NCLEX Pediatrics

A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant? 1. Vomiting 2. Papilledema 3. Vital sign changes 4. Irritability

4. Irritability RATIONALE: An infant with increased ICP is commonly fussy, irritable, and restless at first as a result of a headache cause by the ICP. Vomiting occurs later. Papilledema is a late sign of increased ICP that may not be evident. Changes in vital signs occur later; pressure on the brainstem slows pulse and respiration.

A nurse should question an order for intraosseous infusion of which agent? 1. Sodium bicarbonate 2. Dopamine (Intropin) 3. Calcium chloride 4. Acetaminophen (Tylenol)

4. Acetaminophen (Tylenol) RATIONALE: The nurse should question an order to administer acetaminophen by intraosseous infusion because the drug can only be administered orally or rectally. Any medication that can be administered via I.V. can be administered by intraosseous infusion. Therefore, sodium bicarbonate, dopamine, and calcium chloride can all be administered by way of intraosseous infusion.

A child, age 5, is diagnosed with chronic renal failure. When teaching the parents about diet therapy, the nurse should instruct them to restrict which foods from the child's diet? 1. Meats 2. Carbohydrates 3. Fats 4. Dairy products

1. Meats RATIONALE: The nurse should instruct the parents to restrict meats because they contain a large amount of protein. Dairy products, carbohydrates, and fats are appropriate food choices for this child.

A 4-year-old child is ordered to receive 25 ml/hour of I.V. solution. The nurse is using a pediatric microdrip chamber to administer the medication. For how many drops per minute should the microdrip chamber be set? Record your answer using a whole number. Answer: gtt/minute

25 gtt/minute RATIONALE: When using a pediatric microdrip chamber, the number of milliliters per hour equals the number of drops per minute. If 25 ml/hour is ordered, the I.V. should infuse at 25 gtt/minute.

Which behavior exhibited by parents of a chronically ill child may indicate feelings of guilt about the child's illness? 1. Anger 2. Sadness 3. Shock 4. Overindulgence

4. Overindulgence RATIONALE: Parents who feel guilty about a child's illness may overindulge the child. Anger, sadness, and shock are common in parents of chronically ill children but don't necessarily indicate feelings of guilt.

A preschooler is scheduled to have a Wilms' tumor removed. Identify the area of the urinary system where a Wilms' tumor is located.

RATIONALE: A Wilms' tumor, also known as a nephroblastoma, is a tumor located on the kidney. It's most commonly found in children ages 2 to 4.

A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first? 1. Heart rate, respiratory rate, and blood pressure 2. Recent exposure to communicable diseases 3. Number of immunizations received 4. Height and weight

1. Heart rate, respiratory rate, and blood pressure RATIONALE: The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather data about disease exposure, immunizations, and height and weight later.

After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action? 1. Removing the restraints every 2 hours 2. Removing the restraints while the infant is asleep 3. Keeping the restraints on both arms only while the child is awake 4. Using the restraints until the infant recovers fully from anesthesia

1. Removing the restraints every 2 hours RATIONALE: Removing one elbow restraint at a time every 2 hours for about 5 minutes allows exercise of the arms and inspection for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.

A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order: 1. a barium enema. 2. suprapubic aspiration. 3. nasogastric (NG) tube insertion. 4. indwelling urinary catheter insertion.

1. a barium enema. RATIONALE: A nurse should expect the physician to order a barium enema because this test is commonly used to confirm and correct intussusception. Performing a suprapubic aspiration or inserting an NG tube or an indwelling urinary catheter wouldn't help diagnose or treat this disorder.

The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child? 1. Avoiding suctioning unless cyanosis occurs 2. Elevating the neonate's head and giving nothing by mouth 3. Elevating the neonate's head for 1 hour after feedings 4. Giving the neonate only glucose water for the first 24 hours

2. Elevating the neonate's head and giving nothing by mouth RATIONALE: Because of the risk of aspiration, a neonate with a known or suspected tracheoesophageal fistula should be kept with the head elevated at all times and should receive nothing by mouth (NPO). The nurse should suction the neonate regularly to maintain a patent airway and prevent pooling of secretions. Elevating the neonate's head after feedings or giving glucose water are inappropriate because the neonate must remain on NPO status.

For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in: 1. an arched, side-lying position, with the neck flexed onto the chest. 2. an arched, side-lying position, avoiding flexion of the neck onto the chest. 3. a mummy restraint. 4. a prone position, with the head over the edge of the bed.

2. an arched, side-lying position, avoiding flexion of the neck onto the chest. RATIONALE: For a lumbar puncture, the nurse should place the infant in an arched, side-lying position to maximize the space between the third and fifth lumbar vertebrae. The nurse's hands should rest on the back of the infant's shoulders to prevent neck flexion, which could block the airway and cause respiratory arrest. The infant should be placed at the edge of the bed or table during the procedure, and the nurse should speak quietly to calm the infant. A mummy restraint would limit access to the lumbar area because it involves wrapping the child's trunk and extremities snugly in a blanket or towel. A prone position isn't appropriate because it wouldn't cause separation of the vertebral spaces.

A nurse is administering I.V. fluids to an infant. Infants receiving I.V. therapy are particularly vulnerable to: 1. hypotension. 2. fluid overload. 3. cardiac arrhythmias. 4. pulmonary emboli.

2. fluid overload. RATIONALE: Infants, small children, and children with compromised cardiopulmonary status receiving I.V. therapy are particularly vulnerable to fluid overload. To prevent fluid overload, the nurse should use a volume-control set and an infusion pump or syringe and place no more than 2 hours' worth of I.V. fluid in the volume-control set at a time. Hypotension, cardiac arrhythmias, and pulmonary emboli aren't problems associated with I.V. therapy in infants.

A 13-year-old girl visits the school nurse because she's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the girl may have scoliosis. The nurse should first: 1. send the girl home to recover. 2. inspect the girl for uneven shoulder height or uneven hip height. 3. arrange for the girl to have spinal X-rays as soon as possible. 4. ask the girl's parents to take her to a physician immediately.

2. inspect the girl for uneven shoulder height or uneven hip height. RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the girl's parents.

A nurse is assessing an I.V. in an infant. Which assessment finding is considered normal? 1. Erythema and pain 2. Edema 3. A lack of blood return 4. Blanching or streaking along the vein

3. A lack of blood return RATIONALE: Infants and children have small, fragile veins, making a lack of a blood return normal. Erythema, pain, edema at the site or around it, blanching, and streaking are signs of infiltration. The infusion should be discontinued immediately if any of these signs are observed

For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority? 1. Restricting oral intake 2. Monitoring acid-base balance 3. Avoiding abdominal palpation 4. Maintaining strict isolation

3. Avoiding abdominal palpation RATIONALE: Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a child with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious.

A nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority? 1. Changing the linens on the clients' beds 2. Restocking the bedside supplies needed for a dressing change on the upcoming shift 3. Documenting the care provided during her shift 4. Emptying the trash cans in the assigned client rooms

3. Documenting the care provided during her shift RATIONALE: Documentation should take top priority because it's the only way the nurse can legally claim that interventions were performed. Changing linens, restocking supplies, and emptying trash cans would be appreciated by the nurses on the oncoming shift but aren't mandatory and don't take priority over documentation.

According to Erikson's theory of development, chronic illness can interfere with which stage of development in an 11-year-old child? 1. Intimacy versus isolation 2. Trust versus mistrust 3. Industry versus inferiority 4. Identity versus role confusion

3. Industry versus inferiority RATIONALE: According to Erikson, an 11-year-old child is working through the stage of industry versus inferiority. Chronic illness may interfere with this stage of development in an 11-year-old child because the child may not be able to accomplish tasks, which prevents him from achieving a sense of industry. Intimacy is the developmental task of a young adult. Trust is the developmental task to be achieved during infancy. Identity is the developmental task of adolescence.

An 11-year-old child is diagnosed with scoliosis and scheduled for brace application. The mother asks the nurse how long her child will have to wear the brace. How should the nurse respond? 1. "About 6 to 8 weeks." 2. "About 6 months." 3. "About 1 to 2 years." 4. "About 3 to 5 years."

4. "About 3 to 5 years." RATIONALE: Most children with scoliosis must wear a brace until the spine matures — typically between ages 14 and 16. Therefore, this 11-year-old child will need to wear the brace for 3 to 5 years.

A mother is playing with her infant, who's sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age should the nurse estimate the infant to be? 1. 4 months 2. 6 months 3. 8 months 4. 10 months

4. 10 months RATIONALE: The nurse would estimate that the infant is 10 months old because an infant this age can sit alone and understands object permanence, so he would look for the hidden toy. Between ages 4 and 6 months, children can't sit securely alone. At age 8 months, children can sit securely alone but don't understand the permanence of objects.

A 14-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the child's room, the nurse anticipates using which traction system? 1. Bryant's traction 2. Buck's extension traction 3. Overhead suspension traction 4. 90-90 traction

1. Bryant's traction RATIONALE: Anticipating Bryant's traction is correct because this type of traction is used to treat femoral fractures or congenital hip dislocation in children younger than age 2 who weigh less than 30 lb (13.6 kg). Buck's extension traction is skin traction used for short-term immobilization or to correct bone deformities or contractures. Overhead suspension traction is used to treat fractures of the humerus; and 90-90 traction is used to treat femoral fractures in children older than age 2.

While examining a 2-year-old child, the nurse sees that the anterior fontanel is open. The nurse should: 1. notify the physician. 2. look for other signs of abuse. 3. recognize this as a normal finding. 4. ask about a family history of Tay-Sachs disease.

1. notify the physician. RATIONALE: Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the physician promptly of this abnormal finding. An open fontanel doesn't indicate abuse and isn't associated with Tay-Sachs disease.

A child with diabetes insipidus receives desmopressin acetate (DDAVP). When evaluating for therapeutic effectiveness, the nurse should interpret which finding as a positive response to this drug? 1. Decreased urine output 2. Increased urine glucose level 3. Decreased blood pressure 4. Relief of nausea

1. Decreased urine output RATIONALE: The primary action of DDAVP is to stimulate water reabsorption by the kidneys, thereby decreasing the urine output. DDAVP has no effect on glucose levels, blood pressure, or nausea.

A child, age 4, with a recent history of nausea, vomiting, and diarrhea is admitted to the pediatric unit with a diagnosis of gastroenteritis. During the physical examination, the nurse detects tenting. This finding supports a nursing diagnosis of: 1. Deficient fluid volume related to dehydration. 2. Risk for injury related to capillary fragility. 3. Ineffective peripheral tissue perfusion related to peripheral cyanosis. 4. Activity intolerance related to hypoxia

1. Deficient fluid volume related to dehydration. RATIONALE: Tenting, which indicates decreased skin turgor, is normal only in elderly clients and results from decreased elastin content. However, in other adults and in children, tenting more commonly results from dehydration. This finding supports a nursing diagnosis of Deficient fluid volume related to dehydration. The other diagnoses are inappropriate because capillary fragility, altered tissue perfusion, and hypoxia rarely are associated with gastroenteritis.

A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept regarding oral rehydration therapy should the nurse consider? 1. Give 1 to 3 teaspoons of fluid every 10 to 15 minutes to set up a baseline for the child's tolerance. 2. Sugar is a good source of nutrition when rehydrating a child. 3. If symptoms persist for more than 72 hours, contact the physician. 4. A child who has three wet diapers each day isn't considered dehydrated.

1. Give 1 to 3 teaspoons of fluid every 10 to 15 minutes to set up a baseline for the child's tolerance. RATIONALE: Giving small amounts of fluid at frequent intervals is the first action a nurse should take when a child is vomiting. Doing so allows the nurse to observe the child's tolerance level. Simple sugars aren't a good source of hydration because of their osmotic affects. The nurse shouldn't wait 72 hours before taking action if a child is vomiting or has diarrhea. Toddlers can become dehydrated in a short time. A physician should see a child whose vomiting or diarrhea persists for 24 to 36 hours. Wet diapers are a good source of determining hydration; however, three wet diapers each day isn't a normal finding for toddler-age children. A hydrated toddler should have six to eight wet diapers per day.

A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? 1. Instituting droplet precautions 2. Administering acetaminophen (Tylenol) 3. Obtaining history information from the parents 4. Orienting the parents to the pediatric unit

1. Instituting droplet precautions RATIONALE: Instituting droplet precautions is the priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be ordered but administering it doesn't take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don't take priority.

A child, age 8, is immobilized with a hip spica cast. The nurse enters the room and notices the child is withdrawn and avoiding eye contact. The child's mother states, "He's just bored. He's tired of watching television." The nurse should perform which action? 1. Let the child visit the playroom daily. 2. Sit with the child for an hour in the room. 3. Place a telephone in the child's room. 4. Arrange a visit by a cooperative child from the same unit.

1. Let the child visit the playroom daily. RATIONALE: School-age children need peer interaction and thrive on peer approval and acceptance. Allowing the child to visit the playroom daily provides a nonthreatening atmosphere for peer interaction and helps the child feel less isolated. Sitting with the child for an hour wouldn't foster the necessary peer interaction. Placing a telephone in the child's room would allow the child to communicate with family and friends, but could reinforce feelings of isolation. Having another child visit would be appropriate only if the child is of the same age-group.

A preschool child is admitted to the pediatric unit with acute nephritis. Which electrolyte replacement agent is used as an adjunct to treatment for this condition? 1. Magnesium sulfate 2. Calcium glubionate 3. Potassium chloride 4. Sodium lactate

1. Magnesium sulfate RATIONALE: Magnesium sulfate is an electrolyte that's used as an adjunct to treat acute nephritis. It also is used to treat seizures and severe toxemia. Calcium glubionate, potassium chloride, and sodium lactate aren't therapeutic in acute nephritis and, in fact, may worsen the condition.

In a family with a 7-year-old child with a chronic illness, which family members feel jealousy, resentment, embarrassment, shame, fear of becoming ill, and guilt at causing the illness? 1. Siblings 2. Parents 3. Child with the illness 4. Grandparents

1. Siblings RATIONALE: When a brother or sister is ill, siblings frequently experience jealousy and resentment of the increased attention given to the ill child, embarrassment and shame, fear of becoming ill, and guilt at causing the illness. Parents may experience grieving, denial, overprotectiveness, rejection, and overcompensation. The ill child may regress to a previous developmental stage and feel anxiety, depression, and anger. Both the child's and the siblings' reactions are influenced by the parents' response. Grandparents may experience ambivalence, disappointment, and grief.

A 13-year-old adolescent may have appendicitis. Which finding is a reliable indicator of appendicitis? 1. The severity, location, and movement of pain 2. Fever 3. A history of vomiting and diarrhea, if present 4. A history of irritability and lethargy

1. The severity, location, and movement of pain RATIONALE: The pattern of pain is a reliable indicator of acute appendicitis. It begins with a severe colicky abdominal pain that gets progressively worse. The pain starts in the midabdominal (periumbilical) region and moves to the right lower quadrant after 6 to 12 hours. The degree of fever, a history of vomiting and diarrhea, and a history of irritability and lethargy are also clinical manifestations of acute appendicitis; however, these conditions can also be present in a number of other childhood illnesses so they aren't as reliable as the pattern of pain.

Parents of a 4-year-old child with acute leukemia ask a nurse to explain the concept of complementary therapy. The nurse should tell the parents that: 1. complementary therapy is an alternative to conventional medical therapies. 2. complementary therapy wouldn't help their child. 3. the physician should talk with them about it. 4. there's no research that indicates that complementary therapies are effective.

1. complementary therapy is an alternative to conventional medical therapies. RATIONALE: The nurse should tell the parents that complementary therapy is a form of alternative medicine. This type of therapy can include diet, exercise, herbal remedies, and prayer. Answering the parents' questions builds rapport and trust. The nurse shouldn't dismiss the parents' idea by telling them complementary therapy wouldn't help their child. The nurse doesn't need to direct the parents to the physician. She can provide the basic information and let the parents determine if they'd like to seek further assistance. Studies indicate that complementary therapies are beneficial to the child and the parents.

A nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers: 1. express negativism. 2. have reliable verbal responses to pain. 3. have a good concept of danger. 4. have little fear.

1. express negativism. RATIONALE: A toddler's increasing autonomy is commonly expressed by negativism. They're unreliable in expressing pain — they respond just as strongly to painless procedures as they do to painful ones. Toddlers have little concept of danger and have common fears.

A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents: 1. "Has your child recently been exposed to other children with rheumatic fever?" 2. "Has your child had strep throat recently?" 3. "Does your child have a congenital heart defect?" 4. "Is your child's Haemophilus influenzae vaccine up to date?"

2. "Has your child had strep throat recently?" RATIONALE: Asking if the child had strep throat recently is appropriate because group A streptococcal infection typically precedes rheumatic fever — an inflammatory disease that affects the heart, joints, and central nervous system. Rheumatic fever isn't infectious and can't be transmitted from one person to another. Congenital heart defects don't play a role in the development of rheumatic fever. H. influenzae vaccine doesn't prevent streptococcal infection or rheumatic fever.

A child, age 8, complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses his pain, the child states, "My pain is a 7 out of 10." What action by the nurse would be most appropriate? 1. Ask the child what makes the pain better. 2. Administer pain medication as ordered. 3. Provide diversional activities to distract him. 4. The nurse doesn't need to do anything for this pain level.

2. Administer pain medication as ordered. RATIONALE: A pain rating of 7 out of 10 indicates significant pain. Therefore, the most appropriate action would be to administer pain medication as ordered. The nurse can ask the child what makes the pain better after medication has been given. Providing diversional activities is appropriate only after administration of pain medication. It isn't appropriate to not treat the child's pain.

Which parameter is an appropriate indicator of pain relief in an adolescent? 1. Intermittent sleeping 2. Change in behavior 3. No change in behavior 4. No change in vital signs

2. Change in behavior RATIONALE: Positive changes in behavior and vital signs are indicators of an effective response to pain medication. Sleeping isn't a reliable indicator of pain relief because the teen may use sleep as a coping mechanism.

A nurse is caring for a 2-year-old child admitted for long-term treatment of a chronic illness. Which action should the nurse take to promote normal childhood growth and development? 1. Allow the child to sleep for at least 12 hours per night. 2. Consult with a play therapist about activities in which the child can participate. 3. Make sure the child is continuously isolated because of his chronic illness and risk of infection. 4. Maintain a diet high in carbohydrates and low in fats.

2. Consult with a play therapist about activities in which the child can participate. RATIONALE: Play is an important part of a child's growth and development. A nurse should facilitate play even when a child has a chronic illness. Consulting a play therapist is one way of facilitating such play. Although it's important for children to get adequate sleep, it isn't necessary for a toddler to get 12 hours' sleep per night. A child with a chronic illness may need to be temporarily isolated, but he should still have interaction with family members. A diet high in carbohydrates and low in fat isn't indicated for every toddler with a chronic illness.

A child is admitted to the pediatric unit with a serum sodium level of 118 mEq/L. Which nursing action takes highest priority at this time? 1. Replacing fluids slowly as ordered 2. Instituting seizure precautions 3. Administering diuretic therapy as ordered 4. Administering sodium bicarbonate as ordered

2. Instituting seizure precautions RATIONALE: A serum sodium level of 118 mEq/L indicates severe hyponatremia, which places the client at risk for seizures. Therefore, instituting seizure precautions takes highest priority. Fluid and sodium replacement should be done rapidly. Diuretic therapy isn't indicated because it may cause additional sodium loss. In a child with hyperkalemia, administering sodium bicarbonate would be appropriate because it promotes movement of potassium into the intracellular spaces.

Which nursing intervention should be included in the care of an unconscious child with Reye's syndrome? 1. Keep his arms and legs flexed. 2. Place the child on a sheepskin. 3. Avoid using lotions on his skin. 4. Place the child in a supine position.

2. Place the child on a sheepskin. RATIONALE: Placing the child with Reye's syndrome on a sheepskin helps to prevent pressure on prominent areas of the body. Rubbing lotion on the extremities stimulates circulation and helps prevent drying of the skin, and therefore shouldn't be avoided. Keeping extremities flexed can lead to contractures. Placing the child supine is contraindicated because of the risk of aspiration and increasing intracranial pressure. The supine position isn't appropriate because it puts pressure on the sacral and occipital areas.

An 18-month-old child immobilized with traction to the legs has a nursing diagnosis of Deficient diversional activity related to immobility. Which diversional activity is most appropriate for the nurse to include in the care plan? 1. Playing with Tinker toys 2. Playing with a pounding board 3. Playing with a pull toy 4. Playing board games

2. Playing with a pounding board RATIONALE: Playing with a pounding board is a developmentally appropriate diversional activity for a toddler because it not only promotes physical development but also provides an acceptable energy outlet during immobilization. A child younger than age 3 accidentally may swallow Tinker toys and other toys with small parts. Whereas a pull toy is appropriate for a toddler, it isn't appropriate for one who's immobilized. Playing board games is too advanced for a toddler's developmental stage.

When developing a care plan for a hospitalized child, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds? 1. Infancy 2. Preschool age 3. School age 4. Adolescence

2. Preschool age RATIONALE: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.

One day after an appendectomy, a 9-year-old child rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. What should the nurse document on the child's chart? 1. The child is in no apparent distress, and no pain medication is needed at this time. 2. The child rates pain at 4 out of 5. Administered pain medication as ordered. 3. The child doesn't understand the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling. 4. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain.

2. The child rates pain at 4 out of 5. Administered pain medication as ordered. RATIONALE: Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses passive coping behaviors (such as distraction and cooperative) may rate pain as more intense than children who use active coping behaviors (such as crying and kicking). Nurses frequently make judgments about pain based on behavior, which can result in children being inadequately medicated for pain.

A nurse is caring for a toddler who was diagnosed with an inoperable brain tumor. The parents are having difficulty deciding on a course of action for their child. Why is it important to have the nurse involved in an ethical discussion about a planned course of treatment? 1. The nurse is viewed as the authority on ethical issues at the hospital. 2. The nurse can act as a liaison between the child, the child's parents, and the health care team. 3. The nurse can easily make time to discuss issues with the parents. 4. It isn't important to involve the nurse in this type of discussion.

2. The nurse can act as a liaison between the child, the child's parents, and the health care team. RATIONALE: It is important to involve the nurse because she can act as a liaison between all parties. The nurse has the most direct contact with the child and his parents, and she can listen to and communicate their wishes for treatment. She can also aid in interpreting information about the child's condition and course of treatment, helping the parents to make an informed decision. The nurse isn't viewed as the authority on ethical issues at the hospital. In fact, hospitals commonly employ ethicists to help with ethical dilemmas. Time shouldn't be a factor when it comes to helping parents make decisions about their child's care.

A preschool-age child is admitted to the facility with nephrotic syndrome. Nursing assessment reveals a blood pressure of 100/60 mm Hg, lethargy, generalized edema, and dark, frothy urine. After prednisone (Deltasone) therapy is initiated, which nursing action takes highest priority? 1. Monitoring the child for hypertension 2. Turning and repositioning the child frequently 3. Providing a high-sodium diet 4. Discussing the adverse effects of steroids with the parents

2. Turning and repositioning the child frequently RATIONALE: The child with nephrotic syndrome is at risk for skin breakdown from generalized edema. Because this syndrome typically impairs independent movement, the nurse's highest priority is to turn and reposition the child frequently to help prevent skin breakdown. Frequent turning also helps prevent respiratory infections, which may arise during the edematous phase of nephrotic syndrome. The syndrome typically causes hypotension, not hypertension, from significant loss of intravascular protein and a subsequent drop in oncotic pressure. Dietary sodium should be restricted because it worsens edema. Although the nurse should discuss the adverse effects of steroids with the parents, this action isn't a priority at this time.

A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client? 1. Within hours 2. Within 2 weeks 3. Within 1 month 4. After induction therapy is completed

2. Within 2 weeks RATIONALE: Bone marrow depression is most likely to occur 10 days after methotrexate is administered.

A 4-year-old child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect: 1. subdural hematoma. 2. epidural hematoma. 3. subarachnoid hemorrhage. 4. concussion.

2. epidural hematoma. RATIONALE: An epidural hematoma is characterized by an initial loss of consciousness followed by transient consciousness leading to unconsciousness. Subdural hematoma results in rapid deterioration in level of consciousness. Subarachnoid hemorrhage causes irritability rather than loss of consciousness. As for a concussion, it may result in a brief loss of consciousness.

A child is diagnosed with nephrotic syndrome. When planning the child's care, the nurse understands that the primary goal of treatment is to: 1. manage urinary changes by monitoring fluid intake and output and observing for hematuria. 2. reduce the excretion of urinary protein. 3. help prevent cardiac or renal failure by carefully monitoring fluid and electrolyte balance. 4. decrease edema and hypertension through bed rest and fluid restriction.

2. reduce the excretion of urinary protein. RATIONALE: The primary goal of treatment for a child with nephrotic syndrome is to reduce excretion of urinary protein and maintain protein-free urine. Nephrotic syndrome isn't associated with hematuria, cardiac failure, or hypertension. Fluid restriction isn't warranted.

A nurse must administer an oral medication to a 3-year-old child. The best way for the nurse to proceed is by saying: 1. "It's time for you to take your medicine right now." 2. "If you take your medicine now, you'll go home sooner." 3. "Here is your medicine. Would you like apple juice or grape drink after?" 4. "See how Jimmy took his medicine? He's a good boy. Now it's your turn."

3. "Here is your medicine. Would you like apple juice or grape drink after?" RATIONALE: Asking the child if he would like apple juice or grape drink is the best approach because involving the child promotes cooperation, and permitting the child to make choices provides a sense of control. Telling a child to take the medicine "right now" could provoke a negative response. Promising that the child will go home sooner could decrease the child's trust in nurses and physicians. Telling the child to "see how Jimmy took his medicine" is inappropriate because it compares one child with another and doesn't encourage cooperation.

Which nursing activity supports the principles of palliative care for a dying infant and his family? 1. Maintaining routines and structure for the infant and his family 2. Clustering care activities to provide as much rest as possible for the infant 3. Creating a therapeutic, homelike environment for the infant and his family 4. Minimizing noise and disruption to decrease stress for the infant

3. Creating a therapeutic, homelike environment for the infant and his family RATIONALE: The goal of palliative care is to make the infant and his family as comfortable as possible. Maintaining routines and structure doesn't support the principles of palliative care. Clustering care activities may allow the infant more rest, but this action isn't a principle of palliative care. Minimizing noise and disruption isn't specifically related to palliative care.

An 8-year-old child is refusing to have a scheduled appendectomy even though his parents have given informed consent for the surgery. Which action is most appropriate for the nurse to take? 1. Cancel the surgery until the child gives informed consent. 2. Explain the surgery in detail, telling the child that he might die if he doesn't have the operation. 3. Explore the child's knowledge of the procedure and his prior experiences with surgery. 4. Assure the child that other children have had the surgery and have done very well postoperatively.

3. Explore the child's knowledge of the procedure and his prior experiences with surgery. RATIONALE: By exploring the child's knowledge of the procedure and his prior experiences with surgery, the nurse may be better able to identify the etiology of his feelings about the procedure. Children can't provide informed consent; parents or guardians do so. Explaining the surgical procedure in detail and informing the child that he could die if he doesn't have the surgery would probably make him more fearful. Telling the child that other children have had the surgery and have done well offers false reassurance.

A preschool-age child scheduled for surgery in the morning is admitted to the facility for the first time. Which nursing action would ease the child's anxiety? 1. Beginning preoperative teaching as soon as possible 2. Explaining that the child will be "put to sleep" during the operation and will feel nothing 3. Having the child act out the surgical experience using dolls and medical equipment 4. Explaining preoperative and postoperative procedures step by step

3. Having the child act out the surgical experience using dolls and medical equipment RATIONALE: Having the child act out the surgical experience using dolls and medical equipment would ease anxiety and give the nurse an opportunity to clarify the child's misconceptions. Preschoolers have a limited concept of time, so the nurse should provide preoperative teaching just before surgery rather than starting it as soon as possible; also, a delay between teaching and surgery may heighten anxiety by giving the child a chance to worry or fantasize. The nurse should avoid using such phrases as "put to sleep" because these may have a dual or negative meaning to a young child. Long explanations are inappropriate for the preschooler's developmental level and may increase anxiety.

A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible? 1. Hypocalcemia 2. Hypercalcemia 3. Hypokalemia 4. Hyperkalemia

3. Hypokalemia RATIONALE: The nurse should monitor the client receiving an I.V. infusion of terbutaline for hypokalemia, lactic acidosis, chest pain, arrhythmias, dyspnea, bloating, chills, or anaphylactic shock. Terbutaline doesn't cause calcium imbalances.

Which interview strategy contributes to a poor nurse-adolescent relationship? 1. Maintaining objectivity by avoiding assumptions, judgments, and lectures 2. Beginning with less-sensitive issues and proceed to more-sensitive ones 3. Interviewing adolescents with their parents present 4. Asking open-ended questions and moving to more directive questions when possible

3. Interviewing adolescents with their parents present RATIONALE: When possible, adolescents should be interviewed without their parents present to ensure confidentiality and privacy. Interviewing adolescents with their parents present hinders the formation of the nurse-adolescent relationship. Avoiding assumptions, judgments, and lectures will increase the adolescents' comfort in disclosing sensitive information. Begin with less-sensitive questions so the adolescents won't feel threatened and uncomfortable and become uncooperative during the interview. Ask open-ended questions to give adolescents opportunities to share their psychosocial context.

A 10-year-old boy falls, injures his left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first? 1. Apply a warm compress to the injured shoulder. 2. Ask him to demonstrate full range of motion of his left arm. 3. Keep him in a comfortable position and apply ice to the injured shoulder. 4. Give him a nonopioid analgesic for pain.

3. Keep him in a comfortable position and apply ice to the injured shoulder. RATIONALE: Ice should be applied first to reduce swelling and pain. The client should also be helped into a comfortable position. The nurse shouldn't apply warm compresses because it may increase swelling and cause bleeding into the injured tissue. Demonstrating full range of motion of the left arm may cause further damage to the injured area. In the emergency department, the nurse must have a physician's order to administer an analgesic.

A child, age 5, is to have potassium added to his I.V. fluid. Before initiating this therapy, the nurse first should: 1. assess the child's apical pulse rate. 2. measure the blood pressure. 3. monitor fluid intake and output. 4. assess respiratory rate and depth.

3. monitor fluid intake and output. RATIONALE: The nurse should first monitor fluid intake and output because potassium shouldn't be added to the I.V. fluid until the child's kidney function is shown to be adequate, as indicated by balanced fluid intake and output and certain diagnostic test results. Assessing the child's apical pulse rate, measuring blood pressure, and assessing respiratory rate and depth aren't related to potassium administration.

A dehydrated infant is receiving I.V. therapy. The mother tells the nurse she wants to hold her infant but is afraid this might cause the I.V. line to become dislodged. What should the nurse do? 1. Tell the mother it's best not to move the infant now. 2. Inform the mother that only a nurse should hold the infant during I.V. therapy. 3. Show the mother how to hold the infant properly. 4. Advise the mother to let the infant lie quietly in bed.

3. Show the mother how to hold the infant properly. RATIONALE: Infants with I.V. lines should be held with care. The nurse should encourage and show the mother how to hold the infant properly and teach her about I.V. care measures to enhance her confidence and skill. The nurse should encourage the mother to participate in the child's care whenever possible, not just during I.V. therapy. There's no need for the infant to have to lie quietly in bed.

Most oral pediatric medications are administered: 1. with the nighttime formula. 2. ½ hour after meals. 3. on an empty stomach. 4. with meals.

3. on an empty stomach. RATIONALE: Most oral pediatric medications are administered on an empty stomach. They aren't usually administered with milk or formula because these can affect gastric pH and alter drug absorption. Because a child's meals usually contain milk or a milk product, the nurse wouldn't administer the drugs with meals or even ½ hour after meals.

A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action should the nurse take next? 1. After starting the fluids, contact the maintenance department and request a pump inspection. 2. Hang the fluids without the pump, carefully calculating the drip rate by visual inspection. 3. Take the pump out of commission and locate a pump with a valid inspection sticker. 4. Begin the infusion of the fluids while looking for a pump with a valid inspection sticker.

3. Take the pump out of commission and locate a pump with a valid inspection sticker. RATIONALE: The nurse shouldn't use any equipment that doesn't have current inspection information. The pump could malfunction, causing harm to the patient. The nurse should remove the pump from service and locate a pump with the proper inspection information.

A nurse is caring for a 19-month-old infant with dehydration and weight loss. The infant's mother states that her son doesn't like to eat and that she hates to make him eat. The nurse should: 1. contact the social worker on duty and give her information about the situation. 2. contact the physician to have the child put in isolation. 3. request that a dietitian talk with the parent about infants and nutrition. 4. contact the local police department to report suspected child abuse.

3. request that a dietitian talk with the parent about infants and nutrition. RATIONALE: The infant's mother needs assistance in maintaining her child's diet. Requesting that a dietitian speak with the mother about the child's diet is within the nurse's scope of practice. The nurse shouldn't call the local police or the social worker on duty because there is no evidence of child abuse or neglect. Many infants are picky eaters and choose not to eat or drink. The nurse doesn't need to call the physician to have the infant put in isolation. Isolation isn't indicated for dehydration.

The parents of a 9-year-old child who is scheduled to have surgery ask the nurse not to tell him about the surgery until he's taken to the operating room. Which response best demonstrates the nurse's role in supporting the child's rights? 1. "I agree that the child shouldn't be told about the surgery until it's absolutely necessary to avoid unnecessary stress." 2. "The child should be aware of the impending surgery so he can give informed consent." 3. "I must inform the child because the hospital requires that he be made aware of the surgery." 4. "The child should be aware of the impending surgery so he can develop coping strategies and his questions can be answered."

4. "The child should be aware of the impending surgery so he can develop coping strategies and his questions can be answered." RATIONALE: Advance awareness of the surgery and its significance offers a school-age child time to develop coping strategies and formulate questions. Failure to inform the child about the surgery may result in fear or mistrust of health care workers or the health care system. A school-age child can't give operative consent. Although hospital requirements may require the nurse to inform a child of impending surgery, this response doesn't best reflect the nurse's promotion of the child's rights.

A nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response? 1. "This is only a minor problem. Many other babies are born with worse defects." 2. "Don't worry. After surgical repair you'll hardly remember there was anything wrong with your baby." 3. "I'll ask the physician to explain to you how this defect occurs." 4. "You seem upset. Tell me about it."

4. "You seem upset. Tell me about it." RATIONALE: Asking the client to talk about her feelings is appropriate because by verbalizing the nurse acknowledges the client's feelings. By listening, the nurse acknowledges the client's feelings and can help the client understand them and begin to deal with them. Telling the client that there are babies with worse defects doesn't acknowledge — and may even belittle — her feelings. Providing a stock answer, such as "Don't worry," shows a lack of interest in the client's feelings. Offering to ask the physician also doesn't address the client's feelings.

A mother brings her preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment will the physician probably order? 1. Administration of a dose of ipecac syrup 2. Insertion of a nasogastric tube and administration of an antacid 3. I.V. infusion of normal saline solution 4. Gastric lavage and administration of activated charcoal

4. Gastric lavage and administration of activated charcoal RATIONALE: The physician will probably order gastric lavage or activated charcoal administration. Ipecac syrup is no longer recommended and an antacid isn't an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting, but in itself isn't effective in eliminating the poisonous substance.

An infant is having his 2-month checkup at the pediatrician's office. The physician tells the parents that she's assessing for Ortolani's sign. The nurse explains that the presence of Ortolani's sign indicates dislocation of what joint? 1. Shoulder 2. Elbow 3. Knee 4. Hip

4. Hip RATIONALE: To assess for Ortolani's sign, the nurse abducts the infant's hips while flexing the legs at the knees. This is performed on all infants to assess for congenital hip dislocation. The examiner listens and feels for a "click" as the femoral head enters the acetabulum during the examination. This finding indicates a congenitally dislocated hip.

Which nursing action would be most successful in gaining a preschooler's cooperation in preparing for surgery? 1. Have the child take off his own underwear. 2. Encourage the child to use the hospital blanket as a transition object so his won't be lost. 3. Let the child choose which parent can accompany him to the preoperative waiting area. 4. Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.

4. Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon. RATIONALE: Giving the child a choice would promote cooperation, and children commonly prefer a nonthreatening method of travel such as a wagon. Having the child take off his own underwear isn't appropriate because preschoolers commonly have a fear of genital mutilation; the child would likely resist removing his underwear. Children usually won't transfer feelings of security objects to another object such as a hospital blanket. Both parents are encouraged to accompany the child to the preoperative area, so having the child choose one parent isn't appropriate.

A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff? 1. Proper documentation of a verbal order from a physician 2. Policy changes in the administration of opioids 3. New education materials for the management of diabetes 4. Logging off a computer containing client information

4. Logging off a computer containing client information RATIONALE: All members of the health care team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use. Taking a verbal order, administering medications, and client education aren't within the scope of practice of the clerical support staff.

Parents of a preschooler are told their child needs a blood transfusion to treat hypovolemia. A nurse contacts a physician with the information that the parent's are Jehovah's Witnesses and refuse to sign the consent form. The physician tells the nurse to perform the transfusion. He states that he isn't going to let the child's parents allow him to die. What should the nurse do next? 1. Contact social services and allow that agency to manage the situation. 2. Perform the blood transfusion as directed by the physician. 3. Inform the boy's parents of the physician's decision and ask them to reconsider. 4. Not perform the transfusion but provide comfort measures for the child.

4. Not perform the transfusion but provide comfort measures for the child. RATIONALE: Jehovah's Witnesses believe that a blood transfusion is the same as oral intake of blood, which they regard as a sin. The nurse caring for the child shouldn't perform the transfusion, but she should provide comfort measures for the child. It isn't appropriate for the nurse to call social services because this situation is an ethical matter. The nurse shouldn't ask the parents to reconsider their decision because it violates their cultural beliefs, which the nurse should uphold.

A nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which observation indicates that teaching has been effective? 1. The toddler stays neat while eating. 2. The toddler finishes the meal within a specified period of time. 3. The child lies down to rest after eating. 4. The child eats finger foods by himself.

4. The child eats finger foods by himself. RATIONALE: The child eating finger foods by himself indicates effective teaching because a child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to feed himself. Because spasticity affects coordinated chewing and swallowing as well as the ability to bring food to the mouth, it's difficult for the child with cerebral palsy to eat neatly. In terms of a specified period of time, the child with cerebral palsy may require more time to bring food to the mouth; thus, chewing and swallowing shouldn't be rushed. A child shouldn't lie down to rest after eating because doing so may cause the child to vomit from a hyperactive gag reflex. Therefore, the child should remain in an upright position after eating to prevent aspiration and choking.

Which safeguard should a nurse employ with I.V. fluid administration for an infant? 1. Administration of fluid at the slowest possible rate 2. Use of a gravity infusion set 3. Use of a small I.V. infusion set 4. Use of an infusion pump to regulate the flow rate

4. Use of an infusion pump to regulate the flow rate RATIONALE: Use of an infusion pump to regulate the flow rate is the appropriate safeguard because infants and children with compromised cardiopulmonary status are particularly vulnerable to I.V. fluid overload. Administering fluid at the slowest possible rate may not benefit the infant. Using a gravity infusion set or a small I.V. infusion set won't protect against fluid overload when I.V. administration is too rapid.

A child experiences nausea and vomiting after receiving cancer chemotherapy drugs. To help prevent these problems from recurring, the nurse should: 1. provide a high-fiber diet before the next chemotherapy session. 2. administer allopurinol (Zyloprim) 2 hours before the next chemotherapy session. 3. encourage increased fluid intake before the next chemotherapy session. 4. administer an antiemetic 30 to 60 minutes before the next chemotherapy session.

4. administer an antiemetic 30 to 60 minutes before the next chemotherapy session. RATIONALE: The nurse should administer an antiemetic 30 to 60 minutes before the chemotherapy session because antiemetics counteract nausea most effectively when given before administration of an agent that causes nausea. Antiemetics also work better when given continuously rather than as needed. A high-fiber diet or allopurinol wouldn't prevent or reduce nausea and vomiting. Increasing fluid intake before the next chemotherapy session would only worsen the nausea and could cause more vomiting.

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: 1. using sterile surgical scrubs. 2. preoperative cleansing of jewelry worn by the surgical team. 3. applying bandages to cover any wounds surgical team members have. 4. performing a preoperative surgical scrub for at least 3 to 5 minutes.

4. performing a preoperative surgical scrub for at least 3 to 5 minutes. RATIONALE: The surgical team should perform a surgical scrub lasting at least 3 to 5 minutes before any operative procedure. Although surgical gowns may be considered sterile, surgical scrubs are considered clean rather than sterile. Jewelry harbors bacteria; team members should remove it rather than simply clean it. A surgical team member with an open wound shouldn't be involved in a procedure requiring asepsis.

Which finding in a 3-year-old child with acute renal failure requires immediate follow-up? 1. Potassium level of 6.5 mEq/L 2. Blood pressure in right leg of 90/50 mm Hg 3. Abdominal cramps 4. No albumin in the urine

1. Potassium level of 6.5 mEq/L RATIONALE: A potassium level of 6.5 mEq/L requires immediate follow-up because it's considered critically high, making the child prone to cardiac arrhythmias. Whereas a blood pressure of 90/50 mm Hg should be recorded and monitored, it doesn't require immediate follow-up. Abdominal cramping may be caused by several conditions and can be observed over time.

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit? 1. A sunken fontanel 2. Decreased pulse rate 3. Increased blood pressure 4. Low urine specific gravity

1. A sunken fontanel RATIONALE: In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.

A nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement? 1. Decreased hematuria 2. Increased appetite 3. Increased energy level 4. Decreased diarrhea

1. Decreased hematuria RATIONALE: Decreased hematuria, a sign of improving kidney function, typically is the first sign that a child with APSGN is improving. Increased appetite, an increased energy level, and decreased diarrhea aren't specific to APSGN.

Encouraging fantasy play and participation by children in their own care is a useful developmental approach for which pediatric age-group? 1. Preschool age (3 to 5 years) 2. Adolescence (10 to 19 years) 3. School age (5 to 10 years) 4. Toddler (1 to 3 years)

1. Preschool age (3 to 5 years) RATIONALE: Children in the preschool age-group have a rich fantasy life. Combined with their strong concept of self, fantasy play and participation in care can minimize the trauma of being hospitalized. Adolescents should be allowed choices and control. School-age children are modest and need to have their privacy respected. Procedures should be explained to them. Toddlers should be examined in the presence of their parents because they fear separation. Allow choices when possible.

For children from infancy through the preschool years, what is the major stressor posed by hospitalization? 1. Separation from the family 2. Fear of bodily injury 3. Loss of control 4. Fear of pain

1. Separation from the family RATIONALE: For infants through preschoolers, separation from the family is the major stressor posed by hospitalization. To minimize the effects of separation, the nurse may suggest that a family member stay with the child as much as possible. Reducing this stressor may help a young child withstand other possible stressors of hospitalization, such as fear of bodily injury, loss of control, and fear of pain.

A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals: 1. worsening dyspnea. 2. gastric distention. 3. nausea and vomiting. 4. a temperature of 102° F (38.9° C).

1. worsening dyspnea. RATIONALE: Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess.

An infant who weighs 7.5 kg is to receive ampicillin (Omnipen) 25 mg/kg I.V. every 6 hours. How many milligrams should the nurse administer per dose? Record your answer using one decimal place. Answer: milligrams

187.5 milligrams RATIONALE: The nurse should calculate the correct dose using the following equation: 25 mg/kg × 7.5 kg = 187.5 mg

A child, age 4, fell and broke his arm and had a cast applied. Which of these statements by the child indicates an immediate risk for compartment syndrome? 1. "My arm hurts." 2. "I can't wiggle my fingers." 3. "I need to go home." 4. "Don't touch me."

2. "I can't wiggle my fingers." RATIONALE: Signs and symptoms of compartment syndrome, such as motor weakness, reflect a deficit or deterioration of neuromuscular status in the involved area. Inability to wiggle fingers indicates an immediate risk for compartment syndrome because it could suggest neurovascular pressure or damage caused by edema following the injury. The other statements don't indicate risk for compartment syndrome.

What is a normal systolic blood pressure for a 3-year-old child? 1. 60 mm Hg 2. 93 mm Hg 3. 120 mm Hg 4. 150 mm Hg

2. 93 mm Hg RATIONALE: The normal range for systolic blood pressure in preschoolers is 82 to 110 mm Hg. The normal range for diastolic blood pressure is 50 to 78 mm Hg.

Which toy is appropriate for a 3-year-old child? 1. A bicycle 2. A puzzle with large pieces 3. A pull toy 4. A computer game

2. A puzzle with large pieces RATIONALE: A puzzle is the most appropriate toy because, at age 3, children like to color, draw, and put together puzzles. A bicycle is appropriate for a 5- or 6-year-old child; a pull toy, for a toddler; and a computer game, for a school-age child.

A physician orders penicillin G, 300,000 units I.M., for an 18-month-old child. Where should the nurse administer this injection? 1. Deltoid muscle 2. Vastus lateralis muscle 3. Dorsogluteal muscle 4. Ventrogluteal muscle

2. Vastus lateralis muscle RATIONALE: For a child younger than age 3, the thigh (vastus lateralis muscle) is the best site for I.M. injections because it has few major nerves and blood vessels. The deltoid, dorsogluteal, and ventrogluteal sites aren't recommended for a child younger than age 3 because of the lack of muscle development and the risk of nerve injury during injection. Before the dorsogluteal or ventrogluteal sites can be used safely, the child should have been walking for at least 1 year to ensure sufficient muscle development.

A nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children? 1. Heart 2. Lungs 3. Kidneys

3. Kidneys RATIONALE: The kidneys are most responsible for drug excretion in children. Less commonly, some drugs may be excreted via the lungs or liver. Drugs are never excreted by the heart in children or adults.

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic. The infant's anterior fontanel is sunken. What other assessment data are a priority for the nurse to collect? 1. Temperature, pulse, and respiratory rate 2. Pulse, respiratory rate and skin turgor 3. Respiratory rate, skin and turgor 4. Pulse, skin turgor, and number of wet diapers the infant had in the last 24 hours

4. Pulse, skin turgor, and number of wet diapers the infant had in the last 24 hours RATIONALE: A sunken fontanel indicates dehydration. The nurse should assess pulse, skin turgor, and the number of wet diapers the infant had in the past 24 hours. These findings help evaluate the extent of dehydration. Temperature and respiratory rate may also be assessed, but these assessments don't provide the same detail about dehydration as pulse, skin turgor, and number of wet diapers.

Which intervention provides the most accurate information about an infant's hydration status? 1. Monitoring the infant's vital signs 2. Accurately measuring intake and output 3. Monitoring serum electrolyte levels 4. Weighing the infant daily

4. Weighing the infant daily RATIONALE: Weighing an infant daily provides the most accurate information about the infant's hydration status. Vital signs, intake and output, and electrolyte levels provide helpful information about an infant's hydration status, but they aren't as accurate as weighing daily.

A physician orders an I.V. infusion of dextrose 5% in quarter-normal saline solution to be infused at 7 ml/kg/hour for a 10-month-old infant. The infant weighs 22 lb. How many milliliters per hour should the nurse infuse of the ordered solution? Record your answer using a whole number. Answer: milliliters per hour

70 milliliters per hour RATIONALE: To perform this dosage calculation, the nurse should first convert the infant's weight to kilograms: 2.2 lb/kg = 22 lb/X kg X = 22 ÷ 2.2 X = 10 kg Next, she should multiply the infant's weight by the ordered rate: 10 kg × 7 ml/kg/hour = 70 ml/hour

A critically ill 4-year-old child is in the pediatric intensive care unit. Telemetry monitoring reveals junctional tachycardia. Identify where this arrhythmia originates.

RATIONALE: In junctional tachycardia, the atrioventricular node fires rapidly.

When assessing an infant for changes in intracranial pressure (ICP), a nurse must palpate the fontanels. Identify the area where the nurse should palpate to assess the anterior fontanel.

RATIONALE: The anterior fontanel is formed by the junction of the sagittal, frontal, and coronal sutures. It's shaped like a diamond and normally measures 4 to 5 cm at its widest point. A widened, bulging fontanel is a sign of increased ICP.

Twenty-four hours after birth, a neonate hasn't passed meconium. The nurse suspects which condition? 1. Hirschsprung's disease 2. Celiac disease 3. Intussusception 4. Abdominal wall defect

1. Hirschsprung's disease RATIONALE: Failure to pass meconium is an important diagnostic indicator for Hirschsprung's disease. Hirschsprung's disease is a potentially life-threatening congenital large-bowel disorder characterized by the absence or marked reduction of parasympathetic ganglion cells in a segment of the colorectal wall; narrowing impairs intestinal motility and causes severe, intractable constipation leading to partial or complete colonic obstruction. Celiac disease, intussusception, and abdominal wall defects aren't associated with failure to pass meconium.

When meeting with a family who'll learn that their 3-year-old is seriously ill, which action demonstrates the nurse's role as collaborator of care? 1. Providing the parents with information about financial assistance programs. 2. Informing the family of the diagnosis and recently discovered findings. 3. Coordinate the multidisciplinary services and providing information about them. 4. Referring and consulting with other specialties to help in treating the diagnosis.

3. Coordinate the multidisciplinary services and providing information about them. RATIONALE: Coordinating the multidisciplinary services and providing information about them demonstrate collaboration because the nurse will be explaining the functions of social service, case management, and so forth. Providing parents with information about financial assistance programs is the responsibility of social services, not a nursing role. Informing the family of the diagnosis and recently discovered findings is a physician's responsibility as is referring and consulting with other specialties.

Which relaxation strategy would be effective for a school-age child to use during a painful procedure? 1. Having the child keep his eyes shut at all times 2. Having the child hold his breath and not yell 3. Having the child take a deep breath and blow it out until told to stop 4. Being honest with the child and telling him the procedure will hurt a lot

3. Having the child take a deep breath and blow it out until told to stop RATIONALE: Having the child take a deep breath and blow it out is a form of distraction and will help the child cope better with the procedure. A child may prefer to keep his eyes open, not shut, during a procedure so he can see what is going on and can anticipate what is going to happen. Letting a child yell during a procedure is a form of helpful distraction. In addition, holding the breath isn't beneficial and could have adverse effects (such as feeling dizzy or faint). The nurse should prepare a child for a procedure by using nonpain descriptors and not suggesting pain. For example, the nurse might say, "Sometimes this feels like pushing or sticking, and sometimes it doesn't bother children at all."

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching? 1. "I hope this cast will cure his feet in the next several weeks." 2. "I know I will have to be careful when changing his diapers." 3. "We will have to be careful how we hold our baby." 4. "Immunizations will have to be delayed until the casts come off."

4. "Immunizations will have to be delayed until the casts come off." RATIONALE: The father's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements, indicating effective teaching.

Which intervention takes priority when admitting an infant with acute gastroenteritis? 1. Obtaining a stool specimen 2. Weighing the infant 3. Offering the infant clear liquids 4. Obtaining a history of the illness

4. Obtaining a history of the illness RATIONALE: Obtaining a history of the infant's illness takes priority because the history helps with developing a treatment plan. Getting a stool specimen and weighing the infant can follow taking the history. The nurse shouldn't offer clear liquids because they increase the risk of vomiting, which may worsen the infant's dehydration.

A mother is discontinuing breast-feeding after 5 months. What should the nurse advise the mother to include in her infant's diet? 1. Iron-rich formula and baby food 2. Whole milk and baby food 3. Skim milk and baby food 4. Iron-rich formula alone

4. Iron-rich formula alone RATIONALE: The American Academy of Pediatrics recommends iron-rich formula for 5-month-old infants and cautions against giving infants solid food — even baby food — until age 6 months. The Academy doesn't recommend whole milk before age 12 months or skim milk before age 2 years.

A nurse is caring for an adolescent who underwent surgery for a perforated appendix. When caring for this adolescent, the nurse should keep in mind that the main life-stage task for an adolescent is to: 1. resolve conflict with parents. 2. develop an identity and independence. 3. develop trust. 4. plan for the future.

2. develop an identity and independence. RATIONALE: An adolescent strives for a sense of independence and identity. During this time, conflicts are heightened, not resolved. Trust begins to develop during infancy and matures during the course of development. Adolescents rarely finalize plans for the future; this normally happens later in adulthood.

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? 1. A 2-year-old child who nearly drowned 2 days earlier 2. A 19-month-old infant who had surgery for a fractured tibia 12 hours ago 3. A 6-month-old infant who has gastroenteritis and vomits every 30 minutes 4. A 17-month-old infant who lost consciousness 2 hours earlier because of a head injury

1. A 2-year-old child who nearly drowned 2 days earlier RATIONALE: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. His status could quickly become very critical.

A 14-year-old male reports having right lower quadrant pain, nausea, vomiting, and a low-grade fever for the past 12 hours. A physical examination reveals rebound tenderness and a positive psoas sign. Based on these findings, what should the nurse suspect? 1. Appendicitis 2. Pancreatitis 3. Cholecystitis 4. Constipation

1. Appendicitis RATIONALE: Right lower quadrant pain, rebound tenderness, nausea, vomiting, a positive psoas sign, and a low-grade fever are findings consistent with acute appendicitis. Pancreatitis, cholecystitis, and constipation may mimic appendicitis; however, the pain of pancreatitis is usually localized in the left upper quadrant. Cholecystitis is associated with right upper quadrant pain. Constipation wouldn't cause a fever.

A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information? 1. Measuring the infant's weight 2. Obtaining a stool specimen for analysis 3. Obtaining a urine specimen for analysis 4. Inspecting the infant's posterior fontanel

1. Measuring the infant's weight RATIONALE: Frequent weight measurement provides the most important information about fluid balance and the infant's response to fluid replacement. Although stool or urine analysis may provide some information, the results typically aren't available for at least 24 hours, making the tests less useful than measuring weight. The posterior fontanel usually closes from ages 6 to 8 weeks and therefore doesn't reflect fluid balance in a 9-month-old infant.

A physician orders acetaminophen (Tylenol) elixir, 160 mg every 4 hours, for a 14-month-old child who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters? 1. None because this isn't a safe dose 2. 2.5 ml 3. 5 ml 4. 7.5 ml

1. None because this isn't a safe dose RATIONALE: For this client, the safe dose of this drug is 90.8 mg (9.08 kg × 10 mg/kg = 90.8 mg). This dose is equivalent to 2.8 ml. Therefore, the ordered dose isn't safe.

A child, age 6, is anxious and upset before a scheduled bone marrow aspiration. During client preparation, the nurse should keep in mind that: 1. describing what the child will hear, see, smell, and feel will help the child cope with the procedure. 2. the child's anxiety will decrease with each successive procedure. 3. no small detail about the procedure should go unexplained. 4. explaining bone marrow function will help the child understand the reason for the procedure.

1. describing what the child will hear, see, smell, and feel will help the child cope with the procedure. RATIONALE: Children cope with situations better when they can anticipate sensations rather than just trying to comprehend technical explanations. Therefore, describing what the child will hear, see, smell, and feel will help the child cope. Commonly, a child's anxiety increases rather than decreases with each successive procedure. A school-age child can't assimilate every detail. A 6-year-old child can't understand an explanation of bone marrow function; also, such an explanation would be irrelevant.

A nurse is reviewing a teaching plan with parents of an infant undergoing repair for a cleft lip. Which instructions are the most appropriate for the nurse to give? Select all that apply. 1. Offer a pacifier as needed. 2. Lay the infant on his back or side to sleep. 3. Sit the infant up for each feeding. 4. Loosen the arm restraints every 4 hours. 5. Clean the suture line after each feeding by dabbing it with saline solution. 6. Give the infant extra care and support.

2. Lay the infant on his back or side to sleep. 3. Sit the infant up for each feeding. 5. Clean the suture line after each feeding by dabbing it with saline solution. 6. Give the infant extra care and support. RATIONALE: The nurse should instruct the parents to lay the infant on his back or side to sleep to prevent trauma to the surgery site. She should also instruct them to feed the infant in the upright position with a syringe and attached tubing to prevent stress to the suture line from sucking. In addition, to prevent crusts and scarring, the suture line should be cleaned after each feeding by dabbing it with half-strength hydrogen peroxide or saline solution. The parents should give the infant extra care and support because he can't meet emotional needs by sucking. Extra attention may also prevent crying, which stresses the suture line. Offering a pacifier isn't appropriate. Pacifiers shouldn't be used during the healing process because they stress the suture line. Arm restraints keep the infant's hands away from his mouth. They should be loosened every 2 hours, not every 4 hours.

An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note: 1. symmetrical thigh and gluteal folds. 2. Ortolani's sign. 3. increased hip abduction. 4. femoral lengthening.

2. Ortolani's sign. RATIONALE: In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

A 4-year-old boy is scheduled for a nephrectomy to remove a Wilms' tumor. Which intervention listed in the care plan should the nurse question? 1. Provide preoperative teaching to the child and his parents. 2. Palpate his abdomen to monitor tumor growth. 3. Assess vital signs and report hypertension. 4. Monitor urine for hematuria.

2. Palpate his abdomen to monitor tumor growth. RATIONALE: The abdomen of a child with Wilms' tumor should never be palpated because it may increase the risk of metastasis. All children and their parents require preoperative teaching when surgery is planned. Assessing vital signs and monitoring urine are appropriate interventions because a child with Wilms' tumor may be hypertensive as a result of excessive renin production and may have hematuria.

A nurse observes a 2½-year-old child playing with another child of the same age in the playroom on the pediatric unit. What type of play should the nurse expect the children to engage in? 1. Associative play 2. Parallel play 3. Cooperative play 4. Therapeutic play

2. Parallel play RATIONALE: Two-year-olds engage in parallel play, in which they play side by side but rarely interact. Associative play is characteristic of preschoolers, in which they are all engaged in a similar activity but there is little organization. School-age children engage in cooperative play, which is organized and goal-directed. Therapeutic play is a technique that can be used to help understand a child's feelings; it consists of energy release, dramatic play, and creative play.

A nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity is most appropriate for the nurse to schedule in the care plan? 1. Playing ping-pong 2. Reading books 3. Climbing on play equipment in the playroom 4. Ambulating without restrictions

2. Reading books RATIONALE: During the acute phase of rheumatic fever, the child should be placed on bed rest to reduce the workload of the heart and prevent heart failure. Therefore, an appropriate activity for this child would be reading books. Playing ping-pong, climbing on play equipment, and ambulating without restrictions are too strenuous during the acute phase.

When developing a care plan for an adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on: 1. becoming industrious. 2. establishing an identity. 3. achieving intimacy. 4. developing initiative.

2. establishing an identity. RATIONALE: According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers, and strives to attain a personal identity by becoming more independent from his family. Becoming industrious is the developmental task of the school-age child; achieving intimacy is the task of the young adult; and developing initiative is the task of the preschooler.

A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is: 1. assessing vital signs every 30 minutes. 2. monitoring the blood glucose level closely. 3. elevating the head of the bed 60 degrees. 4. providing a daily bath.

2. monitoring the blood glucose level closely. RATIONALE: Most TPN solutions contain a high glucose content, placing the client at risk for hyperglycemia. Therefore, the most important nursing action is to monitor the child's blood glucose level closely. A child receiving TPN isn't likely to require vital sign assessment every 30 minutes or elevation of the head of the bed. A daily bath isn't a priority.

A physician orders corticosteroids for a child with nephrotic syndrome. What is the primary purpose of administering corticosteroids to this child? 1. To increase blood pressure 2. To reduce inflammation 3. To decrease proteinuria 4. To prevent infection

3. To decrease proteinuria RATIONALE: The primary purpose of administering corticosteroids to a child with nephrotic syndrome is to decrease proteinuria. Corticosteroids have no effect on blood pressure. Although they help reduce inflammation, this isn't the reason for their use in clients with nephrotic syndrome. Corticosteroids may predispose a client to, rather than prevent infection.

A child, age 15 months, is admitted to the health care facility. During the initial nursing assessment, which statement by the mother most strongly suggests that the child has a Wilms' tumor? 1. "My child has grown 3" in the past 6 months." 2. "My child seems to be napping for longer periods." 3. "My child's abdomen seems bigger, and his diapers are much tighter." 4. "My child's appetite has increased so much lately."

3. "My child's abdomen seems bigger, and his diapers are much tighter." RATIONALE: The most common presenting sign of a Wilms' tumor is abdominal swelling or an abdominal mass. Therefore, the mother's observation that her child's abdomen seems bigger suggests a Wilms' tumor. A rapid increase in length (height) isn't associated with this type of tumor. Although lethargy may accompany a Wilms' tumor, abdominal swelling is a more specific sign. Children with a Wilms' tumor usually have a decreased, not increased, appetite.

After a nurse explains dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching? 1. "We'll follow these instructions until our child's symptoms disappear." 2. "Our child must maintain these dietary restrictions until adulthood." 3. "Our child must maintain these dietary restrictions for life." 4. "We'll follow these instructions until our child has completely grown and developed."

3. "Our child must maintain these dietary restrictions for life." RATIONALE: Teaching is effective if the parents say their child must maintain the dietary restrictions for life because the child needs to avoid recurrence of the disease's clinical manifestations. Signs and symptoms will reappear if the client eats prohibited foods later in life.

A physician orders meperidine (Demerol), 30 mg I.M., as preoperative medication for a school-age child who weighs 66 lb (30 kg). The meperidine is supplied as 50 mg/ml. How much meperidine should the nurse administer? 1. 0.3 ml 2. 0.5 ml 3. 0.6 ml 4. 0.8 ml

3. 0.6 ml RATIONALE: By using the fraction method and cross-multiplying to solve for X, the nurse can determine that 0.6 ml should be administered: X ml/30 mg = 1 ml/50 mg X ml × 50 mg = 30 mg × 1 ml X = 0.6 ml.

When administering gentamicin (Garamicin) to a preschooler, which monitoring schedule is best for determining the drug's effectiveness? 1. A serum trough level every morning 2. A serum peak level after the second dose 3. A serum trough and peak level around the third dose 4. Serial serum trough levels after three doses (24 hours)

3. A serum trough and peak level around the third dose RATIONALE: Aminoglycosides such as gentamicin have a narrow range between therapeutic and toxic serum levels. A serum peak and trough level (taken half an hour before the dose and half an hour after the dose has been administered) around the third dose is the most accurate way to determine the correct serum values because the third dose provides enough medication buildup in the blood stream to be measured. A trough level every morning, a serum peak level after the second dose, and serial serum trough levels won't provide sufficient data about the effectiveness of the antibiotic.

An infant undergoes surgery to remove a myelomeningocele. To detect complications as early as possible, the nurse should stay alert for which postoperative finding? 1. Decreased urine output 2. Increased heart rate 3. Bulging fontanels 4. Sunken eyeballs

3. Bulging fontanels RATIONALE: Because an infant's fontanels remain open, the skull may expand in response to increased intracranial pressure, a possible postoperative complication. Decreased urine output and sunken eyeballs (signs of dehydration) and a decrease in heart rate are rarely seen as postoperative complications of myelomenigocele removal.

A child, age 15 months, is recovering from surgery to remove a Wilms' tumor. Which finding best indicates that the child is free from pain? 1. Decreased appetite 2. Increased heart rate 3. Decreased urine output 4. Increased interest in play

4. Increased interest in play RATIONALE: A behavioral change is one of the most valuable clues to pain. A child who's pain-free likes to play. In contrast, a child in pain is less likely to play or to consume food or fluids. An increased heart rate may indicate increased pain. Decreased urine output may signify dehydration.

According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Identity versus role confusion

3. Industry versus inferiority RATIONALE: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence.

A 4-year-old has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first? 1. Notify the physician because the child has an NG tube. 2. Immediately give the child an antiemetic I.V. 3. Irrigate the NG tube to ensure patency. 4. Encourage the mother to calm the child down.

3. Irrigate the NG tube to ensure patency. RATIONALE: The nurse should first irrigate the NG tube because if the tube isn't draining properly or is kinked, the child will experience nausea. There's no reason to notify the physician immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn't really address the problem. Encouraging the mother to calm the child is always a good intervention but isn't the first thing to do in this case.

A nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children? 1. Heart 2. Lungs 3. Kidneys 4. Liver

3. Kidneys RATIONALE: The kidneys are most responsible for drug excretion in children. Less commonly, some drugs may be excreted via the lungs or liver. Drugs are never excreted by the heart in children or adults.

A 17-year-old adolescent with acute lymphocytic leukemia is discharged with written information about chemotherapy administration and his outpatient appointment schedule. He now is in the maintenance phase of chemotherapy but has missed clinic appointments for blood work and admits to omitting some chemotherapy doses. To improve his compliance, the nurse should include which intervention in the care plan? 1. Emphasizing the long-term consequences of noncompliance 2. Reprimanding the adolescent for failing to comply with his treatment 3. Letting the adolescent participate in his planning and scheduling of treatments 4. Threatening to discontinue care if he doesn't comply

3. Letting the adolescent participate in his planning and scheduling of treatments RATIONALE: Because the adolescent is striving for independence, health care providers should promote self-reliance whenever possible, such as by letting him participate in planning and scheduling his treatments. He can help establish realistic goals and evaluation outcomes as well as help schedule procedures and chemotherapy doses to minimize lifestyle disruptions. Adolescents are oriented in the present and have relatively little concern for the long-term consequences of their behavior. Reprimanding him or threatening to discontinue care isn't likely to improve compliance and isn't in his best interest.

A toddler is having a tonic-clonic seizure. What should the nurse do first? 1. Restrain the child. 2. Place a tongue blade in the child's mouth. 3. Remove objects from the child's surroundings. 4. Check the child's breathing.

3. Remove objects from the child's surroundings. RATIONALE: During a seizure, the nurse's first priority is to protect the child from injury caused by uncontrolled movements. Therefore, the nurse must first remove objects from the child's surroundings and pad objects that can't be removed. Restraining the child or placing an object in the child's mouth during a seizure isn't appropriate because it may cause injury. When the seizure stops, the nurse should then check for breathing and, if indicated, initiate rescue breathing.

A toddler is in the hospital. The parents tell the nurse they're concerned about the seriousness of the child's illness. Which response to the parents is most appropriate? 1. "Please try not to worry. Your child will be fine." 2. "If you look around, you'll see other children who are much sicker." 3. "What seems to concern you about your child being hospitalized?" 4. "It must be difficult for you when your child is ill and hospitalized."

4. "It must be difficult for you when your child is ill and hospitalized." RATIONALE: Expressing concern is the most appropriate response because it acknowledges the parents' feelings. False reassurance, such as telling parents not to worry, isn't helpful because it doesn't acknowledge their feelings. Encouraging parents to look at how ill other children are also isn't helpful because the focus of the parents is on their own child. Asking what the concern is merely reinforces the parents' concern without addressing it.

Which assessment should alert a nurse that a hospitalized 7-year-old child is at high risk for a severe asthma exacerbation? 1. Oxygen saturation of 95% 2. Mild work of breath 3. Intercostal or substernal retractions 4. A history of steroid-dependent asthma

4. A history of steroid-dependent asthma RATIONALE: The child's history of steroid-dependent asthma is a contributing factor to making him at high risk for a severe exacerbation. The nurse must treat the situation as a severe exacerbation regardless of the severity of the current episode. Decreased oxygen saturation, cyanosis, retractions, and increase (not mild) work of breathing are all assessments of an asthma exacerbation, not risk factors for it. These findings should be treated with oxygen, nebulized respiratory treatments, and steroids. However, if a significant history of high-risk factors is absent, the episode can be treated without hospitalization and followed up with the pediatrician.

A child, age 9, is admitted to the emergency department with abdominal pain. The child's mother states the pain began about 12 hours ago. The nurse notes the child has a temperature of 100.8° F (38.2° C) and nausea. The child vomited once. Which abdominal area would be most appropriate for the nurse to assess? 1. Left lower abdominal quadrant 2. Right upper abdominal quadrant 3. Left upper abdominal quadrant 4. Lower right abdominal quadrant

4. Lower right abdominal quadrant RATIONALE: The child's symptoms indicate appendicitis. Therefore, the nurse should assess the lower right abdominal quadrant. The nurse would assess the left lower abdominal quadrant to detect descending and sigmoid colon problems; right upper quadrant to detect gallbladder disease; and the left upper quadrant to detect pancreatitis.

A nurse is reviewing a care plan for an infant undergoing phototherapy for hyperbilirubinemia. Which intervention should the nurse remove from the care plan? 1. Repositioning the infant frequently to expose all body surfaces 2. Obtaining frequent serum bilirubin levels 3. Shielding the infant's eyes with an opaque mask to prevent exposure to the light 4. Performing frequent visual assessments of jaundice

4. Performing frequent visual assessments of jaundice RATIONALE: Visual assessment of jaundice isn't a valid method for assessing jaundice. Serum bilirubin levels must be checked every 4 to 12 hours. Repositioning the infant and shielding the infant's eyes are appropriate interventions for an infant undergoing phototherapy and should be included in the care plan.

A child is diagnosed with Wilms' tumor. During assessment, the nurse expects to detect: 1. gross hematuria. 2. dysuria. 3. nausea and vomiting. 4. an abdominal mass.

4. an abdominal mass. RATIONALE: The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Gross hematuria is uncommon, although microscopic hematuria may be present. Dysuria isn't associated with Wilms' tumor. Nausea and vomiting are rare in children with Wilms' tumor.

A nurse is caring for a 9-year-old child who has a grave prognosis after receiving a closed injury from being struck by a car. Which health team member should approach the family about organ donation? 1. Nurse-manager 2. Transplant coordinator 3. Emergency department nurse 4. Pastoral care staff member

2. Transplant coordinator RATIONALE: The transplant coordinator is the best health team member to approach the family about organ donation. The transplant coordinator is typically available to hospitals that routinely perform organ transplants. When the coordinator isn't available, the attending physician or another physician not directly involved in determining brain death should approach the family. Although the emergency department nurse may have admitted the child, she and the nurse-manager aren't directly involved with the child's care or with the family. Pastoral care staff members provide emotional and religious support and aren't involved with approaching the family about organ donation; they may, however, be present in a supportive capacity if the family wishes.

An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.7 kg). The physician orders ceftriaxone (Rocephin), 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial containing 500 mg, to which the nurse adds 2 ml of preservative-free normal saline solution. The nurse should administer how many milliliters? 1. None because this isn't a safe dosage 2. 0.08 ml 3. 1.08 ml 4. 1.8 ml

3. 1.08 ml RATIONALE: Because the infant weighs 17 lb (7.7 kg), the safe dosage range is 385 to 578 mg daily. The ordered dosage, 540 mg daily, is safe. To calculate the amount to administer, the nurse may use the following fraction method: 500 mg/2 ml = 270 mg/X ml 500X = 270 × 2 500X = 540 X = 540/500 X = 1.08 ml

An 18-month-old boy is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this child? 1. A concave abdomen 2. Bulges in the groin area 3. A protuberant abdomen 4. A palpable abdominal mass

3. A protuberant abdomen RATIONALE: The nurse would expect to find a protuberant abdomen caused by the presence of fat, bulky stools; undigested food; and flatus, which are associated with celiac disease. A concave abdomen, bulges in the groin area, and a palpable abdominal mass aren't associated with celiac disease.

A chronically ill school-age child is most vulnerable to which stressor? 1. Mutilation anxiety 2. Anticipatory grief 3. Anxiety over school absences 4. Fear of hospital procedures

3. Anxiety over school absences RATIONALE: The school-age child is becoming industrious and attempts to master school-related activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child who's chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children.

A nurse is providing care to a 5-year-old child with a fractured femur whose nursing diagnosis is Imbalanced nutrition: Less than body requirements. Which change is most likely to occur with this condition? 1. Decreased protein catabolism 2. Increased calorie intake 3. Increased digestive enzymes 4. Increased carbohydrate need

4. Increased carbohydrate need RATIONALE: Increased carbohydrate need is most likely because healing and repair of tissue requires more carbohydrates. Increased — not decreased — protein catabolism is present and decreased appetite — not increased — is a problem. Digestive enzymes are decreased — not increased.

A toddler has a temperature above 101° F (38.3° C). The physician orders acetaminophen (Tylenol), 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of: 1. sepsis. 2. leukocytosis. 3. anemia. 4. thrombocytopenia.

4. thrombocytopenia. RATIONALE: A child with thrombocytopenia or neutropenia shouldn't receive rectal medication because of the increased risk of infection and bleeding that may result from tissue trauma. No contraindications exist for administering rectal medication to a child with sepsis, leukocytosis, or anemia.

A child with osteomyelitis is to receive nafcillin I.V. every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable? 1. 50 mg every 6 hours 2. 100 mg every 6 hours 3. 250 mg every 6 hours 4. 500 mg every 6 hours

3. 250 mg every 6 hours RATIONALE: First, the nurse determines the minimum dose: 50 mg × 10 kg = 500 mg/day 500 mg/4 doses (for administration every 6 hours) = 125 mg/dose. Next, the nurse determines the maximum dose: 100 mg × 10 kg = 1,000 mg/day 1,000 mg/4 doses = 250 mg/dose. Thus, the acceptable dosage range for this client is 125 to 250 mg every 6 hours.

A 2-year-old child is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: 1. question the mother about the child's allergies. 2. initiate standard precautions. 3. evaluate the child's neurologic status. 4. examine the child's throat and ears.

3. evaluate the child's neurologic status. RATIONALE: Petechiae across the child's chest, abdomen, and back are signs of meningitis. The priority is to evaluate neurologic status. Petechiae aren't allergic reactions, so the nurse shouldn't ask about allergies. Standard precautions should be used when there is risk of contacting body fluids. Contact precautions should be instituted for the client diagnosed with meningitis. Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis.

A 5-year-old preschooler suspected of having leukemia is admitted to the hospital for diagnosis and treatment. The physician orders a bone marrow aspiration. Place the interventions below in ascending chronological order according to their importance. Use all options. 1. Act out the procedure using a doll and biopsy kit. 2. Assure the child that the pain will go away. 3. Check the biopsy site for hemorrhage and infection. 4. Discuss the procedure with his parents. 5. Explain the discomforts that he'll feel.

4. Discuss the procedure with his parents. 1. Act out the procedure using a doll and biopsy kit. 5. Explain the discomforts that he'll feel. 2. Assure the child that the pain will go away. 3. Check the biopsy site for hemorrhage and infection. RATIONALE: The nurse must first discuss the procedure with the parents and encourage them to get involved with the plan for preparing the child. Next, the nurse should use play to teach the child about the procedure to help gain the child's confidence and put the child at ease. After the child is comfortable, the nurse can explain the discomfort he'll feel and then assure him that the pain will go away. Lastly, after the procedure, the nurse needs to check for bleeding, inflammation, and signs and symptoms of pain and infection.

A child is to receive valproic acid (Depakote) 10 mg/kg by mouth each day. When teaching the parents about the medication regimen, the nurse should use which approach? 1. Conduct brief teaching sessions, provide written materials during each visit, and repeat information as appropriate. 2. Ask the parents to spend an entire day at the facility so they can learn every detail about their child's care. 3. Call the parents at home and explain everything, allowing time for them to ask questions. 4. Send the parents the drug's package insert so they can become familiar with the medication.

1. Conduct brief teaching sessions, provide written materials during each visit, and repeat information as appropriate. RATIONALE: The nurse should provide simple instructions in short sessions, provide written materials, repeat information, and allow time for questions because these are the most effective teaching methods. Asking the parents to spend the day at the facility, calling the parents at home, and sending the parents the drug's package insert are ineffective teaching strategies because they may be overwhelming for the parents and frustrating for the nurse.

A 4-year-old child has recently been diagnosed with acute lymphocytic leukemia (ALL). What information about ALL should the nurse provide when educating the client's parents? Select all that apply. 1. Leukemia is a rare form of childhood cancer. 2. ALL affects all blood-forming organs and systems throughout the body. 3. Because of the increased risk of bleeding, the child shouldn't brush his teeth. 4. Adverse effects of treatment include sleepiness, alopecia, and stomatitis. 5. There's a 95% chance of obtaining remission with treatment. 6. The child shouldn't be disciplined during this difficult time.

2. ALL affects all blood-forming organs and systems throughout the body. 4. Adverse effects of treatment include sleepiness, alopecia, and stomatitis. 5. There's a 95% chance of obtaining remission with treatment. RATIONALE: In ALL, abnormal white blood cells (WBCs) proliferate, but they don't mature past the blast phase. These blast cells crowd out the healthy WBCs, red blood cells, and platelets in the bone marrow, leading to bone marrow depression. The blast cells also infiltrate the liver, spleen, kidneys, and lymph tissue. Common adverse effects of chemotherapy and radiation include nausea, vomiting, diarrhea, sleepiness, alopecia, anemia, stomatitis, mucositis, pain, reddened skin, and increased susceptibility to infection. There's a 95% chance of obtaining remission with treatment. Leukemia is the most common form of childhood cancer. The child schould continue to brush his teeth, but he should use a soft toothbrush to minimize trauma. The child still needs appropriate discipline and limits. A lack of consistent parenting may lead to negative behaviors and fear.

A preschool child presents with a history of vomiting and diarrhea for 2 days. Which assessment finding indicates that the child is in the late stages of shock? 1. Tachycardia 2. Bradycardia 3. Irritability 4. Urine output 1 to 2 ml/kg/hour

2. Bradycardia RATIONALE: Bradycardia is a sign of late shock in a child. Cardiovascular dysfunction and impairment of cellular function lead to lowered perfusion pressures, increased precapillary arteriolar resistance, and venous capacitance. Decreased cardiac output occurs in late shock if the circulating volume isn't replaced. Sympathetic nervous innervation has limited compensation mechanisms if the volume isn't replaced. Tachycardia and irritability occur during the early phase of shock as compensatory mechanisms are implemented to increase cardiac output. Normal pediatric urine output is 1 to 2 ml/kg/hour; volumes less than this would indicate a decrease in renal perfusion and activation of the renin-angiotensin-aldosterone system to decrease water and sodium excretion.

A nurse is reviewing a care plan for an adolescent girl who's receiving chemotherapy for leukemia who was admitted for pneumonia. The adolescent's platelet count is 50,000 μl. Which item in the care plan should the nurse revise? 1. Keep a sign over the bed that reads "NO NEEDLE STICKS AND NOTHING PER RECTUM." 2. Use two peripheral I.V. intermittent infusion devices, one for blood draws and one for infusions. 3. Administer oxygen at a rate of 4 L/minute using a nonhumidified nasal cannula. 4. Use a tympanic membrane sensor to measure her temperature at the bedside.

3. Administer oxygen at a rate of 4 L/minute using a nonhumidified nasal cannula. RATIONALE: Oxygen should be humidified to assure that irritation of the mucosa doesn't occur. This adolescent's platelet level is decreased, so she's at risk for bleeding. The nose is a vascular region that can bleed easily if the mucosa is dried by the oxygen. Therefore, the nurse should revise the care plan to reflect use of humidified oxygen. A sign to remind others to avoid needle sticks and to not give anything via the rectum, the presence of two peripheral I.V.s, and the use of a tympanic temperature device are all aspects of care that would decrease the adolescent's risk of bleeding.

Which item in the care plan for a toddler with a seizure disorder should a nurse revise? 1. Padded side rails 2. Oxygen mask and bag system at bedside 3. Arm restraints while asleep 4. Cardiorespiratory monitoring

3. Arm restraints while asleep RATIONALE: The nurse should revise a care plan that includes restraints. Restraints should never be used on a child with a seizure disorder because they could harm him if a seizure occurs. Padded side rails will prevent the child from injuring himself during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure.

A 6-year-old child is admitted to the pediatric unit for evaluation of recurrent abdominal pain. The child has been admitted to the pediatric unit with similar complaints several times in the past few months. The child's symptoms are vague, yet his mother provides detailed information about the problem. The nurse is suspicious of the situation. What should the nurse do next? 1. Request that the parent leave the hospital unit immediately. 2. Ask to speak with the child without the parent being present. 3. Notify the physician and request assistance from the interdisciplinary team. 4. Contact the authorities immediately.

3. Notify the physician and request assistance from the interdisciplinary team. RATIONALE: The child's clinical presentation and the mother's behavior suggest Munchausen syndrome by proxy, a condition in which an individual fabricates or induces symptoms of a disorder in another person. Suspicion of this condition mandates a coordinated evaluation by the health care team. Rather than asking the parent to leave, the nurse should establish a rapport with her. Doing so will prevent the parent from becoming suspicious and leaving the health care organization, which would potentially allow the cycle to continue. The nurse must contact authorities when she obtains additional evidence.

How should a nurse position a 4-month-old infant when administering an oral medication? 1. Seated in a high chair 2. Restrained flat in the crib 3. Held on the nurse's lap 4. Held in the bottle-feeding position

4. Held in the bottle-feeding position RATIONALE: The nurse should hold an infant in the bottle-feeding position when administering an oral medication by placing the child's inner arm behind the back, supporting the head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. A 4-month-old infant can't sit unsupported in a high chair. Administering medication to an infant lying flat could cause choking and aspiration. Holding the infant in the lap may cause the medication to spill.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? 1. Single-hole nipple 2. Plastic spoon 3. Paper straw 4. Rubber dropper

4. Rubber dropper RATIONALE: An infant with a surgically repaired cleft lip must be fed with a rubber dropper or Breck feeder to prevent sucking or suture line trauma. A single-hole nipple, a plastic spoon, and a paper straw wouldn't prevent these actions.

A 2-year-old child with a low blood level of the immunosuppressive drug cyclosporine comes to a liver transplant clinic for her appointment. The mother says the child hasn't been vomiting and hasn't had diarrhea, but she admits that her daughter doesn't like taking the liquid medication. Which statement by the nurse is most appropriate? 1. "Let your daughter take her medication only when she wants it; it's okay for her to miss some doses." 2. "Offer the medication diluted with chocolate milk or orange juice to make it more palatable." 3. "Insert a nasogastric (NG) tube and administer the medication using the tube as ordered by the physician." 4. "Give the ordered dose a little bit at a time over 2 hours to ensure administration of the medication."

2. "Offer the medication diluted with chocolate milk or orange juice to make it more palatable." RATIONALE: Because liquid cyclosporine has a very unpleasant taste, diluting it with chocolate milk or orange juice will lessen the strong taste and help the child take the medication as ordered. It isn't acceptable to miss a dose because the drug's effectiveness is based on therapeutic blood levels, and skipping a dose could lower the level. Cyclosporine shouldn't be given by NG tube because it adheres to the plastic tube and, thus, all of the drug may not be administered. Taking the medication over a period of time could negatively affect the blood level.

A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? 1. Registered dietitian 2. Physical therapist 3. Occupational therapist 4. Nursing assistant

3. Occupational therapist RATIONALE: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy but isn't trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nursing assistant can help a child eat; however, the nursing assistant isn't trained in modifying utensils.

While preparing to discharge a 9-month-old infant who's recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topic in the teaching session? 1. Nursery schools 2. Toilet training 3. Safety guidelines 4. Preparation for surgery

3. Safety guidelines RATIONALE: Reinforcing safety guidelines is appropriate because such anticipatory guidance helps prevent many accidental injuries. For parents of a 9-month-old infant, it's too early to discuss nursery schools or toilet training. Because surgery isn't used to treat gastroenteritis, this topic is inappropriate.

A 3-month-old infant just had a cleft lip and palette repair. To prevent trauma to the operative site, the nurse should: 1. give the infant a pacifier to help soothe him. 2. lie the infant in the prone position. 3. place the infant's arms in soft elbow restraints. 4. avoid touching the suture line, even to clean.

3. place the infant's arms in soft elbow restraints. RATIONALE: Soft restraints from the upper arm to the wrist are appropriate because they prevent the infant from touching his lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such objects as pacifiers, suction catheters, and small spoons shouldn't be placed in an infant's mouth after cleft palette repair. An infant in a prone position may rub his face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. Dried blood collecting on the suture line can widen the scar.

A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. The school should be informed that: 1. these students are too young to screen; instead, older students should be screened. 2. these students are too old to screen and will no longer benefit from screening for scoliosis. 3. scoliosis screening requires sophisticated equipment and can't be done in school. 4. this is an appropriate request and arrangements will be made as soon as possible.

4. this is an appropriate request and arrangements will be made as soon as possible. RATIONALE: The school's request is appropriate because screening for scoliosis should begin at age 8 and be performed yearly thereafter. Also, because screening for scoliosis involves inspection of the spine and use of a scoliometer, both can be done in a school setting.

An infant boy has just had surgery to repair his cleft lip. Which nursing intervention is important during the immediate postoperative period? 1. Cleaning the suture line carefully with a sterile solution after every feeding 2. Laying the infant on his abdomen to help drain fluids from his mouth 3. Allowing the infant to cry to promote lung reexpansion 4. Giving the baby a pacifier to suck for comfort

1. Cleaning the suture line carefully with a sterile solution after every feeding RATIONALE: To avoid an infection that could adversely affect the cosmetic outcome of the repair, the suture line must be cleaned very gently with a sterile solution after each feeding. Laying an infant on his abdomen after a cleft lip repair isn't appropriate because doing so will put pressure on the suture line, causing damage. The infant can be positioned on his side to drain saliva without affecting the suture line. Crying puts tension on the suture line and should be avoided by anticipating the baby's needs, such as holding and cuddling him. Hard objects such as pacifiers should be kept away from the suture line because they can cause damage.

A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care? 1. Taking vital signs every 4 hours and obtaining daily weight 2. Obtaining a blood sample for electrolyte analysis every morning 3. Checking every urine specimen for protein and specific gravity 4. Ensuring that the child has accurate intake and output and eats a high-protein diet

1. Taking vital signs every 4 hours and obtaining daily weight RATIONALE: Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation — can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. These actions are less important nursing measures in this situation.

A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing? 1. Caring for the same child from admission to discharge 2. Caring for different children each shift to gain nursing experience 3. Taking vital signs for every child hospitalized on the unit 4. Assuming the charge nurse role instead of participating in direct child care

1. Caring for the same child from admission to discharge RATIONALE: Primary care nursing requires that the primary nurse care for the same child (to whom she's assigned) during her scheduled shift. The associate nurse is assigned to the child care assignment when the primary nurse has a day off or during the evening and night shifts. Caring for different children each shift doesn't promote continuity of care. Taking vital signs for every child on the floor is an example of team nursing, in which each member of the team is assigned one specific task for each child. The charge nurse may be directly involved in child care.

A child has just been admitted to the facility and is displaying fear related to separation from his parents, the room being too dark, being hurt while in the hospital, and having many different staff members come into the room. Based on the nurse's knowledge of growth and development, the child is likely: 1. 7 to 12 months old (an infant). 2. 1 to 3 years old (a toddler). 3. 6 to 12 years old (a school-age child). 4. 12 to 18 years old (an adolescent).

2. 1 to 3 years old (a toddler). RATIONALE: Toddlers show fear of separation from their parents, the dark, loud or sudden noises, injury, strangers, certain persons, certain situations, animals, large objects or machines, and change in environment. Infants show fear of strangers, the sudden appearance of unexpected and looming objects (including people), animals, and heights. School-age children show fear of supernatural beings, injury, storms, the dark, staying alone, separation from parents, things seen on television and in the movies, injury, tests and failure in school, consequences related to unattractive physical appearance, and death. Adolescents show fear of inept social performance, social isolation, sexuality, drugs, war, divorce, crowds, gossip, public speaking, plane and car crashes, and death.

An 8-year-old child is suspected of having meningitis. Signs of meningitis include: 1. Cullen's sign. 2. Koplik's spots. 3. Kernig's sign. 4. Chvostek's sign.

3. Kernig's sign. RATIONALE: Signs and symptoms of meningitis include Kernig's sign, stiff neck, headache, and fever. To test for Kernig's sign, the client is in the supine position with knees flexed; a leg is then flexed at the hip so that the thigh is brought to a position perpendicular to the trunk. An attempt is then made to extend the knee. If meningeal irritation is present, the knee can't be extended and attempts to extend the knee result in pain. Cullen's sign is the bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. Koplik's spots are reddened areas with grayish blue centers that are found on the buccal mucosa of a client with measles. Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. A calcium deficit is suggested if the facial muscles twitch.

A child, age 5, has acute lymphocytic leukemia (ALL) and is receiving induction chemotherapy consisting of vincristine (Oncovin), asparaginase (L-asparaginase [Elspar]), and prednisone (Deltasone). When teaching the parents about the adverse effects of this regimen, the nurse should stress the importance of promptly reporting: 1. hair loss. 2. moon face. 3. blindness. 4. bone pain.

3. blindness. RATIONALE: Neurotoxicity, the primary adverse effect of vincristine, may manifest as blindness that the parents must report promptly. Neurotoxicity may also cause peripheral neuropathy. Hair loss and moon face are expected adverse effects of this chemotherapy regimen and will resolve once therapy ends. Bone pain is common in clients with ALL and results from invasion of the periosteum by leukemic cells.

Which assessment finding in a 4-month-old infant is a concern? 1. The abdominal wall is rising with inspiration. 2. The respiratory rate is between 30 and 35 breaths/minute. 3. The infant's skin is mottled during examination. 4. The spaces between the ribs (intercostal) are delineated during inspiration.

4. The spaces between the ribs (intercostal) are delineated during inspiration. RATIONALE: The presence of intercostal retractions is a sign of respiratory distress from an obstruction or a disease such as pneumonia, which causes the infant to have to work to breathe. Infants and children up to age 7 are abdominal breathers; after that age, they change to an adult pattern of breathing, which uses the diaphragmatic and thoracic muscles. A normal respiratory rate for an infant up to age 1 is 20 to 40 breaths/minute; a rate between 30 and 35 breaths/minute is within this normal range. An infant's skin can become mottled if the infant is left uncovered during the examination; this change isn't a cause for concern.

A nurse is caring for an 18-month-old infant 24 hours after surgery to repair a fractured tibia. Which comfort interventions are appropriate? Select all that apply. 1. Reposition the infant as often as needed. 2. Let the infant play with his favorite toy. 3. Allow the infant's family to participate in his care as much possible. 4. Explain to the infant what she's going to do before she does it. 5. Be sure the infant gets at least 14 hours of sleep each night. 6. Give the infant his favorite foods.

1. Reposition the infant as often as needed. 2. Let the infant play with his favorite toy. 3. Allow the infant's family to participate in his care as much possible. 4. Explain to the infant what she's going to do before she does it. RATIONALE: Frequent repositioning helps decrease discomfort and gives the nurse an opportunity to assess for changes in status. Infants and children derive comfort and security from playing with a favorite toy or animal. Such play should be encouraged as long as it's permitted. Familiarity is a positive force with children, and parents should be encouraged to participate in their child's care. The nurse should explain her actions to the infant. Although the infant may not understand each event, it's better for the nurse to provide an explanation rather than leave the infant fearful of what might happen. It isn't necessary for an infant who has undergone surgery to get at least 14 hours of sleep per night. Pain, comfort level, and general anxiety may prevent him from receiving much sleep in the acute-care setting. Giving the infant favorite foods in the first 24 to 48 postoperative hours may not be an option; physicians order postoperative diet regimens.

A nurse is caring for a 5-year-old child who's in the terminal stages of cancer. Which statements are true? Select all that apply. 1. The parents may be at different stages in dealing with the child's death. 2. The child is thinking about the future and knows he may not be able to participate. 3. The dying child may become clingy and act like a toddler. 4. Whispering in the child's room will help the child to cope. 5. The death of a child may have long-term disruptive effects on the family. 6. The child doesn't fully understand the concept of death.

1. The parents may be at different stages in dealing with the child's death. 3. The dying child may become clingy and act like a toddler. 5. The death of a child may have long-term disruptive effects on the family. 6. The child doesn't fully understand the concept of death. RATIONALE: When dealing with a dying child, parents may be at different stages of grief at different times. The child may regress in his behaviors. The stress of a child's death commonly results in parents' divorce and behavioral problems in siblings. Preschoolers see death as temporary — a type of sleep or separation. They recognize the word "dead" but don't fully understand its meaning. Thinking about the future is typical of an adolescent facing death, not a preschooler. Whispering in front of the child would likely increase his fear of death.

A 12-year-old child has been receiving aggressive treatment for leukemia for the past year. His prognosis is poor and his parents would like to implement a do-not-resuscitate order. They ask the nurse to discuss their decision with their child because they can't bring themselves to talk with him about it. When approaching this subject with the child, the nurse must first assess: 1. what the child knows about the disease. 2. how the child would like to handle the care plan. 3. what interventions the child would like implemented in the event of cardiac or respiratory arrest. 4. the child's experiences with death.

1. what the child knows about the disease. RATIONALE: When discussing a child's wishes for future care, a nurse must first identify what the child knows about the disease. How severe he perceives the illness to be will significantly affect his thoughts about realistic outcomes. A care plan proposed by a child who doesn't understand his disease process or prognosis won't effectively or realistically reflect his actual health status. A child who doesn't understand his disease process or prognosis might feel frightened or threatened by questions about what interventions he'd like to have implemented in the event of cardiac or respiratory arrest. Although exploring the child's experiences with death would be important, it shouldn't be the initial area of discussion.

A physician diagnoses leukemia in a child, age 4, who complains of being tired and sleeps most of the day. Which nursing diagnosis reflects the nurse's understanding of the physiologic effects of leukemia? 1. Ineffective airway clearance related to fatigue 2. Activity intolerance related to anemia 3. Imbalanced nutrition: More than body requirements related to lack of activity 4. Ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells

2. Activity intolerance related to anemia RATIONALE: A nursing diagnosis of Activity intolerance related to anemia reflects the nurse's understanding of leukemia's physiologic effects because a child with leukemia may experience anemia from bone marrow depression, such as from chemotherapy or replacement of normal bone marrow elements by immature white blood cells. Anemia results in fatigue, lack of energy, and activity intolerance. The nurse's findings don't support the other diagnoses of Ineffective airway clearance related to fatigue, Imbalanced nutrition: More than body requirements related to lack of activity, and Ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells.

A nurse is reviewing her shift assignment. Which child should she assess first? 1. A 5-month-old infant with I.V. fluids infusing 2. An 11-month-old infant receiving chemotherapy through a central venous catheter 3. An 8-year-old child in traction with a femur fracture 4. A 14-year-old child who is postoperative and has a nasogastric tube and an indwelling urinary catheter

2. An 11-month-old infant receiving chemotherapy through a central venous catheter RATIONALE: The nurse should assess the 11-month-old infant with a central venous catheter first. This child takes priority because he has an invasive line and is receiving chemotherapy, which may cause toxic effects. Next, the nurse should assess the 5-month-old infant with an I.V. infusion and then the 14-year-old postoperative child. Because he's the most stable, the nurse can assess the 8-year-old child in traction last.

A staffing agency is sending a licensed practical nurse (LPN) to cover a shift for a pediatric nurse who called out sick. The unit's nurse-manager isn't familiar with the LPN's clinical background or comfort level with pediatric clients. The nurse-manager should assign the LPN to: 1. an 8-year-old child admitted that morning with suspected Reye's syndrome. 2. a 9-year-old child receiving subcutaneous (subQ) insulin for treatment of diabetes mellitus. 3. a 10-year-old child who had a tonsillectomy that morning. 4. a 9-year-old child with Legg-Calve'-Perthes disease.

2. a 9-year-old child receiving subcutaneous (subQ) insulin for treatment of diabetes mellitus. RATIONALE: The nurse-manager should assign the LPN to the child with diabetes mellitus. Because he's receiving subQ insulin rather than I.V. insulin, his diabetes is likely stable. Reye's syndrome is an acute condition with the potential to progress into respiratory depression, seizures, loss of deep tendon reflexes, or other neurologic deficits. This child will require frequent nursing assessments. The child who had a tonsillectomy remains at risk for hemorrhage during the first 24 hours following surgery. Legg-Calve'-Perthes Disease is associated with impaired circulation to the femoral capital epiphysis. This condition requires aggressive monitoring.

When developing a postoperative care plan for an infant scheduled for cleft lip repair, the nurse should assign highest priority to which intervention? 1. Comforting the child as quickly as possible 2. Maintaining the child in a prone position 3. Restraining the child's arms at all times, using elbow restraints 4. Avoiding disturbing any crusts that form on the suture line

1. Comforting the child as quickly as possible RATIONALE: After surgery to repair a cleft lip, the primary goal of nursing care is to maintain integrity of the operative site. Crying causes tension on the suture line, so comforting the child as quickly as possible is the highest nursing priority. Parents may help by cuddling and comforting the child. The prone position is contraindicated after surgery because rubbing on the sheet may disturb the suture line. Elbow restraints may cause agitation; if used to prevent the child from disturbing the suture line, they must be removed, one at a time, every 2 hours so that the child can exercise and the nurse can assess for skin irritation. Crusts forming on the suture line contribute to scarring and must be cleaned carefully.

A physician ordered an X-ray for an adolescent in the pediatric unit. With whom should the nurse collaborate to carry out this order? 1. Transport personnel 2. Physician 3. Pharmacist 4. Circulating nurse

1. Transport personnel RATIONALE: Transport personnel are responsible for escorting clients throughout the hospital, including to various test locations. The physician isn't required to transport any client to the radiology department. The pharmacist is responsible for anything related to medications. The circulating nurse assists with surgical procedures in the operating room; she doesn't help transport clients to the X-ray department

An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to: 1. ask to see a copy of the advance directive. 2. administer oxygen to the infant while awaiting the physician's orders. 3. provide palliative care for the infant and his family. 4. contact the nursing supervisor for assistance.

1. ask to see a copy of the advance directive. RATIONALE: In order to have information about how to proceed, the nurse must evaluate the advance directive. Until the nurse evaluates the legitimacy and content of the advance directive, it's inappropriate for her to administer oxygen or provide palliative care. The nurse should ask to see the advanced directive before proceeding with care; contacting the nursing supervisor isn't the most appropriate initial response.

A small child is admitted to the facility with a fever. Which statement made by the child's mother indicates understanding of the nurse's teaching? 1. "I will keep the child in light clothing." 2. "I will starve a fever and feed a cold." 3. "I should bring the child back to the emergency department (ED) if his temperature reaches 103° F (39.4° C)." 4. "If acetaminophen doesn't reduce the fever, I can give Motrin in 2 hours."

1. "I will keep the child in light clothing." RATIONALE: Evidence-based practice recommends keeping a child with a fever in cool clothing and a comfortable environment. Therefore, the mother exhibits understanding by saying she will keep the child in light clothing. A child with a fever needs increased fluids and a proper diet. It isn't necessary to take the child with a temperature of 103° F to the ED. The current recommendation is to call the child's physician and then go to the ED if the child has a temperature greater than 105° F (40.5° C). Acetaminophen should be given every 4 hours and ibuprofen every 6 to 8 hours to prevent hepatotoxicity. Giving the child ibuprofen 2 hours after acetaminophen would be too soon according to these guidelines.

Which statement indicates that a family of a dying 4-year-old may be ready to consider organ donation? 1. "My wife and I feel that our real daughter has moved on even though her body is still functioning." 2. "Those physicians aren't doing everything they can for our daughter. I know she's still in there." 3. "When will our daughter wake up and be with us?" 4. "How can some parents allow their children to be cut up like a piece of meat and given away?"

1. "My wife and I feel that our real daughter has moved on even though her body is still functioning." RATIONALE: Statements indicating that the family has accepted the grave condition of their child is a green light for approaching them about organ donation. Statements that represent the family's nonacceptance of the child's prognosis, the lack of understanding of treatments that are being given, or the misunderstanding of organ and tissue donation are indications that the family isn't ready to be approached or to make a decision.

A child, age 10, is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as ordered. The child's left leg is immobilized in a splint. What is an appropriate expected outcome for this child? 1. "The child will change position with minimal discomfort." 2. "The child will bear weight on the affected limb." 3. "The child will ambulate with crutches." 4. "The child will participate in age-appropriate activities."

1. "The child will change position with minimal discomfort." RATIONALE: To prevent pressure ulcers, the child must turn and change positions periodically. However, during the acute phase of osteomyelitis, moving the affected leg may cause extreme pain and discomfort. Therefore, the nurse must support and handle the leg gently during turning and repositioning. Weight bearing is contraindicated because it may cause pathologic fractures. Ambulating with crutches is an inappropriate outcome because the child is restricted to bed rest and the affected leg is immobilized to limit the spread of infection. Participation in age-appropriate activities isn't a realistic outcome because an acutely ill child isn't likely to be interested in activities; this outcome would be suitable after the acute disease phase ends.

A nurse is taking a history from the parents of a 11-year-old girl admitted with Reye's syndrome. Which illness should the nurse expect the parents to report their child having the previous week? 1. Chickenpox 2. Bacterial meningitis 3. Strep throat 4. Lyme disease

1. Chickenpox RATIONALE: Reye's syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye's syndrome. Bacterial meningitis and strep throat are caused by bacteria and don't lead to Reye's syndrome. Lyme disease is caused by a spirochete and isn't implicated in Reye's syndrome.

A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which assessment findings are consistent with this syndrome? 1. Fever, decreased level of consciousness (LOC), and impaired liver function 2. Joint inflammation, red macular rash with a clear center, and low-grade fever 3. Peripheral edema, fever for 5 or more days, and "strawberry tongue" 4. Red, raised "bull's eye" rash, malaise, and joint pain

1. Fever, decreased level of consciousness (LOC), and impaired liver function RATIONALE: Reye's syndrome occurs in children with a history of a viral infection, varicella, or influenza. It's commonly associated with the administration of aspirin. The child presents with fever and decreased LOC, which can lead to coma and death. As the disease progresses, the child also develops impaired liver function. A child with joint pain, a red macular rash with a clear center, and a low-grade fever probably has rheumatic fever. A child presenting with peripheral edema, fever for more than 5 days, and a "strawberry tongue" probably has Kawasaki disease. A child with a red, raised "bull's eye" rash, malaise, and joint pain should be tested for Lyme disease.

An adolescent in the terminal stage of leukemia cries out for more pain medicine. What is the best action for a nurse to take in caring for this dying adolescent? 1. Give him more pain medication to control his pain and suffering. 2. Withhold pain medication because he may become addicted to it. 3. Maintain a strict medication administration schedule. 4. Withhold medication because the adolescent has a low pain threshold.

1. Give him more pain medication to control his pain and suffering. RATIONALE: The adolescent is in severe pain and requires more pain medication. The goal of treatment at this stage of terminal cancer is to make the adolescent as comfortable as possible. Increased tolerance and addiction potential aren't concerns. Strict timing of medication administration doesn't always coincide with an individual's fluctuating pain. The nurse should give the medication even if the adolescent's need for it doesn't match the administration schedule. Pain is what a client says it is; a nurse shouldn't withhold medication or make judgments about a client's pain threshold.

When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening? 1. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed. 2. Listen for a clicking sound as the child abducts the hips. 3. Have the child run the heel of one foot down the shin of the other leg while standing. 4. Have the child shrug the shoulders as the nurse applies mild pressure to the shoulders.

1. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed. RATIONALE: To screen for scoliosis, a lateral curvature of the spine, the nurse has the child stand firmly on both feet with the trunk exposed and examines the child from behind, checking for asymmetry of the shoulders, scapulae, or hips. The nurse then asks the child to bend forward at the hips and inspects for a rib hump, a sign of scoliosis. Listening for a clicking sound while the child abducts the hips is appropriate when screening for congenital hip dysplasia. The heel-to-shin test evaluates cerebellar function and having the child shrug the shoulders against mild resistance helps evaluate the integrity of cranial nerve XI.

An infant undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively? 1. Ineffective airway clearance 2. Imbalanced nutrition: Less than body requirements 3. Interrupted breast-feeding 4. Hypothermia

1. Ineffective airway clearance RATIONALE: Ineffective airway clearance has the highest priority in the immediate postoperative period. The infant's airway must be carefully assessed and frequent suctioning may be necessary to remove mucus while taking care not to pass the catheter as far as the suture line. Assess breath sounds, respiratory rate, skin color, and ease of breathing. Because of the risk of edema and airway obstruction, keep a laryngoscope and endotracheal intubation equipment readily available. Imbalanced nutrition, Interrupted breast-feeding, and Hypothermia are also important during the postoperative period but only after a patent airway is ensured.

A toddler is admitted to the facility with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip (Labstix). Which finding is the nurse most likely to see? 1. Proteinuria 2. Glycosuria 3. Ketonuria 4. Polyuria

1. Proteinuria RATIONALE: In nephrotic syndrome, the glomerular membrane of the kidneys becomes permeable to proteins, resulting in massive proteinuria. Nephrotic syndrome typically doesn't cause glycosuria or ketonuria. Because the syndrome causes fluids to shift from plasma to interstitial spaces, it's more likely to decrease urine output than to cause polyuria (excessive urine output).

Which use of restraints in a school-age child should the nurse question? 1. To substitute for observation 2. To ensure the child's comfort or safety 3. To facilitate examination 4. To aid in carrying out procedures

1. To substitute for observation RATIONALE: Restraints should never be used as a punishment or as a substitute for observation because if a child is at risk for harming himself when left alone, the child requires one-on-one observation. Ensuring the child's comfort or safety (restraining him to keep an I.V., drainage tube, or orthopedic device in place), facilitating examination, and carrying out procedures are all valid reasons for restraint. Restraining devices aren't without risk and must be checked and documented every 1 to 2 hours.

A nurse caring for an adolescent in traction should: 1. assess pin sites every shift and as needed. 2. ensure that the rope knots catch on the pulley. 3. add and remove weights at the adolescent's request. 4. put all his joints through range of motion every shift.

1. assess pin sites every shift and as needed. RATIONALE: Nursing care for a client in traction includes assessing pin sites every shift and as needed and ensuring that the knots in the rope don't catch on the pulley. The nurse should add and remove weights at the physician's order, not at the adolescent's request. All joints, except those immediately proximal and distal to the fracture, should be put through range of motion every shift.

A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: 1. help the family prepare for the infant's imminent death. 2. implement measures to facilitate the attachment process. 3. provide emotional support so the family can adjust to the birth of an infant with health problems. 4. prepare the family for the extensive surgical procedures the infant will require.

1. help the family prepare for the infant's imminent death. RATIONALE: Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive.

A nurse in the pediatric intensive care unit is caring for the only survivor of a house fire that killed seven people. Reporters from local newspapers and television stations are at the hospital, trying to obtain information about the child's condition. The nurse knows that she: 1. may not disclose information regarding the child's condition. 2. may disclose the child's condition, but not his name. 3. may make a statement about how sad she feels for the little boy's family and friends. 4. should contact an attorney because of the legal issues involved in caring for the child.

1. may not disclose information regarding the child's condition. RATIONALE: According to Health Insurance Portability and Accountability Act standards, a nurse can't provide information regarding a child's care unless the child's parent or guardian authorizes her to do so. It wouldn't be appropriate for the nurse to contact an attorney at this time. Although not legally wrong, it wouldn't be appropriate for the nurse to make a statement about her feelings about the situation.

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is: 1. skin traction applied to a lower extremity, with the extremity suspended above the bed. 2. skeletal traction applied to a lower extremity. 3. skin traction applied to an extended lower extremity. 4. skin traction applied bilaterally to the lower extremities.

1. skin traction applied to a lower extremity, with the extremity suspended above the bed. RATIONALE: Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction.

The parents of a school-age child with a brain tumor have elected to have only comfort measures instituted for their dying child. The child has been experiencing significant discomfort and has been receiving pain medication. A nurse knows that the pain-management principle most effective in controlling the child's pain is: 1. striving to prevent pain by routine administration of pain medication. 2. administering pain medication promptly when the child requests it. 3. using an age-appropriate tool for effectively assessing pain. 4. alternating stronger opioid pain medications with nonopioid agents.

1. striving to prevent pain by routine administration of pain medication. RATIONALE: When providing comfort measures for a child, the nurse should strive to prevent pain by providing routine pain medication. Although the nurse should administer pain medication promptly, the goal of treatment should be to prevent pain rather than simply respond to it. Assessing pain with an age-appropriate tool is important; however, the effective assessment of pain shouldn't take precedence over the effective treatment of pain. Alternating stronger opioid medications with nonopioid medications may be effective, but the nurse should individualize the treatment to meet the child's needs.

A charge nurse is making evening-shift assignments. A unit nurse has requested that she not be assigned to care for a particular child because she has cared for him for the past four shifts and hasn't been able to leave on time. The charge nurse knows that the child and his family have bonded with the unit nurse. The charge nurse's best action would be to: 1. talk with the unit nurse about the assignment and why she doesn't want to take care of the child tonight. 2. promise the unit nurse that she will help her so she can leave on time. 3. assign the child's care to the unit nurse anyway. 4. acknowledge the unit nurse's request and assign the child's care to another nurse.

1. talk with the unit nurse about the assignment and why she doesn't want to take care of the child tonight. RATIONALE: It's the charge nurse's responsibility to make clinical assignments based on safety and client needs. Talking about her reasons for not wanting to care for the child may enable the unit nurse to recognize her duty to the child and to the unit. Continuity of care is in the child's best interest. A nurse should never promise to perform a duty or action; negative feelings will result if she can't keep her promise. Unless there's a valid reason to assign the child's care to another nurse, the charge nurse should talk with the unit nurse before making the assignment.

When telling a 4-year-old child about an upcoming procedure, the nurse's most important consideration is to: 1. use simple terms. 2. speak loudly and clearly. 3. offer a toy to keep the child happy. 4. include every detail.

1. use simple terms. RATIONALE: When explaining a procedure to a 4-year-old child, the nurse must use simple terms that the child can understand. Speaking loudly may provoke anxiety. Distracting the child with a toy is more appropriate during the procedure rather than before it. Because preschoolers have a limited attention span, the nurse should provide only the necessary basic facts — not every detail — to prevent anxiety.

A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The physician diagnoses type 1 diabetes and admits the child to the facility for insulin regulation. The physician orders an insulin regimen of insulin (Humulin R) and isophane insulin (Humulin N) administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act? 1. ½ to 1 hour 2. 1 to 2 hours 3. 4 to 8 hours 4. 8 to 10 hours

1. ½ to 1 hour RATIONALE: Regular insulin, a rapid-acting insulin, begins to act in ½ to 1 hour, reaches peak concentration levels in 2 to 10 hours, and has a duration of action of 5 to 15 hours.

When administering total parenteral nutrition (TPN) through a peripheral I.V. line to a school-age child, what is the lowest amount of glucose that is considered safe and not caustic to small veins that will also provide adequate TPN? 1. 5% glucose 2. 10% glucose 3. 15% glucose 4. 17% glucose

2. 10% glucose RATIONALE: The amount of glucose that is considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. A glucose amount of 5% isn't sufficient nutritional replacement, although it's safe for peripheral veins. Any amount above 10% glucose, such as 15% and 17%, must be administered via central venous access.

A charge nurse on the pediatric unit informs the staff nurse that four children require attention. Which child should the nurse see first? 1. An 8-year-old child admitted from the postanesthesia care unit who's complaining of pain 2. A 10-year-old child with asthma whose oxygen saturation levels are dropping 3. A 7-year-old child whose mother is waiting for discharge instructions 4. A 9-year-old child with a broken leg who wants help moving from the bed to the chair

2. A 10-year-old child with asthma whose oxygen saturation levels are dropping RATIONALE: Decreasing oxygen saturation levels indicate difficulty breathing and increased work of breathing. Airway, breathing, and circulation always take priority. The children complaining of pain and waiting for discharge instructions don't take priority because administration of pain medication and reviewing discharge instructions can be delegated to another registered nurse. Moving a client from the bed to the chair can be delegated to a nursing assistant.

An 8-year-old child is receiving moderate sedation for a medical procedure. The nurse is assessing the child's level of sedation. His gag reflex is intact, he's breathing comfortably on his own, and he opens his eyes on verbal request. The nurse recognizes that the child is: 1. undersedated. 2. appropriately sedated. 3. deeply sedated. 4. oversedated.

2. appropriately sedated. RATIONALE: Moderate sedation is an induced state of depressed consciousness. While under moderate sedation, the child should maintain protective reflexes (such as the gag reflex), maintain a patent airway independently, and respond to physical stimuli or verbal commands such as, "Open your eyes." In this scenario, the nurse assesses that the child is under moderate sedation. An undersedated child would likely be anxious and would complain of pain. In deep sedation, the child isn't as easily aroused and doesn't have protective reflexes or the ability to maintain a patent airway; this type of sedation is closer to general anesthesia. With oversedation, the child is difficult to rouse; however, he is able to maintain a patent airway independently.

A nurse is instructing a school-age child with a fracture on proper use of crutches. Which statement made by the nurse is most accurate? 1. "After advancing both crutches the length of one step, move your 'good' leg forward." 2. "After advancing both crutches the length of one step, move your 'bad' leg forward." 3. "Move one crutch forward, then advance your 'good' leg." 4. "Move one crutch forward, then advance your 'bad' leg."

2. "After advancing both crutches the length of one step, move your 'bad' leg forward." RATIONALE: When walking with crutches, a child should be instructed to advance both crutches, then advance the affected leg. The unaffected leg then supports much of the weight associated with ambulation. It wouldn't be effective to move the unaffected leg forward first. It wouldn't be safe for the child to advance only one crutch.

An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care? 1. "I use a soft toothbrush to clean my teeth." 2. "I remove white patches from my tongue and cheeks with my toothbrush." 3. "I rinse my mouth every 2 to 4 hours with a solution of baking soda and water." 4. "I don't use commercial mouthwashes."

2. "I remove white patches from my tongue and cheeks with my toothbrush." RATIONALE: White patches on the tongue and oral mucosa indicate infection; the adolescent should report the patches, not remove them. Using a soft toothbrush is appropriate because it prevents injury to the fragile oral mucosa. Rinsing his mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution helps prevent stomatitis. Avoiding commercial mouthwashes is appropriate because they may contain alcohol, which may dry the oral mucosa.

A day-shift nurse tells a night-shift nurse that she's been attempting to reduce the risk for Impaired skin integrity related to immobility in a toddler. Which statement by the night-shift nurse should the day-shift nurse question? 1. "I'll gently massage the skin with a lubricating substance." 2. "I'll spread a thin layer of lotion over pressure points." 3. "I'll change the toddler's position frequently." 4. "I'll clean the skin as often as necessary."

2. "I'll spread a thin layer of lotion over pressure points." RATIONALE: Using a lotion on the pressure points will soften the skin and promote its breakdown and therefore, should be avoided. Gently massaging the skin with a lubricating substance is recommended because it will stimulate circulation and help prevent breakdown. Changing the toddler's position frequently will help minimize pressure, prevent edema, and stimulate circulation. Keeping the skin clean will lessen the chances of irritation and breakdown.

A 15-year-old girl with a urinary tract infection is admitted to the facility. She tells the nurse she hopes she's pregnant. How should the nurse respond? 1. "Does your mother know about this?" 2. "Tell me what being pregnant would mean to you." 3. "Congratulations. Does the baby's father know?" 4. "I hope you aren't pregnant; you're too young."

2. "Tell me what being pregnant would mean to you." RATIONALE: When talking with adolescents, it's best to get their viewpoints and thoughts before offering suggestions or giving advice. Doing so promotes therapeutic communication. Asking whether the girl's mother knows about her condition and desire to be pregnant or asking about the baby's father focuses attention away from the adolescent. A statement about the girl being too young to be pregnant is a value judgment and inappropriate for the nurse to make.

A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first? 1. An infant with a myelomeningocele who is scheduled for surgical placement of a ventriculoperitoneal shunt at 10 a.m. 2. A restless infant with a high-pitched cry who was transferred from intensive care unit (ICU) the previous evening 3. An infant with an axillary temperature of 100.4 ° F (38° C) on the third postoperative day 4. An infant whose ventriculoperitoneal shunt must be pumped every 2 hours following shunt revision the previous day. The shunt was last pumped at 6 a.m.

2. A restless infant with a high-pitched cry who was transferred from intensive care unit (ICU) the previous evening RATIONALE: An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transferred from ICU the previous night, assessing him for increased ICP should be a nursing priority. The infant with a myelomeningocele who is scheduled for surgical placement of a ventriculoperitoneal shunt is stable, so assessing him isn't the most urgent nursing priority. Although the nurse must assess a low-grade fever on the third postoperative day, this stable infant isn't the priority at this time. Pumping a ventriculoperitoneal shunt is less urgent than evaluating increased ICP.

Before a routine checkup, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? 1. Measure the head circumference. 2. Auscultate the heart and lungs. 3. Elicit the pupillary reaction. 4. Weigh the child.

2. Auscultate the heart and lungs. RATIONALE: The nurse should first ausculate the heart and lungs because this assessment rarely distresses an infant. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing him may cause distress, making the rest of the examination more difficult.

When assessing a toddler's growth and development, the nurse understands that a child in this age-group displays behavior that fosters which developmental task? 1. Initiative 2. Autonomy 3. Trust 4. Industry

2. Autonomy RATIONALE: The toddler's developmental task is to achieve autonomy while overcoming shame and doubt. Developing initiative is the preschooler's task whereas developing trust is the infant's task. Developing industry is the task of the school-age child.

Which method is reliable for identifying a preschooler before administering a medication? 1. Check the name on the bed. 2. Check the hospital identification bracelet. 3. Ask the child his name. 4. Ask the parents at the bedside.

2. Check the hospital identification bracelet. RATIONALE: The only safe method for identifying the child is to check the identification band for the client's name and medical record number and then compare that information with the medication record. Children sometimes exchange beds during play, so checking the name on the bed isn't reliable. Infants are unable to give their names, toddlers or preschoolers may admit to any name, and school-age children may deny their identities in an attempt to avoid the medication. Parents aren't always at the bedside, so they shouldn't be relied on for identification.

When caring for a child, age 12, who's diagnosed with osteomyelitis of the left femur, the nurse should take which action first? 1. Administer I.V. antibiotics as ordered. 2. Draw blood for cultures as ordered. 3. Monitor hepatic and renal studies. 4. Prepare the child for immediate surgery.

2. Draw blood for cultures as ordered. RATIONALE: Osteomyelitis, an infectious bone disease, typically results from Staphylococcus aureus or Haemophilus influenzae. Blood cultures must be obtained to identify the causative organism and determine its sensitivity to antimicrobial agents. Although treatment may include high doses of antibiotics, blood cultures must be obtained before antibiotic therapy begins. Hepatic and renal studies are obtained during the course of antibiotic therapy to monitor the child for adverse effects. Later, surgery may be necessary to drain abscesses.

A school-age child begins to have a seizure while walking to the bathroom. What should the nurse do first? 1. Call the physician caring for the child. 2. Ease the child to the floor and turn him on his side. 3. Administer diazepam (Valium) through the I.V. tubing. 4. Notify the parents so they can be with their child.

2. Ease the child to the floor and turn him on his side. RATIONALE: Because the child is standing, he should first be eased to the floor and turned to the side to prevent aspiration. Notifying the physician wouldn't be the first action the nurse would take because the child's safety is of primary importance. Diazepam would be administered only if it had been ordered. Notifying the parents, although important, isn't the priority. They can be informed after the seizure is over.

After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate? 1. Removing the Logan bow during feedings 2. Holding the infant semi-upright during feedings 3. Burping the infant less frequently 4. Placing the infant on the abdomen after feedings

2. Holding the infant semi-upright during feedings RATIONALE: Holding the infant semi-upright during feedings is appropriate because it helps prevent aspiration. The Logan bow must be kept in place at all times to protect the suture line. The infant should be burped more frequently to prevent regurgitation and aspiration. Placing the infant on the abdomen could lead to disruption of the suture line if the infant rubs the face.

A nurse is caring for a 4-year-old child with end-stage leukemia. The child's physician has ordered a lumbar puncture. His mother, who has legal custody, has refused to give consent for the child to undergo the procedure. However, the child's father is demanding that the procedure be performed. What should the nurse do first? 1. Prepare the child for the lumbar puncture because the father wants the procedure to be performed. 2. Inform the father that the procedure won't be performed because the mother didn't consent. 3. Ask the child if he would like to have the procedure. 4. Contact social services and the child's physician.

2. Inform the father that the procedure won't be performed because the mother didn't consent. RATIONALE: The parent who has legal custody of a child has medical decision-making rights for that child. The other parent could contest the decision but would need to seek legal counsel. After informing the father that the procedure won't be performed at this time, the nurse should make the physician and social services aware of the situation in case additional problems arise.

When caring for an adolescent who's at risk for injury related to intracranial pathology, which action would maintain stable intracranial pressure (ICP)? 1. Turning the adolescent's head from side to side frequently 2. Keeping the adolescent's head in midline position while raising the head of the bed 15 to 30 degrees 3. Hyperextending the adolescent's head with a blanket roll 4. Suctioning frequently to maintain a clear airway

2. Keeping the adolescent's head in midline position while raising the head of the bed 15 to 30 degrees RATIONALE: Elevating the head of the bed while keeping the adolescent's head in midline position will facilitate venous drainage and avoid jugular compression. Turning the head, hyperextending the neck, and suctioning will increase ICP.

A nurse is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen? 1. Occupational therapist 2. Physical therapist 3. Recreational therapist 4. Nurse

2. Physical therapist RATIONALE: After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability. An occupational therapist, who helps the chronically ill or disabled to perform activities of daily living and adapt to limitations, isn't necessary at this time. A recreational therapist, who uses games and group activities to redirect maladaptive energy into appropriate behavior, also isn't required. The nurse hasn't been trained to design an exercise regimen for a child with congenital clubfoot.

A physician needs to obtain written informed consent for a surgical procedure on an adolescent. Which situation allows the physician to obtain written informed consent from the adolescent rather than his parents? 1. The adolescent's 18th birthday is the following week. 2. The adolescent is estranged from his parents and lives independently. 3. The adolescent gives his verbal consent to the procedure. 4. The physician doesn't need to obtain consent because the procedure is a minor one.

2. The adolescent is estranged from his parents and lives independently. RATIONALE: An emancipated minor is a person younger than age 18 who is legally recognized as an adult under certain conditions. These conditions include becoming pregnant, getting married, graduating from high school, and living independently. Otherwise, an adolescent is considered a minor until his 18th birthday. Written consent must always be obtained, even if verbal consent is given. Major surgery, minor surgery, diagnostic tests such as biopsies, and treatments such as blood transfusions are all examples of procedures that require written informed consent.

A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options. 1. Initiative versus guilt. 2. Trust versus mistrust. 3. Industry versus inferiority. 4. Identity versus role confusion. 5. Autonomy versus shame and doubt.

2. Trust versus mistrust. 5. Autonomy versus shame and doubt. 1. Initiative versus guilt. 3. Industry versus inferiority. 4. Identity versus role confusion. RATIONALE: During the first stage of Erikson's five stages of psychosocial development, trust versus mistrust (birth to age 1), the child develops trust as the primary caregiver meets his needs. In the second stage, autonomy versus shame and doubt (ages 1 to 3), the child gains control of body functions and becomes increasingly independent. In the third stage, initiative versus guilt (ages 3 to 6), the child develops a conscience and learns about the world through play. In the fourth stage, industry versus inferiority (ages 6 to 12), the child enjoys working on projects with others, follows rules, and forms social relationships. As body changes begin to take place, the child enters the fifth stage, identity versus role confusion (ages 12 to 19), and becomes preoccupied with looks, how others view him, meeting peer expectation, and establishing his own identity.

A pediatric nurse preceptor working on an oncology floor observes a new graduate crying in the nurses' lounge. The nurse's best action would be to: 1. let the graduate cry and get it out of her system. 2. ask the graduate what's bothering her. 3. ask the graduate if she thinks she can handle being a pediatric nurse. 4. let the nurse-manager know that the new graduate isn't ready for the emotions that working on this unit evokes.

2. ask the graduate what's bothering her. RATIONALE: Caring for acute or chronically ill children can be emotionally and physically stressful. A preceptor to a new nurse should be supportive and empathetic by asking about the new nurse's feelings. It isn't appropriate for the preceptor to make judgments by asking the new nurse if she thinks she can handle being a pediatric nurse, and it isn't acceptable for the preceptor to talk with the nurse-manager about the issue at this time. It isn't unusual for a nurse to need time to emotionally adjust to a new situation or new client population.

When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, offering choices helps the child achieve: 1. trust. 2. autonomy. 3. industry. 4. initiative.

2. autonomy. RATIONALE: According to Erikson's theory of development, a 2-year-old child is at the stage of autonomy versus shame and doubt. Offering the child choices about some aspects of care encourages autonomy. An infant is at the stage of trust versus mistrust; a school-age child, industry versus inferiority; and a preschooler, initiative versus guilt.

A preschooler has vomiting, diarrhea, and a potassium level of 3 mEq/L. The physician orders an I.V. infusion of 500 ml of dextrose 5% in water and half-normal saline solution with 20 mEq of potassium chloride. The nurse knows that a child with vomiting and diarrhea needs fluids and potassium chloride to: 1. eliminate the cause of diarrhea. 2. meet physiologic needs. 3. avoid hyperglycemia. 4. promote normal stool elimination.

2. meet physiologic needs. RATIONALE: A child with vomiting and diarrhea loses excessive fluids and electrolytes, which must be replaced. Fluid and electrolyte replacement can't eliminate the cause of diarrhea, which may result from various factors. Administration of I.V. fluids that contain glucose (such as dextrose 5% in water) may induce, not prevent, hyperglycemia. Fluid and electrolyte replacement has no effect on stool elimination.

The best way for a nurse to assess pain in an 18-month-old child is to: 1. check the child's pupils. 2. observe for behavioral changes. 3. ask the child, "Are you feeling any pain?" 4. tell the parents to call if the child has pain.

2. observe for behavioral changes. RATIONALE: Behavioral changes are common signs of pain and are especially valuable indicators in an 18-month-old child, who has limited verbal skills. Evaluating pupillary response isn't an appropriate technique for assessing pain. Requesting a parental report of a child's pain isn't a reliable assessment technique.

A nurse is providing dietary teaching for the parents of a child with celiac disease. Which statement by the parents indicates effective teaching? 1. "Our child should avoid eating vegetables." 2. "Our child should avoid eating fruits." 3. "Our child should avoid eating prepared puddings." 4. "Our child should avoid eating rice."

3. "Our child should avoid eating prepared puddings." RATIONALE: Teaching is effective if the parents identify prepared puddings as a food their child should avoid. A child with celiac disease mustn't consume foods containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The other options don't contain gluten and are permitted on a gluten-free diet.

A physician orders meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size? 1. 18G 2. 20G 3. 23G 4. 27G

3. 23G RATIONALE: For an infant, the nurse should use a needle with the smallest appropriate gauge for the medication to be given. For an I.M. injection of meperidine, a 25G to 22G needle is appropriate. An 18G or 20G needle is too large, and the 27G needle too small.

Which statement by a mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective? 1. "I know that I'll need to keep my child as quiet as possible." 2. "I just went out and bought all I'll need for the special diet." 3. "I've been checking the urine for protein so I'll be able to do it at home." 4. "I'm sure that my child will be back to normal soon and I won't have to worry about this anymore."

3. "I've been checking the urine for protein so I'll be able to do it at home." RATIONALE: The mother stating that she'll check her toddler's urine for protein indicates effective teaching because such testing helps detect the progression of nephrotic syndrome. The child doesn't need to be kept quiet and usually isn't placed on a specific diet. How the child feels will dictate the child's activity level. Most children return to normal soon but may relapse.

Before administering a tube feeding to a toddler, which method should the nurse use to check the placement of a nasogastric (NG) tube? 1. Abdominal X-rays 2. Injection of a small amount of air while listening with a stethoscope over the abdominal area 3. A check of the pH of fluid aspirated from the tube 4. Visualization of the measurement mark on the tube made at the time of insertion

3. A check of the pH of fluid aspirated from the tube RATIONALE: Intestinal, gastric, and respiratory fluids have different pH values. Therefore, checking the pH of fluid aspirated from the tube is the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. X-rays can't be performed multiple times a day on a daily basis. Because auscultation of air can be heard when the tube is in the esophagus as well as in the stomach, this isn't the best test for checking placement. Observing the insertion measurement mark isn't a good check either because the mark may remain the same even though the tube has migrated up or down into the esophagus, lungs, or intestines.

How should a nurse prepare a suspension before administration? 1. By diluting it with normal saline solution 2. By diluting it with 5% dextrose solution 3. By shaking it so that all the drug particles are dispersed uniformly 4. By crushing remaining particles with a mortar and pestle

3. By shaking it so that all the drug particles are dispersed uniformly RATIONALE: The nurse should shake a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't recommended for this drug form.

A parent brings a toddler, age 19 months, to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find? 1. Closed anterior fontanel and open posterior fontanel 2. Open anterior fontanel and closed posterior fontanel 3. Closed anterior and posterior fontanels 4. Open anterior and posterior fontanels

3. Closed anterior and posterior fontanels RATIONALE: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.

Which action illustrates the responsibilities of a pediatric case manager on the pediatric orthopedic unit? 1. Providing direct child care 2. Writing orders in the medical chart 3. Consulting with health care providers to make sure the child is following the critical pathway 4. Assisting the orthopedic surgeon in the operating room

3. Consulting with health care providers to make sure the child is following the critical pathway RATIONALE: Case managers follow a group of clients, ensuring that their care follows the appropriate critical pathway. These pathways contain a timeline designed to coordinate the multidisciplinary team toward a common goal of providing a short, safe, and healthy length of stay in the hospital. Registered nurses handle most of the direct bedside client care, whereas physicians and nurse practitioners are responsible for writing medical orders. The circulating nurse and scrub nurse work in the operating room, assisting the orthopedic surgeon.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate? 1. Applying ice to the foot 2. Massaging the toes 3. Elevating the foot of the bed 4. Placing the child on his right side

3. Elevating the foot of the bed RATIONALE: To relieve edema of the toes, the most appropriate reaction is to raise the affected extremity above heart level such as by elevating the foot of the bed. Applying ice, massaging the toes, and placing the child on his right side wouldn't reduce swelling.

The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, as they try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which behavior indicates acceptance? 1. Failure to recognize the seriousness of the girl's condition despite physical evidence 2. Intellectualization about the illness in areas unrelated to the girl's condition 3. Expression of feelings, such as sorrow and anger, about the girl's condition 4. Avoidance of staff, family members, or the girl herself.

3. Expression of feelings, such as sorrow and anger, about the girl's condition RATIONALE: The ability to express feelings and relate them to the diagnosis is the first step in accepting the situation. Failing to recognize the seriousness of the girl's condition despite physical evidence, intellectualizing about the illness in areas unrelated to the girl's condition, and avoiding staff, family members, or the girl herself are all avoidance behaviors that represent a parent's inability to cope with the situation.

Which toxic adverse reaction should the nurse monitor for in a toddler taking digoxin (Lanoxin)? 1. Weight gain 2. Tachycardia 3. Nausea and vomiting 4. Seizures

3. Nausea and vomiting RATIONALE: Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures aren't findings in digoxin toxicity.

Which approach by a nurse is the best for trying to take a crying toddler's temperature? 1. Ignore the crying and screaming. 2. Tell the mother not to hold the child. 3. Talk to the mother first and then to the toddler. 4. Bring extra help so it can be done quickly.

3. Talk to the mother first and then to the toddler. RATIONALE: When dealing with a crying toddler, the best approach is to talk to the mother first then to the toddler. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse. Ignoring the crying and screaming may be the second step. The nurse should encourage the mother to hold the toddler because it will likely help the situation. The last resort is to bring in assistance so the procedure can be completed quickly.

A 10-year-old child must undergo a surgical procedure. Does the nurse need to obtain consent from the child? 1. The child doesn't need to know about the procedure because he is a minor. 2. The child must sign the form giving written informed consent. 3. The child must be informed of the procedure and concur with his mother, who is giving written consent. 4. The child only needs to know if the procedure is part of a research protocol.

3. The child must be informed of the procedure and concur with his mother, who is giving written consent. RATIONALE: Assent, not consent, must be obtained from any child who is in the concrete operations thought stage of development (usually a child older than age 7). Assent involves knowledge of the procedure and agreement with the person authorized to give written informed consent. A child should always be notified of the treatment plan but he is too young to authorize consent. Careful ethical consideration should be given when using any person younger than age 18 in a research protocol.

A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next? 1. No further action is necessary. 2. The nurse should notify the physician of the error. 3. The nurse should follow facility procedures for reporting an error. 4. The nurse should document a medication error in the client's chart.

3. The nurse should follow facility procedures for reporting an error. RATIONALE: Although no harm came to the child, this scenario is an example of a medication error. The nurse should follow the facility's procedure for reporting the error because it allows the facility to adequately assess the causes of medication errors, and isn't meant to place blame on any one person. The nurse in this instance doesn't need to notify the physician because there was no harm to the child. Also, the nurse shouldn't document that an error took place in the child's chart; doing so may place her at risk in the event of a lawsuit.

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? 1. Total iron-binding capacity 2. Hemoglobin (Hb) 3. Total protein 4. Sweat test

3. Total protein RATIONALE: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.

The nurse is administering the Denver Developmental Screening Test to a 6-month-old infant during a well-baby checkup. She notes that the child is unable to use a pincer grasp. The nurse notes that this finding: 1. suggests the infant needs a neurologic evaluation. 2. indicates the need for further developmental testing. 3. is a normal finding in a 6-month-old infant. 4. indicates the infant is ahead in developmental milestones.

3. is a normal finding in a 6-month-old infant. RATIONALE: The Denver Developmental Screening Test evaluates the developmental level of social, motor, and language skills in children ages 1 month to 6 years. An infant doesn't develop the ability to use a pincer grasp until about 9 months, so the lack of such a grasp in a 6-month-old infant is a normal finding. A neurologic evaluation or more developmental testing isn't indicated.

A nurse observes a play group of 2-year-old children. The nurse expects to see: 1. four children playing dodgeball. 2. three children playing tag. 3. two children side by side in the sandbox building sand castles. 4. one child playing with clay and another child using flash cards.

3. two children side by side in the sandbox building sand castles. RATIONALE: Two-year-olds exhibit parallel play; that is, they engage in similar activity, side by side. Playing dodgeball and tag are examples of interactive play, common to school-age children. Playing with clay and using flash cards are behaviors seen in preschool children.

Parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate? 1. "Children of that age view death as temporary and reversible, which makes it hard to explain." 2. "Children of that age typically fantasize about what dying will be like, which is much better than knowing the truth." 3. "At this developmental stage, children are afraid of death, so it's best not to discuss it with them." 4. "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it."

4. "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it." RATIONALE: By age 9 or 10, most children have an adult concept of death. Therefore, caregivers should discuss death with them in terms consistent with their developmental stage. In addition, school-age children respond well to concrete explanations about death and dying. Preschoolers, not school-age children, typically view death as temporary and reversible. While school-age children may fantasize about the unknown aspects of death, these fantasies may actually increase their anxiety. Although a child may fear death, accurate information about death can ease anxiety.

The mother of a 16-year-old girl calls the emergency department, suspecting her daughter's abdominal pain may be appendicitis. In addition to pain, her daughter has a temperature of 100° F (37.7° C) and has vomited twice. What should the nurse tell the mother? 1. "Give your daughter a laxative to rule out the possibility that constipation is causing the pain." 2. "Gently press on the lower left quadrant of your daughter's abdomen to test for rebound tenderness." 3. "It's most likely the flu because your daughter is too young to have appendicitis." 4. "Bring your daughter into the emergency department immediately before her appendix has a chance to rupture."

4. "Bring your daughter into the emergency department immediately before her appendix has a chance to rupture." RATIONALE: Abdominal pain, low-grade fever, and vomiting are cardinal signs of appendicitis. The nurse should instruct the mother to take the girl to the emergency department. Telling the mother to give the girl a laxative is inappropriate because if appendicitis is the cause of the pain the appendix may rupture as a result of the drug. Appendicitis can occur at any age. Rebound tenderness is a symptom of appendicitis, but this finding would be found in the right lower quadrant, not the left.

A 17-year-old adolescent with a history of muscular dystrophy is admitted with aspiration pneumonia. The nurse asks the parents if the client has an advance directive. Which response by the parents leads the nurse to believe that the parents don't understand the severity of the client's medical condition? 1. "He has pneumonia; I shouldn't have let him go to that party last week." 2. "This is the third time he's had pneumonia in the past 6 months. I'm afraid he needs a feeding tube." 3. "Yes, he has an advance directive." 4. "He is only 17. He doesn't need an advance directive."

4. "He is only 17. He doesn't need an advance directive." RATIONALE: The parents stating that their son is too young for an advanced directive suggests that the parents don't fully understand the seriousness of their son's medical condition. Advance directives can be used for any client who has an irreversible condition. Stating that they shouldn't have allowed their son to go to a party shows a lack of knowledge about acquiring aspiration pneumonia. Being concerned about the need for a feeding tube and having an advance directive show an understanding of their son's condition.

A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior suggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved

4. Not crying when moved RATIONALE: Not crying when moved most strongly suggests child abuse because a victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills.

A 4-year-old girl has a urinary tract infection (UTI). Which statement by the mother demonstrates understanding of preventing future UTIs? 1. "I should help my child learn to wipe her bottom from back to front." 2. "When she starts urinating frequently, I should call the physician to request antibiotics." 3. "I will let her take a warm bath for 15 minutes each day." 4. "I shouldn't let my daughter take bubble baths."

4. "I shouldn't let my daughter take bubble baths." RATIONALE: Saying that the child shouldn't take bubble baths demonstrates effective teaching because oils in the bubble bath preparation may irritate the urethra, contributing to UTIs. Girls and women should wipe the perineum from front to back, not back to front, to avoid contaminating the urinary tract with fecal bacteria. Although antibiotics are used to treat UTIs, they aren't given prophylactically. No evidence suggests that warm baths help prevent UTIs.

A nurse is teaching parents how to select appropriate toys for their 10-month-old infant. Which statement by the parents indicates effective teaching? 1. "We'll get a mobile to place over the baby's crib." 2. "We'll get a rattle for the baby to play with." 3. "We'll get the baby some brightly colored blocks." 4. "We'll get the baby a push toy."

4. "We'll get the baby a push toy." RATIONALE: Effective teaching is demonstrated if the parents say they'll get the baby a push toy because at age 10 months, a push toy promotes development of an infant's gross and fine motor skills and aids cognitive development. A mobile provides appropriate visual stimulation for an infant up to age 4 months; after this age, a mobile may pose a danger to an infant. Rattles and brightly colored blocks promote gross and fine motor abilities in infants ages 4 to 8 months.

A nurse in a well-child clinic is assessing children for scoliosis. Which child is most at risk for scoliosis? 1. 8-year-old boy 2. Teenage boy 3. 6-year-old girl 4. 10-year-old girl

4. 10-year-old girl RATIONALE: The 10-year-old girl is most at risk because scoliosis is five times more common in girls than boys, and its peak age of incidence is between ages 8 and 15. The 8-year-old boy or a teenage boy may develop scoliosis but it's more common in females. A 6-year-old girl is typically too young to be diagnosed with scoliosis.

A nurse has just received a report from the nurse who worked the previous shift. Which child should she assess first? 1. A 5-year-old child who needs factor VIII before a tonsillectomy 2. A 4-year-old child admitted with reactive airway disease receiving proventil (Albuterol) every 4 hours 3. A 3-year-old child who had an appendectomy and is complaining of pain 4. A 6-year-old child with acute heart failure on 2 L of oxygen

4. A 6-year-old child with acute heart failure on 2 L of oxygen RATIONALE: Following the ABCs (airway, breathing, and circulation), the nurse should assess the child on oxygen first to make sure the child has the oxygen in place and the pulse oximeter reading is above 94%. The other children should be assessed as soon as possible, but the child on oxygen takes priority.

A nurse is developing a teaching plan for a child with acute poststreptococcal glomerulonephritis. What is the most important point to address in this plan? 1. Infection control 2. Nutritional planning 3. Prevention of streptococcal pharyngitis 4. Blood pressure monitoring

4. Blood pressure monitoring RATIONALE: Because poststreptococcal glomerulonephritis may cause severe, life-threatening hypertension, it is most important for the nurse to teach the parents how to monitor the child's blood pressure. Infection control, nutritional planning, and prevention of streptococcal pharyngitis are important but are secondary to blood pressure monitoring.

A 14-year-old girl in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the girl's need to achieve what developmental milestone? 1. Autonomy 2. Initiative 3. Industry 4. Identity

4. Identity RATIONALE: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. When an adolescent is hospitalized, she is separated from her peer group and her body image may be altered. This alteration in body image may interfere with the ongoing development of her identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

Which factor will most likely decrease drug metabolism during infancy? 1. Decreased glomerular filtration 2. Reduced protein-binding ability 3. Increased tubular secretion 4. Inefficient liver function

4. Inefficient liver function RATIONALE: Inefficient liver function will most likely decrease drug metabolism during infancy. As the liver matures during the first year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism; reduced protein-binding ability may affect drug distribution but not metabolism.

After a series of tests, a 6-year-old client weighing 50 lb (22.7 kg) is diagnosed with complex partial seizures. The physician orders phenytoin (Dilantin), 125 mg by mouth twice per day. After the nurse administers phenytoin, where is the drug metabolized? 1. Pancreas 2. Kidneys 3. Stomach 4. Liver

4. Liver RATIONALE: Phenytoin is metabolized in the liver. The pancreas isn't involved in the pharmacokinetic activity of phenytoin. The stomach absorbs orally administered phenytoin, which is excreted by the kidneys in the urine.

A school-age child is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the child's risk of infection? 1. Implementing reverse isolation 2. Maintaining standard precautions 3. Requiring staff and visitors to wear masks 4. Practicing thorough hand washing

4. Practicing thorough hand washing RATIONALE: Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room.

A 2-month-old infant is brought to the clinic by his mother. His abdomen is distended, and he has been vomiting forcefully and with increasing frequency over the past 2 weeks. On examination, the nurse notes signs of dehydration and a palpable mass to the right of the umbilicus. Peristaltic waves are visible, moving from left to right. The nurse should suspect which condition? 1. Colic 2. Failure to thrive 3. Intussusception 4. Pyloric stenosis

4. Pyloric stenosis RATIONALE: Abdominal distention, forceful vomiting, dehydration, a palpable mass, and visible peristatic waves are classic symptoms of pyloric stenosis caused by hypertrophy of the circular pylorus muscle. Abdominal masses and abnormal peristalsis aren't necessarily related to colic or failure to thrive. Intussusception is usually characterized by acute onset and severe abdominal pain.

A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? 1. Reverse isolation 2. Strict hand washing 3. Standard precautions 4. Respiratory isolation

4. Respiratory isolation RATIONALE: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the child's room wears a mask. Reverse isolation is unnecessary because it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.

A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate? 1. Mixing the medication in milk so the child isn't aware that it's there 2. Explaining the medication's effects in detail to ensure cooperation 3. Making the child feel ashamed for not cooperating 4. Showing trust in the child's ability to cooperate even with an unpleasant procedure

4. Showing trust in the child's ability to cooperate even with an unpleasant procedure RATIONALE: To gain a preschooler's cooperation, the most appropriate strategy is for the nurse to show trust and express faith in the child's ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.

Which of the following objects poses the most serious safety threat to a 2-year-old child in the hospital? 1. Crayons and paper 2. Stuffed teddy bear in the crib 3. Mobile hanging over the crib 4. Side rails in the halfway position

4. Side rails in the halfway position RATIONALE: Side rails in the halfway position pose the biggest threat because the most common accidents in hospitals are falls. To prevent falls, the crib rails always should be raised and fastened securely unless an adult is at the bedside. Crayons and paper and a stuffed teddy bear are safe toys for a 2-year-old child. Although a mobile could pose a safety threat to this child, the threat is less serious than that posed by an incorrectly positioned side rail.

A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes lowest priority? 1. A child who develops a fever during a blood transfusion 2. A child admitted from the postanesthesia care unit who has a blood-saturated surgical dressing 3. A physician waiting on the telephone to give the nurse a verbal order 4. Taking a lunch break

4. Taking a lunch break RATIONALE: Taking a lunch break takes lowest priority over child care. If the nurse is unable to delegate child care responsibilities to another nurse or nursing assistant, the nurse's lunch break needs to be rescheduled. A fever indicates an adverse reaction to the blood transfusion, and requires immediate intervention. The postsurgical child is losing blood through the surgical incision, which also requires attention. The telephone call is important for medication changes and to prevent a delay in treatment.

When administering an oral medication to an infant, the nurse should take which action to minimize the risk of aspiration? 1. Administering the oral medication as quickly as possible 2. Placing the medication in the infant's formula bottle 3. Keeping the infant upright with the nasal passages blocked 4. Using an oral syringe to place the medication beside the tongue.

4. Using an oral syringe to place the medication beside the tongue. RATIONALE: Using an oral syringe is the best way to prevent aspiration because it allows controlled administration of a small amount of medication. Administering the medication too quickly could cause aspiration. Putting the drug in a bottle of formula isn't preferred because the infant may not take the entire dose of medication and because the contents of the bottle could interfere with drug absorption or action. Blocking the nasal passages could cause aspiration.

When administering an I.M. injection to an infant, the nurse should use which site? 1. Deltoid 2. Dorsogluteal 3. Ventrogluteal 4. Vastus lateralis

4. Vastus lateralis RATIONALE: The recommended injection site for an infant is the vastus lateralis or rectus femoris muscle. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year.

Which step should a nurse take first when administering a liquid medication to an infant? 1. Hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. 2. Place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the cheek and gum. 3. Identify the infant by checking the armband. 4. Verify the physician order.

4. Verify the physician order. RATIONALE: The nurse should first verify the physician's order. Next, the nurse should make sure she has the right drug, dose, route, and time. She should then make sure she has the right client by checking the infant's armband. After these steps, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing this keeps him from spitting out the drug and reduces the risk of aspiration.

A school nurse is examining a student at an elementary school. Which findings would lead the nurse to suspect impetigo? 1. Small, red lesions on the trunk and in the skin folds 2. A discrete pink-red maculopapular rash that starts on the head and progresses down the body 3. Red spots with a blue base found on the buccal membranes 4. Vesicular lesions that ooze, forming crusts on the face and extremities

4. Vesicular lesions that ooze, forming crusts on the face and extremities RATIONALE: Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most commonly on the face and extremities. Small red lesions on the trunk and in the skin folds are characteristic of scarlet fever. A discrete pink-red maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Red spots with a blue base found on the buccal membranes, known as Koplik's spots, are characteristic of measles (rubeola).

A child is receiving chemotherapy for treatment of acute lymphocytic leukemia. During discharge preparation, which topic is most important for the nurse to discuss with the child and parents? 1. How to help the child adjust to an altered body image 2. How to increase the child's interactions with peers 3. The need to decrease the child's activity level 4. Ways to prevent infection

4. Ways to prevent infection RATIONALE: Because overwhelming infection is the most common cause of death in clients with leukemia, preventing infection is the most important teaching topic. Although promoting adjustment to an altered body image and increasing peer interactions are important, they don't address life-threatening concerns and therefore take lower priority. The nurse should advise the parents to let the child's desire and tolerance for activity determine the child's activity level.

A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include: 1. a depressed fontanel. 2. slurred speech. 3. tachycardia. 4. an altered level of consciousness.

4. an altered level of consciousness. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge — not depress — if he had increased ICP. Slurred speech isn't a sign of increased ICP in an infant because the child isn't able to speak at this age. However, a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.

According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. A nurse can best promote the development of a hospitalized adolescent by: 1. emphasizing the need to follow the facility regimen. 2. allowing parents and siblings to visit frequently. 3. arranging for tutoring in school work. 4. encouraging peer visitation.

4. encouraging peer visitation. RATIONALE: Peer visitation gives the adolescent an opportunity to continue along his path toward independence and identity. Knowledge of the facility regimen prepares the adolescent for upcoming procedures but doesn't affect his development. To achieve a sense of identity, the adolescent must gain independence from his family. Tutoring may help him maintain a positive self-image relative to his schoolwork but doesn't affect his development.

In a 3-month-old infant, fluid and electrolyte imbalance can occur quickly, primarily because an infant has: 1. a lower percentage of body water than an adult. 2. a lower daily fluid requirement than an adult. 3. a more rapid respiratory rate than an adult. 4. immature kidney function.

4. immature kidney function. RATIONALE: Because of immature kidneys, an infant's glomerular filtration and absorption are inadequate, not reaching adult levels until age 1 to 2 years. An infant actually has a greater percentage of body water as well as higher daily fluid requirements than an adult. Although the infant's respiratory rate is higher, causing insensible water loss, immature kidney function is more responsible for fluid balance in an infant.

A nurse is conducting a physical examination on an infant. Identify the anatomical landmark she should use to measure chest circumference.

RATIONALE: Chest circumference is most accurately measured by placing the measuring tape around the infant's chest with the tape covering the nipples. If measured above or below the nipples, a false measurement is obtained.