PN Children Practice 2020A

A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death?

"At this age, your child likely believes his thoughts can cause another person's death." The nurse should reinforce that, at this age, the preschooler might believe that his thoughts can cause another person's death, which can make him feel guilty or responsible for the death.

A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening?

Bending forward with back parallel to the floor The nurse should observe for asymmetry and prominence of the rib cage by having the students bend forward with the back parallel to the floor.

A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which of the following areas should the nurse observe when monitoring for manifestations of splenic sequestration?

Box B (Anatomic position left side) B is correct. The nurse should observe the location over the infant's spleen when monitoring for manifestations of splenic sequestration. Splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood.

A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis?

Dry cough The nurse should identify that a dry cough is an early manifestation of pertussis.

A nurse is caring for a preschooler who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the parent to administer for an acute asthma attack?

Levalbuterol (The nurse should inform the parent to administer levalbuterol, a short-acting beta2 agonist, to the preschooler for acute asthma attacks.)

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to include in the plan?

Promote oxygen utilization. (The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is promoting oxygen utilization to prevent further sickling of the red blood cells and promote adequate oxygenation of the tissue.)

A nurse is auscultating heart sounds on an infant. The nurse should identify this sound as which of the following?

Sinus rhythm The nurse should identify this heart sound as sinus rhythm. The nurse should auscultate heart sounds at the apical impulse, which is at the left midclavicular line and fifth intercostal space. The expected heart sounds include S1, which is the closure of the atrioventricular valves, and S2, which is the closure of the semilunar valves.

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of enterobiasis. The nurse should advise the guardian to take which of the following actions to prevent infection?

Trim the child's fingernails short. The nurse should instruct the guardian to trim the child's fingernails short to reduce the collection of eggs under their nails and prevent reinfection.

A nurse is reinforcing teaching with the guardians of a school-age childwho has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child?

Use facial expressions when speaking. (The nurse should instruct the guardians to use facial expressions when speaking to assist in conveying the message being spoken.)

A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin. Which of the following manifestations should the nurse identify as an indication of digoxin toxicity and report to the provider?

Vomiting The nurse should identify that vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider.

A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child's diet?

White rice (The nurse should reinforce to the guardian that celiac disease is a genetic autoimmune disorder in which eating gluten, even in very small amounts, can damage the child's small intestine. Currently, the only treatment for the disease is a lifelong, strict adherence to a gluten-free diet. The nurse should stress the importance of avoiding foods containing wheat, rye, barley, and oats. The child should consume foods that are gluten-free, such as milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh poultry, meats, fish, and dried beans.)

A nurse is caring for a child who has a fractured tibia and is in Buck's traction. Which of the following actions should the nurse take?

Ensure the weights are hanging freely (The nurse should ensure that the weights are hanging freely for a child who is in Buck's traction.)

A nurse in reinforcing teaching with the parents of a toddler who has strabismus. Which of the following treatments should the nurse plan to include in the teaching?

Eye patch Treatment of strabismus includes covering the strong eye to strengthen the muscles in the weak eye.

A nurse is collecting data from a child who has iron deficiency anemia. Which of the following data signifies that adherence to ferrous sulfate therapy has occurred?

Green, tarry stools Green, tarry stools are an expected outcome of ferrous sulfate therapy. Therefore, this is an indication of adherence to the prescribed medication regimen.

A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM antibiotic to a child 5 min ago. Which of the following manisfestations should the nurse expect to observe first?

Hives (The nurse should observe for hives first because this is an early manifestation of an anaphylactic reaction.)

A nurse is monitoring a child who is receiving a transfusion of packed RBCs. Which of the following responses by the child is an indication of a transfusion reaction?

"I am cold. Can I have an extra blanket?" (The nurse should identify that being cold and having chills is an indication of a transfusion reaction.)

A nurse is caring for a school-age girl who is being treated for frequent, severe urinary tract infections (UTIs). The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTIs?

"My daughter has bowel movements every 4 to 5 days." The nurse should recognize that this frequency indicates the child is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection.

A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of the following actions should the nurse take first?

Administer pain medication to the client. According to evidence-based practice, the nurse should first provide pain medication to the client to reduce discomfort during the procedure.

A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a nasogastric tube. Which of the following actions should the nurse take?

Confirm that the pH of the stomach contents is 5 or less. (The nurse should test the pH of the stomach contents prior to administering the tube feeding in order to confirm tube placement in the stomach. The nurse should identify that a pH of 5 or less indicates gastric placement.)

A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the following should the nurse recognize as an early manifestation of increased intracranial pressure?

Increased irritability (The nurse should recognize that increased irritability, fatigue, vomiting, and headache are early signs of increased intracranial pressure.)

A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile idiopathic arthritis (JIA). Which of the following statements by the guardian indicates an understanding of the teaching?

"I will have my child sleep in knee, wrist, and hand splints." The nurse should reinforce with the guardian that splinting the child's joints at night will decrease pain and enhance joint function.

A nurse is contributing to the plan of care for an adolescent who has human immunodeficiency virus (HIV). Based on the adolescent's diagnosis, which of the following actions should be included in the plan of care?

Inform the client regarding routes of transmission. (The nurse should inform the client about the transmission of HIV and how to prevent its spread.)

A nurse is collecting data from a toddler at a well-child visit. Which of the following findings should the nurse identify as a possible indication of child maltreatment?

Laceration on the side of the torso A laceration on the side of the torso is not an injury that occurs due to the typical clumsiness of a toddler. This finding indicates the need to further investigate for suspected child maltreatment.

A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory results should the nurse report to the provider?

Lead 14 mcg/dL (This lead level is above the expected reference range for a preschooler. Therefore, the nurse should report this result to the provider.)

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has a new prescription for home oxygen therapy. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will make sure that electrical devices in the house are grounded." This response by the guardian indicates an understanding of the nurse's instructions. Due to the combustible nature of oxygen, all pieces of electrical equipment in the home should be grounded to decrease the risk of a fire caused by an electrical spark.

A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following parent statements indicated an understanding of the teaching?

"I will place a screen in front of the fireplace." The nurse should instruct the parent to place a screen in front of a fireplace or other heating appliances to prevent burns.

A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

"Put your child's finger under warm, running water prior to collecting blood." (The nurse should instruct the parent that placing the child's finger under warm, running water increases the blood flow to the finger, which will make it easier to obtain the sample.)

A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the following parent statements indicates an understanding of the teaching?

"We will purchase a toy storage box with a lightweight lid." The nurse should instruct the parents to avoid toy boxes with heavy, hinged lids. Toddlers may suffocate or have the lid close on their head or neck, causing injury.

A nurse is reinforcing teaching with an adolescent female client who has acne vulgaria and a new prescription for isotretinoin. Which of the following information should the nurse include?

"You will need to have two negative pregnancy tests prior to starting this medication." The nurse should reinforce with the client that isotretinoin is teratogenic. Pregnancy must be ruled out prior to administration and before each subsequent refill. The client should use two effective forms of contraception while taking this medication.

A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child's oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 oz of gelatin, and drank 7 oz of water. What is the child's oral intake for this shift in milliliters? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

690 mL

A nurse has just received change-of-shift for four children in a pediatric unit. Which of the following children should the nurse collect data from the first?

A child who has a fever and nuchal rigidity. (A client who has a fever and nuchal rigidity is unstable. This finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. Therefore, the nurse should collect data from this child first.)

A nurse is reinforcing teaching with the parents of a child who has cystic fibrosis and is taking pancrelipase as a pancreatic enzyme replacement. The nurse should plan to inform the child's parents that the therapeutic effects of this medication can be evaluated by which of the following?

Amount and consistency of stools Recording the amount and consistency of the child's stools will help determine the effectiveness of pancrelipase, which is taken to decrease the bulk of feces.

A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who is recovering from acute glomerulonephritis. Which of the following food choices by the parents indicates an understanding of the teaching?

Apples The nurse should instruct the parents that apples are low in sodium and supply the child with energy needed for recovery.

A nurse is collecting data from a 12-month old infant during a well-child visit. Which of the following findings should the nurse report to the provider?

BP 115/70 mm Hg The nurse should identify that this blood pressure is above the expected reference range for a 12-month-old infant and report this finding to the provider. Temperature 37.5° C (99.5° F)

A nurse is collecting data from a 12-month-old infant during a well-child visit. The nurse should identify which of the following findings as a deviation from expected growth and development?

Birth weight doubled The nurse should identify this finding as a deviation from expected growth and development. The infant's birth weight should triple by 12 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is collecting data from a toddler who has gastroesophageal reflux (GERD). Which of the following findings should the nurse expect?

Chronic cough The nurse should identify that a chronic cough is an expected finding in a child who has GERD.

A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following actions should the nurse take?

Have a suction canister and tubing available in the room. (The nurse should have a suction canister and tubing available in the child's room to keep the child's airway patent during a seizure.)

A nurse is caring for an adolescent client who is experiencing sickle cell crisis. Which of the following laboratory values should the nurse report to the provider?

Hgb 6 g/dL (The expected reference range for an adolescent's Hgb level is 10 to 15.5 g/dL. Therefore, an Hgb of 6 g/dL is below the expected reference range and should be reported to the provider.)

A nurse is collecting data about a 4-year-old preschooler's gross motor skills. The nurse should expect the preschooler to be able to perform which of the following activities?

Hopping on one foot The nurse should expect to find that a 4-year-old preschooler is able to hop on one foot.

A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea. Which of the following findings should the nurse identify as a risk for this disorder? (Select all)

Hypothyroidism is correct. The nurse should identify that hypothyroidism and other endocrine disorders are risk factors for primary amenorrhea. Cannabis use is correct. The nurse should identify that cannabis use is a risk factor for primary amenorrhea. Oral contraceptive use is correct. The nurse should identify that oral contraceptive use affects the estrogen and progesterone cycle and is a risk factor for primary amenorrhea. Emotional stress is correct. The nurse should identify that emotional stress causes hypothalamic suppression and is a risk factor for primary amenorrhea.

A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The nurse should identify which of the following as an indication that the preschooler experienced an allergic reaction to the contrast dye?

Urticaria (The nurse should monitor the child for an allergic reaction to the contrast dye. Manifestations of the allergic reaction include urticaria, itching, flushing of the skin, and possible anaphylaxis.)

A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following instructions should the nurse include to decrease the child's risk of an upper respiratory infection?

Use a cool mist vaporizer in the infant's room. The nurse should reinforce that a cool mist vaporizer should be used to help thin respiratory secretions and decrease the infant's risk for an upper respiratory infection.

A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect?

Weight loss of 10% (The nurse should expect an infant who has severe dehydration to experience weight loss of up to 10%.)

A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which of the following actions should the nurse take?

Place the infant in semi-Fowler's position for 1 hr after the feeding. The nurse should elevate the head of the infant's bed by 30º to 45º for 30 min to 1 hr after the feeding.

A nurse is reviewing the laboratory report of a preschooler who has a Wilms' tumor and is scheduled to begin treatment with an antineoplastic medication regimen. Which of the following laboratory results should the nurse report to the provider?

Platelet count 70,000/mm3 This platelet count is below the expected reference range for a preschooler and increases the risk for spontaneous bleeding. The nurse should hold the medication and report this finding to the provider immediately.

A nurse is assisting with the care of a school-age child who has congestive heart failure and is receiving digoxin. Which of the following manifestations should teh nurse report to the provider?

Potassium 3 mEq/L (The nurse should report a potassium level of 3 mEq/L to the provider. A decreased potassium level can place the child at risk for digoxin toxicity.)

A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg to repair a femur fracture. Which of the following findings is the priority for the nurse to report to the provider?

Report of tingling in the right foot The nurse should identify that the greatest risk to the child is nerve injury. Therefore, tingling in the right foot, which can indicate nerve damage or compartment syndrome, is the priority finding for the nurse to report to the provider.

A nurse is collecting data from an adolescent who has manifestations of physical abuse. Which of the following actions should the nurse take?

Report the suspected abuse to the authorities (Nurses are required mandatory reporters of child abuse. It is the nurse's responsibility to report any type of abuse to the appropriate agencies. This action will assist with ensuring a safe environment for the adolescent.)

A nurse is contributing to the plan of care for a school-age child who has acute poststreptoccal glomerulonephritis (APSGN) and is mu=ildly hypertensive. Which of the following actions should the nurse include in the plan of care?

Restrict the child's sodium intake (The nurse should limit the sodium intake for a child who has APSGN and is hypertensive or who has a decreased urine output to help prevent water retention and edema.) The nurse should monitor the blood pressure of a child who has APSGN every 4 to 6 hr.

A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone. Which of the following laboratory results should the nurse report to the provider?

Sodium 150 mEq/L (Hypernatremia is an adverse effect of prednisone. This level is above the expected reference range for a school-age child. Therefore, the nurse should report this value to the provider.)

A nurse is collecting data from an infant who is receiving IV therapy for fluid replacement. Which of the following findings indicated the infant's status is improving?

Sodium level 145 mEq/L (The nurse should identify that a sodium level of 145 mEq/L is within the expected reference range of 134 to 150 mEq/L and is an indication that the infant's status is improving.)

A nurse is reinforcing teaching with the parents of a 7-year-old female child about behavioral expectations. Which of the following behaviors should the nurse include in the teaching?

Spends a lot of time by herself Spending time alone is an expected characteristic of a 7-year-old female child. When they do spend time with others, children in this age group prefer to socialize with children of the same sex and age.

A nurse assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding?

Stand on one foot for several seconds (Standing on one foot for several seconds is an expected behavior for a toddler.)

A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse paln to administer?

Tetanus, diptheria toxoids, and acellular pertussis (Tdap) The Tdap vaccine is recommended between the ages of 11 and 12 years. Therefore, this adolescent should receive the Tdap vaccine now.

A nurse is collecting data about the dietary habits of an adolescent female client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits?

The client fasts twice a week to manage dietary intake. (The nurse should identify that adolescents are often at risk for developing poor eating habits. Regular fasting puts this client at risk for nutritional deficits.)

A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parent asks the nurse why it is necessary to check the child's urine for protein. Which of the following explanations should the nurse offer?

"A decrease in urine protein indicates that treatment is effective." The desired outcome of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.

A nurse is preparing to administer ophthalmic drops to a child. Which of the following actions should the nurse take?

Apply pressure to the lacrimal punctum for 1 min following administration. The nurse should apply pressure to the lacrimal punctum to prevent the medication from entering the nasopharynx.

A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of acitons the nurse should recommend to the parent.

Determine if the child is breathing Empty the child's mouth of remaining pills and residue Identify the medication and dosage strength Call a poison control center Determine if the child is breathing is the first step. The child's respiratory and cardiovascular status should be checked first to determine if CPR is necessary.Empty the child's mouth of remaining pills and residue is the second step. The child's mouth should be emptied of pills and residue to prevent additional exposure to the medication.Identify the medication and dosage strength is the third step. The parent should identify the medication and dosage strength by looking at the medication container.Call a poison control center is the fourth step. The parent should contact a poison control center for advice on the next course of action.

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has acute lymphocytic leukemia and an absolute neutrophil count of 450/mm3. Which of the following instructions should the nurse include?

"Keep your child away from crowded areas." (The nurse should instruct the guardian to keep the child away from crowds and visitors who have an illness to decrease the risk for infection.)

A nurse is caring for an adolescent client who is a practicing Jehovah's Witness and is scheduled for surgery for a ruptured appendix. The adolescent tells the nurse that based on their religious beliefs, they cannot receive a blood transfusion. Which of the following responses should the nurse make?

"Let's discuss the possible need for transfusion with your parents." (The nurse should offer to involve the child's parents to understand the family's beliefs about blood transfusions.)