pediatric assessment a
A nurse is creating a plan of care for an infant who has an epidural hematoma with a skull fracture. Which of the following actions should the nurse include in the plan? Implement seizure precautions for the infant. Suction the infant's nares every 2 hr while awake to maintain patency. Monitor the infant for tachycardia to prevent brainstem herniation. Position the infant side-lying with her head at a 0 to 5° angle.
Implement seizure precautions for the infant. -The nurse should implement seizure precautions for an infant who has an epidural hematoma as a safety measure.
A nurse is assessing a client who has a new diagnosis of celiac disease. Which of the following clinical manifestations should the nurse expect? steatorrhea
steatorrhea = fats in poops The nurse should realize that clients who have celiac disease are unable to digest gluten. This will cause damage to the cells in the bowel, leading to malabsorption, steatorrhea, and diarrhea.
A nurse is assessing a school aged child immediately postoperative following a perforated appendix repair. Which of the following findings should the nurse expect? Purulent nasogastric drainage A WBC of 6,000/mm3 Passage of dark red stool with mucus Absence of peristalsis
absence of peristalsis -The nurse should expect absence of peristalsis in the immediate postoperative period, until the bowel resumes functioning.
A nurse in an ED is caring for a school age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? Determine the allergen that caused the child's reaction. Insert a large bore IV catheter for the child. Elevate the head of the child's bed. Administer IM epinephrine to the child.
Administer IM epinephrine to the child. -When using the urgent vs nonurgent approach to client care, the nurse determines that the priority action is administering IM epinephrine to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately it causes decreased blood return to the heart.
A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? Encourage the child to play with other children on the unit prior to surgery. Explain to the child that his pain will be managed after the surgery. Avoid palpating the abdomen when bathing the child before surgery. Refrain from auscultating the child's bowel sounds during the postoperative assessment.
Avoid palpating the abdomen when bathing the child before surgery. =The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site.
A nurse in the ED is caring for a toddler who has partial-thickness burns on his right arm. Which of the following actions should the nurse take? Insert a nasogastric tube. Cleanse the affected area with mild soap and water. Apply a topical corticosteroid to the affected area. Initiate prophylactic antibiotics therapy.
Cleanse the affected area with mild soap and water. -The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.
A nurse providing teaching to the parent of a school age child who has oral candidiasis and is to begin taking oral nystatin. Which of the following instructions should the nurse include? Shake the medication prior to administration provide the medication through a straw rinse the child's mouth with water immediately after giving the medication mix the medication with applesauce if the child dislikes the taste
Shake the medication prior to administration rationale: nystatin = shakin The nurse should instruct the parent to shake the medication prior to administration in order to disperse the medication evenly within the suspension.
nurse is preparing to administer an immunization to a 4 year old child. Which of the following actions should the nurse plan to take? Inject the immunization slowly after aspirating for 3 seconds. Place the child in a prone position for the immunization. Request that the child's caregiver leave the room during the immunization. Administer the immunization using a 24-gauge needle.
administer the immunization using a 24 guage needle rationale: The nurse should administer an immunization for a 4-year-old child using a 24-gauge needle to minimize the amount of pain experienced by the toddler.
A school nurse is assessing a school age child's blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first? clear the immediate area around the child of hazardous objects loosen the child's restrictive clothing assist the child to a side-lying position on the floor apply an oxygen mask to the child
assist the child to a side-lying position on the floor The greatest risk to this child is aspiration, occlusion of the airway, and bodily injury from falling out of the chair. The nurse should ease the child down to floor in a side-lying position immediately. This position enables the child's secretions to drain from the mouth, preventing aspiration, and maintaining a patent airway.
A nurse is providing teaching to the parents of a preschooler who has heart failure and who is to begin taking digoxin twice daily. Which of the following instructions should the nurse include in the teaching?
brush the child's teeth after giving the medication rationale: The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste.
A nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following clinical manifestations indicates to the nurse that the medication is effective? decreased edema increased abdominal girth decreased appetite increased protein in the urine
decreased edema (prednisone = corticosteroid = antiinflammatory) A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, decreasing edema.
A nurse is providing teaching to the family of a school age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching
encourage the child to perform independent self care rationale: The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase his self-esteem.
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?
nasal flaring When using the airway, breathing, circulation approach to client care, the nurse should place the priority on nasal flaring. Nasal flaring indicates that the infant is experiencing acute respiratory distress.
A nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when her child will no longer be contagious. Which of the following responses should the nurse make? when your child no longer has an increased temperature three days after your first noticed the rash appear on your child when you childs lesions are crusted, 6 days after they appear two to three weeks, when your child's lesions completely disappear
when your child's lesions are crusted., 6 days after they appear The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.
A nurse is creating an educational plan to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? Apply sunscreen liberally to infants over 3 months of age." "Choose a waterproof sunscreen with an SPF of at least 15." "Dress children in a loose weave polyester fabric prior to sun exposure." "Reapply sunscreen every 4 hours."
"Choose a waterproof sunscreen with an SPF of at least 15." The nurse should instruct parents to apply a waterproof sunscreen with an SPF of at least 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. rationale for others: The nurse should instruct parents to avoid the liberal application of sunscreen on infants under the age of 6 months. Parents should only apply sunscreen on infants under 6 months to small areas of exposed skin and should take other measures to reduce or prevent sun exposure. The nurse should instruct parents to dress their children in a tight weave cotton fabric prior to sun exposure to protect the skin. The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.
A charge nurse in an ED is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following clinical manifestation should the charge nurse include as suggestive of potential physical abuse recurrent urinary tract infections symmetric burns of the lower extrmeties growth failure lack of subcutaneous fat
symmetric burns of the lower extremities The nurse should include in the teaching that symmetric burns of the lower extremities are a suggestive clinical manifestation of physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV Catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? turn off the IV pump occlude the IV tubing remove the tape securing the catheter apply pressure over the catheter insertion site
turn off the IV pump occlude the IV tubing (ie. clamp tube) remove the tape securing the catheter apply pressure over the catheter insertion site First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.
A nurse is assessing the pain level of a 3 year old toddler. Which of the following pain assessment scales should the nurse use? FACES pain rating scale numeric pain rating scale CRIES pain assessment scale noncommunicating children's pain checklist
FACES pain rating scale The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts the current level of pain. The nurse can then determine the need for pain management.
A nurse is providing dietary teaching to the parent of a school age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? Barley soup Rice pudding Vanilla malt Wheat bread
rice pudding -The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet. The child cannot consume oats, rye, barley or wheat, and sometimes lactose deficiency can be secondary to this disease. The nurse should recognize that rice pudding is a gluten-free food. Therefore, it is an acceptable choice for the nurse to recommend to the parent of a child who has celiac disease. rationale for others: Barley soup contains gluten and should be avoided by children who have celiac disease. Malt contains gluten and should be avoided by children who have celiac disease. Wheat bread contains gluten and should be avoided by children who have celiac disease.
A nurse is teaching the parents of a school age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching? My child will have a cast until healing is complete." "My child will receive antibiotics for several weeks." "My child can return to playing sports once he is discharged." "My child needs to be in contact isolation."
"My child will receive antibiotics for several weeks." -The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful.
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? until the adolescent is afebrile for 7 days following admission to the facility until the adolescent has a negative blood culture for 24 hours following initiation of antimicrobial therapy
for 24 hours following initiation of antimicrobial therapy The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent. shouldn't be contagious anymore could still show a positive blood culture wihthout being contagious
A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching? "Play the child's favorite song while teaching him to use the potty chair." "Scold the child when he has a toileting accident." "Teach multiple steps of the skill at the same time." "Award the child with a sticker when he sits on the potty chair."
"Award the child with a sticker when he sits on the potty chair." -The child with a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair.
A nurse is performing a hearing screening at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? An infant who is 3 months old and has an exaggerated startle response An infant who is 8 months old and is not yet making babbling sounds A toddler who is 18 months old and has unintelligible speech A preschooler who is 4 years old and prefers playing with others rather than alone
An infant 8 months old who is not making babbling sounds - The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for more extensive evaluation of hearing.
A nurse is providing discharge teaching to the parents of a 3 month old infant following a cheiloplasty. Which of the following instructions shoule the nurse include?
Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days. The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.
A nurse is assessing the vital signs of a 10 year old child following a burn injury. Which of the following clinical manifestations indicate early septic shock? blood pressure 130/90 HR 60/min temp 39.1 (102.4) urinary output 100ml/hr
temp 39.1 (102.4) The nurse should expect a child who has early septic shock to have a fever and chills.
A nurse in a provider's office is preparing to administer immunization to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? Withhold the tuberculin skin test (TST). Withhold the measles, mumps, and rubella (MMR) vaccine. Withhold the influenza vaccine. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine.
Withhold the measles, mumps, and rubella (MMR) vaccine. - The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication to receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.
A nurse is receiving change of shift report on four children. Which of the following children should the nurse assess first? a toddler who has a concussion and an episode of forceful vomitting A school-age child who has acute glomerulonephritis and brown-colored urine An adolescent who was placed into halo traction 1 hr ago and rates his pain at a 6 on a 0 to 10 scale An adolescent who has infective endocarditis and reports having a headache
a toddler who has a concussion and an episode of forceful vomitting rationale: When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.
A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? playing pat a cake using a push-pull toy creating a scrapbook playing dress up
playing dress up The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child.
The nurse is caring for a school age child who has peripheral edema. Which of the following assessments should the nurse preform to confirm peripheral edema? Observe the child for periorbital swelling. Palpate the dorsum of the child's feet. Assess the child's skin turgor. Weigh the child daily using the same scale.
palpate the dorsum of the child's feet: The nurse should palpate the dorsum of the feet by pressing her fingertip against a bony prominence for 5 seconds to assess for peripheral edema.
A nurse is planning developmental activities for a newly admitted 10 year old child who has neutropenia. Which of the following action should the nurse plan to take? Use puppets to entertain the child Provide the child with a book about adventure Give the child a large-piece puzzle Arrange frequent visits from family members and peers
provide the child with a book about adventure - The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read.
A nurse is preparing to administer 5mg/kg every 6 hr PRN for temperatures above 100.5 F to an infant who weighs 17.6 lb. The infant has a temperature of 101.2 F. Available ibuprofen liquid 100mg/5mL. How many mL should the nurse administer to the infant per dose? ( Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2ml solution: 17.6 lbs x 1 kg/2.2 lbs = 8kg 8 kg x 5mg / kg x 5ml /100 mg = 2ml
a school nurse is assessing an adolescent who presents with multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as suffestive of possible physical abuse?
-denies discomfort during assessment of injuries The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of iron? 1/2 cup whole milk 1 cup orange juice 1/2 cup of raisins 1 cup raw carrots
1/2 cup of raisins The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron the rest does not contain iron
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment? BUN 25 mg/dL Sodium 140 mEq/L Urine specific gravity 1.035 Potassium 2.9 mEq/L
Sodium 140 mEq/L = normal (135-140) The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range and indicates the current treatment regimen the infant is receiving for dehydration is effective.
A nurse in an ED is performing a physical assessment on a 2 week old male infant. Which of the following manifestations is the priority for the nurse to report to the provider? Depressed posterior fontanel Substernal retractions Excoriated scrotal area Multiple capillary hemangiomas
Substernal retractions (*priority finding) -When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the infant is experiencing acute respiratory distress and increased respiratory effort, which could quickly progress to respiratory failure. The nurse should report a depressed posterior fontanel. However, this is not the priority finding.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?
administer analgesic to the child rationale: Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder.
A nurse is providing teaching to the parents of a toddler about the administration of prescribed eye drops and eye ointment. Which of the following instructions should the nurse include? apply the eye ointment within 30 minutes of your toddler awakening in the morning apply the eye ointment from the outer canthus to the inner canthus use only one hand to pull the upper eyelid upward when instilling the eye drops administer the eye drops 3 minutes before the eye ointment
administer the eye drops 3 minutes before the eye ointment rationale: The nurse should instruct the parents to administer the eye drops first and then wait 3 min before administering the eye ointment. This action provides adequate time and spacing for each separate medication to work.
A nurse is teaching the parent of a newborn about ways to prevent sudden infant death syndrome. Which of the following instructions should the nurse include?
give the infant a pacifier at bedtime rationale: The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping rationale for rests: The nurse should instruct the parent to place the infant in a supine position to sleep. Prone and side-lying positions are risk factors for SIDS. The nurse should instruct the parent to use a firm mattress and avoid the use of waterbeds, beanbags, or soft mattresses when placing the infant to bed. The use of a soft mattress in the infant's crib is a risk factor for SIDS and can lead to asphyxiation. Placing the infant on a large pillow to sleep can increase the risk of suffocation, asphyxiation, and SIDS.
A nurse is reviewing the laboratory report of a school age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? hematocrit 28% Hemoglobin 13.5 g/dL WBC 8,000 mm3 platelet 250,000 mm3
hematocrit 28% rationale: The nurse should recognize that this hematocrit level is below the expected reference range for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity. ---------------------------------------------` The rest of the options are: within the expected reference range for a school-age child.
A nurse is assessing a 3 year old toddler at a well child visit. Which of the following manifestations should the nurse report to the provider? blood pressue 90/50 mm HG respiratory rate 45/min weight 14.5 kg (32 lb.) heart rate 110/min
respiratory rate 45/min rationale: A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider immediately.
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? A. instruct the parents to decrease the calcium in their toddler's diet B. prepare the toddler for chelation therapy C. refer the family to child protective services D. schedule the toddler for a yearly rescreening
schedule the toddler for a yearly screening The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure. cheliation therapy not required unless lead level >45mcg/dl could be initiated once over 10
A nurse is caring for a hospitalized preschooler. The child's mother is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when her mother will return? "Your mommy will be back after she takes care of your brother." "Your mommy will be back after you eat." "Your mommy will be back at 7 p.m." "Your mommy will be back in the morning."
"Your mommy will be back after you eat." -Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating. Your mommy will be back after she takes care of your brother." -Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating. "Your mommy will be back at 7 p.m." "Your mommy will be back in the morning." A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words.
A nurse is assessing an adolescent who received sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medications? The adolescent has a blood pressure of 86/52 mm Hg. The adolescent's serum potassium level is 4.1 mEq/L. The adolescent reports an absence of nausea and vomiting. The client experiences onset of loose stools within 15 min of administration.
The adolescent's serum potassium level is 4.1 mEq/L. The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range indicates the effectiveness of the medication. rationale for other: A blood pressure of 86/52 mm Hg is below the expected reference range for an adolescent and does not indicate the effectiveness of the medication. The nurse should continue to monitor blood pressure as an indicator of fluid and electrolyte imbalance. Absence of nausea and vomiting indicates effectiveness of an antiemetic medication. Sodium polystyrene sulfonate is an antidote which exchanges sodium ions in the intestine. Therefore, absence of nausea and vomiting is not an indicator of medication effectiveness. The nurse should monitor the adolescent for diarrhea because it is an adverse effect of sodium polystyrene sulfonate.
A nurse is providing dietary teaching to the parent of a school age child who has cystic fibrosis. Which of the following statements should the nurse make? you should offer your child high-protein meals and snacks throughout the day your child should decrease dietary fates to less than 10% of their caloric intake your child will need to take a 1 gram sodium chloride tablet daily throughout their lifetime you should calculate your child's carbohydrate needs based on her daily activities
you should offer your child high-protein meals and snacks throughout the day The parent should provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients in order to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection.
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following clinical manifestations should the nurse expect? (Select all that apply) negative babinski ankle clonus exaggerated stretch reflexes uncontrollable movements of the face contractures
Ankle clonus exaggerated stretch reflexes contractures Rationale: Negative Babinski reflex is incorrect. A child who has spastic cerebral palsy will exhibit a positive Babinski reflex. Ankle clonus is correct. A child who has spastic cerebral palsy will exhibit ankle clonus which is a rhythmic reflex tremor when the foot is dorsiflexed. Exaggerated stretch reflexes is correct. A child who has spastic cerebral palsy will exhibit spasticity or exaggerated stretch reflexes. Uncontrollable movements of the face is incorrect. Uncontrollable movements of the face and extremities are manifestations of nonspastic (dyskinetic) cerebral palsy, rather than spastic (pyramidal) cerebral palsy. Contractures is correct. A child who has spastic cerebral palsy will exhibit contractures due to the tightening of the muscles.
A nurse in the ED is caring for a school age child who has epiglottis. Which of the following actions should the nurse take? Monitor the child's oxygen saturation. Place the child in the supine position. Put a warm mist humidifier in the child's room. Obtain a throat culture from the child.
Monitor the child's oxygen saturation. -The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. rationale for others: Placing the child in the supine position increases the child's risk for a complete airway obstruction. The nurse should place the child in an upright position, and sometimes it is helpful for the child to lean over the bedside table to help with breathing. The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room. Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing.
A nurse at an urgent care clinic is assessing an adolescent client who has an upper respiratory tract infection. Which of the following findings should the nurse recognize as a manifestation of pertussis Inflamed throat with exudate Purulent eye drainage Dry, hacking cough Koplik spots on buccal mucosa
Dry, hacking cough -The nurse should recognize that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night.
A nurse is providing teaching about car seat use to the mother of a 6 month old infant. Which of the following statements by the mother indicates an understanding of the teaching? "I should secure the car seat using lower anchors and tethers instead of the seat belt." "I should position the car seat harness 1 inch above my baby's shoulders." "I will pad my baby's car seat with a blanket for traveling long distances." "I will make sure that the car seat is placed at a 90 degree angle."
"I should secure the car seat using lower anchors and tethers instead of the seat belt." rationale: Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back-rest for the car seat. Therefore, if this system is available, the seatbelt does not have to be used.
18 month old toddler who has dehydration as a result of acute diarrhea: "I will give my child polyethylene glycol daily for 7 days." "I will monitor my child's number of wet diapers." "I will avoid giving my child solid foods until his diarrhea has stopped." "I will offer my child small amounts of fruit juice frequently."
"I will monitor my child's number of wet diapers." -The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is the best way for the parent to monitor adequate output and hydration status.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? Keep the adolescent in a semi-Fowler's position for 4 hr following the procedure. Restrict fluids for 2 hr following the procedure. Place a cardiac monitor on the adolescent prior to the procedure. Apply topical analgesic cream to the site 1 hr prior to the procedure.
Apply topical analgesic cream to the site 1 hr prior to the procedure. -The nurse should apply a topical analgesic to the lumbar site 60 min prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted. other rationale: The nurse should place the adolescent in the prone position or flat in bed for up to 12 hr to prevent post procedural spinal headache. The adolescent should be encouraged to drink extra fluids following the procedure to replace the cerebrospinal fluid removed during the procedure. Cardiac monitoring is not necessary during a lumbar puncture.
A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? Sodium 155 mEq/L Urine output 35 mL/hr Urine specific gravity 1.045 Blood glucose 45 mg/dL
Sodium 155 mEq/L A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range.
A nurse is caring for a 15 year old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)? sodium 148 urine specific gravity 1.020 mental confusion weak peripheral pulse mental confusion
mental confusion - correct answer A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. A sodium level of 148 mEq/L is above the expected reference range for a 15-year-old adolescent. SIADH is caused by the secretion of excess antidiuretic hormone, which results in a decreased serum sodium level due to increased circulation of free water. A urine specific gravity of 1.020 is within the expected reference range. A child who has SIADH is more likely to have concentrated urine and urine specific gravity above the expected reference range. A child who has SIADH is more likely to have fluid overload, full, bounding pulses, increased blood pressure, and tachycardia.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following
tachypnea The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.
A nurse is providing anticipatory guidance to the mother of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include in the teaching? Expresses likes and dislikes Understands right from wrong Controls impulsive feelings Easily separates from parents for long periods of time
expresses likes and dislikes The nurse should teach the mother that her toddler will begin to express her likes and dislikes. This is the time in life when a toddler is developing autonomy and self-concept. She will try to assert herself and frequently refuse to comply. The parent should allow the child to have some control but also set limits in order for her to learn from her behavior and learn to control her actions.
A nurse is preparing a sample from a toddler for a sickle turbidity test. Which of the following actions should the nurse plan to take? perform a finger stick
perform a finger stick - The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease. rationale for other selections: An Allen test determines adequate circulation by observing capillary refill before an arterial puncture. Therefore, this is not a component of the sickle-turbidity test. Stool specimens are collected to identify organisms or parasites that cause diarrhea or to check for the presence of occult blood. Therefore, this is not a component of the sickle-turbidity test. Sputum specimens are collected to identify the infectious organism in a child who has as acute respiratory tract infection. Therefore, this is not a component of the sickle-turbidity test.
A nurse in an ED is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? HR 124 increased tear production sunken anterior fontanel cap refill 2 sec
--sunken anterior fontanel The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid.
A nurse is creating a plan of care for a toddler who has minimal change nephrotic syndrome (MCNS) and 3+ pitting edema. Which of the following interventions should the nurse include in the plan? Place the child in an airborne infection isolation room. Increase the toddler's dietary sodium intake. Encourage an increased fluid intake for the toddler. Administer corticosteroids to the toddler.
administer corticosteroids to the child rationale: The nurse should recognize that corticosteroids are the treatment of choice for providers caring for children who have MCNS. Therefore, the nurse should include administration of prescribed corticosteroids in the plan of care for this toddler. corticosteroids = antiinflammatory
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? I should buy some plastic shoes to wear at the swimming pool i should wear sandals as much as possible I should place the permethrin cream between my toes twice daily I should seal my non-washing shoes in plastic bags for a couple of weeks
I should wear sandals as much as possible allow air to circulate the feet to decrease sweat in which bacteria like to grow Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of his fungal infection.
A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include? you should give your child his salmeterol inhaler every 4 hours when he is having an acute episode of wheezing you should monitor your child's weight weekly while he is receiving inhaled corticosteroid therapy pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy when using the peak expiratory flow meter, record your child's average of three readings
pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy rationale: The nurse should inform the parent that her child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their symptoms can improve or decline and treatment needs to change accordingly.