practice eaqs for exam 3

A 3-month-old infant with tetralogy of Fallot is admitted for a diagnostic workup in preparation for corrective surgery. The morning after cardiac catheterization the infant suddenly becomes cyanotic and begins breathing rapidly. In what position should the nurse immediately place the infant? 1 Supine 2 Lateral 3 Knee-chest 4 Semi-Fowler

3

A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis? 1 Hypoxia 2 Hyperthermia 3 Emotional trauma 4 Aspiration pneumonia

1

A 7-year-old child was recently found to have juvenile idiopathic arthritis. The parents are concerned about the lifelong effects of the disorder and are investigating other therapies to use with the medications. What referral should the nurse recommend? 1 Physical therapy 2 Special education 3 Nutritional therapy 4 Herbal supplements

1

A nurse is assessing a toddler with vesicoureteral reflux. What clinical finding does the nurse expect to identify? 1 Dysuria 2 Oliguria 3 Glycosuria 4 Proteinuria

1

The nurse assesses a 5-year-old child after a shunt procedure is performed to correct increased intracranial pressure. Which finding is of most concern? 1 Marked irritability 2 Complaints of pain 3 Pulse of 100 beats/min 4 Temperature of 99.4° F (37.4° C)

1

Spinal fusion is performed in an adolescent with scoliosis. What postoperative nursing intervention is specifically related to surgery for scoliosis? 1 Log-rolling every 2 hours 2 Checking the dressing frequently 3 Supervising deep-breathing exercises 4 Maintaining the adolescent in the supine position for 3 days

1

A 5-year-old client has recently been diagnosed with type 1 diabetes. A glucose tolerance test is prescribed. The prescription reads, "Administer glucose 1g/kg." The client weighs 60 pounds. How much glucose should the nurse administer in grams? Record your answer using a whole number. ___ g

27

An 8-year-old child is being discharged after recovery from a sickle cell vaso-occlusive (painful crisis) episode. The nurse teaches the parents the do's and don'ts of the child's care. What statement by the parents satisfies the nurse that they understand the principles of care? 1 Have the child schooled by a private tutor 2 Restrict the child's fluid intake during the night 3 Permit the child to play with just one peer at a time 4 Encourage the child to engage in low-intensity activities

4

A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? 1 Cold, clammy skin 2 Increased pulse rate 3 Increased blood pressure 4 cyanosis of the nail beds

2

An 8-month-old infant undergoes surgical correction for hypospadias. What is a priority nursing intervention during the postoperative period? 1 Ensuring that privacy is maintained 2 Minimizing pain with adequate analgesia 3 Restricting fluid intake until the stent is removed 4 Gradually increasing the time that the urinary catheter is clamped

2

he parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it all right if I give him two baby aspirins?" What is the best response by the nurse? 1 "You seem concerned about giving drugs to your child." 2 "It's all right to give him baby aspirin when he hurts himself." 3 "Aspirin may cause more bleeding. Give him acetaminophen instead." 4 "He should be given acetaminophen every day. It'll prevent bleeding."

3

An infant with congenital hypothyroidism receives levothyroxine for three months. During the return appointment, which statement by the mother indicates to the nurse that the drug is effective? 1 The infant is alert and interactive. 2 The skin is cool to the touch. 3 The baby's fine tremor has ceased. 4 The baby's thyroid stimulating hormone level has increased.

1

What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? 1 A low-phenylalanine diet is required. 2 Phenylalanine is not necessary for growth. 3 Phenylalanine can be administered to correct the deficiency. 4 A substitute for phenylalanine is an increased amount of other amino acids.

1

Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents? 1 How to obtain the vital signs daily 2 Date on which to return to prepare for renal dialysis 3 Instructions about which high-sodium foods to avoid 4 List of activities that will encourage the child to remain active

3

Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? 1 Encouraging fluids 2 Monitoring for seizures 3 Measuring abdominal girth 4 Checking for pupillary reactions

2

Which of these age groups has the highest incidence of lead poisoning? 1 Adult 2 Toddler 3 Adolescent 4 School-age child

2

A 3-week-old infant has surgery for esophageal atresia. What is the immediate postoperative nursing care priority for this infant? 1 Giving the oral feedings slowly 2 Reporting vomiting to the practitioner 3 Checking the patency of the nasogastric tube 4 Monitoring the child for signs of infection at the incision site

3

An 11-year-old child with juvenile idiopathic arthritis will be receiving continued nonsteroidal antiinflammatory drug (NSAID) therapy at home. Which important toxic effect of NSAIDs must be included in the nurse's discharge instructions to the child and family? 1 Diarrhea 2 Hypothermia 3 Blood in the urine 4 increased irritability

3

The nurse takes into consideration that the effect PKU has on the infant's development will depend primarily upon which factor? 1 Blood phenylalanine levels in utero 2 Excessive levels of epinephrine at birth 3 Diagnosis within the first 2 days after birth 4 Adherence to a corrective diet instituted early

4

What should the plan of care for a newborn with hypospadias include? 1 Preparing the infant for insertion of a cystostomy tube 2 Explaining to the parents the genetic basis for the defect 3 Keeping the infant's penis wrapped with petrolatum gauze 4 Giving the parents reasons why circumcision should not be performed

4

An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting? 1 Start with small, frequent feedings. 2 Rock for 20 minutes after a feeding. 3 Keep the infant awake for 30 minutes after feeding. 4 Position the infant flat on the right side during feedings.

1

The mother of a 5-year-old girl child reports to a nurse that her daughter has a genital discharge and recurrent urinary tract infections. What should the nurse suspect from the mother's statement? 1 The child may be a victim of sexual abuse. 2 The child may be a victim of physical abuse. 3 The child may be a victim of physical neglect. 4 The child may be a victim of emotional neglect.

1

Which priority actions should the nurse implement when providing care to a toddler-age child who presents in the emergency department (ED) after an accidental overdose? Select all that apply. 1 Monitor vital signs 2 Assess mental status 3 Question the parents 4 Initiate CPR, if needed 5 Empty mouth of remnants

1,2,4

A toddler-age child presents in the emergency department (ED) with an infected wound. The child's mother states, "I don't have time to take care of this." A review of the child's medical record indicates that each appointment related to the wound was cancelled. Which should the nurse suspect based on the current data? 1 Physical abuse 2 Physical neglect 3 Emotional neglect 4 Psychologic abuse

2

During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse? 1 Diapers should be changed at least every 4 hours. 2 Frequent diaper changes with cleansing are needed. 3 Medicated ointment should be applied six times a day. 4 Powder may be used in the perineal area when it becomes wet.

2

The nurse is reviewing discharge instructions for a mother whose lactose intolerant school-aged child was recently found to have celiac disease. Which statements by the mother demonstrate understanding of the child's nutritional needs? Select all that apply. 1 "Rolled-up lunch meat with cheese is a good alternative to sandwiches." 2 "I'll try to provide meals that are lower in fats and higher in carbohydrates." 3 "I'll start giving her milk with meals so she gets enough calcium in her diet." 4 "She loves raw carrots for snacking, so I'll have to avoid those when the disease is worse." 5 "I'll be sure to look at the labels more closely from now on—we need to avoid hydrolyzed vegetable protein."

2,4,5

At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What is the nurse's priority action in response to this situation? 1 Stimulate crying 2 Substitute sterile water for the formula 3 Suction and then oxygenate the newborn 4 Stop the feeding momentarily and then restart it

3`

A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention? 1 Offering clear fluids whenever the child is awake 2 Checking the child's level of consciousness hourly 3 Assessing the child's blood pressure every four hours 4 Administering the prescribed oral antibiotic medication

4

The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis? 1 Shunting of blood from right to left 2 Shunting of blood from left to right 3 Obstruction of blood flow from the left side of the heart 4 Obstruction of blood flow between the left and right sides of the heart

1

What is the priority of preoperative nursing care for an infant with a cleft lip? 1 Preventing crying 2 Modifying feeding 3 Preventing infection 4 Minimizing handling

2

A 4-month-old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? 1 Decreased tremors 2 Increased hours of sleep 3 Weight loss during next 2 days 4 More rapid heart rate within 2 days

3

A 4-year-old child who barely survived a near-drowning episode is in critical condition in the pediatric intensive care unit. Suddenly the child opens her eyes and smiles, prompting a parent to say to the nurse, "Look! I think she'll get better now." What is the bestresponse by the nurse? 1 "You're right; that's a very good sign." 2 "Try to have your child hold your hand." 3 "We're doing everything we can to promote recovery." 4 "God certainly must be watching over your child today."

3

A nurse is caring for a 3-week-old infant with hypertrophic pyloric stenosis who is severely dehydrated. What finding does the nurse expect when assessing the infant? 1 Weight loss of 5% 2 Severe allergic reactions 3 Depressed anterior fontanel 4 Urine specific gravity of 1.014

3

A young child from a developing country is admitted to the pediatric unit for surgery to correct a congenital heart defect. The mother asks the nurse why her child squats after exertion. The nurse responds, in language that the mother understands, that this position does what? 1 Decreases the number of muscle aches 2 Improves walking capacity and hip mobility 3 Reduces how hard the heart must work 4 Helps more blood return to the heart

3

After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. What assessment should the nurse document that will aid confirmation of the diagnosis? 1 Frequency of crying 2 Amount of oral intake 3 Characteristics of stools 4 Absence of bowel sounds

3

A 16-year-old adolescent with recently diagnosed type 1 diabetes will receive NPH insulin subcutaneously. The nurse teaches the adolescent about peak action of the drug and the risk for hypoglycemia. How many hours after NPH insulin administration does the insulin peak? 1 1 to 2 hours 2 2 to 4 hours 3 5 to 10 hours 4 4 to 12 hours

4

A 2½-year-old toddler is admitted with a fever of 103° F (39.4° C), stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority nursing intervention for this child? 1 Increasing fluids 2 Administering oxygen 3 Giving a tepid sponge bath 4 Instituting droplet precautions

4

The day after undergoing abdominal appendectomy a school-aged child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation? 1 Providing a rest period 2 Offering a reward for walking 3 Encouraging use of the spirometer 4 Administering the prescribed pain medication

4

The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. What body system does the nurse expect will be affected? 1 Neurological 2 Integumentary 3 Gastrointestinal 4 Cardiopulmonary

4

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? 1 pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L) 2 pH 7.35, CO2 47 mm Hg, HCO3- 24 mEq/L (24 mmol/L) 3 pH 7.46, CO2 30 mm Hg, HCO3- 24 mEq/L (24 mmol/L) 4 pH 7.50, CO2 50 mm Hg, HCO3- 22 mEq/L (22 mmol/L)1

1

The mother of a school-aged child with type 1 diabetes asks why it was recommended that her child use an insulin pump rather than insulin injections. What will the nurse tell the mother concerning the greatest advantage of the insulin pump? 1 Independence is fostered. 2 Fear of daily injections is allayed. 3 Dietary restrictions are minimized. 4 Blood glucose monitoring can be eliminated.

1

The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response? 1 Holding may meet needs and reduce tension on the suture line. 2 Sedation limits activity and decreases tension on the suture line. 3 Handling may increase irritability, causing tension on the suture line. 4 Arm movements cannot be controlled, placing tension on the suture line.

1

The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching? 1 "I'll use a straight razor when I start shaving." 2 "I plan on trying out for the swim team next year." 3 "If I injure a joint, I'll keep it still, elevate it, and apply ice." 4 "If I get a little scratch, I can apply gentle pressure for 10 to 15 minutes."

1

The nurse is performing the nursery intake assessment of a 1-hour-old newborn. The assessment reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings? 1 Notify the practitioner, because circumoral pallor may indicate cardiac problems 2 Notify the practitioner, because both signs are indicative of increased intracranial pressure 3 Take no specific action, because both signs are expected in a newborn until 2 weeks of age 4 Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying

1

The nurse is teaching the parents of a toddler-age client about food safety related to choking. Which parental statement indicates the need for further education? 1 "Hot dogs are safe and do not present a choking hazard for my child." 2 "Ice cream is safe and does not present a choking hazard for my child." 3 "Chicken nuggets are safe and do not present a choking hazard for my child." 4 "Mashed potatoes are safe and do not present a choking hazard for my child."

1

The urinary output of a 9-year-old child with acute glomerulonephritis decreases to 250 mL/24 hr. A diet low in sodium and potassium is prescribed. What should the nurse encourage the child to have for lunch? 1 Baked chicken, green beans, and lemonade 2 Cream of tomato soup, salami sandwich, and cola 3 Grilled cheese sandwich, sliced tomatoes, and milk 4 Peanut butter and jelly sandwich, celery, and orangeade

1

The school nurse is assessing a 10-year-old boy with hemophilia who has fallen while playing in the schoolyard. At which site does the nurse expect to find internal bleeding? 1 Joints 2 Abdomen 3 Cerebrum 4 Epiphyses

1

A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease (congenital aganglionic megacolon). What procedure does the nurse expect to be used to confirm the diagnosis? 1 Colonoscopy 2 Rectal biopsy 3 Multiple saline enemas 4 Fiberoptic nasoenteric tube

2

A 4-year-old child with nephrotic syndrome is admitted to the pediatric unit. What clinical finding does the nurse expect when assessing this child? 1 Severe lethargy 2 Dark, frothy urine 3 Chronic hypertension 4 Flushed, ruddy complexion

2

What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever? 1 Negative C-reactive protein 2 Increased reticulocyte count 3 Positive antistreptolysin titer 4 Decreased sedimentation rate

3

A child with hip dysplasia has undergone a closed reduction surgery. The nurse assesses the child 2 days after the surgery and feels that the treatment and care provided for the child were not effective. The nurse made this conclusion based on what findings? 1 The child has a staggering gait. 2 The child is unable to walk independently. 3 The child has impaired muscle tone and flexibility. 4 The child's femoral head did not return to the hip socket.

4

A toddler is found to have coarctation of the aorta. What does the nurse expect to identify when taking the child's vital signs? 1 Irregular heartbeat 2 Weak femoral pulse 3 Thready radial pulses 4 Increased temperature

2

An infant has had surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant? 1 Frequent crying 2 Bulging fontanels 3 Change in vital signs 4 Difficulty with feeding

2

Which are sources of lead the nurse should assess for when providing care to a toddler-age client who is admitted with lead poisoning? Select all that apply. 1 Water 2 Pottery 3 Stained glass 4 Collectable toys 5 Vinyl miniblinds

1,2,4,5

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? 1 Nausea 2 Lethargy 3 Sunset eyes 4 Hyperthermia

2

A 6-year-old child is hospitalized with nephrotic syndrome. The mother asks the nurse what she may bring for her child to play with during the hospitalization. In light of the child's age, what should the nurse suggest? Select all that apply. 1 Checkers 2 Wooden puzzles 3 Paper and crayons 4 Simple card games 5 CDs and a CD player

1,3,4

While performing preoperative teaching a nurse explores a young adolescent's concern about changes in appearance after surgery to correct scoliosis. What is the most appropriate statement by the nurse? 1 "After surgery your back will be much straighter." 2 "You're concerned about how you'll look after surgery." 3 "Many teenagers who have this type of surgery do very well." 4 "Your parents think it's important for you to have this surgery."

2

A nurse is caring for a 3-month-old infant with congenital hypothyroidism. What should the parents be taught about the probable long-term effect of the condition if treatment is not begun immediately? 1 Myxedema 2 Thyrotoxicosis 3 Spastic paralysis 4 Cognitive impairment

4

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply. 1 Raw carrots 2 Boiled spinach 3 Dried apricots 4 Brussels sprouts 5 Asparagus spears

2,3

A 6-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis (painful episode). What are the priority nursing concerns? Select all that apply. 1 Nutrition 2 Hydration 3 Pain management 4 Prevention of infection 5 Oxygen supplementation

2,3,5

Which explanation should the nurse consider when formulating a response to a client's inquiry about intussusception of the bowel? 1 Kinking of the bowel onto itself 2 A band of connective tissue compressing the bowel 3 Telescoping of a proximal loop of bowel into a distal loop 4 A protrusion of an organ or part of an organ through the wall that contains it

3

A nurse who suspects that a newly admitted infant is the victim of child abuse assesses the parents' interaction with their baby. What parental behaviors might support the diagnosis of child abuse? Select all that apply. 1 Displaying sensitivity about their child care ability 2 Taking the initiative in meeting their child's needs 3 Exhibiting difficulty in showing concern for their child 4 Demonstrating heightened interest in their child's welfare 5 Procrastinating in obtaining treatment for their child's injuries

3,5

A nurse is preparing an infant for a lumbar puncture. In what position should the nurse hold the infant? 1 Sitting with the buttocks at the table's edge and the head flexed 2 Prone with the head extended over the table's edge and the extremities swaddled 3 Lateral recumbent with the back at the table's edge and the head and legs extended 4 Side-lying with the back at the table's edge and the head flexed with the knees brought to the chin

4

A nurse is teaching a 10-year-old child with type 1 diabetes about insulin requirements. When does the nurse explain that insulin needs will decrease? 1 When puberty is reached 2 When infection is present 3 When emotional stress occurs 4 When active exercise is performed

4

After a discussion with the primary healthcare provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond? 1 The diameter of the aorta is enlarged. 2 The wall between the right and left ventricles is open. 3 It is a narrowing of the entrance to the pulmonary artery. 4 It is a connection between the pulmonary artery and the aorta.

4

An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify? 1 Cyanosis 2 Restlessness 3 Decreased heart rate 4 Increased respiratory rate

4

An infant with a cardiac defect is fed in the semi-Fowler position. After the nurse feeds and burps the infant and changes the infant's position, the infant has a bowel movement and almost immediately becomes cyanotic, diaphoretic, and limp. Which activity mostlikely caused the infant's response? 1 Burping 2 Feeding 3 Position change 4 Bowel movement

4

An infant with hydrocephalus has a ventriculoperitoneal shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure? 1 Medicating the infant for pain 2 Placing the infant in a high Fowler position 3 Positioning the infant on the side that has the shunt 4 Monitoring the infant for increasing intracranial pressure

4

The nurse is providing discharge instructions to the parents of a child who has undergone surgical correction of hypospadias. What is the priorityinformation for the nurse to include? 1 Ensuring that the child's privacy is maintained 2 Increasing the time that the catheter is clamped 3 Maintaining the surgically implanted tension device 4 Teaching parents how to care for the catheterization system

4

What is the priority of care for a 7-year-old child with recently diagnosed celiac disease? 1 Preventing celiac crisis and resulting problems 2 Minimizing complications of respiratory involvement 3 Teaching the parents to establish a diet that promotes optimal growth 4 Helping the parents and child adjust to the long-term dietary restrictions

4