N483 Exam 1 HESIs

Which education would the nurse provide a group of parents about preventing Reye syndrome in their preschool-age children? a. "Do not give aspirin when your child has a fever." b. "Restrict your child's carb intake when there are signs of a cold." c. "Begin sponge bathing with cold water if your child experiences high fever." d. "You may want to have your child immunized with a recently developed vaccine."

a. "Do not give aspirin when your child has a fever."

Which pain scale is used to measure the intensity of pain in preschoolers? a. FACES scale b. visual analog scale c. numerical rating scale d. verbal descriptor scale

a. FACES scale

A child who has undergone surgery to revise a ventriculoperitoneal shunt is to be discharged. For which behavior would the nurse advise the parent to call the clinic or seek immediate care? a. appears drowsy after a nap and becomes irritable b. talks incessantly regardless of the presence of others c. becomes angry when frustrated and has a temper tantrum d. starts arguments with playmates, claiming that their toys are the child's

a. appears drowsy after a nap and becomes irritable

A 3 month old infant with a 3 day hx of diarrhea has an ABG drawn. Which acid-base balance would the nurse suspect? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

a. metabolic acidosis

Which skin care parent education would the nurse provide to the parents of an infant with spina bifida? a. Diapers should be changed at least every 4 hrs b. Frequent diaper changes with cleansing are needed c. Medicated ointment should be applied 6 times per day d. Powder may be used in the perineal area when it becomes wet.

b. Frequent diaper changes with cleansing are needed

Which education would the nurse provide the parent of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus? a. The prognosis is excellent and the valve is permanent. b. The shunt may need to be replaced as the child grows older. c. If any brain damage has occurred, it is irreversible even after the first year of life. d. Hydrocephalus usually is self-limiting by 2 yrs of age, and then the shunt is removed.

b. The shunt may need to be replaced as the child grows older.

Which nursing assessment finding indicates dehydration in the infant? a. flat anterior fontanel b. decreased urine output c. warm skin temp. d. slow, labored respirations

b. decreased urine output

A protruding tongue and a crease that transverses the entire width of each palm are characteristic of which congenital condition? a. hypothyroidism b. down syndrome c. turner syndrome d. fetal alcohol syndrom

b. down syndrome

Which components would the nurse encourage the parent to increase in the diet of a 4 year old child with spina bifida who spends many hours in a wheelchair? SATA. a. fat b. fiber c. protein d. calories e. carbs

b. fiber c. protein

When assessing a toddler with ASD, which characteristic findings or behaviors would the nurse expect? SATA. a. the desire to hug the nurse b. flat, blank facial expression c. laughing when pulse is taken d. inability to maintain eye contact e. enjoys climbing on stairs and furniture

b. flat, blank facial expression c. laughing when pulse is taken d. inability to maintain eye contact

Which finding for a 6 month old infant would necessitate further developmental assessment by the nurse? a. imitating sounds and gestures b. showing little response when an activity is stopped c. searching for a toy that has fallen on the ground d. exhibiting symptoms of separation anxiety when the parent leaves the room

b. showing little response when an activity is stopped

Which physical assessment finding would the nurse expect in a 9 month old infant with severe dehydration? a. frothy stools b. weak rapid pulse c. pale copious urine d. bulging anterior fontanel

b. weak rapid pulse

The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve site. What statement indicates that they understand the teaching? a. "We'll place her in the position that seems comfortable." b. "The flat left side-lying position is the safest position for our baby." c. "We should place her on her back with a small support under the neck." d. "The right side-lying position with the head supported is the best position."

b. "The flat left side-lying position is the safest position for our baby."

Which parental statement would the nurse recognize as signs that an infant may need to be evaluated for cerebral palsy? SATA. a. "My baby doesn't make eye contact." b. "My baby seems to have a voracious appetite." c. "My baby was able to turn from front to back by 2 months of age." d. "I've noticed that this baby clings to me more than other children of the same age." e. "All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone."

c. "My baby was able to turn from front to back by 2 months of age." e. "All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone."

What does a nurse recognize as the most serious complication of meningitis in young children? a. Epilepsy b. Blindness c. Peripheral circulatory collapse d. Communicating hydrocephalus

c. Peripheral circulatory collapse

Which parent education would the nurse provide the parent caring for their infant with cerebral palsy? a. Focus on cognitive rather than motor skills b. Maintain immobility of the limbs with splints. c. Preserve muscle tone to prevent joint contractures. d. Continue to offera special formula to limit gagging.

c. Preserve muscle tone to prevent joint contractures.

The nurse must restart a peripheral IV infusion on a child. Which would the nurse do to promote the child's sense of security? a. Inform the child that it will feel like a bee sting. b. Ask the child if the parent should leave the room. c. Take the child to the treatment room for the procedure. d. Tell the child that it is important to have a new IV started.

c. Take the child to the treatment room for the procedure.

A toddler with a repaired myelomeningocele has urinary incontinence and some flaccidity of the lower extremities. What should the nurse teach the parents? a. An ileal bladder will be necessary once the child is of school age. b. An indwelling catheter offers the best hope for bladder management. c. The child will probably require a program of intermittent straight catheterization. d. The child will have to wear diapers for many years because bladder training is a slow process.

c. The child will probably require a program of intermittent straight catheterization.

Which education would the nurse provide the parent of an infant with cerebral palsy to support setting care goals? a. Cognitive impairments require special education b. Progressive deterioration requires future institutionalization c. Unknown extent of the disability requires continual adjustments d. Diminished immune responses require protection from infection

c. Unknown extent of the disability requires continual adjustments

Which assessment finding would the nurse recognize as common in infants with Down syndrome? a. bulging fontanels b. stiff lower extremities c. abnormal heart sounds d. unusual pupillary reactions

c. abnormal heart sounds

Which method is best for the nurse to assess an infant's response to oral rehydration therapy? a. noting the color of the stools b. assessing skin turgor frequently c. obtaining the weight at the same time every day d. measuring the abdominal girth over the umbilicus

c. obtaining the weight at the same time every day

The nurse on the peds unit is observing the developmental skills of several 2 yr old children in the playroom. Which child would the nurse continue to evaluate? a. one who cannot stand on one foot b. one who builds a tower of seven blocks c. one who exhibits echolalia when speaking d. one who colors outside the lines of a picture

c. one who exhibits echolalia when speaking

Which is the most important safety measure for the nurse to institute immediately when a 2 year child has a seizure? a. monitoring the child's VS b. padding the side rails of the toddler's crib c. placing the child in the side-lying position d. bringing suction equipment to the bedside

c. placing the child in the side-lying position

Which action would the nurse take after finding a child having a tonic-clonic seizure? a. applying restraints b. administering oxygen c. protecting the child from self-injury d. inserting a plastic airway in the child's mouth

c. protecting the child from self-injury

The nurse is planning to teach ADLs to a developmentally disabled 3 yr old child. Which activity would the nurse plan to teach to the child first? a. dressing b. toileting c. self-feeding d. hair combing

c. self-feeding

The HCP has written a prescription for potassium chloride to be added to the IV fluids of a 6 month old infant with dehydration who weights 15.5 lb (7 kg). Which assessment finding would signal the nurse to questions this prescription? a. Incessant crying b. inadequate tissue turgor c. urinary output of 4 mL over 2 hrs d. oral fluid intake of 12 mL over 8 hrs

c. urinary output of 4 mL over 2 hrs

Why is it essential for the nurse to obtain the height and weight of a severely dehydrated toddler? a. The extent of dehydration is based on these measurements. b. These measurements are used as the baseline for future growth. c. The management of dietary needs is based on height and weight. d. The values are used to calculate fluid replacement and med dosages.

d. The values are used to calculate fluid replacement and med dosages.

Which pain scale would the nurse use when assessing a 4 year old child? a. CRIES b. FLACC c. Numerical d. Wong-Baker

d. Wong-Baker

Which factor would the nurse consider when preparing a 2 yr old child for admission to the hospital for surgery? a. gratification of the child's wishes b. previous experience of being hospitalized c. avoiding leaving the child with strangers d. assurance of continued parental affection

d. assurance of continued parental affection

Which assessment would the nurse perform to monitor for a major complication in an infant after surgery to correct a myelomeningocele? a. daily weights b. fluid output every 8 hrs c. BP every 12 hrs d. daily head circumference measurements

d. daily head circumference measurements

A 15 yr old adolescent with Down syndrome is scheduled for surgery. The parent informs the nurse that their child has a mental age of 8. At which age level would the nurse prepare the child's pre-op teaching plan? a. adult, for the parent to understand b. specific age, as ordered by the HCP c. adolescent, because this is the child's chronological age d. school-age, because this is the child's developmental age

d. school-age, because this is the child's developmental age

Which action would the nurse include in the plan of care for a 3 month old infant with a newly placed ventriculoperitoneal shunt? a. keeping the infant in the prone position b. applying moist sterile dressings to the incision c. watching for signs of cerebrospinal fluid leakage d. teaching the parents signs of increased intracranial pressure

d. teaching the parents signs of increased intracranial pressure

Which behavior would the nurse recognize as a sign of a hearing deficit in a 7 month old infant? a. the infant does not always turn the head when called by name b. the mother says that the infant is unable to learn the word "mama" c. the infant fails to demonstrate the Moro reflex in response to handclapping d. the mother says the infant stopped making verbal sounds about a month ago

d. the mother says the infant stopped making verbal sounds about a month ago

A 3.5 yr old child is admitted to the hospital for an appendectomy. Which strategy would the nurse use to prepare the child for the hospital experience? a. a diagram b. puppet play c. a storybook d. therapeutic play

d. therapeutic play

Which assessment would the nurse perform to assess the magnitude of an infant's fluid loss from diarrhea? a. tissue turgor b. hematocrit value c. moistness of mucous membranes d. weight compared with prior weight

d. weight compared with prior weight