NCLEX Style Pediatrics Cardiac, Infectious, Burns, and Integumentary Questions

The nurse is providing anticipatory guidance to the mother of a 10-month-old child. The mother asks how soon her daughter will be able to receive the chickenpox (varicella) vaccine. What is the best nursing response? 1. "She will receive it today." 2. "She can receive it when she is 12 months old." 3. "She can receive it any time before her first birthday." 4. "She will receive it before entry into kindergarten, at 4 to 6 years of age."

2. The varicella vaccination is recommended to be administered when the child is between 12 and 18 months of age; therefore, the remaining options are incorrect.

A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When the mother is holding the infant 4. When drawing blood for electrolyte level testing

4. Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action? 1. Retake the apical pulse. 2. Withhold the medication. 3. Administer the medication. 4. Notify the health care provider.

3. The apical pulse rate for a 1-year-old infant is 90 to 130 beats/min. Because the apical rate is normal, the remaining options are incorrect.

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1. Scarring is less severe in a child than in an adult. 2. A delay in growth may occur after a burn injury. 3. An immature immune system presents an increased risk of infection for infants and young children. 4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. 5. The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

2.3.6. Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. The mother reports that the child is having intermittent episodes of diarrhea. 4. The mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. The mother reports that the child has recently been exposed to an infectious disease.

2.5. The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women. A vaccine is administered with caution to an individual with a moderate or severe acute illness, with or without fever. Options 1, 3, 4, and 6 are not contraindications to receiving a vaccine

The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

3. Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? 1. Anxiety 2. A temper tantrum 3. A hypercyanotic episode 4. The need for immediate health care provider notification

3. Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate health care provider (HCP) notification is not required unless other appropriate nursing interventions are unsuccessful. Anxiety and a temper tantrum are unrelated to tetralogy of Fallot.

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing

3. HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF, but is not an early sign.

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? 1. "It is extremely contagious." 2. "It is most common in humid weather." 3. "Lesions most often are located on the arms and chest." 4. "It might show up in an area of broken skin, such as an insect bite."

3. Impetigo is a contagious bacterial infection of the skin caused by β-hemolytic streptococci or staphylococci, or both. Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose, but may be present on the hands and extremities.

The nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? 1. Skin turgor 2. Level of edema at burn site 3. Adequacy of capillary filling 4. Amount of fluid tolerated in 24 hours

3. Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1, 2, and 4 may provide some information related to fluid volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate.

The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching? 1. "I need to purchase the medication from the pharmacy." 2. "After rinsing out the medication, I need to avoid washing my child's hair for 24 hours." 3. "I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours." 4. "I need to shampoo my child's hair, apply the medication, and leave it on for 10 minutes and then rinse it out."

3. Permethrin is an over-the-counter antilice product that kills both lice and eggs with one application and has residual activity for 10 days. It is applied to the hair after shampooing and left for 10 minutes before rinsing out. The hair should not be shampooed for 24 hours after the rinsing treatment.

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the schoolchildren. Which statement made by a parent indicates a need for further teaching regarding this communicable disease? 1. "Small blue-white spots with a red base may appear in the mouth." 2. "The rash usually begins on the face and spreads downward toward the feet." 3. "The disease can be spread to others from 10 days before any sign of the disease appears to 15 days after the rash appears." 4. "Respiratory symptoms such as a profuse runny nose, cough, and fever occur before the development of a rash."

3. The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal stage. All other options are accurate descriptions of rubeola, so they would not indicate a need for further teaching. The small blue-white spots found in this communicable disease are called Koplik's spots. The incorrect option describes the incubation period for rubella, not rubeola.

The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that aspirin is prescribed for the child. Which nursing action is most appropriate? 1. Administer acetaminophen for temperature elevation. 2. Administer the aspirin if the child's temperature is elevated. 3. Administer the aspirin if the child experiences any joint pain. 4. Consult with the health care provider to verify the prescription.

4. Antiinflammatory agents, including aspirin, may be prescribed for the child with rheumatic fever. Aspirin should not be given to a child who has chickenpox or other viral infections because of the risk of Reye's syndrome. Therefore, the nurse should consult with the health care provider (HCP) to verify the prescription. The nurse would not administer acetaminophen without specific HCP prescriptions. Administering aspirin is not an appropriate action without consulting the HCP first.

A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? 1. Varicella, hepatitis B vaccine (HepB) 2. Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubella (MMR); inactivated poliovirus vaccine (IPV) 3. MMR, Haemophilus influenzae type b (Hib), DTaP 4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV)

4. DTaP, Hib, IPV, PCV, and RV are administered at 4 months of age. DTaP is administered at 2, 4, and 6 months of age; at 15 to 18 months of age; and at 4 to 6 years of age. Hib is administered at 2, 4, and 6 months of age and at 12 to 15 months of age. IPV is administered at 2, 4, and 6 months of age and at 4 to 6 years of age. PCV is administered at 2, 4, and 6 months of age and at 12 to 15 months of age. The first dose of MMR vaccine is administered at 12 to 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of HepB is administered at birth, the second dose is administered at 1 month of age, and the third dose is administered at 6 months of age. Varicella-zoster vaccine is administered at 12 to 15 months of age and again at 4 to 6 years of age.

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "I will take my child's pulse before administering the medication." 3. "If more than 1 dose is missed, I will call the health care provider." 4. "If my child vomits after medication administration, I will repeat the dose."

4. Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered.

The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the health care provider? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure 4. A weight gain of 1 lb (0.5 kg) in 1 day

4. Heart failure (HF) is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic needs of the body. A weight gain of 1 lb (0.5 kg ) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the health care provider. Tachypnea and increased blood pressure occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation and usually occurs with exertional activities.

A 12-month-old child with human immunodeficiency virus infection is currently immunocompromised. The nurse determines that the immunization needs of this child include which action? 1. Withholding the inactivated polio vaccine 2. Recommending against any influenza vaccinations 3. Administering the measles-mumps-rubella (MMR) vaccine 4. Delaying the administration of the varicella virus vaccine until the child is not immunocompromised

4. Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. The immunocompromised child with human immunodeficiency virus (HIV) infection should not receive live vaccines. With both the varicella and the MMR vaccinations, live vaccines are given. Once the child's immune status improves, these vaccinations can then be given. The correct option is chosen because the varicella vaccination would be delayed until the child is not immunocompromised. The inactivated polio vaccine is not a live virus, so it can be administered. The MMR vaccine would not be administered at this time. Influenza vaccinations do not typically involve live viruses, so the child could receive these vaccinations.

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the priority action by the nurse? 1. Notify the nursing supervisor. 2. Contact the respiratory therapist. 3. Place the infant in a prone position. 4. Place the infant in a knee-chest position.

4. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia. Therefore, the remaining options are not the best initial or priority actions.

The nurse is counseling the young mother of a small child recently diagnosed with impetigo. The nurse should make which statement that provides the best information about impetigo? 1. "The main treatment while your daughter has impetigo will be to force fluids." 2. "Your daughter probably caught the impetigo because you don't wash her hands enough." 3. "There is no risk of passing impetigo to the other children once you begin the prescribed antibiotics." 4. "You will need to prevent any of the fluid from the blisters from coming into contact with your other children."

4. Impetigo is a highly contagious bacterial infection of the skin. Fluids are important but are not a component of the main treatment for this infection. Additionally, fluids should never be forced. Although impetigo occurs in situations of poor hygiene, a judgmental statement is inappropriate and nontherapeutic. The infection is communicable for 48 hours beyond initiation of antibiotic treatment.

The home health nurse visits a child with infectious mononucleosis and provides home care instructions to the parents. Which instruction should the nurse give to the parents? 1. Maintain the child on bed rest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the health care provider (HCP) if the child develops a fever. 4. Notify the HCP if the child develops abdominal pain or left shoulder pain.

4. Infectious mononucleosis is caused by Epstein-Barr virus. The parents need to be instructed to notify the HCP if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens also are instructed to avoid contact sports until splenomegaly resolves. Bed rest is unnecessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen or ibuprofen per HCP preference.

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.

4. On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is unnecessary. Option 1 may be an appropriate intervention, but is not specific to the subject of the question, a localized reaction at the injection site. Hot packs are not applied and can be harmful by causing burning of the skin.

The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check? 1. Maculopapular lesions behind the ears 2. Lesions in the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area

4. Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.

Permethrin is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment? 1. Apply the lotion to areas of the rash only. 2. Apply the lotion and leave it on for 6 hours. 3. Avoid putting clothes on the child over the lotion. 4. Apply the lotion to cool, dry skin at least 30 minutes after bathing.

4. Permethrin is massaged thoroughly and gently into all skin surfaces (not just the areas that have the rash) from the head to the soles of the feet. Care should be taken to avoid contact with the eyes. The lotion should not be applied until at least 30 minutes after bathing and should be applied only to cool, dry skin. The lotion should be kept on for 8 to 14 hours, and then the child should be given a bath. The child should be clothed during the 8 to 14 hours of treatment contact time.

The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? 1. "We need to encourage our child to drink fluids." 2. "Coughing spells may be triggered by dust or smoke." 3. "Vomiting may occur when our child has coughing episodes." 4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

4. Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are accurate components of home care instructions.

A child hospitalized with pertussis is in the convalescent stage, and the nurse is preparing the child for discharge. The nurse has provided instructions to the parents for home care of the child. Which statement by a parent indicates a need for further teaching? 1. "It is important that my child drinks plenty of fluids." 2. "A quiet environment helps to prevent episodes of coughing spells." 3. "We need to teach the other members of the family how to use good hand washing techniques to prevent the spread of infection." 4. "I need to make sure that the child is isolated from the other children for at least 2 weeks to prevent the spread of the virus to them."

4. Pertussis is transmitted by direct contact or respiratory droplets from coughing. The infectious period occurs during the catarrhal stage (from the first to second week until the fourth week). Respiratory isolation is not required during the convalescent stage.

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child? 1. "Has the child been vomiting?" 2. "Has the child had any diarrhea?" 3. "Does the child complain of chest pain and numbness in the right arm?" 4. "Has the child complained of a sore throat within the past few months?"

4. Rheumatic fever (RF) characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child or any family members have had a sore throat or unexplained fever within the past 2 months. The remaining options are unrelated to RF.

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1. Immunoglobulin 2. Red blood cell count 3. White blood cell count 4. Anti-streptolysin O titer

4. Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of 2 major manifestations or 1 major and 2 minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay. Options 1, 2, and 3 would not help to confirm the diagnosis of rheumatic fever.

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding prevention of the transmission to siblings and other household members. Which instruction should the nurse provide? 1. Isolate the child from others for 2 weeks because the virus is transmitted by breathing and coughing. 2. Wash sheets and towels used by the child separately in bleach to prevent spread of the infection to others. 3. Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection. 4. Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva.

4. Roseola is transmitted via saliva, so others should not share drinking glasses or eating utensils. The remaining options are not accurate instructions regarding the prevention of the transmission of roseola.

A school-age child is seen in the health care provider's office for complaints of intense itching mostly at night. The health care provider makes a diagnosis of scabies and prescribes permethrin for treatment of the skin condition. Which at-home instruction should the nurse provide to the mother? 1. Retreatment is recommended the next day. 2. The child's bedding and clothing should be washed in cold water. 3. Leave the lotion on throughout the day and rinse off within 6 hours. 4. Apply the lotion liberally to the body and head, avoiding the eyes and mouth.

4. Scabies can be treated with topical application of permethrin. The medication is applied to the body and head, avoiding the eyes and mouth. The lotion is left in place for 8 to 14 hours, and then the child is bathed. Retreatment for most skin alterations is in 1 week, and all bedding and clothing are washed in hot water.

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take? 1. Retake the apical pulse. 2. Administer the medication. 3. Withhold the medication for 1 hour. 4. Withhold the medication and notify the health care provider.

4. The apical pulse rate for a newborn is 120 to 160 beats/min. The therapeutic digoxin level ranges from 0.5 to 0.8 ng/dL (0.64 to 1.02 mmol/L). Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the health care provider. Therefore, the remaining options are incorrect.

A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home and asks the nurse if the child is infectious to the other children. Which response by the nurse is most appropriate? 1. "The infectious period occurs after the lesions begin." 2. "The infectious period begins with the onset of the rash." 3. "The infectious period is not known, and it is possible that the children may develop the chickenpox within the next 2 weeks." 4. "The infectious period begins 1 to 2 days before the onset of the rash and ends about 5 days after the onset of the lesions and crusting of the lesions."

4. The infectious period of chickenpox is 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and the crusting of the lesions. The remaining options are inaccurate statements.

The nurse is providing a yearly summer educational session to parents in a local community. The topic of the session is prevention and treatment measures for poison ivy. The nurse instructs the parents that if the child comes into contact with poison ivy to take which action? 1. Immediately report to the emergency department. 2. Avoid becoming concerned if a rash is not noted on the skin. 3. Apply calamine lotion immediately to the exposed skin areas. 4. Shower the child immediately, lathering and rinsing the exposed skin several times.

4. When a person comes into contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to shower immediately; the skin should be lathered several times and rinsed each time in running water. Application of calamine lotion is a treatment that is used if dermatitis develops. It is not necessary for the client to be seen in the emergency department at the time of initial contact with poison ivy.

The clinic nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5-year-old child. The nurse should administer this vaccine by which method? 1. Subcutaneously in the gluteal muscle 2. Intramuscularly in the deltoid muscle 3. Subcutaneously in the outer aspect of the upper arm 4. Intramuscularly in the anterolateral aspect of the thigh

3. MMR vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is not recommended for injections. MMR vaccine is not administered by the intramuscular route.

The nursing student is assigned to administer immunizations to children in a clinic. The student should question whether to administer immunizations to a child with which condition? 1. A cold 2. Otitis media 3. Mild diarrhea 4. A severe febrile illness

4. A severe febrile illness is a reason to delay immunization but only until the child has recovered from the acute stage of the illness. Minor illness, such as a cold, otitis media, or mild diarrhea, is not a contraindication to immunization.

Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Monitor the child's weight. 2. Frequent hand washing is important. 3. The child should avoid exposure to other illnesses. 4. The child's immunization schedule will need revision. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

1.2.3.5. AIDS is a disorder caused by human immunodeficiency virus (HIV) infection and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, and diarrhea and notifying the health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; monitoring weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding sharing eating utensils. Gloves are worn for care, especially when in contact with body fluids and changing diapers; diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with the tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10:1 ratio of water to bleach).

A child diagnosed with scarlet fever is being cared for at home. The home health nurse performs an assessment on the child and checks for which clinical manifestations of this disease? Select all that apply. 1. Pastia's sign 2. Koplik's spots 3. White strawberry tongue 4. Edematous and beefy-red pharynx 5. Petechial red, pinpoint spots on the soft palate 6. Small red spots with a bluish-white center and a red base located on the buccal mucosa

1.3.4. Pastia's sign describes a rash seen in scarlet fever that will blanch with pressure except in areas of deep creases and the folds of joints. The tongue initially is coated with a white furry covering, with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off, leaving a red swollen tongue (strawberry tongue). The pharynx is edematous and beefy red. Koplik's spots are associated with rubeola (measles). These are small red spots with a bluish-white center and a red base located on the buccal mucosa. Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella (German measles).

The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Check the blood pressure and then administer the medication. 4. Check the respiratory rate and then administer the medication.

1. Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity, and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (0.5 to 0.8 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. The apical pulse rate for an infant is 90 to 130 beats/min If the heart rate is less than 90 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider. Therefore, the remaining options are incorrect actions; it would be harmful to administer the medication.

The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."

1. HIV is transmitted through blood, semen, vaginal secretions, and breast milk. The mother of an infant with HIV should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child's diaper. Alcohol would not be effective in destroying the virus. Options 2, 3, and 4 are accurate instructions related to basic infection control.

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a urinary catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula

1. Heart failure is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although urinary catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection.

The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record? 1. The child is 18 months old. 2. The child is being bottle-fed. 3. A sibling is using lindane for the treatment of scabies. 4. The child has a history of frequent respiratory infections.

1. Lindane is a pediculicide product that may be prescribed to treat scabies. It is contraindicated for children younger than 2 years because they have more permeable skin, and high systemic absorption may occur, placing the children at risk for central nervous system toxicity and seizures. Lindane also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members should be treated simultaneously. Options 2 and 4 are unrelated to the use of lindane. Lindane is not recommended for use by a breast-feeding woman because the medication is secreted into breast milk.

The nurse is developing a plan of care for a 10-year-old girl with an exacerbation of eczema. Which problem should be addressed in the care for this child? 1. The client is at risk for infection related to viral lesions. 2. The client is at risk for infection related to scratching of pruritic lesions. 3. The client may have poor nutritional intake related to throat edema and mouth ulcers. 4. The client may have a negative body image related to the presence of thick, white crusty plaques over the elbows and knees.

2. Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent and control secondary infection. Secondary infection can occur when areas affected by eczema are scratched as a result of the itching because open skin is a portal of entry for pathogens. The lesions are not viral, and they do not present as thick, white crusty plaques. They appear as red and scaly lesions that can weep, ooze, and crust. They commonly occur in the antecubital and popliteal areas. Throat edema and mouth ulcers are not characteristics of this disorder.

A child with acquired immunodeficiency syndrome is hospitalized for the treatment of Pneumocystis jiroveci pneumonia. The child will be receiving nebulizer treatments at home when discharged. The nurse instructs the mother regarding the maintenance of the nebulizer equipment. What should the nurse tell the mother to do? 1. Boil the nebulizer pieces for 15 minutes after each treatment. 2. Clean the nebulizer pieces with warm water after each treatment and allow to air dry. 3. Clean the nebulizer pieces after each treatment with one-fourth strength bleach and water. 4. Clean the mouthpiece with alcohol after each use, and soak in alcohol for 30 minutes at the end of each day.

2. Nebulizer pieces are cleaned with warm water after each treatment and allowed to air dry. They are soaked in white vinegar and water for 30 minutes at the end of each day. The instructions in the remaining options are inaccurate and would damage the nebulizer equipment.

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition? 1. Bleeding 2. Heart failure 3. Failure to thrive 4. Decreased tolerance to stimulation

2. Nursing care initially centers on observing for signs of heart failure. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distension. The remaining options are not conditions directly associated with this disorder.

A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions? 1. Enteric 2. Airborne 3. Protective 4. Neutropenic

2. Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and persons in contact with the child should wear masks. The child is placed in a private room if hospitalized, and the hospital room door remains closed. Gowns and gloves are unnecessary, but standard precautions are used. Articles that are contaminated should be bagged and labeled. Special enteric precautions and protective (neutropenic) isolation are not indicated in rubeola.

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? 1. Prone position 2. Knee-chest position 3. High Fowler's position 4. Reverse Trendelenburg's position

2. Tetralogy of Fallot includes four defects-ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. If pulmonary vascular resistance is higher than systemic resistance, the shunt is from right to left; if systemic resistance is higher than pulmonary resistance, the shunt is left to right. If a hypercyanotic spell occurs, the nurse immediately places the infant in a knee-chest position. This position improves systemic arterial oxygen saturation. All other options will not improve systemic arterial oxygen saturation.

An infant is brought to the clinic for his third diphtheria-tetanus toxoid-acellular pertussis vaccination (DTaP). The mother reports that the infant developed a 99.4°F (37.4°C) temperature after the last DTaP. Which action is most appropriate? 1. Withhold the vaccination. 2. Administer the vaccination. 3. Draw blood for a pertussis titer. 4. Notify the health care provider.

2. The vaccination should be given. Mild fever after the DTaP is not uncommon, and the vaccination would not be withheld for that reason. A vaccination is withheld for true contraindications such as a previous anaphylactic reaction or sensitivity to a product in the vaccination. Drawing blood for determination of a pertussis titer would not be indicated. It is not necessary to notify the health care provider about this side effect.

The nurse is verifying that a mother understands how to care for her infant who has thrush. Which comment by the mother would indicate that further teaching is indicated? 1. "I will feed my baby before I apply the medication." 2. "I can put the medication in my son's bottle for him to drink." 3. "I need to thoroughly clean bottles and nipples after every use." 4. "I will slowly put the medication in each cheek of my baby's mouth."

2. Thrush is a fungus caused by Candida albicans. The white patches resemble mild curds and are visible on the tongue, inner lips, oral mucosa, and gums. An antifungal topical medication may be prescribed and needs to be slowly administered in each cheek of the baby's mouth after eating to increase the time that the medication is in contact with the mucous membranes. It is not placed in the baby's bottle. This action does not provide the topical treatment needed; additionally, medication is not added to a child's bottle because the infant may not finish drinking everything from the bottle. All bottles and nipples need to be thoroughly cleaned after every used to prevent further infection.

A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. The nurse should tell the mother to implement which action? 1. Keep the child in a room with dim lights. 2. Give the child warm baths to help prevent itching. 3. Allow the child to play outdoors because sunlight will help the rash. 4. Take the child's temperature every 4 hours and administer 1 baby aspirin for fever.

1. A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Warm baths and sunlight will aggravate itching. Additionally, the child needs to rest. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome.

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. 1. Elevated C-reactive protein 2. Elevated antistreptolysin O titer 3. Presence of Reed-Sternberg cell 4. Decreased erythrocyte sedimentation rate 5. Presence of group A beta-hemolytic strep

1.2.5. Rheumatic fever usually develops after a group A beta-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated C-reactive protein level; an elevated antistreptolysin O titer; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication? 1. Prevents blue (tet) spells 2. Maintains adequate cardiac output 3. Maintains an adequate hormonal level 4. Maintains the position of the great arteries

2. A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing is inadequate to maintain adequate cardiac output. The remaining options are incorrect. In addition, tet spells occur in tetralogy of Fallot, not in transposition of the great arteries.

The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation? 1. Possible trauma 2. Possible sexual abuse 3. Presence of an allergy 4. Presence of a respiratory infection

2. Conjunctivitis is an inflammation of the conjunctiva. A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse. Trauma, allergy, and infection can cause conjunctivitis, but the causative organism is not likely to be Chlamydia.

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to the figure (circled area) to determine the condition. (Figure is circled showing a connection between the aorta and pulmonary artery) 1. Aortic stenosis 2. Atrial septal defect 3. Patent ductus arteriosus 4. Ventricular septal defect

3. A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure. Aortic stenosis is a narrowing or stricture of the aortic valve. Atrial septal defect is an abnormal opening between the atria. Ventricular septal defect is an abnormal opening between the right and left ventricles.

A child is sent to the school nurse by the teacher. On assessment of the child the nurse notes the presence of a rash. The nurse suspects that the child has erythema infectiosum (fifth disease) based on which assessment finding? 1. A discrete rose-pink maculopapular rash on the trunk 2. A highly pruritic, profuse macule-to-papule rash on the trunk 3. Erythema on the face, giving a "slapped cheeks" appearance 4. A discrete pinkish-red maculopapular rash on the arms and trunk

3. The classic rash of erythema infectiosum, or fifth disease, affects the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule-to-papule rash is the rash of varicella (chickenpox). The discrete pinkish-red maculopapular rash is the rash of rubella (German measles).

A topical corticosteroid is prescribed by the health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? 1. Apply the cream over the entire body. 2. Apply a thick layer of cream to affected areas only. 3. Avoid cleansing the area before application of the cream. 4. Apply a thin layer of cream and rub it into the area thoroughly

4. Atopic dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleaned gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia? 1. Tachypnea 2. Tachycardia 3. Sucking on the fingers 4. Clubbing of the fingers

4. The child with congenital heart disease may develop clubbing of the fingers. Clubbing of the fingers is thought to be caused by anoxia or poor oxygenation. Tachypnea and tachycardia are signs of acute hypoxia. Sucking on the fingers may indicate hunger or irritability. Further assessment is needed to determine if this behavior is due to congenital heart disease.

A 2-year-old child is admitted to a hospital burn unit with partial- and full-thickness burns involving 35% of body surface area. After admission assessment and review of the health care provider's prescriptions, the priority nursing intervention should focus on which action? 1. Inserting a nasogastric tube 2. Sedating with morphine sulfate 3. Inserting an indwelling urinary catheter 4. Restricting intravenously administered fluids

3. An indwelling urinary catheter is inserted into the child's bladder first so that urine output can be measured accurately each hour and response to fluid resuscitation can be determined. A nasogastric tube may or may not be required, but this is not the priority intervention. Although pain medication may be required, the child should not be sedated initially. Intravenously administered fluids are not restricted and are administered at a rate sufficient to keep the child's urine output at 1 mL/kg of body mass per hour, thus reflecting adequate tissue perfusion.

The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother? 1. "The child may return to school in 1 week." 2. "The child will not be able to return to school during this academic year." 3. "The child may return to school in 1 week but needs to go half-days for the first 2 weeks." 4. "The child may return to school in 3 weeks but needs to go half-days for the first few days."

4. After heart surgery, the child may be able to return to school in 3 weeks but needs to go half-days for the first few days. The mother also should be told that that the child cannot participate in physical education for 2 months. The remaining options are incorrect.

Nursing care of the infant with eczema should focus on which action as a priority nursing intervention? 1. Keeping the infant content 2. Maintaining adequate nutrition 3. Applying antibiotic ointment to lesions 4. Preventing secondary infection of the lesions

4. Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent or control secondary infections. Keeping the infant content and maintaining adequate nutrition are not priority care for an infant with eczema. Antibiotic ointment should be applied only for treatment of a secondary infection as prescribed by a health care provider.

A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever? 1. Absence of C-reactive protein 2. Presence of Reed-Sternberg cells 3. Decreased antistreptolysin O titer 4. Elevated erythrocyte sedimentation rate

4. Rheumatic fever develops after a group A beta- hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptolysin O titer; an elevated C-reactive protein level; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.

An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes swollen lymph nodes, and laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse provides instruction regarding care of the adolescent. Which statement made by the mother indicates an understanding of the care measures? 1. "I will call the doctor if my child has abdominal or left shoulder pain." 2. "I need to keep my child on bed rest for 3 weeks to discourage physical activity." 3. "I will notify the health care provider if my child is still feeling tired in 1 week." 4. "I need to isolate my child so that the respiratory infection is not spread to others."

1. The mother needs to be instructed to notify the health care provider (HCP) if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus.

A child is seen in the health care clinic, and the nurse suspects the presence of pinworm infection (enterobiasis). The nurse instructs the mother as to how to obtain a cellophane tape rectal specimen. Which statement by the mother indicates an understanding of the correct procedure to obtain the specimen? 1. "I need to collect the specimen after I give my child a bath." 2. "I need to collect the first bowel movement of the day and place it in a sealed container." 3. "I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens and bring it to the clinic for examination." 4. "I need to place a piece of transparent cellophane tape lightly over the anal area after my child has a bowel movement and bring it to the clinic for examination."

3. Diagnosis of pinworm is confirmed by direct visualization of the worms. Parents can view the sleeping child's anus with a flashlight. The worm is white, thin, and about ½ to1 inch (1.3 to 2.5 cm) long, and it moves. A simple technique, the cellophane tape slide method, is used to capture worms and eggs. Transparent tape is lightly touched to the anus and then applied to a slide for examination. The best specimens are obtained as the child awakens, before toileting or bathing.

A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching? 1. "Quiet activities are allowed." 2. "The child should play inside for now." 3. "Visitors are not allowed for 1 month." 4. "The regular schedule for naps is resumed."

3. Visitors without signs of any infection are allowed to visit the child. The mother should be instructed, however, that the child needs to avoid large crowds of people for 1 week following discharge. The remaining options are accurate instructions regarding activity following heart surgery.

A mother brings her 6-year-old child to the clinic because the child has developed a rash on the trunk and scalp. The mother reports that the child has had a low-grade fever, has not felt like eating, and has been tired. The child is diagnosed with chickenpox. The mother inquires about the communicable period associated with chickenpox, and the nurse bases the response on which statement? 1. The communicable period is unknown. 2. The communicable period ranges from 2 weeks or less to 4 weeks. 3. The communicable period is 10 days before the onset of symptoms to 15 days after the rash appears. 4. The communicable period is 1 to 2 days before the onset of the rash to 6 days, when crusts have formed.

4. Chickenpox is transmitted via direct contact, droplet (airborne) spread, and contaminated objects. The communicable period for chickenpox is 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. In roseola, the communicable period is unknown. A communicable period ranging from 2 weeks or less to 4 weeks describes diphtheria. A communicable period of 10 to 15 days describes rubella.

The nurse is collecting data on a child with a 1-week-old cat scratch injury. While assessing the scratch the nurse notes redness, heat, swelling, and red streaking surrounding the area. The child states that the scratch hurts. Cellulitis is diagnosed. When providing home care instructions, which statement by the mother indicates a need for further teaching? 1. "The child should rest in bed." 2. "I will apply cool, moist soaks every 4 hours." 3. "I should take the child's temperature and watch for a fever." 4. "The affected extremity should be elevated and immobilized."

2. Cellulitis is an infection of the dermis and the underlying hypodermis of the skin. The child with cellulitis should rest in bed, and the affected extremity should be elevated and immobilized. Warm, moist soaks applied every 4 hours increase circulation to the infected area, relieve pain, and promote healing. Frequent hand washing is essential to prevent the spread of infection. The child should be carefully monitored for signs of sepsis, increased fever, chills, and confusion, or for the spread of infection.

The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure? 1. Paleness of the skin 2. Strong sucking reflex 3. Diaphoresis during feeding 4. Slow and shallow breathing

3. The early symptoms of heart failure (HF) include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Paleness of the skin, pallor, may be noted in the infant with HF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of HF.

A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? 1. Elevated antistreptolysin O titer 2. Decreased erythrocyte sedimentation rate 3. Negative result on antinuclear antibody assay 4. Negative result on C-reactive protein determination

1. In the presence of rheumatic fever, the child will exhibit an elevated antistreptolysin O titer, an elevated erythrocyte sedimentation rate, leukocytosis, and a positive result on C-reactive protein determination. A positive result on antinuclear antibody testing is used to diagnose a wide variety of connective-tissue, vascular, and immune complex disorders and also will be positive with rheumatic fever.

The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which supplies should the nurse bring to the child's room to prevent transmission of the virus? 1. Mask and gloves 2. Gown and gloves 3. Goggles and gloves 4. Gown, gloves, and goggles

1. Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory isolation is required, and a mask should be worn by those in contact with the child. Gloves are also worn as necessary to prevent contact with infectious droplets. Gowns and goggles are not specifically indicated for care of the child with rubeola. Any articles that are contaminated should be bagged and labeled.

The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? 1. Fine grayish red lines 2. Purple-colored lesions 3. Thick, honey-colored crusts 4. Clusters of fluid-filled vesicles

1. Scabies is a parasitic skin disorder caused by an infestation of Sarcoptes scabiei (itch mite). Scabies appears as burrows or fine, grayish red, threadlike lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid-filled vesicles are seen in herpesvirus infection.

A child who is 4 years old is seen for a well-child checkup. He has been regularly receiving immunizations. Which immunizations should the child receive at this visit? Select all that apply. 1. Varicella vaccine 2. Rotavirus vaccine 3. Inactivated polio vaccine 4. Meningococcal conjugate vaccine 5. Haemophilus influenzae type B vaccine 6. Measles, mumps, rubella (MMR) vaccine

1.3.6. At age 4, the child will receive the diphtheria, tetanus, acellular pertussis vaccine, inactivated polio vaccine, MMR, and varicella vaccine.

A child is scheduled to receive immunizations. The child's mother reports to the nurse that the child has been receiving long-term immunosuppressive therapy. The nurse prepares the scheduled immunizations knowing that which vaccine is contraindicated? 1. Hepatitis B 2. MMR (measles-mumps-rubella) 3. Hib (Haemophilus influenzae type b) 4. DTaP (diphtheria-tetanus-acellular pertussis)

2. Known altered immunodeficiency from long-term immunosuppressive therapy is a contraindication to MMR immunization because a live vaccine is given. The vaccines identified in the remaining options are not live vaccines and can be administered.

The nurse is estimating the body surface area of a child with a burn injury using the West nomogram. After noting the child's height (45 inches [114 cm]) and weight (65 lb [29.5 kg]), the nurse reads the nomogram and determines that the body surface area is approximately which number? Refer to Figure. (West nomogram available through googling) 1. 0.2 2. 1.0 3. 1.9 4. 2.0

2. The body surface area of a child can be estimated using the West nomogram. A straight line is drawn on the nomogram connecting the height and the weight of the child. The point at which the line crosses the surface area column is the estimated body surface area. This yields a body surface area of 1.0.

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."

2. The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.

A child is scheduled to receive inactivated poliovirus vaccine (IPV), and the nurse who is preparing to administer the vaccine reviews the child's record. The nurse questions the administration of IPV if which is documented in the child's record? 1. Recent recovery from a cold 2. A history of frequent respiratory infections 3. A history of anaphylactic reaction to neomycin 4. A local reaction at the site of injection of a previous IPV

3. IPV contains neomycin. A history of anaphylactic reaction to neomycin is considered a contraindication to IPV. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is not a contraindication to receiving a vaccine.

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Cracked lips 2. Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

3. Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

The nurse provides instructions to the mother of a child with mumps regarding respiratory precautions, and the mother asks the nurse about the length of time required for the respiratory precautions. The nurse should make which statement to the mother? 1. "Precautions are not necessary once the swelling appears." 2. "Precautions are not necessary before the swelling begins." 3. "Precautions are indicated during the period of communicability." 4. "Precautions are indicated for 20 days following the onset of parotid swelling."

3. Mumps is transmitted via direct contact with or droplet spread from an infected person. Droplet precautions are indicated during the period of communicability (immediately before and after swelling begins); therefore, all other options are incorrect.

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding? 1. Severe bradycardia 2. Asymptomatic after feeding 3. Bluish discoloration of the skin 4. Higher than normal body weight

3. The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is bluish discoloration of the skin, known as cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities. Severe bradycardia and asymptomatic after feedings are inaccurate findings. Many children with a left-to-right shunt may remain asymptomatic. High body weight is incorrect because these children usually have lower than normal body weight.

The nurse should expect to administer the first dose of the measles, mumps, and rubella (MMR) vaccine at which age? 1. 2 years 2. 4 years 3. 12 months 4. 22 months

3. The first dose of the measles, mumps, and rubella vaccine should be administered at 12 to 15 months of age. A second dose is administered at 4 to 6 years of age.

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? 1. Eggs 2. Penicillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component

4. A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

The mother of a preschooler who attends day care calls a clinic nurse and tells the nurse that the child is constantly scratching the perianal area and that the area is irritated. The nurse suspects the possibility of pinworm infection (enterobiasis) and instructs the mother to obtain a rectal specimen by a tape test. At what time should the nurse tell the mother to obtain the specimen? 1. After bathing 2. After toileting 3. When the child is put to bed 4. In the morning, when the child awakens

4. Diagnosis of pinworm infection is confirmed by direct visualization of the worms. Parents can view the sleeping child's anus with a flashlight. The worm is white, thin, about ½ to 1 inch (1.3 to 2.5 cm) long, and moves. A simple technique, the tape test, is used to capture worms and eggs. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimens are obtained as the child awakens, before toileting or bathing.

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?"

4. Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to rheumatic fever.