtaining an accurate stool count.

. 1, 2, 3, 5. Accurate intake and output recording includes noting all intake, including I.V. fl uids; noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine specifi c gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children who are dehydrated must receive suffi cient fl uid intake. Restricting fl uids just prior to weighing the child will not alter the accuracy of the weight, and the nurse should continue to encourage fl uids for this dehydrated child.

An infant is being treated at home for bronchiolitis. Which of the following should the nurse teach the parent about home care? Select all that apply. ■ 1. Offering small amounts of fluids frequently. ■ 2. Allowing the infant to sleep prone. ■ 3. Calling the clinic if the infant vomits. ■ 4. Writing down how much the infant drinks. ■ 5. Performing chest physiotherapy every 4 hours. ■ 6. Watching for difficulty breathing.

. 1, 6. An infant with bronchiolitis will have increased respirations and will tire more quickly, so it is best and easiest for the infant to take fl uids more often in smaller amounts. The parents also would be instructed to watch for signs of increased diffi culty breathing, which signal possible complications. Healthy infants and even those with bronchiolitis should sleep in the supine position. Calling the clinic for an episode of vomiting would not be necessary. However, the parents would be instructed to call if the infant cannot keep down any fl uids for a period of more than 4 hours. Parents would not need to record how much the infant drinks. Chest physiotherapy is not indicated because it does not help and further irritates the infant

After surgery to correct pyloric stenosis, the nurse instructs the parents about the postoperative feeding schedule for their infant. The parents exhibit understanding of these instructions when they state that they can start feeding the child within which of the following time frames? ■ 1. 6 hours. ■ 2. 8 hours. ■ 3. 10 hours. ■ 4. 12 hours

. 1. Clear liquids containing glucose and electrolytes are usually prescribed 4 to 6 hours after surgery. If vomiting does not occur, formula or breast milk then can be gradually substituted for clear liquids until the infant is taking normal feedings.

A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teaching the child's parents about dietary management. The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet? ■ 1. Regular. ■ 2. Clear liquid. ■ 3. Full liquid. ■ 4. Soft.

. 1. Dietary management following rehydration for diarrhea and mild dehydration would include offering the child a regular diet. Following rehydration, there is no need for the child to be on a special diet, such as a clear liquid, full liquid, or soft diet

The breast-feeding mother of a 1-month-old diagnosed with cow's milk sensitivity asks the nurse what she should do about feeding her infant. Which of the following recommendations would be most appropriate? ■ 1. Continue to breast-feed but eliminate all milk products from your own diet. ■ 2. Discontinue breast-feeding and start using a predigested formula. ■ 3. Limit breast-feeding to once per day and begin feeding an iron-fortifi ed formula. ■ 4. Change to a soy-based formula exclusively and begin solid foods

. 1. Mothers of infants with a cow's milk allergy can continue to breast-feed if they eliminate cow's milk from their diet. It is important to encourage mothers to continue to breast-feed because breast milk is usually the least allergenic and most easily digested food for an infant. In addition, the infant is able to obtain protein through the mother's milk. If the mother stops breast-feeding, then a predigested protein hydrolysate formula would be the fi rst choice. An iron-fortifi ed formula is a cow's milk-based formula. A soy-based formula is not used because approximately 20% of infants with cow's milk sensitivity are also sensitive to soy. Solid foods are not introduced until the infant is 4 to 6 months of age

The physician orders intravenous fl uid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before adding the potassium chloride to the intravenous fl uid, which of the following assessments would be most important? ■ 1. Ability to void. ■ 2. Passage of stool today. ■ 3. Baseline electrocardiogram. ■ 4. Serum calcium level.

. 1. Potassium chloride is readily excreted in the urine. Before adding potassium chloride to the intravenous fl uid, the nurse should ascertain whether the child can void; if not, potassium chloride may build up in the serum and cause hyperkalemia. An electrocardiogram could be done during intravenous potassium replacement therapy to evaluate for these changes. Having a stool daily is important but, because potassium is primarily excreted in the urine, the child's ability to void must be verifi ed. Serum calcium levels do not indicate the child's ability to tolerate potassium replacement.

. The nurse is administering gastrostomy feedings to an infant after surgery to correct a tracheoesophageal fi stula (TEF). To prevent air from entering the stomach once the syringe barrel is attached to the gastrostomy tube the nurse should: ■ 1. Unclamp the tube after pouring the complete amount of formula to be administered into the syringe barrel. ■ 2. Pour all of the formula to be administered into the syringe barrel after opening the clamp. ■ 3. Maintain a continuous fl ow of formula down the side of the syringe barrel once the clamp is opened. ■ 4. Allow a small amount of formula to enter the stomach before pouring more formula into the syringe barrel.

. 1. The best way to prevent air from entering the stomach when feeding an infant through a gastrostomy tube is to open the clamp after all the formula has been placed in the syringe barrel. Doing so prevents air from mixing with the formula and thus being introduced into the stomach. Pouring all the formula into the barrel after opening the clamp, maintaining a continuous fl ow of formula down the side of the barrel after unclamping the tube, and allowing a small amount of formula to enter the stomach before adding more formula to the barrel permit air to enter the stomach.

When developing a recreational therapy plan of care for a 3-year-old child hospitalized with pneumonia and cystic fi brosis, which of the following toys would be appropriate? ■ 1. 100-piece jigsaw puzzle. ■ 2. Child's favorite doll. ■ 3. Fuzzy stuffed animal. ■ 4. Scissors, paper, and paste

. 2. The child's favorite doll would be a good choice of toys. The doll provides support and is familiar to the child. Although a 3-yearold may enjoy puzzles, a 100-piece jigsaw puzzle is too complicated for an ill 3-year-old child. In view of the child's lung pathology, a fuzzy stuffed animal would not be advised because of its potential as a reservoir for dust and bacteria, possibly predisposing the child to additional respiratory problems. Scissors, paper, and paste are not appropriate for a 3-year-old unless the child is supervised closely

. A client's diagnosis of cystic fibrosis was made 13 years ago, and he has since been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which nursing actions are most important initially? ■ 1. Placing the client on bed rest and ordering a blood gas analysis. ■ 2. Ordering a high-calorie, high-protein, lowfat, vitamin-enriched diet and pancreatic granules. ■ 3. Applying an oximeter and initiating respiratory therapy. ■ 4. Inserting an I.V. line and initiating antibiotic therapy.

. 3. Clients with cystic fi brosis commonly die from respiratory problems. The mucus in the lungs is tenacious and diffi cult to expel, leading to lung infections and interference with oxygen and carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed rest due to respiratory distress. However, although blood gases will probably be ordered, the oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A diet high in calories, proteins, and vitamins with pancreatic granules added to all foods ingested will increase nutrient absorption, and help the malnutrition; however, this intervention is not the priority at this time. Inserting an I.V. to administer antibiotics is important, and can be done after ensuring adequate respiratory function

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered I.V. fl uids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 Meq/L. The nurse should: ■ 1. Notify the primary care provider. ■ 2. Administer the ordered fl uids. ■ 3. Verify that the infant has urinated. ■ 4. Have the potassium level redrawn

. 3. Normal serum potassium levels are 3.5 to 4.5 Meq/L. Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4 Meq/L is not unexpected and should be corrected with the ordered fl uids. The lab value does not need to be redrawn as the fi ndings are consistent with the infant's condition

The health care team wishes to establish a policy regarding sleep positions for infants with gastroesophageal refl ux (GER). The first step should be to search for: ■ 1. Policies from other hospitals. ■ 2. Data from retrospective studies. ■ 3. Published national standards. ■ 4. Expert opinions.

. 3. Published national standards are based on the best evidence and when available should serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be evidence based. Retrospective studies and expert opinions should only be used to form policy when data from experimental studies or national standards are not available

On a home visit following discharge from the hospital after treatment for severe gastroenteritis, the mother tells the nurse that her toddler answers "No!" and is diffi cult to manage. After discussing this further with the mother, the nurse explains that the child's behavior is most likely the result of which of the following? ■ 1. Beginning leadership skills. ■ 2. Inherited personality trait. ■ 3. Expression of individuality. ■ 4. Usual lack of interest in everything.

. 3. The "no" behavior demonstrated by a toddler is typical of this age group as the child attempts to be self-assertive as an individual. The negativism does not demonstrate an inherited personality trait or disinterest. Rather, it refl ects the developmental task of establishing autonomy. The toddler is attempting to exert control over the environment. It is too early to assess leadership qualities in a toddler.

A newborn who had a surgical repair of a tracheoesophageal fi stula (TEF) is started on oral feedings. Which of the following should the nurse include in the teaching plan for the mother about oral feedings? ■ 1. They are better tolerated when larger, but less frequent feedings are offered. ■ 2. They should be offered on a feeding schedule to help the infant accept the feedings more readily. ■ 3. They are best accepted by the infant when offered by the same nurse or by the infant's mother. ■ 4. They are best planned in conjunction with observations of the infant's behavior

. 4. When initiating oral feedings after surgical repair of a TEF, it is best to follow a plan of care in conjunction with observation of the infant's needs and behavior. When the infant's needs and behavior are overlooked, plans are likely to be unsatisfactory and are more likely to meet the nurse's needs rather than the infant's needs. After a surgical procedure, infants initially tolerate small amounts of fl uids offered more frequently better than larger amounts offered less often. Smaller amounts cause less bloating as the infant becomes used to feeding again. Although infants accept feedings more readily from their mother or from someone who feeds the infant repeatedly, the priority is to meet the infant's nutritional needs based on the infant's behavior

A child is admitted with a tentative diagnosis of shigella. The nurse should do which of the following? Select all that apply. ■ 1. Assess the child for nausea and vomiting. ■ 2. Collect a stool specimen for white blood cells (WBCs). ■ 3. Place the child on strict isolation. ■ 4. Monitor the child for signs and symptoms of dehydration. ■ 5. Initiate an intake and output record.

1, 2, 4, 5. Shigella is caused by the Shigella organism. Clinical manifestations of shigella include fever, nausea and vomiting, some cramping, headache, seizures, rectal prolapse, and loose, watery stools containing pus, mucus, and blood. The nurse should assess the child for these symptoms on an ongoing basis. Shigella is spread via direct contact with the organism, which is found in the stool. A stool specimen will show increased numbers of WBCs, blood, and mucus. Vomiting and loose stools can result in severe dehydration and electrolyte imbalance. Thus, the nurse should record intake, output, and daily weights. There is no need for strict isolation; masks are not needed as shigella is not transmitted by airborne methods.

Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply. ■ 1. Coughing. ■ 2. Respiratory rate of 35 breaths/minute. ■ 3. Heart rate of 95 beats/minute. ■ 4. Restlessness. ■ 5. Malaise. ■ 6. Diaphoresis

1, 2, 4, 6. Coughing, especially at night and in the absence of an infection, is a common symptom of asthma. Early signs of respiratory distress include restlessness, tachypnea, tachycardia, and diaphoresis. Other signs also include hypertension, nasal fl aring, grunting, wheezing, and intercostal retractions. A heart rate of 95 bpm is normal for a toddler. Malaise typically does not indicate respiratory distress

Which of the following should the nurse assess in a newborn diagnosed with an anorectal malformation? Select all that apply. ■ 1. Abdominal distension. ■ 2. Loose stools. ■ 3. Vomiting. ■ 4. Meconium in the urine. ■ 5. Meconium stools.

1, 3, 4. Anorectal malformations present with lack of stool or evidence of meconium in the urine through a fi stula. Meconium is not found in the stool. Because stool does not pass, abdominal distension and vomiting occur.

On the second postoperative day after repair of a cleft palate, which of the following should the nurse use to feed a toddler? ■ 1. Cup. ■ 2. Straw. ■ 3. Rubber-tipped syringe. ■ 4. Large-holed nipple

1. A cup is the preferred drinking or eating utensil after repair of a cleft palate. At the age when repair is done, the child is ordinarily able to drink from a cup. Use of a cup avoids having to place a utensil in the mouth, which would increase the potential for injury to the suture lines

Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which of the following findings should alert the nurse to notify the physician immediately? ■ 1. A 3-cm increase in abdominal circumference. ■ 2. Periods of occasional fussiness. ■ 3. Absence of bowel sounds since surgery. ■ 4. Evidence of the infant's returning appetite.

1. Abdominal circumference is measured to monitor for abdominal distention. An increase of 3 cm in 8 hours would require notifi cation of the physician; it would indicate a substantial degree of abdominal distention, possibly from fl uid or gas accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness.

A recent history of which of the following should alert the nurse to gather additional information about the possibility of a urinary tract infection in a 2-year-old child who is exhibiting fever and fussiness? ■ 1. Abdominal pain. ■ 2. Swollen lymph glands. ■ 3. Skin rash. ■ 4. Back pain.

1. Abdominal pain frequently accompanies urinary tract infection in children 2 years of age and older. Other associated signs and symptoms include decreased appetite, vomiting, fever, and irritability. The presence of swollen lymph glands (lymphadenopathy) is unrelated to urinary tract infections. Lymphadenopathy is associated with a systemic infection or possibly cancer. Skin rash is associated with exposure to allergens or irritants (e.g., poison ivy or harsh soaps); prolonged contact with urine (e.g., diaper dermatitis); or illnesses such as measles, rheumatic fever, or juvenile rheumatoid arthritis. Flank or back pain is associated with urinary tract infection in children older than 2 years of age and in adults.

Which of the following client actions should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy? ■ 1. Insisting on wearing a T-shirt and gym shorts rather than pajamas. ■ 2. Avoiding interactions with other adolescents on the nursing unit. ■ 3. Refusing to fi ll out the menu, and allowing the nurse to do so. ■ 4. Not taking telephone calls from friends so he can rest

1. Adolescents struggle for independence and identity, needing to feel in control of situations and to conform with peers. Control and conformity are often manifested in appearance, including clothing, and this carries over into the hospital experience. The adolescent feels best when he is able to look and act as he normally does-for example, wearing a T-shirt and gym shorts. Adolescents normally want to interact with peers and commonly seek every opportunity to do so. Avoiding other adolescents on the nursing unit or not taking phone calls from friends might suggest ineffective coping behavior. Refusing to fi ll out the menu and allowing the nurse to do so demonstrates dependent behavior, not a healthy coping mechanism

Which of the following outcome criteria would the nurse develop for a child with cystic fi brosis who has a nursing diagnosis of Ineffective airway clearance related to increased pulmonary secretions and inability to expectorate? ■ 1. Respiratory rate and rhythm within expected range. ■ 2. Absence of chills and fever. ■ 3. Ability to engage in age-related activities. ■ 4. Ability to tolerate usual diet without vomiting.

1. After treatment, the client outcome would be that respiratory status would be within normal limits, as evidenced by a respiratory rate and rhythm within expected range. Absence of chills and fever, although related to an underlying problem causing the respiratory problem (e.g., the infection), do not specifi cally relate to the respiratory problem of ineffective airway clearance. The child's ability to engage in age-related activities may provide some evidence of improved respiratory status. However, this outcome criterion is more directly related to a nursing diagnosis of Activity intolerance. Although the child's ability to tolerate his or her usual diet may indirectly relate to respiratory function, this outcome is more specifi cally related to a nursing diagnosis of Imbalanced nutrition: Less than body requirements, which may or may not be related to the child's respiratory status.

. Which of the following measures would be most effective in helping the infant with a cleft lip and palate to retain oral feedings? ■ 1. Burp the infant at frequent intervals. ■ 2. Feed the infant small amounts at one time. ■ 3. Place the end of the nipple far to the back of the infant's tongue. ■ 4. Maintain the infant in a lying position while feeding.

1. An infant with a cleft lip and palate typically swallows large amounts of air while being fed and therefore should be burped frequently. The soft palate defect allows air to be drawn into the pharynx with each swallow of formula. The stomach becomes distended with air, and regurgitation, possibly with aspiration, is likely if the infant is not burped frequently. Feeding frequently, even in small amounts, would not prevent swallowing of large amounts of air. A nipple placed in the back of the mouth is likely to cause the infant to gag and aspirate. Holding the infant in a lying position during feedings can also lead to regurgitation and aspiration of formula. The infant should be fed in an upright position.

When counseling an obese adolescent, the nurse should advise the client that which complication is the most common? ■ 1. Lifelong obesity. ■ 2. Gastrointestinal problems. ■ 3. Orthopedic problems. ■ 4. Psychosocial problems.

1. The most common complication of adolescent obesity is its persistence into adulthood. The incidence of gastrointestinal and orthopedic problems, such as Legg-Calvé-Perthes disease and genu valgum (knock knees), is greater for obese adolescents; however, they are not the most common complication. Although psychosocial problems do occur, they are not the most common complication

A nasogastric tube is ordered to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next? ■ 1. Ask for the order to be changed to oral gastric tube. ■ 2. Attempt to place the tube into the duodenum. ■ 3. Test the gastric aspirate for blood. ■ 4. Use extra lubrication when inserting the nasogastric tube.

1. Because a basilar skull fracture can involve the frontal and ethmoid bones, inserting a nasogastric tube carries the risk of introducing the tube into the cranial cavity through the fracture. An oral gastric tube is preferred for a client with a basilar skull fracture. The tube would not be placed into the duodenum. Gastric aspirate is not routinely tested for blood unless there is an indication to suggest bleeding, such as a falling hemoglobin or visible blood in the drainage

An 8-year-old has a body mass index (BMI) for age at the 90th percentile, but has no other risk factors. The nurse should: ■ 1. Refer the family to a dietician. ■ 2. Recommend the child be reweighed in one year. ■ 3. Refer the child to a physician specializing in pediatric weight loss. ■ 4. Recommend the child participate in a commercial diet program.

1. Children ages 2 to 20 years of age with a BMI-for-age at the 90th percentile are considered at risk for being overweight. If no other risk factors are present, the family should receive dietary counseling to slow the child's weight gain until an appropriate height for weight is attained. Without intervention, the child may become overweight. A physician who specializes in pediatric weight loss should be considered when the child is overweight and has complicating factors. Commercial diet programs alone do not include the necessary monitoring for children, thus are rarely appropriate.

Which of the following should the nurse include when teaching the father of an infant just admitted with gastroenteritis about initial treatment for his infant? ■ 1. The infant will receive no liquids by mouth. ■ 2. Intravenous antibiotics will be started. ■ 3. The infant will be placed in a mist tent. ■ 4. An iron-fortifi ed formula will be used.

1. Children hospitalized with gastroenteritis are usually not allowed fl uids by mouth to allow the gastrointestinal tract time to rest. Antibiotics are not indicated unless there is a bacterial infection. A mist tent would be used to treat respiratory disorders, not gastroenteritis. Once the infant is allowed oral intake, clear fl uids are used initially.

When developing a teaching plan for the mother of an infant about introducing solid foods into the diet, which of the following measures should the nurse expect to include in the plan to help prevent obesity? ■ 1. Decreasing the amount of formula or breast milk intake as solid food intake increases. ■ 2. Introducing the infant to the taste of vegetables by mixing them with formula or breast milk. ■ 3. Mixing cereal and fruit in a bottle when offering solid food for the fi rst few times. ■ 4. Using a large-bowled spoon for feeding solid foods during the fi rst several months.

1. Decreasing the amount of formula given as the infant begins to take solids helps prevent excess caloric intake. Because the infant is receiving calories from the solid foods, the formula no longer needs to provide the infant's total caloric requirements. Mixing vegetables with formula or breast milk does not allow the child to become accustomed to new textures or tastes. Solid foods should be given with a spoon, not in a bottle. Using a bottle with food allows the infant to ingest more food than is needed. Also, the infant needs to learn to eat from a spoon. A small-bowled spoon is recommended for infants because infants have a tendency to push food out with the tongue. The small-bowled spoon helps in placing the food at the back of the infant's tongue when feeding.

When obtaining the nursing history from the mother of an infant with suspected intussusception, which of the following questions would be most helpful? ■ 1. "What do the stools look like?" ■ 2. "When was the last time your child urinated?" ■ 3. "Is your child eating normally?" ■ 4. "Has your child had any episodes of vomiting?

1. For the infant with intussusception, stools characteristically have the appearance of currant jelly because of the intestinal infl ammation and hemorrhage resulting from intestinal obstruction. These stools occur later in the course of the disease process. Questions that focus on urination, vomiting, and food intake do not elicit information about the effects of intussusception

The nurse is planning interventions for the nursing diagnosis Defi cient diversional activity for a school-age child. Which of the following activities should the nurse expect to include? ■ 1. Playing a card game with someone the same age. ■ 2. Putting together a puzzle with mother. ■ 3. Playing video games with a 4-year-old. ■ 4. Watching a movie with a younger brother

1. Generally, school-age children enjoy activities with their peers fi rst, then family members, and lastly younger children. School-age children like to be busy but also to accomplish something. This helps to meet their task of industry versus inferiority, feeling good about what they are able to accomplish

The mother of a toilet-trained toddler who was admitted to the hospital for severe gastroenteritis and subsequent dehydration and is now at home asks the nurse why the child still wets the bed. Which of the following should be the nurse's best response? ■ 1. "Hospitalization is a traumatic experience for children. Regression is common and it takes time for them to return to their former behavior." ■ 2. "The stress of hospitalization is hard for many children, but usually they have no problems when they return home." ■ 3. "After returning home from being hospitalized, children still feel they should be the center of attention." ■ 4. "Children do not feel comfortable in their home surroundings once they return home from being hospitalized."

1. Hospitalization is a traumatic time for a child, and it takes some time to readjust to the home environment. The child may regress at home for a period until she feels comfortable. Children normally do not dislike their home environment; in fact, they usually are eager to get home to familiar surroundings where they feel safe

A pregnant mother who has brought her toddler to the clinic for a check-up asks the nurse how she can keep her next baby from becoming obese. The mother plans to bottle-feed her next child. Which information should the nurse include in the teaching plan to help the mother avoid overnourishing her infant? ■ 1. Recognizing clues indicating that a baby is full. ■ 2. Establishing a regular feeding schedule. ■ 3. Supplementing feedings with sterile water. ■ 4. Adding more water than directed when preparing formula.

1. Infants generally do not overeat unless they are urged to do so. Parents should watch for clues indicating that the infant is full—for example, stopping sucking and pushing the nipple out of the mouth. Bottle-feeding instead of breast-feeding is more likely to lead to excessive caloric intake. A demand schedule, rather than a regulated schedule, allows the infant to regulate intake according to individual needs. Normally, giving an infant a regular supplementation of water is unnecessary; the infant's sucking needs can be met by providing a pacifi er. Adding more water to the formula than as directed decreases the caloric intake and also places the infant at risk for hyponatremia due to decreased sodium and increased water intake

An infant is to be discharged after surgery for intussusception. In developing the discharge teaching plan, the nurse should tell the mother? ■ 1. The infant will experience a change in the normal home routine. ■ 2. The infant can return to the prehospital routine immediately. ■ 3. The infant needs to ingest more calories at home than what was consumed in the hospital. ■ 4. The infant will continue to experience abdominal cramping for a few days.

1. Infants who have had an interruption in their normal routine and experiences, such as hospitalization and surgery, typically manifest behavior changes when discharged. The infant's normal routine has been signifi cantly altered, so it will take time to reestablish another routine. Calorie requirements at home will continue to be the same as those in the hospital. The infant does not need more calories at home. The surgical procedure corrected the problems, so the infant should not continue to have abdominal cramping

The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should fi rst: ■ 1. Administer oxygen. ■ 2. Institute rewarming. ■ 3. Prepare for intubation. ■ 4. Start an intravenous infusion

1. Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fl uid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.

A mother states that she thinks her 9-monthold "is developing slowly." When assessing the infant's development, the nurse is also concerned because the infant should be demonstrating which of the following characteristics? ■ 1. Vocalizing single syllables. ■ 2. Standing alone. ■ 3. Building a tower of two cubes. ■ 4. Drinking from a cup with little spilling

1. Normally, a 9-month-old infant should have been voicing single syllables since 6 months of age. Absence of this finding would be a cause for concern. An infant usually is able to stand alone at about 10 months of age. An infant usually is able to build a tower of two cubes at about 15 months of age. An infant usually is able to drink from a cup with little spilling at about 15 months of age

A mother brings her 3-month-old child into the emergency department. The child is listless with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from first to last should the nurse implement the physician's orders? 1. Obtain vital signs and weight 2. Insert an I.V. and infuse fluids. 3. Apply a urine collection bag. 4. Draw blood for laboratory tests.

1. Obtain vital signs and weight 3. Apply a urine collection bag. 2. Insert an I.V. and infuse fl uids as ordered. 4. Draw blood for laboratory tests The nurse should fi rst obtain vital signs and evaluate the child for signs of shock or cardiac arrhythmias. The weight can also be obtained at this time to estimate the amount of fl uid lost. The nurse should next apply the urine collection bag. As soon as possible after these steps, the nurse should insert an I.V. to replace lost fl uids, electrolytes, and sugar to reduce the incidence of metabolic acidosis created by the lack of calorie intake and the loss of electrolytes. Blood should be drawn to assess the severity of electrolyte imbalance and other possible causes for the diarrhea and vomiting

When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis? ■ 1. "Where did the pain start?" ■ 2. "What did you do for the pain?" ■ 3. "How often do you have a bowel movement?" ■ 4. "Is the pain continuous, or does it let up?"

1. Sudden relief of pain in a client with appendicitis may indicate that the appendix has ruptured. Rupture relieves the pressure within the appendix but spreads the infection to the peritoneal cavity. Periumbilical pain (pain centered around the navel), vomiting, and abdominal tenderness on palpation are common fi ndings associated with appendicitis.

A school-age child with cystic fi brosis asks the nurse what sports she can become involved in as she becomes older. Which of the following activities would be appropriate for the nurse to suggest? ■ 1. Swimming. ■ 2. Track. ■ 3. Baseball. ■ 4. Javelin throwing

1. Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball, and javelin throwing usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system. The strenuous activity and increased energy expenditure associated with track events, in conjunction with the dust and possible heat, would play a role in placing the child at risk for an upper respiratory tract infection and compromising her respiratory function.

The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which of the following would be appropriate for the nurse to administer at this visit? ■ 1. Diphtheria, tetanus, and acellular pertussis (DTaP); Haemophilus infl uenzae type B (Hib); inactivated poliomyelitis vaccine (IPV); and purifi ed protein derivative (PPD). ■ 2. DTaP; Hib; oral polio vaccine (OPV); and measles, mumps, and rubella (MMR). ■ 3. PPD, MMR, hepatitis B (hepB), and OPV. ■ 4. HepB, IPV, Hib, and varicella

1. The American Academy of Pediatrics recommends that infants who are delayed in receiving their immunizations or have not started their series by 9 months of age begin with DTaP, Hib, IPV, and PPD. OPV is not used because cases of polio have been reported with use of the vaccine. MMR and varicella vaccines are not administered until 12 months of age

A nasogastric tube inserted during surgery to correct an infant's intussusception is no longer freely removing gastric secretions. Which of the following should the nurse do next? ■ 1. Aspirate the tube with a syringe. ■ 2. Irrigate the tube with distilled water. ■ 3. Increase the level of suction. ■ 4. Rotate the tube

1. The fi rst action is to check the placement of the tube to ensure that it is in the correct position. To check tube position, the nurse should aspirate the tube with a syringe. A return of gastric contents indicates that the end of the tube is in the stomach. Another method is to inject a small amount of air while auscultating with a stethoscope over the epigastric area. The tube is irrigated with normal saline, not distilled water, and only after the position of the tube is confi rmed. The suction level should not be increased, because doing so could damage the mucosa. Rotating the tube could irritate or traumatize the nasal mucosa

After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal? ■ 1. Encouraging self-care skills in the child. ■ 2. Teaching the child something new each day. ■ 3. Encouraging more lenient behavior limits for the child. ■ 4. Achieving age-appropriate social skills.

1. The goal in working with mentally retarded children is to train them to be as independent as possible, focusing on developmental skills. The child may not be capable of learning something new every day but needs to repeat what has been taught previously. Rather than encouraging more lenient behavior limits, the parents need to be strict and consistent when setting limits for the child. Most children with Down syndrome are unable to achieve age-appropriate social skills due to their mental retardation. Rather, they are taught socially appropriate behaviors.

Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Defi cient fl uid volume related to passage of profuse amounts of watery diarrhea? ■ 1. Moist mucous membranes. ■ 2. Passage of a soft, formed stool. ■ 3. Absence of diarrhea for a 4-hour period. ■ 4. Ability to tolerate intravenous fl uids well.

1. The outcome of moist mucous membranes indicates adequate hydration and fl uid balance, showing that the problem of fl uid volume defi cit has been corrected. Although a normal bowel movement, ability to tolerate intravenous fl uids, and an increasing time interval between bowel movements are all positive signs, they do not specifi cally address the problem of defi cient fl uid volume

A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. The nurse should tell the parents to: ■ 1. Avoid tub baths until the stent is removed. ■ 2. Measure output in the urinary bag. ■ 3. Avoid drinking fruit juice. ■ 4. Clean the tip of the penis 3 times a day with soap and water

1. The parents should keep the penis as dry as possible until the stent is removed. Soaking in a tub bath is not recommended. Children this age typically go home voiding directly into a diaper. Infants may be started on juice at 6 months of age. Parents are advised to keep their child well hydrated after a hypospadius repair. Therefore, there is no reason to avoid juice. Cleaning the tip of the penis 3 times a day may cause unnecessary irritation.

A nurse is teaching the parents of a child diagnosed with a urinary tract infection secondary to vesicoureteral refl ux. How should the nurse explain how the refl ux contributes to the infection? ■ 1. "It prevents complete emptying of the bladder." ■ 2. "It causes urine backfl ow into the kidney." ■ 3. "It results in painful bladder spasms." ■ 4. "It causes painful urination."

1. The reason that urinary tract infections are a problem in children with vesicoureteral refl ux is that urine fl ows back up the ureter, past the incompetent valve, and back into the bladder after the child has fi nished voiding. This incomplete emptying of the bladder results in stasis of urine, providing a good medium for bacterial growth and subsequent infection. Vesicoureteral refl ux does not cause bladder spasms or painful urination. However, the child may experience painful urination with a urinary tract infection

Which of the following would be most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with severe diarrhea to help her comfort her infant who is fussy? ■ 1. Offering a pacifi er. ■ 2. Placing a mobile above the crib. ■ 3. Sitting at crib side talking to the infant. ■ 4. Turning the television on to cartoons

1. Typically, an infant hospitalized with severe diarrhea receives fl uid replacement intravenously rather than orally. Oral fl uids and food are usually withheld. Although activities such as placing a mobile over the crib, speaking to the infant, or turning on the television may provide distraction for or help in calming the infant, a fussy infant receiving nothing by mouth is usually best comforted by providing a pacifi er to satisfy sucking needs.

The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant's condition has been controlled. The nurse should determine that the father understands when he explains that which of the following will occur with his infant? ■ 1. The infant will receive clear liquids for a period of time. ■ 2. Formula and juice will be offered. ■ 3. Blood will be drawn daily to test for anemia. ■ 4. The infant will be allowed to go to the playroom.

1. The usual way to treat an infant hospitalized with gastroenteritis is to keep the infant nothing-by-mouth status to rest the gastrointestinal tract. The resulting fl uid volume defi cit is treated with intravenous fl uids. When the infant's condition is controlled (e.g., when vomiting subsides), clear liquids are then started slowly. Formula and juice will be started once the infant's vomiting has subsided and the infant has demonstrated the ability to tolerate clear liquids for a period of time. In this situation, there is no need to test the infant's blood every day for anemia. Most likely, the infant's serum electrolyte levels would be monitored closely. Typically, an infant is placed in a private room because gastroenteritis is most commonly caused by a virus that is easily transmitted to others

A nurse compares a child's height and weight with standard growth charts and fi nds the child to be in the 50th percentile for height and in the 45th percentile for weight. The nurse interprets these fi ndings as indicating that the child is: ■ 1. Average height and weight. ■ 2. Overweight for height. ■ 3. Underweight for height. ■ 4. Abnormal in height

1. The values of height and weight percentiles are usually similar for an individual child. Measurements between the 5th and 95th percentiles are considered normal. Marked discrepancies identify overweight or underweight children.

After teaching the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home, the nurse determines that the teaching has been successful when the parent states which of the following? ■ 1. "We will keep the restraints on continuously except when checking the skin under them for redness." ■ 2. "We will keep the restraints on during the day while he is awake, but take them off when we put him to bed at night." ■ 3. "After we get home, we won't have to use the restraints because our child does not suck on his hands or fingers." ■ 4. "We will be sure to keep the restraints on all the time until we come to see the physician for a follow-up visit."

1. To keep the infant from disturbing the suture line by placing fingers or other objects in the mouth, either intentionally or accidentally, the restraints should be in place at all times. They should be removed for a short period, however, so that the underlying skin can be checked for any redness or breakdown. While the restraints are removed, the parents should be instructed to manually restrain the hands and arms.

A nurse is assessing a child who is mildly mentally retarded. The best indication of how a mentally retarded child is progressing can be obtained by observing him: ■ 1. At school with his teacher. ■ 2. At home with his family. ■ 3. In the clinic with his mother. ■ 4. Playing soccer with his friends

1. Watching the child relate to his teacher and school work is the best indication of how he is progressing. School involves interacting with a person who is not a relative and in a situation that is not totally familiar. Observing the client in situations with family and friends shows social relationships but does not indicate how the child is learning new intellectual skills.

A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following? ■ 1. Protest. ■ 2. Despair. ■ 3. Regression. ■ 4. Detachment.

1. Young children have specifi c reactions to separation and hospitalization. In the protest stage, the toddler physically and verbally attacks anyone who attempts to provide care. Here, the child is fussing and crying and visibly pushes the nurse away. In the despair stage, the toddler becomes withdrawn and obviously depressed (e.g., not engaging in play activities and sleeping more than usual). Regression is a return to a developmentally earlier phase because of stress or crisis (e.g., a toddler who could feed himself before this event is not doing so now). Denial or detachment occurs if the toddler's stay in the hospital without the parent is prolonged because the toddler settles in to the hospital life and denies the parents' existence (e.g., not reacting when the parents come to visit)

An adolescent who has had an appendectomy and developed peritonitis has nausea. Which of the following should the nurse do fi rst? ■ 1. Administer an antiemetic. ■ 2. Irrigate the nasogastric (NG) tube. ■ 3. Notify the surgeon. ■ 4. Take the blood pressure.

2. After an appendectomy, the client who develops peritonitis typically has an NG tube in place. When a client complains of nausea, the nurse would fi rst check to ensure that the NG tube is functioning correctly, because the client's nausea may be related to a blockage of the NG tube. If the tube is clogged, it can be irrigated with normal saline. An antiemetic may be given, but only after the nurse has determined that the NG tube is functioning properly. Postoperative orders usually include an antiemetic. Typically, the nurse would notify the surgeon if the client did not obtain relief from irrigation of the NG tube or administration of an ordered antiemetic. Although taking the client's blood pressure is an important postoperative nursing activity, it is unrelated to relieving the client's nausea.

A child is started on a soft diet after having been on clear liquids following an episode of severe gastroenteritis. When helping the mother choose foods for her child, which of the following foods would be most appropriate? ■ 1. Muffi ns and eggs. ■ 2. Bananas and rice cereal. ■ 3. Bran cereal and a bagel. ■ 4. Pancakes and sausage.

2. After clear liquids, the foods of choice are soft foods. These foods should be easily digested and low in fat. Additionally, the foods should be non-bulk-forming. Bananas and rice cereal are low in fat and easy to digest. Muffi ns and eggs, as well as sausage and pancakes, are typically high in fat and would be avoided. Although a bagel is low in fat, bran cereal is high in fi ber and would be avoided because it may cause more diarrhea.

A 15-year-old has been diagnosed with acute glomerulonephritis and has been in the hospital for 1 day. Which of the following fi ndings requires immediate action? ■ 1. Large amount of generalized edema. ■ 2. Urine specifi c gravity of 1.030. ■ 3. Large amount of albumin in the urine. ■ 4. 24-hour output of 1,500 mL

2. An adolescent with acute glomerulonephritis has a high urine specifi c gravity related to oliguria caused by infl ammation of the glomeruli. The client will have periorbital edema, but not the generalized edema that occurs in nephrotic syndrome. In glomerulonephritis, there is some albumin in the urine, but there are large amounts of red blood cells, giving the urine a brown color. The urine in glomerulonephritis is scanty, averaging about 400 mL in 24 hours, which leads to fl uid volume excess and hypertension

41. A child has just ingested about 10 adultstrength acetaminophen (Tylenol) pills. The mother brings the child to the emergency department. What should the nurse do? Place the interventions in the order of priority from first to last. 1. Administer activated charcoal. 2. Assess the airway. 3. Reassure the mother. 4. Check serum acetaminophen levels. . 5. Obtain information about how the child obtained the pills. 6. Complete a physical examination

2. Assess the airway. 1. Administer activated charcoal. 3. Reassure the mother. 6. Perform a physical exam. 5. Obtain a history of the incident. 4. Check serum acetaminophen levels. Immediate care of the child who has ingested acetaminophen is to ensure airway, breathing, and circulation. Next, the nurse should administer activated charcoal. Acetylcysteine (Mucomyst) may also be used as an antidote. When the child is stable, the nurse should reassure the mother. Next, the nurse should perform a physical exam to assess the child for other health problems, and then obtain further information about how the child obtained the aspirin. The serum acetaminophen level should be obtained 4 hours after ingestion

The parents of a 3-year-old suspect that the child has recently ingested a large amount of acetaminophen. The child does not appear in immediate distress. The nurse should anticipate doing which of these interventions in order of priority, from fi rst to last? 1. Draw acetaminophen serum levels. 2. Attempt to determine the exact time and amount of drug ingested. 3. Administer acetylcysteine (Acetadote IV). 4. Administer activated charcoal

2. Attempt to determine the exact time and amount of drug ingested. 4. Administer activated charcoal. 1. Draw acetaminophen serum levels. 3. Administer acetylcysteine (Acetadote IV) The nurse should fi rst attempt to determine exactly when and how much acetaminophen the parents think the child has taken. Determining the time of ingestion helps establish the immediate care and when lab values should be drawn. Gastric decontamination with activated charcoal is used within 4 hours of ingestion to bind the drug and help prevent toxic serum levels. Serum blood levels should be done after the gastric decontamination, but preferably not too soon after ingestion since levels drawn before 4 hours may not refl ect maximum serum concentrations and will need to be repeated. The decision to administer acetylcysteine and prevent liver damage is based on serum levels.

Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing severe diarrhea? ■ 1. Monitoring the total 8-hour formula intake. ■ 2. Weighing the infant each day. ■ 3. Checking the anterior fontanel every shift. ■ 4. Monitoring abdominal skin turgor every shift

2. Because an infant experiencing severe diarrhea is at high risk for Defi cient fl uid volume, the nurse needs to evaluate the infant's fl uid balance status by weighing the infant at least every day. Body weight is the best indicator of hydration status because a higher proportion of an infant's body weight is water, compared with an adult. Initially, the infant with severe diarrhea is not allowed liquids but is given fl uids intravenously. Therefore, monitoring the oral intake of formula is inappropriate. Although checking the anterior fontanel for depression or bulging provides information about hydration status, this method is not considered the best indicator of the infant's fl uid balance. Monitoring skin turgor can provide information about fl uid volume status. The abdomen is commonly used to assess skin turgor in an infant because it is a large surface area and can be accessed quickly. However, weight is the best indicator of fl uid balance.

Which of the following assessments should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively? ■ 1. Measurement of urine specifi c gravity. ■ 2. Auscultation of bowel sounds. ■ 3. Inspection of the fi rst stool passed. ■ 4. Measurement of gastric output.

2. Development of a paralytic ileus postoperatively is a functional obstruction of the bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine specifi c gravity provides information about fl uid and electrolyte status. The fi rst stool and the amount of gastric output provide information about the return of gastric function

A toddler is brought to the emergency room after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which of the following fi rst? ■ 1. Administering an emetic. ■ 2. Performing a tracheostomy. ■ 3. Performing gastric lavage. ■ 4. Inserting an indwelling urinary (Foley) catheter

2. Drain cleaner almost always contains lye, which can burn the mouth, pharynx, and esophagus on ingestion. The nurse would be prepared to assist with a tracheostomy, which may be necessary because of swelling around the area of the larynx. An emetic is contraindicated because, as the substance burns on ingestion, so too would it burn when vomiting. Additionally, the mucosa becomes necrotic and vomiting could lead to perforations. Gastric lavage is contraindicated because the mucosa is burned from the ingestion of the caustic lye, causing necrosis. Gastric lavage also could lead to perforation of the necrotic mucosa. Insertion of an indwelling urinary (Foley) catheter would be indicated after the measures to remove the caustic substance have been started.

When developing the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery, which of the following would be most helpful in facilitating parent-infant bonding? ■ 1. Explaining to the parents that they can visit at any time. ■ 2. Encouraging the parents to hold their infant. ■ 3. Asking the parents to help monitor the infant's intake and output. ■ 4. Helping the parents plan for their infant's discharge.

2. Encouraging the parents to hold their neonate promotes parent-infant attachment. Parent- infant bonding is based on a relationship that begins when the parent fi rst touches the infant. Both the parents and the infant have predictable steps that they go through in this process. Explaining that the parents can visit at any time promotes bonding only if they do visit with, talk to, and hold the newborn. Asking the parents to help monitor intake and output at this time may be too anxiety-producing, thus interfering with bonding. Helping the parents plan for the infant's discharge involves them in the newborn's care and is important. However, it is not the fi rst step in the development of bonding.

When providing intermittent nasogastric feedings to an infant with failure to thrive which method is preferred to confi rm tube placement before each feeding? ■ 1. Obtain a chest X-ray. ■ 2. Verify that the gastric PH is less than 5.5. ■ 3. Auscultate the stomach while instilling an air bolus. ■ 4. Compare the tube insertion length to a standardized chart

2. For children receiving intermittent gavage feedings the best method to verify the tube placement before each feeding is to aspirate a small amount of gastric contents to verify that the PH is acidic. A PH of 5.5 or less should indicate correct placement in most babies. Depending on the type of feeding tube used, an x-ray may be used to confi rm the original tube placement, but use before every feeding would expose the child to unnecessary radiation. Air boluses are misleading because placement in the esophagus or respiratory tract may make the same sound in small infants. Charts might be helpful in determining initial tube insertion length, but do not substitute for nursing assessments.

The nurse is inserting a nasogastric (NG) tube in a child admitted with head trauma. The nurse should explain to the parents that the NG tube will be used for what purpose? ■ 1. Administer medications. ■ 2. Decompress the stomach. ■ 3. Obtain gastric specimens for analysis. ■ 4. Provide adequate nutrition

2. For the child with serious head trauma, a nasogastric tube is inserted initially to decompress the stomach and to prevent vomiting and aspiration. Medications would be administered intravenously in the initial period. The tube will not be used to obtain gastric specimens. Nutrition is not a priority initially. Later on, the tube may be used to administer feedings.

A nurse is planning a diet for a client with cystic fi brosis. Which of the following foods should not be included in the meal plan? ■ 1. Roasted chicken. ■ 2. Fried scallops. ■ 3. Milk shake. ■ 4. Egg omelet

2. Fried scallops are high in fat, and fats are diffi cult for a client with cystic fi brosis to digest; scallops are also not commonly preferred by most children. Clients with cystic fi brosis commonly lack calories and protein because their bodies do not absorb nutrients. Nutrients are not absorbed because tenacious mucus blocks key digestive enzymes from entering the digestive system. Thus, a diet rich in proteins and carbohydrates is essential for these clients. Roasted chicken and an egg omelet are high in protein and help with growth and development. The milk shake is high in carbohydrate and protein

Which of the following nursing diagnoses would be appropriate for the nurse to identify as a priority diagnosis for an infant just admitted to the hospital with a diagnosis of gastroenteritis? ■ 1. Pain related to repeated episodes of vomiting. ■ 2. Defi cient fl uid volume related to excessive losses from severe diarrhea. ■ 3. Impaired parenting related to infant's loss of fl uid. ■ 4. Impaired urinary elimination related to increased fl uid intake feeding pattern.

2. Given this infant's history of gastroenteritis, the priority nursing diagnosis would be Defi cient fl uid volume. With gastroenteritis, vomiting and diarrhea occur, leading to the loss of fl uids. This loss of fl uids is problematic in infants because a higher proportion of their body weight is water. Pain is not a priority nursing diagnosis, although the nurse should continue to assess the infant for pain. There are no data to indicate impaired parenting. Impaired urinary elimination is related to the infant's fl uid volume defi cit resulting from vomiting and diarrhea associated with gastroenteritis. If the infant's fl uid volume defi cit is not corrected, then this nursing diagnosis may become the priority.

The parents of a child tell the nurse that they feel guilty because their child almost drowned. Which of the following remarks by the nurse would be most appropriate? ■ 1. "I can understand why you feel guilty, but these things happen." ■ 2. "Tell me a little bit more about your feelings of guilt." ■ 3. "You should not have taken your eyes off of your child." ■ 4. "You really shouldn't feel guilty; you're lucky because your child will be all right."

2. Guilt is a common parental response. The parents need to be allowed to express their feelings openly in a nonthreatening, nonjudgmental atmosphere. Telling the parents that these things happen does not allow them to verbalize their feelings. Telling the parents that they should not have taken their eyes off the child blames them, possibly further contributing to their guilt. Telling the parents that they shouldn't feel guilty denies the parents' feelings of guilt and is inappropriate. Telling the parents that they are lucky that the child will be okay does not remove the feelings of guilt.

A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately: ■ 1. Put the client to bed. ■ 2. Obtain the child's blood pressure. ■ 3. Notify the physician. ■ 4. Administer acetaminophen (Tylenol)

2. Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fl uid and sodium; the fl uid is reabsorbed, causing fl uid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the physician before confi rming the cause of the symptoms would not assist the physician in his treatment. Putting the client to bed may help treat an elevated blood pressure, but fi rst the nurse must establish that high blood pressure is the cause of the symptoms. Administering Tylenol for high blood pressure is not recommended.

The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor's heated swimming pool to the emergency department. The nurse should assess the child for: ■ 1. Hypothermia. ■ 2. Hypoxia. ■ 3. Fluid aspiration. ■ 4. Cutaneous capillary paralysis.

2. Hypoxia is the primary problem because it results in brain cell damage. Irreversible brain damage occurs after 4 to 6 minutes of submersion. Hypothermia occurs rapidly in infants and children because of their large body surface area. Hypothermia is more of a problem when the child is in cold water. Although fl uid aspiration occurs in most drownings and results in atelectasis and pulmonary edema, further aggravating hypoxia, hypoxia is the primary problem. Cutaneous capillary paralysis is not a problem.

. At a follow-up appointment after being hospitalized, an adolescent with a history of cystic fi brosis (CF) describes his stools to the nurse. Which of the following descriptions should the nurse interpret as indicative of continued problems with malabsorption? ■ 1. Soft with little odor. ■ 2. Large and foul-smelling. ■ 3. Loose with bits of food. ■ 4. Hard with streaks of blood.

2. In children with CF, poor digestion and absorption of foods, especially fats, results in frequent bowel movements that are bulky, large, and foul-smelling. The stools also contain abnormally large quantities of fat, which is called steatorrhea. An adolescent experiencing good control of the disease would describe soft stools with little odor. Stool described as loose with bits of food indicates diarrhea. Stool described as hard with streaks of blood may indicate constipation.

During physical assessment of a 4-month-old infant with Hirschsprung's disease, the nurse should most likely note which of the following? ■ 1. Scaphoid-shaped abdomen. ■ 2. Weight less than expected for height and age. ■ 3. Cyanosis of the fi ngers and toes. ■ 4. Hyperactive deep tendon refl exes

2. Infants with Hirschsprung's disease typically display failure to thrive, with poor weight gain due to malabsorption of nutrients. Therefore, the nurse would expect to see a child who weighs less than that which is expected for height and age. A distended, rather than a scaphoid-shaped, abdomen would be noted. Cyanosis of fi ngers and toes is associated with congenital heart disease. Hyperactive deep tendon refl exes are associated with upper motor neuron problems, such as cerebral palsy.

4. When developing the plan of care for a toddler who has taken an acetaminophen overdose, which of the following should the nurse expect to include as part of the initial treatment? ■ 1. Frequent blood level determinations. ■ 2. Gastric lavage. ■ 3. Tracheostomy. ■ 4. Electrocardiogram

2. Initial management of a child who has ingested a large amount of acetaminophen would include inducing vomiting or performing gastric lavage with or without activated charcoal to aid in the removal of the substance. Frequent blood level determinations may be obtained during the follow-up phase, but they are not done as part of the initial treatment. Tracheostomy is not typically part of the initial treatment for acetaminophen overdose. However, it may be necessary later if respiratory distress develops. Acetaminophen primarily affects the liver, not the heart. Therefore, an electrocardiogram would not be considered part of the initial treatment plan

The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." The nurse should: ■ 1. Explain that completing a teaching checklist is required by the hospital. ■ 2. Help the client find information on the Internet. ■ 3. Provide the client with written information instead. ■ 4. Explain that information found on the Internet cannot be trusted.

2. Part of providing client-centered care is to honor the client's preferred method of learning. The nurse should help the adolescent fi nd accurate information about the procedure. By assisting with the information search the nurse can verify learning. Teaching straight from a checklist does not encourage customization. If the client has requested to use the Internet, it is unlikely that written information will be read. While it is true that some information on the Internet is not accurate, the nurse can take this opportunity to help the client learn how to determine if a source is reliable.

When developing the plan of care for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage, the nurse should anticipate performing postural drainage at which of the following times? ■ 1. After meals. ■ 2. Before meals. ■ 3. After rest periods. ■ 4. Before inhalation treatments.

2. Postural drainage, which aids in mobilizing the thick, tenacious secretions commonly associated with CF, is usually performed before meals to avoid the possibility of vomiting or regurgitating food. Although the child with CF needs frequent rest periods, this is not an important factor in scheduling postural drainage. However, the nurse would not want to interrupt the child's rest period to perform the treatment. Inhalation treatments are usually given before postural drainage to help loosen secretions.

The mother of a 4-year-old expresses concern that her child may be hyperactive. She describes the child as always in motion, constantly dropping and spilling things. Which of the following actions would be appropriate at this time? ■ 1. Determine whether there have been any changes at home. ■ 2. Explain that this is not unusual behavior. ■ 3. Explore the possibility that the child is being abused. ■ 4. Suggest that the child be seen by a pediatric neurologist.

2. Preschool-age children have been described as powerhouses of gross motor activity who seem to have endless energy. A limitation of their motor ability is that in moving as quickly as they do, they are not always able to judge distances, nor are they able to estimate the amount of strength and balance needed for activities. As a result, they have frequent mishaps. This level of activity typically is not associated with changes at home. However, if the behavior intensifi es, a referral to a pediatric neurologist would be appropriate. Children who have been abused usually demonstrate withdrawn behaviors, not endless energy.

When teaching a mother about measures to prevent lead poisoning in her children, which of the following preventive measures should the nurse include as the most effective? ■ 1. Condemning of old housing developments. ■ 2. Educating the public on common sources of lead. ■ 3. Educating the public on the importance of good nutrition. ■ 4. Keeping pregnant women out of old homes that are being remodeled.

2. Public education about the sources of lead that could cause poisoning has been found to be the most effective measure to prevent lead poisoning. This includes recent efforts to alert the public to lead in certain types of window blinds. Condemning old housing developments has been ineffective because lead paint still exists in many other dwellings. Providing education about good nutrition, although important, is not an effective preventive measure. Pregnant women and children should not remain in an older home that is being remodeled because they may breathe in lead in the dust, but this is not the most effective preventive measure

After teaching the parents of a child with febrile seizures about methods to lower temperature other than using medication, which of the following statements indicates successful teaching? ■ 1. "We'll add extra blankets when he complains of being cold." ■ 2. "We'll wrap him in a blanket if he starts shivering." ■ 3. "We'll make the bath water cold enough to make him shiver." ■ 4. "We'll use a solution of half alcohol and half water when sponging him."

2. Shivering, the body's defense against rapid temperature decrease, results in an increase in body temperature. Therefore the parents need to take measures to stop the shivering (and the resulting increase in body temperature) by increasing the room temperature or the temperature of the child's immediate environment (such as with blankets) until the shivering stops. Then, attempts are made to lower the temperature more slowly. Shivering does not necessarily correlate with being cold. Alcohol, a toxic substance, can be absorbed through the skin. Its use is to be avoided

The parents of a child on sulfamethoxazole and trimethoprim (Bactrim) for a urinary tract infection report that the child has a red, blistery rash. The nurse should tell the parents to: ■ 1. Apply lotion to the affected areas. ■ 2. Discontinue the medicine and come for immediate further evaluation. ■ 3. Use sunblock while on the medication. ■ 4. Increase the child's fl uid intake.

2. Sulfonamides have been associated with severe adverse reactions. A blistering rash may be a sign of Stevens-Johnson syndrome, a severe allergic reaction that manifests as skin lesions. This reaction is life threatening and requires immediate attention. Lotion should not be applied to skin with blisters. Bactrim may cause photosensitivity, but this usually appears as a mild red rash, not blisters. Increasing the child's fl uid intake may help the urinary tract infection, but does not address the rash

Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for a scheduled herniorrhaphy the next day. Which of the following should the nurse expect to implement to accomplish this goal? ■ 1. Explaining the preoperative and postoperative procedures to the mother. ■ 2. Having the mother stay with the infant. ■ 3. Making sure the infant's favorite toy is available. ■ 4. Allowing the infant to play with surgical equipment.

2. The best way to prepare a 7-month-old infant psychologically for surgery is to have the primary caretaker stay with the child. Infants in the second 6 months of life commonly develop separation anxiety. Therefore, the priority in this case is to support the child by having the parent present. Teaching the mother what to expect may decrease her anxiety; this is important because infants sense anxiety and distress in parents, but the priority in this case is to have the parent present. Actual play and acting out life experiences are appropriate for preschool-age children. Allowing an infant to play with surgical equipment would be inappropriate and dangerous

A 9-month-old child with cystic fibrosis does not like taking pancreatic enzyme supplement with meals and snacks. The mother does not like to force the child to take the supplement. The most important reason for the child to take the pancreatic enzyme supplement with meals and snacks is: ■ 1. The child will become dehydrated if the supplement is not taken with meals and snacks. ■ 2. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins. ■ 3. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear. ■ 4. The child will experience severe diarrhea if the supplement is not taken as prescribed.

2. The child must take the pancreatic enzyme supplement with meals and snacks to help absorb nutrients so he can grow and develop normally. In cystic fibrosis, the normally liquid mucus is tenacious and blocks three digestive enzymes from entering the duodenum and digesting essential nutrients. Without the supplemental pancreatic enzyme, the child will have voluminous, foul, fatty stools due to the undigested nutrients and may experience developmental delays due to malnutrition. Dehydration is not a problem related to cystic fibrosis. The pancreatic enzymes have no effect on the viscosity of the tenacious mucus. Diarrhea is not caused by failing to take the pancreatic enzyme supplement.

The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which of the following explanations should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision? ■ 1. The associated chordee is diffi cult to remove during circumcision. ■ 2. The foreskin is used to repair the deformity surgically. ■ 3. The meatus can become stenosed, leading to urinary obstruction. ■ 4. The infant is too small to have a circumcision.

2. The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fi brous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The infant is not too small to have a circumcision, which is commonly performed on the fi rst or second day of life

An infant diagnosed with Hirschsprung's disease undergoes surgery with the creation of a temporary colostomy. Which of the following statements by the parent regarding the colostomy indicates the need for further teaching? ■ 1. "The colostomy is only temporary." ■ 2. "The colostomy will give time for the nerves to return to normal." ■ 3. "The colostomy may include two separate abdominal openings." ■ 4. "Right after the procedure the stoma may appear purple."

2. The goal of the surgery is to remove the aganglionic portion of the intestine. The remaining intestines should have normal innervation. Colostomies are used to relieve the obstruction and allow the remaining intestines to return to normal size. A temporary loop or double-barreled colostomy has stomas for both the proximal and distal portion of the bowel. The fi nal surgical repair is usually done when the infant is around 20 lb. A new stoma is frequently swollen and bruised after surgery.

When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the mother to relate which of the following about the infant's crying and episodes of pain? ■ 1. Constant accompanied by leg extension. ■ 2. Intermittent with knees drawn to the chest. ■ 3. Shrill during ingestion of solids. ■ 4. Intermittent while being held in the mother's arms.

2. The infant with intussusception experiences acute episodes of colic-like abdominal pain. Typically, the infant screams and draws the knees to the chest. Between these episodes of acute abdominal pain, the infant appears comfortable and normal. Feeding does not precipitate episodes of pain. Additionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited by crying that occurs when the infant is placed in a reclining position, as in the mother's arms, is not associated with intussusception. This type of cry may indicate that the infant wants attention, wants to be held, or needs to have a diaper change

Which of the following methods should the nurse use to provide the most accurate assessment of an adolescent's status regarding obesity? ■ 1. A food intake diary for 1 week. ■ 2. Body mass index. ■ 3. A 4-hour dietary history. ■ 4. Skinfold thickness measurements.

2. The most accurate way to determine whether an adolescent has a problem with obesity is to calculate the body mass index (BMI). The BMI indicates a relationship between height and weight. Numbers obtained through calculation are then applied to a BMI table for interpretation. A food diary will provide information on what the adolescent is eating but does not provide information about obesity. A 4-hour diet history will not provide suffi cient information about the client's typical eating patterns over time. Measuring skinfold thickness with skinfold calipers is a common method used to assess obesity. The skinfold thickness test, which determines the amount of subcutaneous fat, determines obesity more accurately than does a height and weight chart. However, it is not the most accurate method and is not routinely performed by nurses

When developing the plan of care for a school-age child with acute poststreptococcal glomerulonephritis who has a fl uid restriction of 1,000 mL/day, which of the following fl uids should the nurse consider as most appropriate for the client's condition and effective for preventing excessive thirst? ■ 1. Diet cola. ■ 2. Ice chips. ■ 3. Lemonade. ■ 4. Tap water

2. The most appropriate and effective choice would be ice chips, because they help moisten the mouth and lips while keeping fl uid intake low. However, ice chips must still be counted as intake with the fl uid restriction. Sweet beverages, such as diet cola or lemonade, commonly increase thirst. Tap water effectively relieves thirst but does not help keep fl uid intake low. CN

A nurse walks into the room just as a 10-month-old infant places an object in his mouth and starts to choke. After opening the infant's mouth, which of the following should the nurse do next to clear the airway? ■ 1. Use blind fi nger sweeps. ■ 2. Deliver back slaps and chest thrusts. ■ 3. Apply four subdiaphragmatic abdominal thrusts. ■ 4. Attempt to visualize the object.

2. The nurse should use mechanical force- back slaps and chest thrusts-in an attempt to dislodge the object. Blind fi nger sweeps are not appropriate in infants and children because the foreign body may be pushed back into the airway. Subdiaphragmatic abdominal thrusts are not used for infants age 1 year or younger because of the risk of injury to abdominal organs. If the object is not visible when opening the mouth, time is wasted in looking for it. Action is required to dislodge the object as quickly as possible. Don't waste time looking for shit, if its close enough to the outside world then it'll fly out when you back slap tf out of them

The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate? ■ 1. "You really shouldn't leave right now. Your child is very sick." ■ 2. "I understand, but feel free to visit or call anytime to see how your child is doing." ■ 3. "It really isn't necessary to stay with your child. We'll take very good care of him." ■ 4. "Can you fi nd someone to stay with your children? Your child needs you here."

2. The nurse's best course of action would be to support the mother. This is best done by conveying understanding and encouraging the mother to visit or call. Telling the mother that she shouldn't leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt should the mother leave. Commenting that the child does not need anyone is not appropriate or true. Toddlers, in particular, need family members present because of the stresses associated with hospitalization. They experience separation anxiety, a normal aspect of development, and need constancy in their environment. Asking the mother to fi nd someone else to stay with her children is inappropriate. The children at home also need the support of the mother and/or other family members to minimize the disruptions in family life resulting from the toddler's hospitalization and to maintain consistency.

Which of the following actions initiated by the parents of an 8-month-old indicates they need further teaching about preventing childhood accidents? ■ 1. Placing a fire screen in front of the fireplace. ■ 2. Placing a car seat in a front-seat, front-facing position. ■ 3. Inspecting toys for loose parts. ■ 4. Placing toxic substances out of reach or in a locked cabinet.

2. The recommended safety-seat arrangement for infants up to 20 lb and less than 1 year old is rear-facing with shoulder restraints. The middle of the back seat is considered the safest area of the car. Burns are a major cause of childhood accidents, and using fi re screens in front of fireplaces can help prevent children from getting too close to a fire in a fireplace. Toys that contain loose parts or plastic eyes that can be swallowed or aspirated by small children should be avoided. Parents should inspect all toys for these parts before giving one to a child. Poisonings are most commonly caused by improper storage of a toxic substance. Keeping toxic substances in a child-proof container in a locked cabinet and continually observing the child's activities can prevent most poisonings.

A father of a child with a urinary tract infection calls the clinic and explains, "My wife and I are concerned because our child refuses to obey us concerning the preventions you told us about. Our child refuses to take the medication unless we buy a present. We don't want to use discipline because of the illness, but we're worried about the behavior." Which response by the nurse is best? ■ 1. "I sympathize with your diffi culties, but just ignore the behavior for now." ■ 2. "I understand it's hard to discipline a child who is ill, but things need to be kept as normal as possible." ■ 3. "I understand that things are diffi cult for you right now, but your child is ill and deserves special treatment." ■ 4. "I understand your concern, but this type of behavior happens all the time; your child will get over it when feeling better."

2. To ensure appropriate psychosocial development, a child needs to have normal patterns maintained as much as possible during illness. It is tempting to give ill children special treatment and to relax discipline. However, family routines and discipline should be kept as normal as possible. The child needs to know the limits to ensure feelings of security. When they are ill, children commonly attempt to stretch the rules and limits. If this occurs, returning to the previous well-behavior patterns will take time.

When planning a 15-month-old toddler's daily diet with the parents, which of the following amounts of milk should the nurse include? ■ 1. ½ to 1 cup. ■ 2. 2 to 3 cups. ■ 3. 3 to 4 cups. ■ 4. 4 to 5 cups.

2. Toddlers around the age of 15 months need 2 to 3 cups of milk per day to supply necessary nutrients such as calcium. A daily intake of more than 3 cups of milk may interfere with the ingestion of other necessary nutrients.

An infant with Hirschsprung's disease is to be discharged 1 or 2 days after surgery to create a colostomy. After teaching the infant's parents about the overall effects of their infant's surgery, the nurse determines that the teaching has been effective when the parents state which of the following? ■ 1. "His abdomen will be large for awhile." ■ 2. "When he's ready, toilet training may be diffi cult." ■ 3. "We need to limit his intake of dairy products." ■ 4. "We will give him vitamin supplements until he is an adolescent."

2. Toilet-training is commonly more diffi cult for children who have undergone surgery for Hirschsprung's disease than it is for other children. This is because of the trauma to the area and the associated psychological implications. Abdominal distention is an early sign of infection and therefore the parents need to report it to the physician. Typically, dietary restrictions are not required. Usually the infant is placed on an age-appropriate diet. Vitamin supplementation is not necessary if the infant's dietary intake is adequate

When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, which of the following descriptions about the stoma's appearance should the nurse include in the teaching? ■ 1. Becoming dark brown in 2 months. ■ 2. Staying deep red in color. ■ 3. Changing to several shades of pink. ■ 4. Turning almost purple in color

2. Typically, the stoma should remain deep red in color as long as the infant has the colostomy. A dark-red to purplish color may indicate impaired circulation to the stoma.

A charge nurse is making assignments for a group of children on a pediatric unit. The nurse should avoid assigning the same nurse to care for a 2-year-old with respiratory syncytial virus (RSV) and: ■ 1. An 18-month-old with RSV. ■ 2. A 9-year-old 8 hours post-appendectomy. ■ 3. A 1-year-old with a heart defect. ■ 4. A 6-year-old with sickle cell crisis.

3 (but it must've meant 1). RSV may be spread though both direct and indirect contact. While contact and standard precautions should be employed, a measure to further decrease the risk of nosocomial infections is to avoid assigning the same nurse caring for an RSV client to a client at risk for infection. Children 2 years of age and younger are most at risk for RSV, especially if they have other chronic problems such as a heart defect. From an infection control perspective, pairing 2 clients with RSV is ideal. RSV infections are unlikely to pose a serious problem in older children

. A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The physician is calling in a telephone order for ampicillin. The nurse should do which of the following? Select all that apply. ■ 1. Ask the unit clerk to listen on the speaker phone with the nurse and write down the order. ■ 2. Ask the physician to come to the hospital and write the order on the chart. ■ 3. Repeat the order to the physician. ■ 4. Ask the physician to confirm that the order is correct as understood by the nurse. ■ 5. Ask the nursing supervisor to cosign the telephone order as transcribed by the nurse.

3, 4. To ensure client safety in obtaining telephone orders, the order must be received by a registered nurse. The nurse should write the order, read the order back to the physician, and receive confi rmation from the physician that the order is correct. It is not necessary to ask the unit clerk to listen to the order, to require the physician to come to the hospital to write the order on the chart, or to have the nursing supervisor cosign the telephone order.

The health care provider has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family: ■ 1. "I will request an order for a sedative to help him relax." ■ 2. "I can't do anything to reduce the pain, but you can hold him during the procedure." ■ 3. "I will get an order for a lidocaine-based lubricant to make the procedure more comfortable." ■ 4. "I can apply a topical anesthetic 20 minutes before placing the catheter."

3. 2% lidocaine lubricants have been found to signifi cantly reduce the pain of urinary catheter insertion in children. If the unit does not have a standing protocol to use the lubricant, the nurse should request an order. A sedative would carry with it additional risks that could be avoided with the use of other methods to reduce pain. The parents should be encouraged to hold the child in addition to other pain relief methods. Frequent urination would make the use of topical anesthetics that must be left in place for a period of time impractical.

When assessing a 2-year-old child brought by his mother to the clinic for a routine checkup, which of the following should the nurse expect the child to be able to do? ■ 1. Ride a tricycle. ■ 2. Tie his shoelaces. ■ 3. Kick a ball forward. ■ 4. Use blunt scissors.

3. A 2-year-old child usually can kick a ball forward. Riding a tricycle is characteristic of a 3-year-old child. Tying shoelaces is a behavior to be expected of a 5-year-old child. Using blunt scissors is characteristic of a 3-year-old child

A mother of a toilet-trained 3-year-old expresses concern over her child's bedwetting while hospitalized. The nurse should tell the mother: ■ 1. "He was too immature to be toilet trained. In a few months he should be old enough." ■ 2. "Children are afraid in the hospital and frequently wet their bed." ■ 3. "It's very common for children to regress when they're in the hospital." ■ 4. "This is normal. He probably received too much fluid the night before."

3. A child will regress to a behavior used in an earlier stage of development in order to cope with a perceived threatening situation. Readiness for toilet training should be based on neurological, physical, and psychological development, not the age of the child. Children are afraid of hospitalization but the bedwetting is a compensatory mechanism done to regress to a previous stage of development that is more comfortable and secure for the child. Telling the mother that bedwetting is related to fluid intake does not provide an adequate explanation for the underlying regression to an earlier stage of development.

A mother brings her 18-month-old to the clinic because the child "eats ashes, crayons, and paper." Which of the following information about the toddler should the nurse assess first? ■ 1. Evidence of eruption of large teeth. ■ 2. Amount of attention from the mother. ■ 3. Any changes in the home environment. ■ 4. Intake of a soft, low-roughage diet.

3. A craving to eat nonfood substances is known as pica. Toddlers use oral gratification as a means to cope with anxiety. Therefore, the nurse should first assess whether the child is experiencing any change in the home environment that could cause anxiety. Teething or the eruption of large teeth and the amount of attention from the mother are unlikely causes of pica. Nutritional deficiencies, especially iron deficiency, were once thought to cause pica, but research has not substantiated this theory. A soft, low-roughage diet is an unlikely cause.

When the infant returns to the unit after imperforate anus repair, the nurse should place the infant in which of the following positions? ■ 1. On the abdomen, with legs pulled up under the body. ■ 2. On the back, with legs extended straight out. ■ 3. Lying on the side with the hips elevated. ■ 4. Lying on the back in a position of comfort

3. After surgical repair for an imperforate anus, the infant should be positioned either supine with the legs suspended at a 90-degree angle or on either side with the hips elevated to prevent pressure on the perineum. A neonate who is placed on the abdomen pulls the legs up under the body, which puts tension on the perineum, as does positioning the neonate on the back with the legs extended straight out.

The nurse discusses the eating habits of school-age children with their parents, explaining that these habits are most influenced by: ■ 1. Food preferences of their peers. ■ 2. Smell and appearance of foods offered. ■ 3. Examples provided by parents at mealtimes. ■ 4. Parental encouragement to eat nutritious foods.

3. Although children may be influenced by their peers and smell and appearance of foods may be important, children are most likely to be influenced by the example and atmosphere provided by their parents. Coaxing and badgering a child to eat most likely will aggravate poor eating habits

Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload? ■ 1. A drop in blood pressure. ■ 2. Change to slow, deep respirations. ■ 3. Auscultation of moist crackles. ■ 4. Marked increase in urine output.

3. An early sign of circulatory overload is moist rales or crackles heard when auscultating over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fl uid intake and output (with a higher intake than output), shortness of breath, increased respiratory rate, dyspnea, and cyanosis occur later.

The parents of a child with a serious head injury ask the nurse if the child is going to be all right. Which of the following responses by the nurse would be most appropriate? ■ 1. "Children usually don't do very well after head injuries like this." ■ 2. "Children usually recover rapidly from head injuries." ■ 3. "It's hard to tell this early, but we'll keep you informed of the progress." ■ 4. "That's something you'll have to talk to the doctor about."

3. As a rule, children demonstrate more rapid and more complete recovery from coma than do adults. However, it is extremely diffi cult to predict a specifi c outcome. Reassuring the parents that they will be kept informed helps open lines of communication and establish trust. Telling the parents that children do not do well would be extremely negative, destroying any hope that the parents might have. Telling the parents that children recover rapidly may give the parents false hopes. Telling the parents to talk to the doctor ignores the parents' concerns and interferes with trust-building.

After the acute stage following an ingestion of drain cleaner by a child, the nurse should be alert for the development of which of the following as a likely complication? ■ 1. Tracheal stenosis. ■ 2. Tracheal varices. ■ 3. Esophageal strictures. ■ 4. Esophageal diverticula.

3. As the burn from the lye ingestion heals, scar tissue develops and can lead to esophageal strictures, a common complication of lye ingestion. Tracheal stenosis would occur if the child had vomited and aspirated. Tracheal varices do not commonly occur after the ingestion of lye or other substances. Although very rare, esophageal diverticula may occur. Diverticula are commonly found in the colon of adults.

A 2-year-old tells his mother he is afraid to go to sleep because "the monsters will get him." The nurse should tell his mother to: ■ 1. Allow him to sleep with his parents in their bed whenever he is afraid. ■ 2. Increase his activity before he goes to bed, so he eventually falls asleep from being tired. ■ 3. Read a story to him before bedtime and allow him to have a cuddly animal or a blanket. ■ 4. Allow him to stay up an hour later with the family until he falls asleep

3. Behavior problems related to sleep and rest are common in young children. Consistent rituals around bedtime help to create an easier transition from waking to sleep. Allowing a child to sleep with his parents commonly creates more problems for the family and child and does not alleviate the problem or foster autonomy. Increasing activity before bedtime does not alleviate the separation anxiety in the toddler and causes further anxiety. Allowing him to stay up later than his normal time for bed will increase his anxiety, make it more diffi - cult for him to fall asleep, and do nothing to lessen his fear

An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When initially discussing the diagnosis and treatment with the parents, which of the following would be most appropriate? ■ 1. Assessing the adequacy of their coping skills. ■ 2. Reassuring them that their child will be fi ne. ■ 3. Encouraging them to ask questions. ■ 4. Giving them printed material on the procedure.

3. By encouraging parents to ask questions during information-sharing sessions, the nurse can clarify misconceptions and determine the parents' understanding of information. A better understanding of what is happening allows the parents to feel some control over the situation. Assessing the adequacy of the parents' coping skills is important but secondary to encouraging them to express their concerns. The questions they ask and their interactions with the nurse may provide clues to the adequacy of their coping skills. The nurse should never give false reassurance to parents. At this point, there is no way for the nurse to know whether the child will be fi ne. Written materials are appropriate for augmenting the nurse's verbal communication. However, these are secondary to encouraging questions.

A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the infant is not developing appropriately. Which findings in the infant would indicate the need for further developmental screening? ■ 1. Has no interest in peek-a-boo games. ■ 2. Does not turn front to back. ■ 3. Does not babble. ■ 4. Continues to have head lag.

3. By the end of 3 months infants should babble. Lack of babbling suggests a language delay and warrants further investigation. Infants typically would begin playing peek-a-boo around 7 months. The ability to roll front to back typically occurs at 5 months. Head lag is expected to resolve by 5 months.

After teaching a group of parents of preschoolers attending a well-child clinic about oral hygiene and tooth brushing, the nurse determines that the teaching has been successful when the parents state that children can begin to brush their teeth without help at which of the following ages? ■ 1. 3 years. ■ 2. 5 years. ■ 3. 7 years. ■ 4. 9 years.

3. Children younger than 7 years of age do not have the manual dexterity needed for tooth brushing. Therefore, parents need to help with this task until that time.

When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which of the following possible sources of infection? ■ 1. Nonrefrigerated custard. ■ 2. A pet canary. ■ 3. Undercooked eggs. ■ 4. Unwashed fruit

3. Diarrhea related to Salmonella bacilli is commonly spread by raw or undercooked fowl and eggs, pet turtles, and kittens. Food poisoning caused by Staphylococcus species is commonly spread by inadequately cooked or refrigerated custards, cream fi llings, or mayonnaise. Psittacosis, a respiratory illness, may be spread by canaries. Contaminated, unwashed fruit is associated with typhoid fever (caused by Salmonella typhi), a disorder rarely seen in the United States

The family of a 5-year-old, only child has just moved to a rural setting where the father has started a dental practice. At the well-child visit, the father expresses concern that his child seems prone to minor accidents such as, skinning his elbow and knees or falling off his scooter. The nurse tells the father: ■ 1. "Only children use accidents as a way to seek parental attention." ■ 2. "Children who live in the suburbs typically have more accidents." ■ 3. "Children frequently have more accidents when families experience change." ■ 4. "We see a relationship between accidents and parental education."

3. Family changes and stresses (e.g., moving, having company, taking a vacation, adding a new member) can distract parents and contribute to accidents. Only children typically receive more attention than those with siblings. Thus, the risk would be less. Families who live in the suburbs frequently are more affl uent and, therefore, better able to maintain a home less conducive to accidents. A parent's formal education is unrelated to accidents

In an initial screening for lead poisoning a 2-year-old child is found to have a lead level of 12 mcg/dL. The nurse should: ■ 1. Arrange a follow-up appointment in 6 months. ■ 2. Obtain a consultation for chelation therapy. ■ 3. Educate parents on ways to reduce lead in the environment. ■ 4. Assure the parents this is a normal lead level

3. Healthy People 2010 has set a goal of eliminating blood lead levels of greater than 10 mcg/dL in children age 1 to 5 years of age. The CDC recommends that the treatment for children with lead levels between 10 and 14 mcg/dL should include family lead education, follow-up testing, and a social service consultation if needed. Waiting 6 months for a follow-up screening is too long because the effects of lead are irreversible. Oral chelation therapy is not begun until levels approach 45 mcg/dL. There is no such thing as a "normal" lead level because there is no benefi cial action in the body

The nurse formulates the nursing diagnosis Imbalanced Nutrition: Less than body requirements related to negative feeding patterns for a 5-month old infant diagnosed with failure to thrive. To meet the short-term outcomes of the infant's plan of care, the nurse should expect to do which of the following? ■ 1. Instruct the parents in proper feeding techniques. ■ 2. Give infant formula that has 24 calories/ ounce. ■ 3. Provide consistent staff to care for the infant. ■ 4. Allow the infant to sit in a high chair during feedings.

3. In the short-term care of this infant, it is important that the same person feed the infant at each meal and that this person be able to assess for negative feeding patterns and replace them with positive patterns. Once the infant is gaining weight and shows progress in the feeding patterns, the parents can be instructed in proper feeding techniques. This is a long-term outcome of nursing care. Because there is no organic reason for the failure to thrive, it should not be necessary to increase the formula calorie content from 20 to 24 calories/ounce. A 5-month-old infant is too young to be expected to sit in a high chair for feedings and should still be bottle-fed

Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine? ■ 1. What they know about the legal implications of drinking. ■ 2. The type of alcohol they usually drink. ■ 3. The reasons they choose to use alcohol. ■ 4. When and with whom they use alcohol

3. Information about why adolescents choose to use alcohol or other drugs can be used to determine whether they are becoming responsible users or problem users. The senior students likely know the legal implications of drinking, and the nurse will establish a more effective relationship with the students by understanding motivations for use. The type of alcohol and when and with whom they are using it are not the first data to obtain when assessing the situation

A preschooler with pneumonococci meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the needle is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age-group has a need to accomplish which of the following? ■ 1. Trust those caring for her. ■ 2. Find diversional activities. ■ 3. Protect the image of an intact body. ■ 4. Relieve the anxiety of separation from home.

3. Preschool-age children worry about having an intact body and become fearful of any threat to body integrity. Allowing the child to participate in required care helps protect her image of an intact body. Development of trust is the task typically associated with infancy. Additionally, allowing the child to apply a dressing over the intravenous insertion site is unrelated to the development of trust. Finding diversional activities is not a priority need for a child in this age group. Separation anxiety is more common in toddlers than in preschoolers.

The mother asks the nurse about her 9-yearold child's apparent need for between-meal snacks, especially after school. When developing a sound nutritional plan for the child with the mother, the nurse should advise the mother: ■ 1. The child does not need to eat between-meal snacks. ■ 2. The child should eat the snacks the mother thinks are appropriate. ■ 3. The child should help with preparing his or her own snacks. ■ 4. The child will instinctively select nutritional snacks.

3. Snacks are necessary for school-age children because of their high energy level. School-age children are in a stage of cognitive development in which they can learn to categorize or classify and can also learn cause and effect. By preparing their own snacks, children can learn the basics of nutrition (such as what carbohydrates are and what happens when they are eaten). The mother and child should make the decision about appropriate foods together. School-age children learn to make decisions based on information, not instinct. Some knowledge of nutrition is needed to make appropriate choices.

The mother of a 6-month-old states that she started her infant on 2% milk. The nurse should first ask the mother: ■ 1. "Do you think your baby will be fine with this milk?" ■ 2. "Is it possible for you to switch your baby to whole milk?" ■ 3. "Can you tell me more about the reason you switched your baby to 2% milk?" ■ 4. "You cannot switch to 2% milk right now. Did your pediatrician tell you to do this?"

3. The American Academy of Pediatrics recommends that infants remain on iron fortified formula or breast milk until 1 year of age. The nurse needs to first assess if the mother switched the baby prematurely to due to lack of information or lack of resources. Then appropriate teaching or referrals may be determined. At 1 year of age the infant may be switched to whole milk, which has a higher fat content than 2%. The higher fat content is needed for brain growth. Demanding clients change behaviors without addressing the cause is unlikely to produce desired results.

Which of the following would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration? ■ 1. Deep, rapid respirations. ■ 2. Diaphoresis. ■ 3. Absence of tear formation. ■ 4. Decreased urine specific gravity.

3. The absence of tears is typically found when moderate dehydration is observed as the body attempts to conserve fl uids. Other typical fi ndings associated with moderate dehydration include a dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with moderate dehydration. The specifi c gravity of urine increases with decreased output in the presence of dehydration

The charge nurse fi nds the mother of a child with a chronic bladder condition requiring clean intermittent catheterization (CIC) visibly upset. The mother states, "That other nurse said parents are not allowed to perform CIC in the hospital because of increased infection risk." The charge nurse should tell the parent: ■ 1. "Your child is exposed to additional bacterial in the hospital that makes CIC unsafe." ■ 2. "You can catheterize your child as long as you use sterile technique." ■ 3. "You can use CIC on your child. I will talk with your nurse to clarify the policy." ■ 4. "I can tell you are having a confl ict with this nurse. I will switch assignments."

3. The charge nurse should assure the parent that it is okay to use CIC and discuss the conversation with the nurse. It is possible that the nurse was unaware of current research fi ndings or unit policies. The charge nurse should also determine if the parent has the supplies and space to clean the catheters. If not, the procedure may need to be modifi ed to use a new catheter each time, but the insertion principles would not change. Parents are frequently taught how to do CIC while a child is in the hospital. Therefore, the rationale that it now becomes unsafe, or that sterile technique is needed, is faulty. Switching nurses will not solve the underlying problem.

A child diagnosed with Wilms' tumor undergoes successful surgery for removal of the diseased kidney. When the child returns to the room, the nurse should place the child in which position? ■ 1. Modifi ed Trendelenburg. ■ 2. Sims'. ■ 3. Semi-Fowler's. ■ 4. Supine.

3. The child who has undergone abdominal surgery is usually placed in a semi-Fowler's position to facilitate draining of abdominal contents and promote pulmonary expansion. The modifi ed Trendelenburg position is used for clients in shock. The Sims' position is likely to be uncomfortable for this child because of the large transabdominal incision. The supine position, without the head elevated, puts the child at increased risk for aspiration

A school-age client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with acute poststreptococcal glomerulonephritis. Which of the following actions should receive the highest priority? ■ 1. Assessing vital signs every 4 hours. ■ 2. Monitoring intake and output every 12 hours. ■ 3. Obtaining daily weight measurements. ■ 4. Obtaining serum electrolyte levels daily.

3. The child with acute poststreptococcal glomerulonephritis experiences a problem with renal function that ultimately affects fl uid balance. Because weight is the best indicator of fl uid balance, obtaining daily weights would be the highest priority

Which of the following foods would be appropriate for a 12-month-old child with celiac disease? ■ 1. Cheerios. ■ 2. Pancakes. ■ 3. Rice Chex. ■ 4. Waffl es

3. The child with celiac disease should not eat foods containing wheat, oats, rye, or barley. Foods containing rice, such as Rice Chex cereal, or corn are appropriate. Because Cheerios are made from oats, this cereal should be avoided. Pancakes and waffl es are made from fl our that typically is derived from wheat and therefore should be avoided.

The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents: ■ 1. "It is only necessary to have the vaccine if your daughter will be living in a dormitory." ■ 2. "Yes, we recommend the vaccine, but it needs to be given as a series of three injections." ■ 3. "Let's review your records. The vaccine may have already been given a few years ago." ■ 4. "We highly recommend this vaccine, but we will need to do a pregnancy screening fi rst

3. The current recommendation is that the MCV4 vaccine be given at the earliest opportunity after the age of 11. Therefore, it is quite possible that the client received the vaccine at a previous visit and did not remember. On a college campus, students living in dormitories are at highest risk, but because it is diffi cult to target that group colleges may elect to require proof of vaccination for all incoming students. Other risk factors should also be considered, such as if the student plans to travel abroad. The vaccination is typically given as a single injection, but sometimes a second dose is recommended based on risk factors. The MCV4 is not a live vaccine. It may be given during pregnancy if the client is at risk

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. When contacting the physician about these symptoms the nurse should request: ■ 1. A referral to a lactation consultant. ■ 2. That the physician further assess the client. ■ 3. An order for an x-ray with orogastric catheter placement. ■ 4. A serum blood glucose level per laboratory

3. The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fi stula. The initial diagnosis is made when an orogastric catheter cannot be passed to the stomach. A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency

When teaching the mother of a toddler diagnosed with lead poisoning, which of the following should the nurse include as the most serious complication if the condition goes untreated? ■ 1. Cirrhosis of the liver. ■ 2. Stunted growth rate. ■ 3. Neurologic defi cits. ■ 4. Heart failure

3. The most serious and irreversible consequence of lead poisoning is mental retardation due to neurologic changes. It can be expected if lead poisoning is long-standing and goes untreated. Lead poisoning also affects the hematologic and renal systems. Cirrhosis is the end stage of several chronic liver diseases, such as biliary atresia and hepatitis. Lead poisoning is not associated with stunted growth. Chronic illnesses, such as cystic fi brosis, cause slowing of the growth velocity. Heart failure is associated with congenital heart disease and rheumatic fever

The parent of an infant with a cleft lip and palate asks the nurse when the infant's cleft palate will be repaired. The nurse responds by stating that the fi rst repair of a cleft palate is usually done at which of the following times? ■ 1. Before the eruption of teeth. ■ 2. When the child weighs approximately 10 kg (22 lb). ■ 3. Before the development of speech. ■ 4. After the child learns to drink from a cup

3. The optimal time for cleft palate repair depends on many factors. However, it is best done before speech develops and the child learns faulty speech habits as a result of the defect, usually before 12 to 15 months of age. Tooth eruption usually begins at about 6 months of age. The child should weigh about 10 kg (22 lb) at 6 months, but the important consideration is to schedule surgery before speech patterns begin to develop. An infant may learn to start drinking from a cup as early as 6 to 7 months of age, possibly up to the first birthday

After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the father states which of the following? ■ 1. "There is no rectal opening for stool to pass." ■ 2. "There is a tube between the trachea and esophagus." ■ 3. "The nerves at the end of the large colon are missing." ■ 4. "The muscle below the stomach is too tight."

3. The primary defect in Hirschsprung's disease is an absence of autonomic parasympathetic ganglion cells in the distal portion of the colon. Thus, the nerves at the end of the large colon are missing. Absence of a rectal opening refers to an imperforate anus. A tube between the trachea and esophagus refers to a tracheoesophageal fi stula. Presence of a tight muscle below the stomach refers to pyloric stenosis.

The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine? ■ 1. A family history of sudden infant death syndrome (SIDS). ■ 2. A fever of 38.5 °C following the 4-month vaccinations. ■ 3. An acute bilateral ear infection. ■ 4. Living with a family member who is immunosuppressed.

3. Vaccination in the presence of a moderate to severe infection, with or without fever, increases the risk of injury and decreases the chance of mounting good immunity. There is currently no evidence to suggest vaccines raise the risk of SIDS. A mild temperature may be expected with the DTaP. A fever of greater than 40.5° within 48 hours of vaccination would warrant caution. The DTaP is not a live vaccine. No special precautions are needed regarding immunosuppressed family members.

A 3-year-old child receiving chemotherapy after surgery for a Wilms' tumor has developed neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room. Which food would not be appropriate for this child? ■ 1. Fudge. ■ 2. French fries. ■ 3. Fresh strawberries. ■ 4. A milk shake

3. When a client receiving chemotherapy develops neutropenia, eating uncooked fruits and vegetables may pose a health risk due to possible bacterial contamination. All other foods are either cooked or pasteurized and would not produce a health risk.

The nurse should refer the parents of an 8-month-old child to a health care provider if the child is unable to: ■ 1. Stand momentarily without holding onto furniture. ■ 2. Stand alone well for long periods of time. ■ 3. Stoop to recover an object. ■ 4. Sit without support for long periods of time

4 According to the Denver Developmental Screening Examination, a child of 8 months should sit without support for long periods of time. An 8-month-old child does not have the ability to stand without hanging on to a stationary object for support. His muscles are not developed enough to support all his weight without assistance. His balance has not developed to the point that he can stand and stoop over to reach an object

The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse should include which of the following points in the teaching plan? ■ 1. Items from all four food groups should be introduced to the infant by the time the child is 10 months old. ■ 2. Solid foods should not be introduced until the infant is 10 months old. ■ 3. Iron deficiency rarely develops before 12 months of age, so iron-fortified cereals should not be introduced until the infant is 12 months old. ■ 4. The infant's diet can be changed from formula to whole milk when the infant is 12 months old.

4 Infants should be kept on formula or breast milk until 1 year of age. The protein in cow's milk is harder to digest than that found in formula. The infant cannot digest fats well, so some foods from the four food groups are not necessary in his diet during infancy. Solids are introduced into the infant's diet around 4 to 6 months, after the extrusion reflex has diminished and when the child will accept new textures. Iron deficiency develops in term infants between 4 to 6 months when the prenatal iron stores are depleted. Fortified cereals can be added to the infant's diet at 4 to 6 months to prevent iron deficiency anemia

To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to: ■ 1. Smile and laugh out loud. ■ 2. Roll from back to side. ■ 3. Hold a rattle briefly. ■ 4. Turn the head from side to side

4. A 1-month-old infant is usually able to lift the head and turn it from side-to-side from a prone position. The full-term infant with no complications has probably been able to do this since birth. Smiling and laughing is expected behavior at 2 to 3 months. Rolling from back to side and holding a rattle are characteristics of a 4-month-old.

A mother brings her 7-month-old infant to the well-baby clinic for a checkup. She is concerned that the infant is overweight. She feeds the infant formula that has 20 calories per ounce whenever the infant is hungry. The nurse should instruct the mother to: ■ 1. Give the infant 2% milk formula and add vitamins. ■ 2. Use skim milk because it is high in protein and lower in calories. ■ 3. Decrease the amount of formula feedings to 16 oz daily, and supplement with juice and water. ■ 4. Continue with the formula, keep a 3-day record of the infant's intake, and bring the infant back to the clinic for further evaluation.

4. A 3-day diet history is the best way to accurately assess the child's intake. Children under age 1 year should not drink cow's milk because of the risk of allergy. Children over age 1 year should drink whole milk because skim milk and 2% milk do not contain all the essential fatty acids needed by young children. It is unknown at this time how much formula the child is actually taking, but an infant should not have more than 6 oz of juice per day and additional water is usually not necessary. If an infant is taking no more than 32 oz of formula per day and is eating some baby food and cereal, additional fl uids and frequent feeding should not be necessary.

When teaching the parent of an infant with Hirschsprung's disease who received a temporary colostomy about the types of foods the infant will be able to eat, which of the following would the nurse recommend? ■ 1. High-fi ber diet. ■ 2. Low-fat diet. ■ 3. High-residue diet. ■ 4. Regular diet

4. A regular diet would be recommended for the child with a colostomy; no special diet is needed. High-fi ber foods, such as fruits and vegetables, should be minimized because they increase the bulk in the stool. Fat is necessary for brain growth in the fi rst year of life. A high-residue diet would result in bulkier stools and increased gas production, which will collect in the colostomy bag. Therefore, a high-residue diet is not indicated

Which of the following would be an important assessment fi nding for an 8-month-old infant admitted with severe diarrhea? ■ 1. Absent bowel sounds. ■ 2. Pale yellow urine. ■ 3. Normal skin elasticity. ■ 4. Depressed anterior fontanel.

4. An infant with severe diarrhea will experience some degree of dehydration. In an 8-month-old child, the anterior fontanel has not closed. Therefore, a depressed anterior fontanel would be an important fi nding. Additionally, the infant would exhibit dry mucous membranes, lethargy, hyperactive bowel sounds, dark urine, and sunken eyeballs. Skin turgor would be decreased or delayed (e.g., slow to return when pinched).

When teaching the parents of an older infant with cystic fi brosis (CF) about the type of diet the child should consume, which of the following would be appropriate? ■ 1. Low-protein diet. ■ 2. High-fat diet. ■ 3. Low-carbohydrate diet. ■ 4. High-calorie diet

4. CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high protein, high-carbohydrate, moderate-fat diet is indicated.

While assessing a preschooler brought by her parents to the emergency department after ingestion of kerosene, the nurse should be alert for which of the following? ■ 1. Uremia. ■ 2. Hepatitis. ■ 3. Carditis. ■ 4. Pneumonitis.

4. Chemical pneumonitis is the most common complication of ingestion of hydrocarbons, such as in kerosene. The pneumonitis is caused by irritation from the hydrocarbons aspirated into the lungs. Uremia is the result of renal insufficiency, which causes nitrogenous waste products to build up in the blood rather than being excreted. Hepatitis is caused by a viral infection. Carditis in a preschooler may be the result of rheumatic fever

After teaching the parents of a toddler about commonly aspirated foods, which of the following foods, if identified by the parents as easily aspirated, would indicate the need for additional teaching? ■ 1. Popcorn. ■ 2. Raw vegetables. ■ 3. Round candy. ■ 4. Crackers.

4. Crackers, because they crumble and easily dissolve, are not commonly aspirated. Because children commonly eat popcorn hulls or pieces that have not popped, popcorn can be easily aspirated. Toddlers frequently do not chew their food well, making raw vegetables a commonly aspirated food. Round candy is often difficult to chew and comes in large pieces, making it easily aspirated

Immediately after the fi rst oral feeding after corrective surgery for pyloric stenosis, a 4-week-old infant is fussy and restless. Which of the following actions would be most appropriate at this time? ■ 1. Encourage the parents to hold the infant. ■ 2. Hang a mobile over the infant's crib. ■ 3. Give the infant more to eat. ■ 4. Give the infant a pacifi er to suck on.

4. Giving the infant a pacifi er would help meet non-nutritive sucking needs and ensure oral gratifi cation. Additionally, sucking aids in calming the infant. Holding the infant to decrease fussiness and restlessness is more effective in an older infant. Also, the reason for the infant's fussiness needs to be explored. Hanging a mobile over the crib frequently does not decrease fussiness. After surgery to correct pyloric stenosis, feeding the infant more formula would lead to vomiting, putting additional stress on the operative site.

When teaching the mother of an infant who has undergone surgical repair of a cleft lip how to care for the suture line, the nurse demonstrates how to remove formula and drainage. Which of the following solutions should the nurse use? ■ 1. Mouthwash. ■ 2. Povidone-iodine (Betadine) solution. ■ 3. A mild antiseptic solution. ■ 4. Half-strength hydrogen peroxide

4. Half-strength hydrogen peroxide is recommended for cleaning the suture line after cleft lip repair. The bubbling action of the hydrogen peroxide is effective for removing debris. Normal saline also may be used. Mouthwashes frequently contain alcohol, which can be irritating. Also, mouthwashes are not as effective in removing debris as halfstrength peroxide solutions are. Povidone-iodine solution is not used because the iodine contained in the solution can be absorbed through the skin, leading to toxicity. A mild antiseptic solution has some antibacterial properties but is ineffective in removing suture-line debris

Which of the following is the nurse's best response to a mother who asks about the outcome for her child with lead poisoning? ■ 1. "Many children suffer brain damage from lead poisoning." ■ 2. "Many of its effects require the child to receive special schooling." ■ 3. "Most children with lead poisoning experience problems with the law." ■ 4. "Most effects of lead poisoning are reversible if diagnosed early."

4. Most of the pathologic effects of lead poisoning are reversible as long as the problem is diagnosed early. The most serious effects are those on the central nervous system (e.g., brain damage, mental retardation, behavior changes), not problems with the law. However, because of screening programs, many children with lead poisoning are diagnosed and treated early. As a result, little if any brain damage occurs that would require children to receive special schooling

The nurse discusses with the parents how best to raise the IQ of their child with Down syndrome. Which of the following would be most appropriate? ■ 1. Serving hearty, nutritious meals. ■ 2. Giving vasodilator medications as prescribed. ■ 3. Letting the child play with more able children. ■ 4. Providing stimulating, nonthreatening life experiences.

4. Nonthreatening experiences that are stimulating and interesting to the child have been observed to help raise IQ. Practices such as serving nutritious meals or letting the child play with more able children have not been supported by research as benefi cial in increasing intelligence. Vasodilator medications act to increase oxygenation to the tissues, including the brain. However, these medications do not increase the child's IQ.

After teaching the mother of a 2-year-old child with lactose intolerance about which dairy products to include in the child's diet, which of the following if stated by the mother indicates effective teaching? ■ 1. Ice cream. ■ 2. Creamed soups. ■ 3. Pudding. ■ 4. Cheese.

4. People who are lactose-intolerant usually are able to tolerate dairy products in which lactose has been fermented, such as yogurt, cheese, and buttermilk. Pudding, ice cream, and creamed soups contain lactose that has not been fermented.

The nurse is discharging an 8-month-old who weighs 15 lb from the hospital. The parents have put the child in the back seat of the car with the car seat facing the front. The nurse should: ■ 1. Ask the parents to wait while obtaining the correct car seat. ■ 2. Complete the discharge with the child sitting facing the front seat. ■ 3. Give the parents a manual on proper car seat placement. ■ 4. Explain the need for the rear-facing position and request assistance from a car seat technician.

4. Proper car seat placement for a child younger than 1 year or weighing less than 20 lb is facing the rear of the car. Without specialized training, nurses may not understand how to correctly use all brands of car seats. Families who need help installing car seats should be referred to persons who have had specialized training. The car seat is not in question and does not need to be replaced. Keeping the infant in an incorrect position while completing the discharge reinforces the incorrect placement. The parents are unlikely to read a manual, especially since the child is 8 months old and it is very likely that they have been using this position since birth. Additionally, the manual may not be specifi c for their brand of car seat.

A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child? ■ 1. Enjoys physical demonstrations of affection. ■ 2. Is selfish and insensitive to the welfare of others. ■ 3. Is uncooperative in play and school. ■ 4. Has a strong sense of justice and fair play

4. School-age children are concerned about justice and fair play. They become upset when they think someone is not playing fair. Physical affection makes them embarrassed and uncomfortable. They are concerned about others and are cooperative in play and school.

After surgery to repair a tracheoesophageal fi stula, an infant receives gastrostomy tube feedings. After feeding the infant by this method, the nurse cradles and rocks the infant for about 15 minutes, primarily to help accomplish which of the following? ■ 1. Promote intestinal peristalsis. ■ 2. Prevent regurgitation of formula. ■ 3. Relieve pressure on the surgical site. ■ 4. Associate eating with a pleasurable experience.

4. The nurse can help meet the psychological needs of an infant being fed through a gastrostomy tube by rocking the infant after a feeding. The infant soon learns to associate eating with a pleasurable experience and learns to trust the caregiver. Rocking the infant will not promote peristalsis or prevent regurgitation. Holding the baby will not relieve pressure on the surgical site. However, holding the child right after feeding promotes comfort and pleasure.

. A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The parents ask the nurse if this behavior is normal. The nurse should explain to the parents that toddlers use ritualistic patterns to: ■ 1. Establish a sense of identity. ■ 2. Establish control over adults in their environment. ■ 3. Establish sequenced patterns of learning behavior. ■ 4. Establish a sense of security.

4. Toddlers establish ritualistic patterns to feel secure, despite inconsistencies in their environment. Establishing a sense of identity is the developmental task of the adolescent. The toddler's developmental task is to use rituals and routines to help in making autonomy easier to accomplish. Ritualistic patterns do involve patterns of behavior but they are not utilized to develop learning behaviors.

The nurse mentions that a group meeting for mothers of mentally retarded children is to be held soon. "Not retarded!" the child's mother angrily blazes, "Exceptional." When responding to this outburst, which of the following replies by the nurse would be most appropriate? ■ 1. "'Retarded' is the commonly used and accepted term." ■ 2. "I'm sorry if I offended you by my thoughtless remark." ■ 3. "No matter what it's called, the condition is still the same, isn't it?" ■ 4. "I'd like to hear more of your thoughts and feelings on that.

4. When responding to a mother who becomes angry when someone calls her child mentally retarded instead of exceptional, the nurse should give the mother a chance to explore her feelings on the subject. Because the mother obviously has diffi culty with the term "retarded," stressing the use of this term would cause further angry feelings. Apologizing, trying to use logic, and defending the comment are not effective ways to handle the situation because the mother's feelings need to be addressed.

When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which of the following for the parents? ■ 1. Affection for their child. ■ 2. Responsibility for their child's welfare. ■ 3. Understanding of their child's disability. ■ 4. Confi dence in their ability to care for their child

4. When teaching the parents of a child with Down syndrome, activities should focus on increasing the parents' confi dence in their ability to care for the child. The parents must continue to work daily with their child. Most parents feel affection and a sense of responsibility for their child regardless of the child's limitations. Parents usually understand the child's disability on the cognitive level but have diffi culty accepting it on the emotional level. As the parents' confi dence in their caring abilities increases, their understanding of the child's disability also increases on all levels.

When developing the preoperative plan of care for an infant with Hirschsprung's disease, which of the following should the nurse include? ■ 1. Administering a tap water enema. ■ 2. Inserting a gastrostomy tube. ■ 3. Restricting oral intake to clear liquids. ■ 4. Using povidone-iodine solution to prepare the perineum

. 3. Before intestinal surgery, dietary intake is limited to clear liquids for 24 to 48 hours. A clear liquid diet meets the child's fl uid needs and avoids the formation of fecal material in the intestine. Typically, repeated saline enemas, not tap water enemas, are given to empty the bowel. Soapsuds enemas are contraindicated for infants, as are tap water enemas. A nasogastric tube may be inserted for gastric decompression. Insertion of a gastrostomy tube is outside the scope of nursing practice. Because the perineal area is not involved in the surgery, it does not need to be prepared.

Which of the following, if described by the parents of a child with cystic fi brosis (CF), indicates that the parents understand the underlying problem of the disease? ■ 1. An abnormality in the body's mucus-secreting glands. ■ 2. Formation of fi brous cysts in various body organs. ■ 3. Failure of the pancreatic ducts to develop properly. ■ 4. Reaction to the formation of antibodies against streptococcus.

1. CF is characterized by a dysfunction in the body's mucus-producing exocrine glands. The mucus secretions are thick and sticky rather than thin and slippery. The mucus obstructs the bronchi, bronchioles, and pancreatic ducts. Mucus plugs in the pancreatic ducts can prevent pancreatic digestive enzymes from reaching the small intestine, resulting in poor digestion and poor absorption of various food nutrients. Fibrous cysts do not form in various organs. Cystic fi brosis is an autosomal recessive inherited disorder and does not involve any reaction to the formation of antibodies against streptococcus

A parent asks why it is recommended that the second dose of the measles, mumps, and rubella (MMR) vaccine be given at 4 to 6 years of age? The nurse should explain to the parent that the second dose is given at this age for what reason? ■ 1. If the child reaches puberty and becomes pregnant when receiving the vaccine, the risks to the fetus are high. ■ 2. The chance of contracting the disease is much lower at this age. ■ 3. The dangers associated with a strong reaction to the vaccine are increased at this age. ■ 4. A serious complication from the vaccine is swelling of the joints

1. After receiving the MMR vaccine, the person develops a mild form of the disease, stimulating the body to develop immunity. Administration to a pregnant adolescent early in pregnancy puts the fetus at risk for deformity or spontaneous abortion. Some authorities recommend withholding the immunization for rubella until after puberty because a woman does not always know when she is pregnant and a fetus could be placed in jeopardy. However, the risk of contracting the disease is not lower at this age. There is no difference in the reaction to the vaccine at this age or in an older child. Swelling of the joints is a rare complication of the rubella vaccine

A child with cystic fibrosis is receiving gentamicin. Which of the following nursing actions is most important? ■ 1. Monitoring intake and output. ■ 2. Obtaining daily weights. ■ 3. Monitoring the client for indications of constipation. ■ 4. Obtaining stool samples for hemoccult testing

1. Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.

Which of the following statements by the mother of an 18-month-old child should indicate to the nurse that the child needs laboratory testing for lead levels? ■ 1. "My child does not always wash after playing outside." ■ 2. "My child drinks 2 cups of milk every day." ■ 3. "My child has more temper tantrums than other kids." ■ 4. "My child is smaller than other kids of the same age."

1. Eating with dirty hands, especially after playing outside, can lead to lead poisoning because lead is often present in soil surrounding homes. Also, children who eat lead-containing paint chips commonly develop lead poisoning. Drinking 2 cups of milk per day is less than that which is recommended for this age group, so more nutritional information would need to be obtained. Temper tantrums are characteristic of 18-month-old children as they try to assert themselves. Determining whether the child is smaller than other children the same age requires measuring height and weight and plotting them on growth charts. In addition, inadequate growth could be a result of numerous causes, such as genetics, chronic illness, or chronic drug use (e.g., prednisone).

A child is admitted to the pediatric unit with the diagnosis of severe gastroenteritis. To prevent spread of the disease the nurse should? ■ 1. Institute standard precautions. ■ 2. Place the child in a semiprivate room. ■ 3. Serve meals with eating utensils that can be sterilized. ■ 4. Single-bag all linens

1. For the child with severe gastroenteritis, diarrhea is a problem; it exposes all persons caring for the child to possibly infectious body fl uids. Subsequently, any other clients being cared for by these individuals are also at risk. Therefore, the nurse should institute standard precautions, including good handwashing and use of appropriate personal protective equipment (gowns, gloves, eye protection) to minimize the risk for exposure. Typically, the child with severe gastroenteritis is placed in a private room until the causative organism is determined, to prevent transmission and protect others, including clients, families, and staff, from acquiring the infection. Because gastroenteritis is usually viral in origin and highly contagious, disposable eating utensils should be used to prevent transmission. For the child with gastroenteritis, double-bagging all linens is appropriate to prevent possible transmission from contaminated linens.

The nurse is caring for a child who has just returned from surgery for repair of a cleft lip. In which order, from first to last, should the nurse do the following? 1. Maintain a clear and adequate airway 2. Maintain sufficient fluid and caloric intake. 3. Provide emotional comfort to the child. 4. Apply elbow restraints. 5. Teach the parents proper feeding methods.

1. Maintain a clear and adequate airway. 4. Apply elbow restraints. 2. Maintain sufficient fluid and caloric intake. 3. Provide emotional comfort to the child. 5. Teach the parents proper feeding methods. The nurse should fi rst ensure that the child has a patent airway, because swelling and secretions following surgery can block the airway. Next, the nurse should restrain the infant's arms to keep him from rubbing with his hands or fi ngers on the incision line, which could cause scarring and damage to the incision. The child will need adequate nourishment and fl uids as soon as he recovers from anesthesia. The nurse must comfort the child, and try to prevent him from crying as much as possible, because crying puts a strain on the suture line and can cause scarring. The nurse should involve the parents in the child's care and feeding as soon as possible after she has assessed the child's ability to safely ingest his feedings.

The mother of a toddler hospitalized for episodes of diarrhea reports that when her toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don't know what to do!" After teaching the mother about ways to manage this behavior, which of the following statements indicates that the nurse's teaching was successful? ■ 1. "Next time she screams and throws her legs, I'll ignore the behavior." ■ 2. "I'll allow her to have what she wants once in a while." ■ 3. "I'll explain why she cannot have what she wants." ■ 4. "When she behaves like this, I'll tell her that she is being a bad girl."

1. The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums, because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child's behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering the child's ability to develop a sense of autonomy.

Which of the following is a normal response from an adolescent who has just returned to her room after an appendectomy? ■ 1. "I'll need plastic surgery for this scar." ■ 2. "I'm worried about the size of my scar." ■ 3. "I don't want to have any pain." ■ 4. "What will my boyfriend say about the scar?"

2. Adolescents are concerned about the immediate state and functioning of their bodies. The adolescent needs to know whether any changes (e.g., illness, trauma, surgery) will alter her lifestyle or interfere with her quest for physical perfection.Having a scar may be devastating to the adolescent. The need for plastic surgery cannot be determined at this point. The adolescent has just returned from surgery and has yet to see the scar. Healing has yet to occur. Typically scars become smaller and fade over time. The desire for no pain is unrealistic. Although adolescents are worried about pain and how they will respond, they typically are discharged within 24 hours after an appendectomy with pain well controlled by oral analgesics. The immediate concern of adolescents is the state and functioning of their bodies. After concerns about themselves, then adolescents are concerned about their peer group and their responses. Although the boyfriend's response will matter, this concern would be more common later in the course of the adolescent's recovery.

When developing the plan of care for an infant with pyloric stenosis, the nurse identifi es a nursing diagnosis of Defi cient fl uid volume related to prolonged vomiting. Which of the following parameters should the nurse expect to use when evaluating the client outcome? ■ 1. Abdominal distention. ■ 2. Weight loss. ■ 3. Vomiting. ■ 4. Respiratory effort

2. For the client with a nursing diagnosis of Defi cient fl uid volume related to vomiting, the outcome would focus on restoration of fl uid balance. Typically, the nurse would evaluate the client for evidence of dehydration. Parameters would include assessment of the client's weight for loss or decreased skin turgor. Abdominal distention is caused by the stenosis and is not relieved until the child has surgery. The child may have increased respiratory effort due to abdominal distention; however, to evaluate the outcome related to fl uid defi cit, the nurse should weigh the infant. The nurse should record the amount of emesis, but evaluation of the outcome is accomplished by weighing the infant.

A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is: ■ 1. The vital signs. ■ 2. Level of consciousness. ■ 3. Reactions of the pupils. ■ 4. Motor strength

2. The level of consciousness (LOC) is the best indicator of brain function. If the child's condition deteriorates, the nurse would notice changes in LOC before any other changes and should notify the physician that these changes are occurring. Changes in vital signs and pupils typically follow changes in LOC. Motor strength is primarily assessed as a voluntary function. With changes in levels of consciousness there may be motor changes.

When developing the plan of care for a child who is unconscious after a serious head injury, in which of the following positions should the nurse expect to place the child? ■ 1. Prone with hips and knees slightly elevated. ■ 2. Lying on the side, with the head of the bed elevated. ■ 3. Lying on the back, in the Trendelenburg position. ■ 4. In the semi-Fowler's position, with arms at the side.

2. The unconscious child is positioned to prevent aspiration of saliva and minimize intracranial pressure. The head of the bed should be elevated, and the child should be in either the semiprone or the side-lying position. Lying prone with hips and knees slightly elevated increases intracranial pressure, as does lying on the back in the Trendelenburg position. The semi-Fowler's position with arms at the side is not the best choice.

When developing the plan of care for an infant with a cleft lip before corrective surgery is performed, which of the following should be a priority? ■ 1. Maintaining skin integrity in the oral cavity. ■ 2. Using techniques to minimize crying. ■ 3. Altering the usual method of feeding. ■ 4. Preventing the infant from putting fingers in the mouth.

3. Before corrective surgery for a cleft lip, the infant needs to consume formula. Methods for feeding may need to be adjusted to fi t the infant's needs, because the infant with a cleft lip experiences a decreased ability to suck, which interferes with the infant's ability to compress the nipple. A special feeder may be used to feed the infant to ensure adequate caloric intake. Problems with infection and skin integrity in the mouth are uncommon because the areas of the defect are not open areas. Although crying may cause the infant to swallow more air because of the defect, crying poses no harm to the infant. There is no need to keep the infant's fingers out of the mouth preoperatively. The fingers will not harm the defect or cause an infection.

The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse's best response? ■ 1. "Newborns cry and cannot be distracted to stop crying." ■ 2. "When faced with a pain, newborns try to roll away from it." ■ 3. "Newborns typically move their whole body in response to pain." ■ 4. "Pain causes the newborn to withdraw the affected part."

3. The neonate responds to pain with total body movement and brief, loud crying that ceases with distraction. After age 6 months, an infant reacts to pain with intense physical resistance and tries to escape by rolling away. A toddler reacts to pain by withdrawing the affected part

Immediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child? ■ 1. On the back with the head in a position of comfort. ■ 2. In low Fowler's position with the head turned to the side. ■ 3. Lying on the abdomen with the head turned to the side. ■ 4. In reverse Trendelenburg with the head tilted forward.

3. Immediately after a surgical repair of a cleft palate, the child is placed on the abdomen with the head turned to the side to lessen the chance of aspiration by allowing secretions to drain out. Positioning the child on the back places the child at risk for aspiration should any regurgitation or vomiting occur, even in low Fowler's position with the head to the side or in reverse Trendelenburg position with the head tilted forward.

Which of the following meals would be most appropriate for a 15-year-old with glomerulonephritis with severe hypertension? ■ 1. Egg noodles, hamburger, canned peas, milk. ■ 2. Baked ham, baked potato, pear, canned carrots, milk. ■ 3. Baked chicken, rice, beans, orange juice. ■ 4. Hot dog on a bun, corn chips, pickle, cookie, milk.

3. The best selection of food would include no added salt or salty food. Because sodium cannot be excreted due to the oliguria and to avoid increasing the hypertension, a low-salt diet is recommended. Most canned foods have sodium added as a preservative. Hamburger, ham, hot dogs, canned peas, canned carrots, corn chips, pickles, and milk are high in sodium.

The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which of the following would be the most effective method of follow-up? ■ 1. Daily phone calls from the hospital nurse. ■ 2. Enrollment in community parenting classes. ■ 3. Twice-weekly clinic appointments. ■ 4. Weekly visits by a community health nurse.

4. The most effective follow-up care would occur in the home environment. The community health nurse can be supportive of the parents and will be able to observe parent-infant interactions in a natural environment. The community health nurse can evaluate the infant's progress in gaining weight, offer suggestions to the parents, and help the family solve problems as they arise.

The nurse has identifi ed a priority nursing diagnosis of Anxiety related to surgery for a 4-yearold preparing for a tonsillectomy. The nurse should tell the child: ■ 1. "You won't have so many sore throats after your tonsils are removed." ■ 2. "The doctor will put you to sleep so you don't feel anything." ■ 3. "Show me how to give the doll an I.V." ■ 4. "When it is done you will get to see your mommy and get a Popsicle."

4. When preparing a child for a procedure the nurse should use neutral words, focus on sensory experiences, and emphasize the positive aspects at the end. Being reunited with parents and having an ice pop would be considered pleasurable events. Children this age fear bodily harm. To reduced anxiety, the nurse should use the word "fixed" instead of "removed" to describe what is being done to the tonsils. Using the terms "put to sleep" and "I.V." may be threatening. Additionally, directing a play experience to focus on I.V. insertion may be counterproductive as the child may have little recollection of this aspect of the procedure.

The physician orders an intravenous infusion of 5% dextrose in 0.25 normal saline to be infused at 2 mL/kg/hour in an infant who weighs 9 lb. How many milliliters per hour of the solution should the nurse infuse? Round to one decimal. ________________________ mL/hour

8.2 mL/hour 2.2 lb/kg = 9 lb/X kg X = 9 ÷ 2.2 X = 4.09 kg, rounded to 4.1 kg 4.1 kg × 2 mL/kg = 8.2 mL/hour