Peds Unit 1 & 2 ATI

A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? a. "The teacher says my child has to squint to see the board." b. "My child has recently lost both front top teeth." c. "My child often cheats when we play board games." d. "Sometimes my child acts bossy with his friends."

a. "The teacher says my child has to squint to see the board." Squinting to see the board can indicate a vision problem. It is essential to assess children for hearing and vision problems. If not caught early, they lead to frustration and decreased ability to learn.

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages? a. 3 years b. 4 years c. 5 years d. 6 years

a. 3 years At age 3, children can typically ascend stairs using alternating feet but still descend by placing both feet on each step.

A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions? a. An anxiety reaction b. Regression c. Resentment toward the mother d. Developing autonomy

a. An anxiety reaction Hospitalization is stressful, regardless of the age of the client. However, for an 18-month-old toddler, separation from parents adds to that stress. The toddler's behavior indicates an anxiety reaction to the stress of hospitalization. Separation anxiety initially causes demonstrations of protest. Remaining sad and quiet when a parent leaves indicates the second response to separation anxiety, which is despair.

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? a. At the end b. At the beginning c. Before examining the head and neck d. Before auscultating the chest and abdomen

a. At the end When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows.

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? a. Closed posterior fontanel b. Uses thumb and index fingers in a pincer grasp c. Lateral incisors d. Sitting steadily without support

a. Closed posterior fontanel The infant's posterior fontanel should close by about 8 weeks of age.

A nurse is providing health promotion teaching to the parents of an infant. Which of the following conditions should the nurse identify as the leading cause of death among this age group? a. Congenital anomalies b. Respiratory distress c. Low birth weight d. Sudden infant death syndrome

a. Congenital anomalies Congenital anomalies are the leading cause of infant mortality in the U.S.

A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time? a. Crushed ice b. Orange juice c. Vanilla milkshake d. Cranberry juice

a. Crushed ice Cold, clear liquids are well-tolerated following a tonsillectomy. Liquids that are brown or red should be avoided in order to tell the difference between the liquid and fresh or old blood.

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson? a. Encourage the client to complete school work. b. Vary the child's schedule each day. c. Discourage visits from the client's friends. d. Provide a daily session with a play therapist.

a. Encourage the client to complete school work. Erikson's stage of psychosocial development for a 10-year-old child is industry vs. inferiority. By providing school-age children the opportunity to keep up with their school work, they can continue to develop skills and knowledge and maintain a sense of accomplishment.

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level? a. FLACC b. Oucher c. FACES d. Visual Analog Scale

a. FLACC The FLACC pain scale is appropriate to use with infants and children between the ages of 2 months and 7 years.

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) a. Have a parent stay with the child during procedures. b. Cluster invasive procedures whenever possible. c. Perform the procedure as quickly as possible. d. Allow the child to keep a toy from home with her. e. Use mummy restraints during painful procedures.

a. Have a parent stay with the child during procedures. c. Perform the procedure as quickly as possible. d. Allow the child to keep a toy from home with her. Have a parent stay with the child during procedures is correct. Maintaining parent-child contact is one of the most supportive interventions for toddlers and preschoolers undergoing painful procedures. Perform procedures as quickly as possible is correct. Moving quickly through the steps of a painful procedure is a supportive intervention for children undergoing painful procedures. Allow the child to keep a toy from home with her is correct. Having familiar and cherished objects nearby is therapeutic for children during their hospitalization.

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? a. Large building blocks b. Hanging crib toys c. Modeling clay d. Crayons and a coloring book

a. Large building blocks Large building blocks are age-appropriate toys for a 12-month-old toddler.

A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. Management of tantrums b. How to establish trust c. How to encourage cooperative play d. Dental care e. Need for increased caloric intake

a. Management of tantrums d. Dental care Management of tantrums is correct. It is expected for toddlers to have temper tantrums. Dental care is correct. Toddlers should be receiving dental care.

A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority? a. Respiratory rate b. Burns of the mouth c. Bowel sounds d. Visual acuity

a. Respiratory rate Using the airway, breathing, circulation approach to client care, the nurse should prioritize assessing the client's respiratory rate. Small amounts of kerosene can enter the lungs and damage them directly, causing a severe aspiration pneumonia. Because the pneumonia is caused by chemical irritation rather than bacteria, antibiotics aren't useful for prevention or treatment. Breathing becomes rapid and gasping, and vomiting and persistent coughing can follow. In severe cases, brain damage can occur.

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.) a. The reason why the child is taking the medication b. Written information about the medication c. Stopping the medication when the child feels better d. The adverse effects of the medication e. Using a kitchen spoon to administer the medication

a. The reason why the child is taking the medication b. Written information about the medication d. The adverse effects of the medication The reason why the child is taking the medication is correct. The nurse should include the reason why the child is taking the medication in the discharge instructions. Written information about the medication is correct. The nurse should include written information about the medication in the discharge instructions. The adverse effects of the medication is correct. The nurse should include the adverse effects of the medication in the discharge instructions.

A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect? a. Tugging on the affected ear lobe b. Clear drainage from the affected ear c. Pain when manipulating the affected ear lobe d. Erythema and edema of the affected ear

a. Tugging on the affected ear lobe Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear.

The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make? a. "Let your child sleep in your bed with you." b. "Keep a night light on in your child's room." c. "Tell your child that monsters are not real." d. "Stay with your child until the child is asleep."

b. "Keep a night light on in your child's room." Fears of the dark and "monsters" are common in preschool-age children who are imaginative thinkers and have difficulty distinguishing between real and make-believe. After the parent reassures the child that there are no monsters, the night light provides enough illumination for the child to see that there is nothing hiding in the closet.

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate? a. Carotid artery b. Apex of the heart c. Brachial artery d. Radial artery

b. Apex of the heart The most effective way to assess an infant's heart rate is to auscultate at the apex of the heart.

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent? a. Restrain the child physically. b. Ignore the temper tantrums. c. Tell the child that temper tantrums are not acceptable. d. Distract the child by offering to play a game.

b. Ignore the temper tantrums. Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly.

A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client's history, the nurse should determine that which of the following is the priority risk factor for suicide completion? a. Active psychiatric disorder b. Previous suicide attempt c. Loss of a parent d. History of substance abuse

b. Previous suicide attempt A prior suicide attempt is found in as many as half of the adolescents who attempt suicide.

A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress? a. Set of building blocks b. Toy hammer and pounding board c. Picture book about hospitals d. Stuffed animal

b. Toy hammer and pounding board A toy hammer and pounding board helps the child to express the anger and frustration he feels about the parent leaving but lacks the verbal ability to express.

A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching? a. "Share piercing needles only with close friends you trust." b. "Limit your caloric intake to avoid becoming overweight." c. "Your need for sleep will increase during periods of growth." d. "Tanning beds are much safer then lying in the sun."

c. "Your need for sleep will increase during periods of growth." The nurse should inform the adolescent that sleep needs increase during growth spurts. Adequate sleep and rest during the adolescent period is important for optimal health.

A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following instructions should the nurse provide to the parent? a. Provide a high-carbohydrate meal. b. Give the child syrup of ipecac. c. Contact the poison control center. d. Bring the child to the office for a rapid infusion of deferoxamine.

c. Contact the poison control center. The nurse should instruct the parent to immediately notify the poison control center who will provide more detailed instructions.

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? a. "Newborns are abdominal breathers." b. "Newborns do not expand their lungs fully with each respiration." c. "Activity will increase the respiratory rate." d. "The rate and rhythm of breath are irregular in newborns."

d. "The rate and rhythm of breath are irregular in newborns." Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate.

A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation? a. Uses a unidextrous grasp b. Has a fear of strangers c. Shows preferences towards foods d. Babbles one-syllabus sounds

d. Babbles one-syllabus sounds A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds; therefore, this finding indicates a need for further evaluation.

A nurse in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching? a. Have the child remain at the table after meals to increase food intake. b. Add fruit juice to the child's diet to increase vitamin intake. c. Emphasize the quantity, rather than the quality, of food consumed. d. Expect that food consumption might not decrease significantly.

d. Expect that food consumption might not decrease significantly. Food consumption varies and most preschool-age children consume an adequate quantity of food despite their fads and preferences.

A nurse is developing a health program for the parents of school-age boys. Which of the following information about pubescent changes should the nurse include in the program? a. Changes in the voice signal the beginning of puberty. b. Gynecomastia commonly occurs during late puberty. c. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years. d. Growth spurts in height occur toward the end of midpuberty.

d. Growth spurts in height occur toward the end of midpuberty. Growth spurts in height occur toward the end of midpuberty. Boys grow an average of 10 to 30 cm (4 to 12 inches) during this period.

A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? a. Imaginary playmates b. Erikson's stage of initiative versus guilt c. Demonstrations of sexual curiosity d. Negative behaviors characterized by the need for autonomy

d. Negative behaviors characterized by the need for autonomy Assertion of autonomy is seen in toddlers as they begin their language and social development.