LV3 EXAM 1 Class Review

The triage nurse is assessing an unvaccinated 4 month old infant for fever, irritability, and open-mouthed drooling. After the infant is successfully treated for epiglottitis, the parents wonder how this could have been avoided. Which response by the nurse would be MOST APPROPRIATE? 1. its impossible to know for sure what could have caused this episode 2. most cases of epiglottitis are preventable by standard immunizations 3. we are still waiting for the formal report from the microbiology laboratory 4. there is nothing you could have done; the most important thing is that your child is safe now

2. epiglottitis is rarely seen in vaccinated children, it is caused by Hemophilus influenza

The nurse is talking with the parent of an adolescent client who has infectious mononucleosis. Which of the following statements by the parent would require follow-up? 1. my child may take acetaminophen for fever or discomfort 2. my child will need to complete a full course of antibiotic therapy 3. my child should avoid participating in contact sports for at least 3 weeks 4. my child may continue to experience fatigue after the fever and sore throat subside

2. mononucleosis is caused by Epstein-Barr Virus, it does not need an antibiotic

the nurse assesses a child who has been treated for an acute asthma exacerbation. Which client assessment is the best indicator that treatment has been effective? 1. episodes of spasmodic coughing have decreased 2. no wheezes are audible on chest auscultation 3. oxygen saturation has increased from 88%-93% 4. peak expiratory flow rate has dropped from 212 L/min to 127 L/min

3 oxygen saturation is the best indicator of treatment effectiveness as it reflects gas exchange.

The nurse is talking with the parent of a 3-year-old client. The parent reports that the client has recurrent nighttime wheezing and a cough, which is occasionally productive of frothy sputum. Which of the following actions should the nurse take? 1. prepare the client for a tuberculin skin test 2. ask the client's parent about exposure to environmental triggers. 3. assess the client for the presence of a butterfly rash 4. check the client's medical record for a history of wheat intolerance

2. Asthma is an obstructive lung disease characterized by hypereactive airways and chronic airway inflammation. Clinical manifestations include chest tightness, wheezing, cough, dyspnea, commonly occur at night or in the early morning

The nurse is caring for a 12 month old client. Which of the following would be expected age-related findings? SATA birth weight has tripled cruises along furniture kicks a ball searches for hidden objects speaks in two word phrases

1,2,4

The nurse is caring for a child who has had a tonsillectomy. Which of the following are appropriate nursing interventions? SATA 1. anticipate ear pain and give acetaminophen as needed 2. educate parents to expect bad breath postop 3. encourage to drink cold liquids through straw 4. notify health care provider about frequent increased swallowing 5. use an oral suction device to remove secretions

1,2,4

The nurse is caring for a 12-month-old client who is HIV-positive and severely immunosuppressed. Which of the following scheduled immunizations should the nurse anticipate administering to the client? SATA 1. haemophilus influenzae type b 2. hepatitis A 3. measles, mumps, rubella 4. pneumococcal conjugate vaccine 5. varicella

1,2,4 live vaccines are contraindicated

The parents of a 2 year old client ask how they can help their child cope with hospitalization. Which of the following suggestions should the nurse give the parents? SATA 1. follow as many home routines as possible 2. organize a visit from a playgroup friend 3. sleep in the child's hospital room at night 4. take child on regular visits to the playroom 5. tell the child they did not cause the illness

1,3,4 hospitalization for toddlers is particularly difficult due to separation anxiety and a limited ability to cope with stress. toddlers thrive on home rituals and routines, which bring stability and reassurance.

Which pediatric respiratory presentation in the emergency department is a priority for nursing care? 1. client with an acute asthma exacerbation but no wheezing 2. client with bronchiolitis with low-grade fever and wheezing 3. client with runny nose with seal-like barking cough 4. cystic fibrosis with fever and yellow sputum

1. ACUTE ASTHMA EXACERBATION, 'silent chest" is an ominous sign and an EMERGENCY priority in this situation, the onset of wheezing will be an improvement as it shows that air is now moving in the lungs

a 9 year old child has terminal cancer, but the parents do not want the child to know the prognosis. over the past few days, the child has started asking questions such as what dying is like and whether the child will die. What action by the nurse is most appropriate? 1. encourage the parents to openly discuss the child's questions 2. notify the health care provider about the child's questions 3. remind the child that everyone is trying to help the child get better 4. tell the child to ask the parents these questions about death

1. encourage the parents to openly discuss the child's questions School age children ( age 6-12) understand the concept of death and may sense impending death before their health deteriorates; these children may demonstrate their fear of death through uncooperative behavior. Terminally ill children need accurate information about their treatment and prognosis. Parents should be involved in open communication with the child from the beginning of treatment, before they have to answer difficult questions once the child's health declines

the nurse is conducting a well-child check up on a 30 month old child. What assessment finding should be reported to the primary health care provider? 1. communicates in single word sentences 2. follows two step directions 3. imitates others bytalking on the phone 4. prefers to play next to, not with, others

1. is concerning, by 2 they should be using 2 word sentences, deficits are often caused by underlying conditions (recurring ear infections, autism spectrum disorder)

The nurse prepares a 7 year old client for an influenza injection. The nurse explains that the client will receive "medicine under the skin," and the client is visibly anxious. Which nursing intervention is appropriate? 1. ask the child to count to 10 during injection 2. ask the parent to hold the child's arms tightly 3. explain to the child that the injection will not hurt 4. keep the injection needle out of the child's view

1. school age children develop concrete thought and may fear a loss of control, counting aloud and deep breathing are good coping mechanisms

a nurse receives report on a group of clients. Which client should the nurse assess first? 1. a preschool age child with a harsh cough, expiratory wheezes, and mild intercostal retractions 2. a toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak 3. a toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air 4. an infant with an axillary temperature of 100.1 F who is tugging at the left ear

2. aspiration of a foreign body occurs most often in the toddler age group. can be life threatening, manifestations include: choking, gagging, cyanosis, inability to speak when object is lodged in the larynx

A 6 month old client has been diagnosed with cystic fibrosis. Which of the following would be appropriate for the registered nurse to teach to the parents? 1. monitor for and report development of a 'white pupil' 2. perform manual chest physiotherapy 3. place child in knee-chest position during hyper cyanotic episode 4. provide a low-calorie diet to prevent obesity

2. chest physiotherapy is used to help with thickened mucous

The clinic nurse assesses an 8 year old client who reports a sore throat and has a bright red, pruritic rash on the chest that feels like fine bumps and looks like a sunburn. Which diagnostic tool does the nurse anticipate the health care provider will prescribe? 1. allergy skin test 2. complete blood count 3. rapid streptococcal antigen test 4. skin biopsy

3. group A streptococcal infection, characterized by distinctive red rash. begins on neck and chest and spreads to the extremities, resembles a bad sunburn, sandpaper like

The nurse is assessing a 7 month client during a well-child visit. Which assessment finding should the nurse report to the health care provider? 1. infant laughs and makes some consonant sound but has not spoken any words 2. infant was gaining 5 oz per week at age 6 months and is now gaining 3 oz per week 3. infants head stays behind the shoulders when raised from a supine to sitting position 4. infants posterior fontanel is not palpable when preforming assessment of the head

3. head lag should not appear after 4 months of age, if it remains after 6 months it is an abnormal finding

The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse provide to the caregivers before they leave the clinic? 1. call the office if the toddlers temp reaches 100 F (37.7 C) 2. fussiness and anorexia are common for 1 week after immuniztions 3. redness at the injection sites and a mild fever are common 4. the toddler's activity level should be restricted for 24 hours

3. redness at the injection site is common adverse effect including a mild fever and soreness and redness

the school nurse is assessing a 10-year-old client with asthma who has a mild cough. Which of the following actions should the nurse take first? 1. notify the client's parent 2. remind the client how to avoid triggers 3. check the client's peak expiratory flow reading 4. instruct the client to avoid participating in physical education class

3. symptoms of asthma exacerbation include wheezing, chest tightness, dyspnea, cough, retractions, before implementing interventions the nurse should assess the peak expiratory flow reading to determine the severity of current symptoms

The nurse in the emergency department is caring for a 3 year old client who has sudden-onset dyspnea, high fever, and irritability. The client is drooling while leaning forward in a sitting position. Which of the following actions should the nurse take? 1. prepare the client for a thoracentesis 2. administer nebulized racemic ephinephrine 3. prepare the client for endotracheal intubation 4. inspect the clients throat using a tongue depressor

3. this is an emergency situation

Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination? 1. Haemophilus influenza type b vaccine for client allergic to penicillin. 2. Hepatitis A vaccine for a client with a "cold" and temperature of 99.0 F (37.2 C). 3. Pneumococcal vaccine for client with local swelling after last immunization. 4. Varicella-zoster vaccine for client recently diagnosed with leukemia.

4 immunocompromised should not receive live vaccines (varicella, measles, mumps, rubella, rotavirus, yellow fever)

The nurse in a clinic is caring for an 8 month old client with a new diagnosis of bronchiolitis due to respiratory syncytial virus. Which of the following instructions should the nurse provide to the parent? 1. administration of cough suppressant and an antihistamine 2. prophylactic treatment of family members 3. temporary cessation of breastfeeding 4. use of saline drops and a bulb syringe to suction nares

4. bronchiolitis is self-limited and supportive care is the mainstay of treatment. This intervention thins and removes secretions, making it easier for the child to breathe, sleep, and eat.

The parent of an 8 year old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what? 1. react anxiously to altered daily routines 2. realize that death eventually effects everyone 3. think about the spiritual or religious aspects of death 4. understand that death is permanent but can be curious about it

4. it is very important for parents to be honest during discussions about death, provide guidance to reduce fears, talk about lost loved one.

Ganciclovir

Antiviral inhibits replication of viral DNA treats Herpes family CMV in immunodeficient patiens including HIV pts. Eye drops PO Take with food

This distinctive rash is an indication of Cytomegalovirus?

Blueberry rash

Salmeterol

Bronchodilator-andrenergic agonist. Long-acting relaxes smooth muscle treats asthma, COPD SE: HA, dizziness, nasal congestion, sleep disturbances, tremors, palpitations, tachycardia, hyperglycemia, pain teach patient to rinse mouth after using

developmental milestones 12 months?

moves to standing position may walk with help or take independent steps uses 2 finger pincer grasp identifies caregivers by name searches for hidden objects uses nonverbal gestures (wave bye bye)

Methylphenidate

CNS stimulant for ADHD SE: irregular HR, tachycardia, palpitations, hypertension, trouble sleeping, anorexia, weight loss, dry mouth, N/V, stomach pain, HA, dizziness, decreased growth drug free "holidays" reduce dependence and assess need for medication

Macules start on trunk, spreading to face and extremities

Chicken Pox (Varicella)

inflammation of the parotoid glands is present with?

mumps

epinephrine

nonselective adrenergic agonist contracts smooth muscle in vascular and intestinal systems, pupillary dilator muscles. Bronchodilation SE: jittery, palpitations, tachycardia, dizziness, HA Treats: Anaphylaxis

what virus causes mononucleosis?

Epstein-Barr virus

Rash appears in face like a "slapped cheek" and progresses to trunk and extremities, spreading proximal to distal over one week

Erythema Infectiosum (fifth's disease)

Diphenhydramine

H1 receptor antagonist, antihistamine Treats allergic reactions including rhinorrhea, watery eyes. anticholinergic side effects

The parent of a 2 YO tells the nurse at the well-child clinic, "I am concerned because my child does not like to be cuddles, does not respond when called by name, and does not make eye contact when being fed." What is the PRIORITY question for the nurse to ask when completing the health history? "How would you describe your child's speech?" "is your child potty trained?" "what are your childs favorite food?" "what kind of toys does your child like to play with?"

How would you describe your child's speech a 2 year old should be using 2-word phrases by age 2

In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is most important for the nurse to take which of these actions? 1. assess the client for intercostal retractions 2. assess the client's blood pressure in both arms 3. auscultate the client's lung sounds 4. observe the color of the client's fingernail beds

MOST IMPORTANT is 3. airway is the priority

blueberry muffin baby rash starts on face, pink

Rubella

what infectious disease is noted with Koplik spots 2 days before rash and the rash begins on the face and spreads down (cephlacaudal)?

Rubeola (measles)

Beclomethasone

anti-inflammatory-Corticosteroid decreases mucous production and edema in airway used to prevent asthma attacks NOT to treat acute asthma attack SE: hoarseness, dry mouth, change in taste, oral candidiasis

Montelukast

anti-inflammatory-leukotriene modifier inhibits inflammatory response, decreasing edema, inflammation and bronchoconstriction. **ONLY drug in its class approved for peds prevention of exercise-induced bronchospasm, take 2 HOURS BEFORE

Beliefs bout death by age:

birth to 2: no understanding 3-5: death is reversible; magical/fantasy thinking 6-9: understands the concrete finality of death. Difficulty in perceiving their own death; may be preoccupied with the medical or physical aspects of dying 10-12: death is final and eventually everyone is affected adolescence: views death at an adult level. spiritual and religion aspects of death

albuterol

bronchodilator-andrenergic agonist relaxes smooth muscle, first line to treat bronchospasms treats Asthma and Anaphylaxis SE: palpitations, tachycardia, HA, throat irritations, tremor, anxiety, insomnia, dry mouth. teach patient to rinse mouth after using

Ipratropium

bronchodilator-anticholinergic blocks parasympathetic nervous system resulting in bronchodilation. Slower onset of action with longer lasting effects Treats Asthma SE: dry cough, dry nasal passage teach to rinse mouth after using

The palliative care nurse is assessing a pediatric client who does not respond to verbal stimuli. Which of the following findings may indicate that the client is experiencing pain? SATA 1. moaning/ whimpering 2. neutral facial expression 3. frequent shifting of positions 4. knees bent up near the chest 5. closed eyes and a clenched jaw

everything except 2. remember FLACC scale (facial expression, leg movement, activity, cry, consolability) (0= normal, 1= mild, 2 = worst)

developmental milestones 4 months?

gains head control when held holds objects placed in hand makes cooing sounds turns head to caregivers voice tracks caregiver with eyes

developmental milestones 2 months?

hold up head when prone opens/ closes hands startles to loud noises smiles in response to smiling and talking

30 month milestones?

jumps removes clothes turns pages says over 50 words follows 2 step command knows 1 color

developmental milestones 9 months?

moves to sitting position moves objects between hands babbles may have stranger anxiety

The nurse is performing a well-child assessment on a sleeping 2 month old client. Organize the assessment in the correct order based on the developmental age of the client. All options must be used 1. assess pupillary response 2. auscultate heart and lungs 3. elicit moro reflex 4. observe skin color and respiratory pattern 5. palpate fontanelles and abdomen

observe skin color and resp pattern auscultate heart and lungs palpate fontanelles and abdomen assess pupillary response elicit moro reflex

What developmental milestones should a 1 year old have accomplished?

pulls to stand cruises pincer grasp says mama, dada understand NO plays "pat-a-cake" looks for hidden objects

developmental milestones 6 months?

rolls from prone to supine later progresses to rolling sits with support puts objects in mouth begins to laugh makes some consonant sounds becomes calmed by caregiver's voice

2 years milestones?

runs kicks ball walks up stairs uses spoon says 2 word phrases knows 2 body parts parallel play

Nystatin

superficial antifungal Treats candidiasis, skin, oral, vaginal, intestinal monitor for allergic reaction

What developmental milestones should a 15 month have accomplished?

takes a few steps stacks 2 blocks says 1 or 2 words plus mama, dada follows 1 step commands with gesture points to get something shows affection

18 months milestone?

walks easily climbs on/off chair scribbles feeds with fingers says more than 3 words follows 1 step command without gesture imitates

3 years

walks up stairs alternating feet rides tricycle dresses with help uses form copies circle says more than 3 word sentences speech 75% intelligible knows age/sex plays with other children