Peds Children Practice B
A nurse is reinforcing dietary teaching with the parent of a 2-year-old toddler. Which of the following should the nurse include in the teaching? "It is recommended that the toddler consumes no more than 12 ounces of fruit juice each day." "An appropriate serving size is 1 tablespoon of food per year of age." "Introduce healthy finger foods like carrots and celery sticks." "Encourage 5 cups of low-fat milk each day."
"An appropriate serving size is 1 tablespoon of food per year of age." The nurse should include that an appropriate serving size for a 2-year-old toddler is 1 tbsp of food per year of age.
A nurse is reinforcing teaching with the parent of an infant who has a new diagnosis of human immunodeficiency virus (HIV). Which of the following statements made by the parent indicates an understanding of the teaching? "The antiretroviral medication will stop the progression of the disease." "It won't be possible for my child to attend daycare." "I should bring my child in for immunizations on schedule." "My child's nutritional needs will not change."
"I should bring my child in for immunizations on schedule." Immunizations provide protection from communicable diseases and should be administered on schedule.
A nurse is reinforcing teaching about interventions for mild hypoglycemia with the parent of a child who has diabetes mellitus. Which of the following statements by the parent indicates that the teaching has been effective? "I should administer a glucagon injection to my child." "I should give my child 5 grams of a simple carbohydrate." "I should give my child 4 ounces of orange juice followed by cheese and crackers." "I should give my child a snack that is 10 percent of his daily caloric intake."
"I should give my child 4 ounces of orange juice followed by cheese and crackers." The parent should treat mild hypoglycemia with 10 to 15 g of a simple carbohydrate, such as 4 oz of orange juice, and follow it with a starch-protein snack.
A nurse is reinforcing teaching about home care with the guardian of a 14-month-old toddler who has spastic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching? "I will perform daily stretching exercises to my toddler's affected muscles." "I will ensure my toddler avoids activities that involve repetitive joint movements." "I will place my toddler on his stomach to nap after meals." "I will give my toddler pain medication just after he performs strenuous activities.
"I will perform daily stretching exercises to my toddler's affected muscles." The nurse should reinforce that performing stretching exercises of the toddler's affected muscles will prevent muscle contractures.
A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse, "I'm a bad parent, and I can't deal with this." Which of the following responses should the nurse make? "I'm not sure I follow you. Can you explain?" "I understand. Other parents say the same thing." "Let's talk about home care for your child." "I disagree. You're a great parent."
"I'm not sure I follow you. Can you explain?" The nurse should use open-ended statements that will allow the parent to share their feelings and emotions. During times of grief, the parent needs to express emotions. The use of an open-ended statement relays the message that it is safe to do so with the nurse.
A nurse in a pediatric clinic is talking on the telephone with the parent of a 6-month-old infant who has a UTI and started taking an oral antibiotic the day before. Listen to the (audio clip) and determine which of the following responses the nurse should make? "Mix the medicine with ¼ cup of juice before giving it to your baby." "Mix the medicine with 1 teaspoon of honey before giving it to your baby." "Mix the medicine with ¼ cup of formula before giving it to your baby." "Mix the medicine with 1 teaspoon of applesauce before giving it to your baby."
"Mix the medicine with 1 teaspoon of applesauce before giving it to your baby." To enhance acceptance of an oral medication, the parent can mix the medication with a small amount of a sweet, nonessential food item.
A nurse in a pediatric clinic is caring for an infant who has heart failure and a prescription for digoxin. Which of the following statement by the parent indicates the desired therapeutic effect of the medication? "My baby is breathing easier than she used to." "My baby is taking longer naps." "My baby is having fewer wet diapers." "My baby's heart rate is faster than it used to be."
"My baby is breathing easier than she used to." The nurse should identify that the desired effect of digoxin is to increase cardiac output and decrease venous pressure and pulmonary edema, which will reduce respiratory demands.
A nurse is reinforcing teaching regarding the immunization schedule with the parent of a 6-month-old infant during a well-baby visit. Which of the following statements by the parent indicates an understanding of the teaching? "My baby will receive his third DTaP vaccine today." "My baby is old enough to receive the varicella vaccine today." "My baby will receive his final polio vaccine today." "My baby will receive his first hepatitis B vaccine today."
"My baby will receive his third DTaP vaccine today." The nurse should reinforce with the parent that the infant should receive his third diphtheria, tetanus, and pertussis (DTaP) immunization at 6 months of age.
A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the following statements by the parent requires immediate intervention by the nurse? "My child has refused to drink any fluids for the past 8 hours." "My child has been coughing throughout the night." "My child is very hoarse and has a fever of 100.4 degrees Fahrenheit." "My child recently had the flu."
"My child has refused to drink any fluids for the past 8 hours." An inadequate fluid intake indicates the child is at greatest risk for dehydration and electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention by the nurse.
A nurse is reinforcing teaching with the guardian of a child who has a new prescription for levalbuterol solution for use in a nebulizer. Which of the following statements by the guardian indicates an understanding of the teaching? "I should store the unused medication in the freezer." "I should make sure I use the vial within 3 weeks of opening it from the foil package." "My child might be drowsy while taking this medication." "My child might experience palpitations after taking this medication."
"My child might experience palpitations after taking this medication." Palpitations are an adverse effect of levalbuterol. If this occurs, the guardian should discontinue the medication and notify the provider.
A nurse is reinforcing teaching with an adolescent who has an inflamed, nonperforated appendix and is scheduled for a laparoscopic assisted appendectomy. Which of the following instructions should the nurse include in the teaching? "You can begin drinking fluids again 2 days after surgery." "You will need to ask for pain medication for the first 24 hours after surgery." "You will have your vital signs monitored every 8 hours after surgery." "You will sit in your chair at least twice a day after surgery."
"You will sit in your chair at least twice a day after surgery." The nurse should instruct the client that she will sit in a bedside chair at least twice a day and will be encouraged to ambulate as soon as possible following surgery. This activity will enhance lung function and help prevent postoperative complications.
A nurse is reinforcing dietary teaching with an adolescent who is a lacto-vegetarian and has iron deficiency anemia. The nurse should recommend which of the following as the best source of iron? 1 cup (8 oz) shredded wheat cereal 1 cup (8 oz) apple juice ½ cup (4 oz) sweet green peppers ⅛ cup (1 oz) low-fat cheese
1 cup (8 oz) shredded wheat cereal The nurse should determine that shredded wheat cereal is an iron-fortified food. Therefore, it is the best option to recommend because it contains 1 g of iron per serving.
A nurse is assisting with the care of a 4-year-old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure? (Select all that apply.) 1. Discuss benefits of the procedure. 2. Provide the child with a detailed explanation of the procedure. 3. Implement interactive sessions of 30 min. 4. Give the child needleless IV supplies to play with. 5. Allow the child to perform the procedure with a doll.
1. Discuss the benefits of the procedure. The nurse should discuss the benefits of the procedure with the child, because this action is an age-appropriate activity that will decrease the child's anxiety about the procedure. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. 4. Give the child needleless IV supplies to play with. The nurse should allow the child to see, hold, and collect the supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. 5. Allow the child to perform the procedure with a doll. The nurse should allow the child to mimic the procedure with a doll to alleviate anxiety. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure.
A nurse is caring for a school-age child who has hypocalcemia. Which of the following manifestations should the nurse expect? Oliguria Hypotension Paralytic ileus Flushed skin
2. Hypotension The nurse should identify that hypotension is a manifestation of hypocalcemia. Oliguria The nurse should identify that oliguria is a manifestation of hypernatremia, not hypocalcemia. Paralytic ileus The nurse should identify that paralytic ileus is a manifestation of hypokalemia, not hypocalcemia. Flushed skin The nurse should identify that flushed skin is a manifestation of hypernatremia, not hypocalcemia.
A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22 lb). The prescription reads phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer with each dose?
6.25 mL
A nurse is screening a group of school-age children for abuse. The nurse should identify that which of the following conditions places a child at risk for physical abuse? A child who has ADHD Recurrent otitis media Obesity Assertiveness
A child who has ADHD The nurse should identify that ADHD places a child at an increased risk for physical abuse, due to the increased emotional and physical demands the condition can place on the child's parents
A nurse is caring for a group of children in an acute care setting. The nurse should identify that which of the following children is at risk for impaired elimination? A child who has hyperglycemia A child who has enuresis A child who has hypothyroidism A child who has juvenile idiopathic arthritis
A child who has hyperglycemia A client who has hyperglycemia exhibits manifestations of polyuria, lethargy, confusion, thirst, nausea, vomiting, abdominal pain, signs of dehydration, rapid respirations, and fruity breath. A child who has hyperglycemia is at risk for dehydration.
A nurse is caring for a toddler who has otitis media and a temperature of 39.1 C (102.4 F). Which of the following actions should the nurse take first? Administer an antipyretic. Reduce the room temperature. Dress the child in minimal clothing. Apply cool compresses to the child's forehead.
Administer an antipyretic When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature.
A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate? Apical Radial Carotid Femoral
Apical The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line.
A nurse is caring for a 3-year-old female child who is prescribed an indwelling urinary catheter. Which of the following actions should the nurse take when performing this procedure? Place a nonsterile drape under the buttocks. Use a catheter that is 12 French in size. Insert the catheter another 10 cm (3.9 in) after urine returns. Apply 2% lidocaine lubricant into the urethral meatus.
Apply 2% lidocaine lubricant into the urethral meatus. The nurse should apply 2% lidocaine lubricant into the urethral meatus to assist in decreasing the discomfort the child might experience during catheterization.
A nurse is reinforcing dietary teaching with the parent of a child who has phenylketonuria. Which of the following foods should the nurse include the best recommendation for a low phenylalanine diet? Banana Boiled egg Yogurt Hamburger
Banana The nurse should determine that foods such as a banana is the best food source to recommend because bananas contain low protein and low levels of phenylalanine. The nurse should also reinforce with the parent the importance of a low protein diet for their child.
A nurse is reinforcing anticipatory guidance to the parents of an adolescent. Which of the following recommendations should the nurse include? Compare the adolescent's behavior to older siblings. Be open to the adolescent's point of view. Select school activities for the adolescent. Provide the adolescent with flexible rules.
Be open to the adolescent's point of view. During this stage of development, adolescents are developing autonomy and self-identity. The nurse should recommend that the parents actively listen and be open to the adolescent's point of view, even if the parents disagree with his viewpoint.
A nurse is assisting with the care of an adolescent following a cardiac catherization. Which of the following is the priority finding the nurse should report to the provider? Reports of pain 4 out of 10 on the pain scale Heart rate 104/min Distal pulse 1+ Bleeding noted on the dressing
Bleeding noted on the dressing Bleeding noted on the dressing is an indication that the client is at greatest risk for hemorrhage at the catherization site; therefore, the nurse should identify bleeding on the dressing as the priority finding. The nurse should apply continuous pressure 2.5 cm (1 in) above the site and notify the provider.
A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further? Respiratory rate 25/min Blood pressure 120/80 mm Hg Heart rate 110/min Rectal temperature 37.4° C (99.3° F)
Blood pressure 120/80 mm Hg A blood pressure of 120/80 mm Hg is outside the expected reference range for an 18-month-old toddler and requires further investigation by the nurse.
A nurse is collecting data from a school-aged child. The nurse should identify that which of the following findings is a manifestation of physical abuse? Multiple dental caries Malnutrition Recurrent urinary tract infections Bruises at various stages of healing
Bruises at various stages of healing The nurse should recognize that bruises at various stages of healing are a clinical manifestation of physical abuse.
A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For which of the following adverse effects should the nurse monitor? Hypersalivation Depression Bradycardia Hyperreflexia
Depression Clients taking isotretinoin can experience mental status changes, such as suicidal thoughts, aggression, emotional lability, and depression. The nurse should monitor the adolescent's mental status while taking isotretinoin.
A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate? Protective environment Contact precautions Airborne precautions Droplet precautions
Droplet precautions The nurse should plan to initiate droplet precautions for this child, because bacterial meningitis caused by Haemophilus influenzae type B is transmitted through the air via large-particle droplets.
A nurse is reinforcing teaching with the parent of a child who is being treated with diphenhydramine for allergic rhinitis. The nurse should tell the parent to monitor the child for which of the following? Polyuria Drowsiness Drooling Hypogeusia
Drowsiness Diphenhydramine can cause drowsiness due to CNS depression. The nurse should reinforce with the parent to administer the medication at bedtime to avoid daytime sedation.
A nurse is contributing to the plan of care for a child who has type 1 diabetes mellitus and is experiencing an acute illness. Which of the following actions should the nurse include in the plan of care? Monitor blood glucose levels every 6 hr. Withhold insulin until the illness has passed. Encourage an increased fluid intake. Administer glucagon every 3 hr.
Encourage an increased fluid intake. The nurse should encourage an increased fluid intake to flush out ketones and prevent dehydration. Children who have diabetes mellitus and an acute illness are more likely to experience ketonuria and hyperglycemia. Dehydration increases the risk of the child developing diabetic ketoacidosis.
A nurse is reinforcing teaching with a guardian whose child was exposed to poison ivy. Which of the following instructions should the nurse provide? Flush the child's skin within 15 min with cold, running water. Apply miconazole topical ointment to the area daily for 1 week. Wash child's clothes in cool, detergent-free water. Encourage the guardian to keep the child away from other children for a week.
Flush the child's skin within 15 min with cold, running water. The nurse should instruct the guardian to flush the child's skin with cool running water to remove the urushiol, the oil from the poison ivy plant, from the child's skin.
A nurse is reinforcing teaching to the guardian of a toddler who is receiving chemotherapy and has developed stomatitis. Which of the following instructions should the nurse include in the teaching? Administer viscous lidocaine before feedings. Brush teeth using a firm toothbrush. Frequently rinse the mouth with chlorhexidine mouthwash. Increase vitamin C intake by offering orange slices.
Frequently rinse the mouth with chlorhexidine mouthwash. The nurse should encourage the guardian to rinse the toddler's mouth frequently with chlorhexidine mouthwash.
A nurse is preparing to leave the room after performing nasal suctioning for an infant who has respiratory syncytial virus (RSV). Identify the sequence in which the nurse should remove the following personal protective equipment (PPE).
Gloves Goggles Gown Mask The infant is on droplet and contact precautions due to the RSV. First, the nurse should remove his gloves, because these are the most contaminated. Second, the nurse should remove goggles, so they do not interfere with removing the other PPE. The nurse should then remove the gown, and finally the mask, to decrease exposure to the disease.
A nurse is administering an injection of epinephrine to a child who is experiencing manifestations of anaphylaxis. The nurse should monitor for which of the following adverse effects? Pinpoint pupils Decreased heart rate Increased systolic blood pressure Dry skin
Increased systolic blood pressure Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should expect the child to have an increased systolic blood pressure following administration of epinephrine.
A nurse is reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetaminde. Which of the following instructions should the nurse include? Remove dried drainage with a cold washcloth. Instill medication immediately after cleansing the eye. Apply an occlusive gauze over the child's eye. Cleanse the eye by gently wiping from the outer aspect of the eye inward toward the nose.
Instill medication immediately after cleansing the eye. The nurse should instruct the guardian to place the medication in the eye immediately after cleansing.
A nurse is caring for a school-aged child who has hemophilia A. Which of the following should the nurse recognize as a manifestation of this disorder? Joint pain and stiffness Concave fingernails Prominent frontal bossing Increased risk of infection
Joint pain and stiffness The nurse should recognize that joint pain and stiffness can occur as a result of bleeding into the joint, which is a manifestation of hemophilia A.
A nurse is preparing to administer levabuterol via nebulizer to a child with asthma. Which of the following data should the nurse collect prior to administering the medication? Peak flow reading Lung sounds ABGs Inspiratory reserve volume
Lung sounds Levalbuterol is a bronchodilator used to increase air exchange. The nurse should evaluate lung sounds prior to and after the administration of the medication to determine changes in respiratory status.
A nurse is contributing to the plan of care for a child who is in Buck's traction. Which of the following interventions should the nurse include in the plan? Remove the weights when changing the bed linens. Maintain the leg in an extended position. Monitor the halo device every 4 hr. Provide pin care as prescribed.
Maintain the leg in an extended position. The nurse should have the child maintain her affected leg in an extended position while in Buck's traction. This position decreases the risk for further injury to the extremity and minimizes the occurrence of muscle spasms.
A nurse is preparing to assist a provider with a lumbar puncture for a school-aged child. Which of the following actions is the nurse's priority? Labeling collected specimens Providing reassurance to the child Maintaining the child's position Monitoring the child's vital signs
Maintaining the child's position The greatest risk to the child is injury to the spinal nerves or the major vessels. Therefore, the priority action is for the nurse to maintain the child's position to prevent trauma.
A nurse is providing care to parents immediately following their child's unexpected death. Which of the following actions should the nurse take? Limit the amount of time the parents spend with the child's body. Inform the parents that siblings should not view the body. Offer the parents the opportunity to bathe and dress the child's body. Avoid touching the parents when expressing sympathy.
Offer the parents the opportunity to bathe and dress the child's body. The nurse should offer the parents the opportunity to bathe and dress their child's body. This can facilitate the grieving process and allow them to provide care for their child one last time.
A nurse is assisting in the care of a male child who has acute post-streptococcal glomerulonephritis (APSGN). For which of the following manifestations should the nurse monitor? Hypotension Oliguria Epispadias Chordee
Oliguria The nurse should monitor the child who has APSGN for oliguria due to the decreased glomerular filtration rate and retention of sodium and water associated with the disease process.
A nurse is contributing to the plan of care for a 10-month-old infant who is postoperative following a cleft palate repair. Which of the following actions should the nurse include in the plan of care? Place the infant in side-lying position. Offer the infant liquids with a straw. Prohibit the guardian from holding the infant for 8 hr. Cleanse the suture line with a lemon glycerin swab.
Place the infant in side-lying position. The nurse should place the infant in side-lying position to promote healing and prevent injury to the surgical site.
A nurse is reviewing the laboratory findings of a school-age child who reports feeling tired and being easily bruised. Which of the following laboratory values should the nurse report to the provider? Platelets 85,000/mm3 Hematocrit 39% Hemoglobin 14.2 g/dL RBC count 5 million/mm3
Platelets 85,000/mm3 This value is below the expected reference range for a school-age child and should be reported to the provider.
A nurse is caring for a 1-month-old infant who has a nasogastric tube in place for intermittent feedings. Which of the following actions should the nurse take? Position the head of the crib at a 30° angle between feedings. Place the infant on her left side after a feeding. Administer feedings over 5 min. Flush the tube with 30 mL of tap water.
Position the head of the crib at a 30° angle between feedings. The nurse should place the infant with the head of the crib elevated 30° to 45° to prevent aspiration.
A nurse is assisting with planning dietary needs for a toddler. Which of the following interventions should the nurse include in the plan of care? Give the toddler ½ cup (113 g) of fruit daily. Encourage the toddler to drink 8 oz (236.6 mL) of juice daily. Give the child 40 oz (1.2 L) of milk daily. Provide 1 Tbsp (15 g) of solid food for each year of age.
Provide 1 Tbsp (15 g) of solid food for each year of age. The nurse should ensure the toddler receives food serving sizes of 1 Tbsp (15 g) of solid food for each year of age of the toddler
A nurse in a care provider's office is preparing to administer scheduled vaccines to an infant. The infant's parent refuses to allow the nurse to administer the vaccines. Which of the following actions should the nurse take? Ask the parent why they do not want the vaccines to be administered. Provide the parent with a vaccine information sheet (VIS). Question the parent if their other children are vaccinated. Tell the parent that the vaccines must be completed at the next visit.
Provide the parent with a vaccine information sheet (VIS). The nurse should provide the parent with a copy of the VIS for each of the vaccines to be administered to ensure the parent has the most current information regarding the benefits and risks of the vaccines.
During a well-child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make? Vary the time the toddler goes to bed each night. Allow the toddler to watch television before bedtime. Provide the toddler with a favorite toy at bedtime. Increase the toddler's activity prior to bedtime.
Provide the toddler with a favorite toy at bedtime. The nurse should recommend to the parent that providing the toddler with a favorite toy at bedtime will help the toddler to feel more secure and facilitate sleep.
A nurse is reinforcing teaching with the parents of a 2-year-old toddler at a well-child visit. Which of the following should the nurse recommend as an age-appropriate activity for the toddler? Creating a rock collection Learning the alphabet with flash cards Putting together a large-piece puzzle Riding a tricycle
Putting together a large-piece puzzle The nurse should recommend putting together a large-piece puzzle as an age-appropriate activity for a 2-year-old toddler. Puzzles provide the child an opportunity to develop fine motor skills. Other fine motor skill activities include finger painting and coloring with thick crayons.
A nurse is collecting data for an adolescent who has asthma and has received an albuterol nebulizer treatment. Which of the following findings indicates an improvement in the adolescent's condition? Temperature 38.1° C (100.5° F) Respiratory rate 20/min SaO2 91% Bilateral wheezing
Respiratory rate 20/min The nurse should recognize that a respiratory rate of 20/min is within the expected reference range and indicates an improvement in the adolescent's condition.
A nurse is contributing to the plan of care for an infant who has bronchiolitis and is tachypneic. Which of the following actions should the nurse include in the plan of care? Provide high flow oxygen via facemask. Implement chest percussion every 2 hr. Suction nasal passages with a bulb syringe. Initiate airborne precautions.
Suction nasal passages with a bulb syringe. The nurse should suction the infant's nasal passages using a bulb syringe to clear the nasal passages and decrease respiratory effort.
A nurse is collecting data from a child during a well-child visit. The nurse should recognize that which of the following findings places the child at a higher risk for abuse? The child is 6 years old. The child is male. The child was born at 30 weeks of gestation. The child was born via cesarean birth.
The child was born at 30 weeks of gestation. The nurse should identify that children who are born prematurely are at greater risk for abuse because of the potential for impaired bonding during early infancy.
A nurse is reviewing the plan of care for a child who has cystic fibrosis. Which of the following is the priority goal for this child? The child will participate in age-appropriate recreational activities. The child will maintain an effective breathing pattern. The child will maintain an adequate bowel elimination pattern. The child will receive immunizations as recommended.
The child will maintain an effective breathing pattern. Manifestations of cystic fibrosis, such as chronic cough, pulmonary infection, and bronchiolar obstruction lead to severely impaired ventilation and gas exchange, which causes long-term pulmonary complications. Therefore, when utilizing the airway, breathing, circulation approach to client care, maintaining an effective breathing pattern is the priority goal for the child who has cystic fibrosis.
A nurse is collecting physical data from a 4-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child's skin turgor? The child's sacral area. The top of the child's hand. The child's sternal area. The child's abdomen.
The child's abdomen. The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. To check skin turgor, the nurse should grasp the skin on the child's abdomen, pull it taut, and release it quickly. The child who is dehydrated will have a prolonged period of tenting.
A nurse is collecting data from an 18-month-old toddler. Which of the following is a deviation from expected growth and development that the nurse should report to the provider? The toddler is unable to recognize familiar objects by name. The toddler is unable to dress himself in simple clothing. The toddler is unable to talk in complete sentences. The toddler is unable to draw a circle.
The toddler is unable to recognize familiar objects by name. The nurse should report that the toddler is unable to recognize familiar objects by name, because this is a deviation from expected growth and development. The toddler should be able to accomplish this task by 12 months of age.
A nurse is preparing to administer an IM injection to an 11-month-old infant. In which of the following areas should the nurse administer the injection?
Vastus lateralis The nurse should administer an IM injection in the vastus lateralis muscle of an 11-month-old infant. The vastus lateralis is a well-developed muscle that is safe to use for infants and small children.
A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance. Which of the following supplements should the nurse instruct the parent to include in the child's diet? Zinc Vitamin D Thiamine Folic acid
Vitamin D Lactose intolerance is managed by eliminating dairy products from the diet. However, this can result in a decrease in bone density because of the lack of calcium and vitamin D in the diet. The nurse should instruct the parent to administer a vitamin D supplement to the child to enhance the absorption of calcium from foods other than those containing lactose.
A nurse is reinforcing discharge teaching with the guardians of a 6-month-old infant following a surgical procedure to repair a hypospadias. Which of the following instructions should the nurse include? Wait 1 week before giving the infant a tub bath. Apply antifungal ointment to the infant's penis. Avoid giving the infant fruit juice. Apply dry gauze dressing to the infant's penis twice daily.
Wait 1 week before giving the infant a tub bath. The nurse should instruct the guardians to keep the infant's penis as dry as possible until the stent or catheter is removed. The parent should provide sponge-baths to the child until the stent or catheter is removed.
A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend? Graham crackers Rye bread Whole wheat spaghetti Yellow corn
Yellow corn A client who has celiac disease is unable to process gluten, a protein found in wheat, barley, rye, and oats. The nurse should instruct the family that the client's diet is restricted to foods that are free of gluten, such as corn, rice, and millet.
A nurse is reinforcing teaching with the guardians of a school-age child who has frequent nosebleeds. Which of the following instructions should the nurse include? Place ice on the child's forehead. Apply pressure to the child's nose. Have the child lie down to rest until the bleeding stops. Tape cotton gauze on the child's nose.
Apply pressure to the child's nose. The nurse should instruct the guardians to apply pressure to the child's nose for at least 10 min to decrease bleeding. The nurse should also instruct the guardians to tilt the child's head forward, because this position prevents aspiration of the blood.
A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler? Ask the child to state her name. Ask the pharmacy for the child's room number. Ask the child to state her birthday. Ask the guardian to verify the child's name.
Ask the guardian to verify the child's name. Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should ask the guardian to verify the identity of the child and use the identification band as the second identifier.
A nurse is assisting with the care for a 7-month-old infant who has a cleft palate. Which of the following actions should the nurse take to decrease the infant's risk for aspiration? Feed the infant in supine position. Encourage the mother to breastfeed the infant exclusively. Burp the infant frequently during feedings. Perform nasotracheal suctioning if coughing occurs.
Burp the infant frequently during feedings. Infants with a cleft palate have difficulty creating a seal around a bottle. Burping the infant frequently, following every ounce of fluid consumed, dissipates swallowed air and helps to prevent aspiration.
A nurse is assisting with the care of a child who is postoperative and received a transfusion during a surgical procedure. Which of the following findings indicates the child is having a hemolytic reaction? Chills and flank pain Pruritus and flushing Rales and cyanosis Bradycardia and diarrhea
Chills and flank pain Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify this finding as an indication that the child is having a hemolytic reaction.
A nurse is reinforcing teaching with the parent of a 4-month-old infant who has a new prescription for nystatin to treat oral candidiasis and is breastfeeding. Which of the following instructions should the nurse include in the teaching? Continue nystatin for 2 weeks after the symptoms disappear. Clean the infant's pacifier every 2 days. Discontinue breastfeeding until the infant is symptom-free. Wipe the white patches from the infant's tongue using a gauze pad.
Continue nystatin for 2 weeks after the symptoms disappear. To prevent relapse, nystatin therapy should continue for at least 2 weeks after the lesions disappear.
A nurse is caring for a toddler following a tonsillectomy. Which of the following is the priority finding that the nurse should report to the provider? Drowsiness Throat pain Continuous swallowing Dark brown emesis
Continuous swallowing When using the urgent vs. nonurgent approach to client care, the nurse should identify that continuous swallowing is a manifestation of hemorrhage. Therefore, this is the priority finding for the nurse to report to the provider.
A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching? "I should not give my child aspirin for pain or fever." "My child will take antibiotics for 6 months." "My child might have a period of irregular movement of the extremities." "I should expect there to be blood in my child's urine."
"My child might have a period of irregular movement of the extremities." MY ANSWER The nurse should instruct the guardian that the child might experience chorea weeks or months after the initial diagnosis. Chorea is a temporary lack of coordination and the presence of sudden, irregular movements or periods of clumsiness.
A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching? "I will let my baby sleep with me in bed at night." "I will allow my baby to have a pacifier while sleeping." "I will place my baby on a soft mattress to sleep." "I will cover my baby with a quilt while he is sleeping."
"I will allow my baby to have a pacifier while sleeping." The nurse should reinforce with the parent that allowing the infant to fall asleep with a pacifier in his mouth decreases the risk for SIDS.
A nurse is reinforcing teaching about liquid oral supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching? "I will give my child a double dose of this medication if she misses a dose." "I will give this medication to my child with a cup of skim milk." "This medication will turn my child's stools white." "I will give this medication to my child with a straw."
"I will give this medication to my child with a straw." The nurse should reinforce with the guardian to administer this medication with a straw to prevent staining the child's teeth.
A nurse is reinforcing teaching about vital signs with the guardian of a 1-year-old toddler. Which of the following statements by the guardian indicates an understanding of the teaching? "My child's pulse could increase to 150 beats a minute with activity." "My child's temperature should be 96.8 degrees Fahrenheit." "My child should take 40 breaths a minute." "My child's pulse could get as low as 60 beats a minute while asleep."
"My child's pulse could increase to 150 beats a minute with activity." A pulse rate of 150/min is within the expected reference range for a toddler during physical activity.
A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when his child will no longer be contagious. Which of the following responses should the nurse make? "When your child no longer has a fever." "Three days after the rash started." "Six days after lesions appear if they are crusted." "When your child's lesions disappear."
"Six days after lesions appear if they are crusted." The nurse should inform the guardian that a child will stop being contagious around 6 days after the lesions appeared, as long as they are crusted over.
A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse, "I'm a bad parent, and I can't deal with this." Which of the following responses should the nurse make? "Tell me more about what you are feeling." "I understand how you are feeling." "Let's talk about home care for your child." "I'm sure you're just tired right now."
"Tell me more about what you are feeling." The nurse should use open-ended statements that will allow the parent to share his feelings and emotions. During times of grief, the parent needs to express his emotions. The use of an open-ended statement relays the message that it is safe to do so with the nurse.
A nurse is caring for a child who has type 1 diabetes mellitus and has been receiving insulin via subcutaneous infusion pump. Which of the following laboratory tests would verify the average blood glucose level over the past 2 months? Postprandial blood glucose Fasting blood glucose Glycosylated hemoglobin Mean corpuscular hemoglobin
Glycosylated hemoglobin Glycosylated hemoglobin provides an accurate average of the client's blood glucose level over the past 120 days. This test can be used to determine the effectiveness of, or compliance with, a treatment plan. It can also be used to diagnose diabetes mellitus.
A nurse is preparing to obtain a peak expiratory flow rate from an adolescent. Which of the following actions should the nurse take? Document the average of the client's three attempts. Instruct the client to exhale slowly over 5 seconds into the meter. Determine the zone according to the client's age. Have the client stand during the procedure.
Have the client stand during the procedure. To obtain the peak expiratory flow rate, the nurse should have the client stand during the procedure, which will allow the nurse to get an accurate reading.
A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect? Hgb 9.0 g/dL Hct 37% Iron 100 mcg/dL Total iron binding capacity 325 mcg/dL
Hgb 9.0 g/dL The nurse should expect a child who has iron deficiency anemia to have an Hgb level below the expected reference range of 9.5 to 15.5 g/dL. An Hgb of 9.0 g/dL is below the expected reference range.
A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints? Mummy restraint Jacket restraint Elbow restraints Wrist restraints
Mummy restraint The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the toddler that involves the head and neck. The nurse should always use the least amount of restraint necessary.
A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats in a motor vehicle. Which of the following instructions should the nurse include in the teaching? Ensure the shoulder-lap portion of the seat belt fits across the child's abdomen when sitting in the booster seat. Use a no-back, belt-positioning booster seat if the motor vehicle does not have head rests. Discontinue using a booster seat when the child is 135 cm (4 feet 5 in) in height. Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt.
Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt. The nurse should instruct the parents to secure both the child and the booster seat with the shoulder-lap seat belt inside the motor vehicle, because booster seats do not have built-in straps.
A nurse is collecting data from a 10-month-old infant. Which of the following findings should the nurse report to the provider? Pulls self to standing position Moves by creeping on hands and knees Takes intentional steps when standing Sits with support by leaning on hands
Sits with support by leaning on hands The nurse should identify that sitting with support can indicate a developmental delay, because an infant should be able to sit unsupported by 8 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is collecting data from a 12-month-old infant during a well-child visit. At birth, the infant's weight was 3.6 kg (8 lb) and his length was 50.8 cm (20 in). Based on this data, which of the following findings should the nurse expect? The infant weighs 6.4 kg (14 lb) The infant is 101.6 cm (40 in) long The infant is 76.2 cm (30 in) long The infant weighs 14.5 kg (32 lb)
The infant is 76.2 cm (30 in) long The nurse should expect a length of 76.2 cm (30 in), because the infant's length should increase by about 50% by 12 months of age.
A nurse is assisting with the development of a health promotion program for the guardians of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program? The sleep patterns of adolescents are well established. The percentage of adolescents that consider suicide is higher for males than for females. The leading cause of death in adolescents is physical injury. The caloric intake needs of adolescents are less than that of school-age children.
The leading cause of death in adolescents is physical injury. The nurse should recommend including this information, because injuries from motor-vehicle crashes are the leading cause of death in the adolescent population.
