NCLEX Child Health

The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder?

Sulfisoxazole

The nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity should the nurse suggest that the child can safely participate in with peers?

Swimming

The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation may be indicative of this condition?

The child consistently tilts his or her head to see.

A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report?

The child's cervical spine

An infant with heart failure (HF) is receiving diuretic therapy, and the nurse is closely monitoring the intake and output. Which is the best method for the nurse to use to monitor the urine output?

Weighing the diapers

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child?

When drawing blood for electrolyte levels

The nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child?

Using pillows to elevate the head and shoulders

The nurse reinforces home-care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?

"I will avoid immunizations and dental hygiene treatments for my child."

The nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications?

"If my baby has a high-pitched cry, I should call the health care provider."

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement by a parent indicates the need for further teaching?

"If my child vomits after medication administration, I will repeat the dose."

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching?

"It is okay to share towels and washcloths."

The nurse is assisting in collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching?

"Our child sleeps in our bedroom at night."

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?

A weight gain of 1 lb in 1 day

The nurse is assisting to develop a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

Time the seizure. Stay with the child. Move furniture away from the child.

The nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which is the priority nursing action?

Notify the registered nurse.

The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should the nurse take?

Notify the registered nurse.

The nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder?

A child of Mediterranean descent

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take?

Document the findings.

The nurse is checking the capillary refill of a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger, and it returns to its original color in 2 seconds. Which action should be taken by the nurse?

Document the findings.

A child with a brain tumor returns from the recovery room following "debulking" of the tumor. The nurse assigned to care for the child monitors the child for brainstem involvement. Which sign would indicate that brainstem involvement occurred during the surgical procedure?

Elevated temperature

The nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. Which action would best assist in determining the causes of the seizure?

Obtaining a history regarding factors that may occur before the seizure activity

The nurse is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should instruct the mother to do which?

Pad crib rails and table corners.

The nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, which is a priority intervention?

Palpating the anterior fontanel

A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of which condition?

Peripheral hypoxia

A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. To meet these goals, which action should the nurse take when working with the child?

Place the child on a wheeled scooter board.

A child has a basilar skull fracture. Which health care provider's prescription should the nurse question?

Suction via the nasotracheal route as needed.

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF?

Tachycardia

A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding should be reported to the registered nurse immediately?

Temperature 100.9° F

The nurse is reinforcing home care instructions to the mother of a child with bacterial conjunctivitis. Which instruction should the nurse give the mother?

That the child's towels and washcloths should not be used by other members of the household

The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing Down syndrome?

The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).

Which finding would indicate that a child had a tonic-clonic seizure during the night?

Blood on the pillow

A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need for further research of this disorder?

"This disease is twice as likely to occur in boys rather than girls."

Which represents a primary characteristic of an autism spectrum disorder?

Lack of social interaction and awareness

A child is diagnosed with Reye's syndrome. The nurse assists to develop a nursing care plan for the child and should include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

"Did the child have a sore throat or a fever within the past 2 months?"

The nurse reinforces instructions to parents regarding the methods that will decrease the risk of recurrent otitis media in infants. Which should the nurse include in the instructions?

"Feed the infant in an upright position."

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother?

"Have the child perform simple isometric exercises during this time."

The nurse has reinforced home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement by the mother indicates the need for further teaching?

"I can apply lotion or powder to the incision if it is itchy."

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. After an x-ray, it is determined that the child has a fractured arm, and a plaster cast is applied. The nurse reinforces instructions to the mother regarding cast care for the child. Which statement by the mother indicates the need for further teaching?

"I can use lotion or powder around the cast edges to relieve itching."

The nurse reinforces discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which statement by the mother indicates a need for further teaching?

"I need to be sure my child uses soft tissues to blow his nose."

The nurse provides information to the mother of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the mother indicates the need for further teaching regarding this disorder?

"I need to bring my child back to the clinic in 1 month for a new cast."

The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching?

"I need to give frequent, small, nutritious meals if my child starts to vomit."

The nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The child needs further teaching if which statement is made?

"This brace will correct my curve."

A child is to be admitted to the orthopedic unit following a Harrington rod insertion for the treatment of scoliosis. The nurse is assisting in preparing a plan of care for the child. The nurse plans to monitor which priority item in the immediate postoperative period?

Capillary refill, sensation, and motion in all extremities

A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor would the nurse expect to find documented in the child's record?

Elevated vanillylmandelic acid (VMA) levels in the urine

The nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate?

Exercise intolerance

The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period?

Maintain moisture of the normal saline dressing on the gibbus area.

Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy?

Maximize the child's assets and minimize the limitations.

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?

Nausea

The nurse assists in developing a plan of care for the child with meningitis. Which should be the priority client problem for a child with a meningitis diagnosis?

Neurological dysfunction

The nurse is assigned to care for a child after a spinal fusion for the treatment of scoliosis. The child complains of abdominal discomfort and begins to have episodes of vomiting. On data collection, the nurse notes abdominal distention. Which action should the nurse take?

Notify the registered nurse (RN).

A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action?

Notify the registered nurse of the finding.

A health care provider prescribes "eye patching" for a child with strabismus of the right eye. The nurse reinforces instructions to the mother to use which procedure for eye patching?

Place the patch on the left eye.

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?

Placing the bed linens on the traction ropes

The mother of a child arrives at the clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and a culture is sent to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, which should require further investigation?

Possible sexual abuse

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child asks the nurse why the child needs the medication. The nurse correctly responds that which is the purpose of this medication?

Provides adequate oxygen saturation and maintains cardiac output

The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which is the priority nursing intervention?

Providing a quiet atmosphere with dimmed lights

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which should be included in the plan?

Pull the earlobe down and back before instilling the eardrops.

A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease?

Reticulocyte count

The nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother?

The synthetic cast allows for greater mobility than a plaster cast.

The nurse is assigned to care for an infant with a diagnosis of tricuspid atresia. The nurse plans care, knowing which is true regarding this diagnosis?

There is no communication from the right atrium to the right ventricle.

The nursing student is asked to discuss the topic of clubfoot at a clinical conference. The student plans to tell the group which fact about clubfoot?

It is a congenital anomaly.

The nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?

Conjunctival hyperemia

The nurse, caring for a child with aplastic anemia, is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 cells/mm3 and a platelet count of 20,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?

Encourage quiet play activities.

A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which should the nurse instruct the mother to do?

Give the child acetaminophen (Tylenol) for the discomfort as per discharge instructions.

The nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor which fact about hemophilia?

Hemophilia A results from deficiency of factor VIII.

The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching?

I will apply lotion under the brace to prevent skin breakdown."

Antibiotics are prescribed for a child following a myringotomy with insertion of tympanostomy tubes, and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement made by a parent would indicate that the instructions were understood?

"We will administer the antibiotics until they are gone."

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?

A chronic disability characterized by impaired muscle movement and posture

The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic?

A greater risk of infection than a simple fracture

A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about the causes of this illness. The nurse responds, knowing that which is an unassociated risk factor related to otitis media?

A history of urinary tract infections

The nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which items are essential for the nurse to place at the bedside?

A suction apparatus and oxygen

Acetylsalicylic acid (aspirin) is prescribed for a child with rheumatic fever (RF). The nurse should question this prescription if the child had documented evidence of which condition?

A viral infection

The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study should assist in confirming the diagnosis of RF?

Antistreptolysin O titer

An infant is seen in a clinic and is diagnosed with unilateral hip dysplasia. Which finding is associated with this condition?

Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery should the nurse explain to the mother?

Before the child is 3 years old

The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?

Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.

The nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which would be the priority action in the plan of care for this child on return from the procedure?

Check circulation in the feet.

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease?

It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.

The nurse, reinforcing home care instructions, prepares a list for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.

Keep small toys and sharp objects away from the cast. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.

The nurse should implement which in the care of a child who is having a seizure? Select all that apply.

Loosen clothing around the child's neck. Stay with the child. Time the seizure.

Laboratory studies are performed on a child suspected of iron deficiency anemia. The nurse reviews the laboratory results, knowing that which finding indicates this type of anemia?

RBCs that are microcytic and hypochromic

The nurse is assisting a health care provider (HCP) during the examination of an infant with hip dysplasia. The HCP performs the Ortolani maneuver. Which best describes the reason for performing the Ortolani maneuver?

Reducing the dislocated femoral head back into the acetabulum

The nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Restrict fluid intake. Administer meperidine (Demerol) 25 mg for pain.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On data collection of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs

The nurse is developing a plan of care for a child with autism. The nurse should identify which priority problem for this child?

Risk for injury

The pediatric nursing instructor asks a nursing student to describe the cause of the symptoms that occur in sickle cell disease. Which is the correct response by the nursing student?

Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow.

A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a course of chemotherapy, it is decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which statement made by the nurse will best assist in alleviating the child's fear?

This aching and cramping is normal and temporary and will subside.

The mother of a child who had a myringotomy with insertion of tympanostomy tubes calls the nurse and tells the nurse that the "tubes" fell out. The nurse should make which response to the mother?

"This is not an emergency. I will speak to the health care provider and call you right back."

When checking a child's trochlear nerve function, the nurse should perform which data collection technique?

Have the child look down and in.

The nurse is caring for a pediatric client in skin traction. To prevent skin breakdown, which nursing intervention for this child is best?

Stimulate circulation with gentle massage over pressure areas.

The nurse is reinforcing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which instruction?

"Call the health care provider if the infant has a high-pitched cry."

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?

"Has the child complained of a sore throat within the past few months?"

A client has been prescribed valproic acid (Depakene) for the treatment of generalized seizures, and the nurse reinforces instructions to the child about the potential side effects of the medication. Which statement by the client would indicate a need for further teaching?

"I am so glad that I won't lose any of my hair. I was worried what my friends would think."

The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness?

"I can remove the harness to bathe my infant."

The nurse is reinforcing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which statement made by the mother indicates an understanding of the use of this medication?

"I need to wash the sites gently before I apply the medication."

When reinforcing instructions to the caregiver of a child about cast care, the nurse anticipates the need for further teaching when the caregiver makes which statement?

"I will allow my child to put cotton balls inside the cast to relieve pressure."

The mother of a 5-year-old child brings the child to the emergency department and tells the nurse that the child fell. A fracture is suspected and an x-ray is taken. The results indicate that the child has a comminuted fracture of the right humerus. The mother asks the nurse to describe this type of fracture, and the nurse draws a picture for the mother. Which picture identifies this type of fracture? Refer to figure.

2

The parents of a child with sickle cell disease are both carriers of the gene and ask the nurse how likely it is that they will have another biological child with the disease. What is the correct percent? Fill in the blank.

25 %

The nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which priority item at the newborn's bedside?

A bottle of sterile normal saline

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. Which action should the nurse take?

Place the infant in a knee-chest position.

A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the health care provider regarding necessary follow-up because this infection can be associated with which finding?

Possible sexual abuse

The nurse in a health care provider's office receives a telephone call from the mother of a child who tells the nurse that the child was just stung by a bee. The mother asks the nurse for instructions regarding removal of the stinger. Which instruction should the nurse reinforce to the mother?

Remove the stinger by carefully scraping it out horizontally.

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met?

Safety with activities

The nurse is reinforcing information to parents regarding the signs of meningitis. The nurse informs the parents that which are the primary signs/symptoms of meningitis?

Severe headache and neck stiffness

The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for which complication?

Signs of increased intracranial pressure

A camp nurse is reinforcing instructions to the parents of the children who are attending a daytime camp for the summer. The nurse instructs the parents to check their child daily for the presence of tick bites and tells the parents that if a tick is found to do which action first?

Suffocate the tick with a substance such as nail polish.

The licensed practical nurse (LPN) is assisting in the admission of a child with suspected sickle cell crisis because of which signs/symptoms noted in this client? Select all that apply.

Swollen knee joint Pulse,120 beats per minute Peripheral oxygen level of 89% Pain rated as a 6 on a scale of 1 to 10

The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis?

Blood cultures

The nurse is caring for a child with a platelet disorder and should expect which prescriptions from the health care provider? Select all that apply.

Observe for bleeding. Encourage the child to rest. Assist the registered nurse (RN) with blood transfusions.

The nurse is providing discharge teaching regarding skin care to a new mother of a 2-day-old infant. Which statements by the mother demonstrate an understanding of how to care for the infant's skin? Select all that apply.

"We will apply ointments containing zinc oxide to the baby's bottom to prevent diaper rash." "To prevent diaper rash, we will change our baby's diaper as soon as he has pooped or peed."

The nurse reinforces home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further teaching?

"When I'm feeling better, I'm returning to the soccer team."

The 16-year-old client presents to the dermatology clinic with a diagnosis of acne vulgaris. The client says to the nurse, "I don't know what else to do! I wash my face twice a day. I wear noncomedogenic makeup. I shower after I work out. I guess I'm just going to have acne on my face forever." Which responses by the nurse would be most appropriate? Select all that apply.

"You feel like there's nothing else you can do to cure your acne." "You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating."

A 5-week-old infant is brought to the well-baby clinic by the mother because the mother has noted white patches in the infant's mouth. Following examination, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breast-feeding the infant and asks the nurse if breast-feeding can be continued. Which response is appropriate?

"You should bottle-feed the infant for 1 week and then resume breast-feeding."

The nurse is attempting to ensure the parent is able to safely administer at home the prescribed ear drops to the 2-year-old client. The parent demonstrates understanding of the teaching by listing the steps of the process in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

1-Warm the bottle of ear drops by rolling it in the palms of the hands to help decrease discomfort. 2-Have the child lie on his or her back with the affected ear facing up. 3-Straighten the ear canal by pulling the pinna of the affected ear down and back. 4-Slowly instill the number of drops prescribed by the health care provider into the ear. 5-Massage the area anterior to the ear to facilitate entry of the drops. 6-Keep the child in the same position for 2 to 3 minutes.

The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?

An elevated temperature

Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron in which way?

Between meals

An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse reinforces instructions to the adolescent regarding home care for treatment of the sprain and provides the adolescent with which information?

Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.

A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure?

Assess for any bleeding on the dressing.

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding should the nurse expect to note documented in the infant's record regarding this condition?

Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign?

Changes in level of consciousness

The nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication?

Checking the child's ability to perform range of motion to the shoulder area of the affected extremity

A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of which finding?

Confirmation of the diagnosis

The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which nursing action is appropriate?

Consult with the registered nurse to verify the prescription.

The nurse is reinforcing discharge instructions to the mother of a child who had a myringotomy with insertion of tympanostomy tubes. The nurse instructs the mother that if the tubes fall out, she should take which action?

Contact the health care provider

The nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing which?

Decorticate posturing

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse should expect which blood pressure readings in the child's legs and arms?

Decreased in the legs and increased in the arms

The nurse is caring for an infant with congenital heart disease. Which signs, if noted in the infant, should alert the nurse to the early development of heart failure (HF)?

Diaphoresis during feeding

The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which action should the nurse take?

Document the findings.

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions should the nurse reinforce to prevent another crisis from occurring? Select all that apply.

Drink plenty of fluids. Report a sore throat immediately. Wash hands before meals and after playing.

The nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which finding?

Dysfunction in the cerebral hemisphere

A 10-month-old child presents to the clinic with irritability, rubbing and pulling at the right ear, and a temperature of 102.4° F. The health care provider diagnoses the child with acute otitis media (OM) of the right ear, prescribes broad-spectrum antibiotics, and provides instructions to the parent, who verbalizes an understanding of the treatment plan. The parent later asks the nurse how to prevent future episodes of OM. Which instructions should the nurse reinforce in parent teaching? Select all that apply.

Ensure the child is not exposed to smoke. Have the child remain in a sitting position while awake. Consider avoiding individuals with upper respiratory infections.

The nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms should the nurse expect to find during the initial data collection? Select all that apply.

Fever Irritability Nuchal rigidity

The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply.

Our child will eventually grow out of this condition. It is not necessary to avoid individuals with the common cold.

A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder?

Pain

The nurse and a mother are discussing care of her child's iron deficiency anemia and the nurse should suggest including which foods in the child's diet that are highest in iron? Select all that apply.

Spinach Apricots Raisins

The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding should the nurse expect to note in this child?

Tachycardia

When checking a child's glossopharyngeal nerve function, the nurse should perform which data collection technique?

Test sense of sour or bitter taste on the posterior segment of the tongue.

The nurse is reviewing a chart of a child with a head injury. The nurse notices that the level of consciousness has been documented as obtunded. Which observation should the nurse expect to make during data collection of the child?

The child sleeps unless aroused and, once aroused, interacts poorly with the environment.

A 1-year-old child is seen in the health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media?

The mother states the child had purulent discharge from the ear last night.

The nurse receives a call from the mother whose child has a foreign body in the eye. The object is clearly visible and not embedded. When the mother asks for the most effective way to get it out, the nurse should give which response?

Touch the object gently with a cotton swab, and lift it out.

A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse should perform which actions in order to protect the child from injury? Select all that apply.

Turn the client to the side during a seizure. Keep side rails and other hard objects padded.

A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action?

Weighing the diapers

Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?

"When picking up your infant, support the infant's neck and head with the open palm of your hand."

The nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. Which is the appropriate procedure to elicit a Kernig's sign?

Extend the leg and knee and check for pain.

The nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). Which should the nurse perform to monitor for a major symptom of this condition?

Check for responses to painful stimuli from the torso downward.

The nurse is preparing to perform a neurovascular check for tissue perfusion in the child with an arm cast. Which is the priority when performing this procedure?

Checking the peripheral pulse in the affected arm

The nurse reinforces instructions to the mother of a child with sickle cell disease regarding the precipitating factors related to pain crisis. Which, if identified by the mother as a precipitating factor, indicates the need for further teaching?

Fluid overload

The nurse is reviewing a health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan?

Immune globulin

A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct?

Is a type of skin traction that pulls the hip and leg into extension

The nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate?

The harness needs to be removed to check the skin and for bathing.

The nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for which signs?

Heart failure (HF)

A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition?

"It involves only the anterior portions of the client's brain."

The nurse is teaching first aid measures to a group of adolescents about appropriate treatment for burns. The nurse should anticipate the need for further teaching when one of the adolescents makes which statement?

"It is appropriate to place butter on the burn."

A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse reinforces instructions to the mother regarding cast care at home. Which instructions should the nurse provide to the mother?

"The cast needs to be kept dry because, when wet, it will begin to disintegrate."

The nurse is reinforcing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further teaching?

"The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."

The nurse is caring for a mother and her infant who was born 12 hours ago. Which statements made by the mother should prompt the nurse to have the baby evaluated for early heart failure? Select all that apply

I'm chilly but my baby's forehead is sweaty." "I can feel my baby's heart rate when he's sleeping, it seems much faster than it did yesterday." "My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."

A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which will be prescribed initially?

Insertion of a Foley catheter

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. Following x-ray examination, it has been determined that the child has a fractured arm, and a plaster cast is applied. The nurse reinforces instructions to the mother regarding cast care for the child. Which statement by the mother indicates a need for further teaching?

"The cast will feel warm when it is dried."

The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the health care provider regarding this client's condition? Select all that apply.

I am concerned this client has Kawasaki's disease. Can you please come assess this client?" "This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days." I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." "I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."

A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which characteristic of this disease?

Increased reticulocyte count

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?

Initiating seizure precautions

The nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation?

Level of consciousness

The nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 cells/mm3, and the platelet count is 150,000 cells/mm3. Which nursing intervention should the nurse incorporate into the plan of care?

Maintain strict isolation precautions.

The nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which components should be included in the plan of care? Select all that apply.

Maintain the bed in a low position. Pad the side rails of the bed with blankets. Place the child in a side-lying lateral position if a seizure occurs. Protect the child's head, body, and extremities if a seizure occurs.

The nurse is collecting data from a child suspected of having juvenile idiopathic arthritis (JIA). Which findings should the nurse expect to note if JIA were present? Select all that apply.

Malaise, fatigue, and lethargy Painful, stiff, and swollen joints Limited range of motion of the joints History of late afternoon temperature, with temperature spiking up to 105° F

A nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which statement by the student indicates a need for further research?

Males inherit hemophilia from their fathers.

The nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage also is noted on the posterior dressing. Which is the best nursing action?

Notify the registered nurse (RN).

The nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure (HF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which is the appropriate nursing action?

Withhold the medication.