Prep U peds Ch 1-14
A parent of a child recently diagnosed with attention deficit hyperactivity disorder (ADHD) asks the nurse to explain how the provider determined the diagnosis. Which statement made by the nurse correctly explains the diagnostic criteria for ADHD? "A pattern of attention and/or hyperactivity-impulsivity persisting for 6 months that interferes with functioning or development." "A pattern of inattention and/or hyperactivity-impulsivity persisting for 6 months that interferes with functioning or development." "A pattern of inattention and/or hyperactivity-impulsivity persisting for 3 months that interferes with functioning or development." "A pattern of attention and/or hyperactivity-impulsivity persisting for 1 year that interferes with functioning or development."
"A pattern of inattention and/or hyperactivity-impulsivity persisting for 6 months that interferes with functioning or development." Explanation: The diagnosis of ADHD is made by meeting criteria established by the American Psychiatric Association and to be diagnosed, a person must meet six or more of the inattention behaviors or symptoms and/or six or more of the hyperactive/impulsive behaviors or symptoms. These symptoms of inattention and/or hyperactive/impulsivity must be present for at least 6 months, in two or more settings, such as home and school, and create a negative impact on social, academic, or occupational activities.
A 14-year-old child has frequent sickle cell crises and is in pain, but fears taking analgesia and becoming addicted. Which response made by the nurse is most appropriate? "Ask for pain medicine before the pain becomes too bad." "Only use acetaminophen to control your pain." "Only take enough pain medication to stay sedated until the crisis is over." "You can become addicted easily, so you are wise to not take opioid pain medication."
"Ask for pain medicine before the pain becomes too bad." Explanation: It should be suggested that the child requests analgesia before the pain becomes unbearable, explaining that because the child needs the medication to reduce pain the child will not become addicted. Addiction and dependence in children are extremely rare and it's unlikely to cause dependence when given according to the health care provider's prescription. Using very little analgesia (or none) will impair mobility and possibly put the child in a state of depression. Acetaminophen is a safe, popular pain reliever and fever reducer, but is usually not enough to cover the pain of a sickle cell crisis.
The nurse is reviewing discharge instructions with the parents of a 2-year-old child admitted with gastroenteritis and dehydration. Which statement by the parents requires further follow-up by the nurse? "Fussiness and irritability may mean that my child is not getting well." "If my child becomes lethargic again, I should call the doctor." "I will sing through 'Happy Birthday' in my head to ensure I am washing my hands long enough." "As long as my child is eating and drinking, it is not necessary to give antipyretics."
"I will sing through 'Happy Birthday' in my head to ensure I am washing my hands long enough." Explanation: Singing through "Happy Birthday" one time does not provide adequate time for handwashing. This statement requires further follow-up by the nurse. The recommendation is to perform handwashing for 20 to 30 seconds, or the time it takes to sing "Happy Birthday" twice. Lethargy, fussiness, and irritability are reasons that the parents should follow up with the client's health care provider. If the client is eating and drinking, antipyretics should be avoided.
The nurse has just finished teaching the parents of a 7-year-old child with attention deficit hyperactivity disorder (ADHD) about the disorder and treatments. Which statement by the parents indicates a need for further teaching? "With medication and teaching, we can promote optimal growth and development in our child." "Teachers will provide structure and decrease classroom stimuli to enhance school performance." "If our child takes the prescribed medication, we will not see signs of ADHD." "Medications should not be given after 6 pm, to allow our child to sleep."
"If our child takes the prescribed medication, we will not see signs of ADHD." Explanation: Medications alone are rarely effective in the treatment of ADHD. It is the combination of both ADHD medications and behavioral therapy that are most effective. The parents will need further education if they make this statement. The other statements are correct, and parents should be commended for their learning.
The nurse is reviewing the side effects of chemotherapy with the parent of a 4-year-old child about to undergo treatment for acute lymphoblastic leukemia. Which statement requires further follow-up by the nurse? "If side effects occur, it means the treatment is taking effect." "Eating and drinking may become very difficult." "Nausea, vomiting, and fatigue are common side effects." "Side effects that my child experiences may be different from another child with the same treatment." SUBMIT ANSWER
"If side effects occur, it means the treatment is taking effect." Explanation: The presence or absence of side effects is not an indication of the effectiveness of treatment. Not all children experience the same side effects of chemotherapy, and side effects may be experienced at different levels of severity among children, even for the same treatment. Nausea, vomiting, and fatigue are among the most common side effects, and several of these side effects make eating and drinking difficult.
The nurse is caring for a newborn client with a suspected congenital cardiac anomaly whose oxygen saturation levels are 92% to 94%, and the client appears to be in respiratory distress. The client's parents ask the nurse, "Why aren't you giving oxygen?" How should the nurse respond? "Oxygen will not be of help with a heart condition." "The oxygen levels are still high." "Being upset can look like breathing problems." "It may worsen the condition."
"It may worsen the condition." Explanation: The nurse should respond by explaining that oxygen may worsen the client's condition. Oxygen can lower pulmonary vascular resistance, which creates pulmonary overcirculation or flooding of the lungs. The oxygen saturation levels, generalized distress appearing to be breathing problems, and oxygen not being of help for treating a heart condition are incorrect rationales for forgoing the use of oxygen for the client; oxygen may still be used for other clients with oxygen saturations levels as low as 92% to 94%. Fussiness in a newborn is a finding distinct from respiratory distress. Some cardiac conditions may benefit from the use of oxygen.
A 7-year-old child with type 1 diabetes tested positive for influenza A and stayed home from school today. The parent calls the clinic reporting that the child does not have an appetite and only drank tea and ate toast. What instruction should the nurse give the parent regarding insulin dosage? "Test blood glucose every 3 to 4 hours and administer insulin as needed." "Test urine glucose every 2 hours." "There is no need to test blood glucose, because the child is not eating much." "Give short-acting insulin even if not eating."
"Test blood glucose every 3 to 4 hours and administer insulin as needed." Explanation: The child should never stop taking insulin, even if the child is not eating well. The parent should continue to give the usual amount of long-acting insulin or basal insulin. The parent should test glucose every 3 to 4 hours, along with testing urine.
The nurse is assigned to a toddler with sickle cell anemia who is scheduled for an exchange transfusion. The parents ask about the purpose of the procedure. What is the nurse's best response? "The procedure is done to prevent further sickling during vasoocclusive crisis." "When the spleen is removed, it is necessary to do exchange transfusions." "The procedure is routine for sickle cell crisis." "The procedure reduces side effects of blood transfusions."
"The procedure is done to prevent further sickling during vasoocclusive crisis." Explanation: Exchange transfusions reduce the number of circulating sickled cells and slows the cycle of hypoxia, thrombosis, and tissue ischemia. Exchange transfusion is not a routine procedure. After splenectomy, transfusions may still have to be done depending on the child's hemoglobin level. Exchange transfusions do not decrease the risk of transfusion reactions; the child continues to be at risk.
The nurse is assessing a 4-year-old child whose parents are concerned the child has attention deficit hyperactivity disorder (ADHD). Which statement made by the nurse is correct? "To make a diagnosis, symptoms must occur for 6 months." "To make a diagnosis, symptoms must occur for 5 months." "To make a diagnosis, symptoms must occur for 4 months." "To make a diagnosis, symptoms must occur for 2 months."
"To make a diagnosis, symptoms must occur for 6 months." Explanation: Behaviors persist for at least 6 months, in two or more settings, and create a negative impact on social, academic, or occupational activities. All other answers are not enough time to evaluate behaviors.
The nurse is caring for a 6-year-old child who presents with inattention and hyperactivity. The parents ask the nurse how these symptoms will be treated. What is the best response by the nurse? "Treatment may include psychotherapy and medications." "Treatment may include psychotherapy and antipsychotic medications." "Treatment may include behavioral therapy and medications." "Treatment may include behavioral therapy and antipsychotic medications
"Treatment may include behavioral therapy and medications." Explanation: These are symptoms of attention deficit hyperactivity disorder (ADHD), and the most effective treatment of ADHD is a combination of pharmacological and behavioral therapies. Using both modalities helps to control symptomatic behaviors by the medication while working on changing maladaptive behavior patterns through therapy with the child and family. Psychotherapy and antipsychotic medications are not appropriate for this child.
A parent asks the nurse how it is determined that the child has respiratory syncytial virus (RSV). What is the nurse's best response? "We will swab your child's nose and send that specimen for testing." "We will do a simple blood test to determine whether your child has RSV." "We will have to send a viral culture to an outside laboratory for testing." "There is no specific test for RSV. The diagnosis is made based on the child's symptoms."
"We will swab your child's nose and send that specimen for testing." Explanation: The nurse will swab the child's nose and have the swab tested. RSV is not diagnosed by blood tests. Viral cultures are usually not done and do not have to be sent to a special laboratory for evaluation. The specific test for RSV is the nasal swab or "nasal wash."
The emergency department nurse is caring for a pediatric client with asthma and documents the above notes. The client states, "My favorite activity is swimming. Can I continue to do this?" How should the nurse respond? "Yes, swimming is a physical exercise that you can tolerate." "Swimming takes too much oxygen away from your lungs." "Yes, swimming will prevent bronchospasms." "No, swimming is not a physical exercise within your tolerance limit."
"Yes, swimming is a physical exercise that you can tolerate." Explanation: Physical exercise such as swimming, walking, and stationary cycling within the client's limit of tolerance is beneficial and may require pretreatment or long-term control of symptoms to prevent bronchospasms. Swimming will help to strengthen the lungs; it does not take too much oxygen away from the lungs nor will it prevent bronchospasms.
The nurse is preparing to administer IV rehydration therapy for a 2-year-old child who is severely dehydrated. Based on the above diagnostic results, the nurse should prepare to administer which type of fluids?
0.9% normal saline solution Explanation: A dehydrated client with a serum sodium level within normal range should receive isotonic fluid replacement therapy such as with 0.9% normal saline solution. Normal saline solutions of 0.45%, 0.33%, and 0.225% are all examples of hypotonic fluids.
The nurse is preparing to administer Regular U100 insulin to a 7-year-old child admitted for diabetic ketoacidosis. When should the nurse plan to recheck the child's blood glucose level? 60 to 90 minutes 2 to 4 hours 5 to 15 minutes 30 to 60 minutes
30 to 60 minutes Explanation: The nurse should plan to recheck the child's blood glucose level in 30 to 60 minutes, because this is the onset of action for Regular U100 insulin. Lispro and Aspart insulin both have an onset of 5 to 15 minutes and have a peak action of 30 to 90 minutes. Isophane insulin has an onset of 2 to 4 hours, and is an intermediate-acting insulin.
A child with attention deficit hyperactivity disorder (ADHD) presents to the school nurse's office with problems focusing at school. The student nurse observing in the office asks the nurse, "What can be done to help improve focus in the school setting for this child?" What action would the nurse take? Select all that apply. Discuss with the teacher seating the child in front of a window. Advocate for an aide to sit with the child. Advocate for moving the child to a less stimulating space for completing assignments. Work with the teacher to offer more time to complete tests and homework. Suggest the child have a friend help with assignments.
Advocate for an aide to sit with the child. Advocate for moving the child to a less stimulating space for completing assignments. Work with the teacher to offer more time to complete tests and homework. Explanation: Accommodations that will help improve focus in the school setting includes providing an aide to sit with the child and help the child stay focused, allowing more time to complete tests and homework, and providing a nonstimulating environment to complete activities and not be distracted. Seating the child in front of a window and having a friend help with assignments do not promote focus; instead, these would promote distraction.
The nurse is caring for a 2-year-old child admitted for dehydration. The client refuses to drink fluids from a cup and is asking to drink from a bottle. How should the nurse respond? Allow the client to drink from a bottle. Request that the parent bring a cup from home. Offer the client a reward for drinking from a cup. Explain to the client why drinking from a cup is recommended.
Allow the client to drink from a bottle. Explanation: The client is exhibiting behavior consistent with regression, which is a defense mechanism due to stress in the client's life. Once the client is back home and in the usual routine, these behaviors should disappear. Because rehydration is a higher priority for the client, the nurse should permit the client to drink from a bottle. Therefore, offering the client a reward for drinking from a cup, requesting that the parent bring a cup from home, and explaining to the client why drinking from a cup is recommended are not necessary actions.
The nurse is educating an 11-year-old child with obesity on age-appropriate nutritional guidelines. Which action should the nurse take first? Review the use of "My Plate" to visualize proper food choices. Ask for a description of typical breakfast, lunch, dinner, and snacks. Identify examples of healthy foods to include in each meal. Explain the importance of portion control.
Ask for a description of typical breakfast, lunch, dinner, and snacks. Explanation: The nurse should ask for a description of the child's typical breakfast, lunch, dinner, and snacks. This will allow the nurse to identify healthy foods the child is already consuming, as well as areas of change on which the child should focus. The remaining actions should be performed during the education, but should be done after the nurse collects information about the child's dietary habits.
The nurse is teaching a pediatric client who is newly diagnosed with asthma. What instruction(s) should the nurse include in the teaching? Select all that apply. Avoid allergens. Use inhalers every 2 hours. Get 10 hours of sleep per night. Keep a trigger diary. Maintain good hydration.
Avoid allergens. Maintain good hydration. Keep a trigger diary. Explanation: Teaching environmental and trigger control will support successful living with asthma. Avoiding allergens, maintaining good hydration, and using a trigger diary will help to improve the client's quality of life. Overuse of inhalers will increase dependence on the medication.
The nurse is assessing a 2-year-old child during the 2-year well-child visit. Which finding requires further follow-up by the nurse? BMI in the 89th percentile copying siblings holding the rail while walking up and down the stairs daily temper tantrums
BMI in the 89th percentile Explanation: A BMI in the 89th percentile for the client's age group requires further follow-up by the nurse, because this is higher than expected. The nurse may review dietary and activity guidelines that are appropriate for the client's growth and development with the parents. Daily temper tantrums, holding the rail while walking up and down the stairs, and copying siblings are expected findings for a 2-year-old child.
The nurse is demonstrating the steps of blood glucose testing with a 7-year-old child newly diagnosed with type 1 diabetes and the child's parents. Place the steps that the nurse will review with the child and parents in the correct order. Use all options.
Clean hands with soap and water, or alcohol wipes. Load the lancet device. Use the side of the fingertip to obtain a drop of blood with the lancet. Place a drop of blood on the test strip in the glucometer. Wait the appropriate amount of time and read the results. Record the results in a logbook or journal. Explanation: The correct order of steps that the nurse will review with the child for blood glucose testing is: 1) Clean hands with soap and water, or alcohol wipes; 2) Load the lancet device; 3) Use the side of the fingertip to obtain a drop of blood with the lancet; 4) Place a drop of blood on the test strip in the glucometer; 5) Wait the appropriate amount of time and read the results; and 6) Record the results in a logbook or journal.
The nurse is reviewing foods and nutrients to increase with an 11-year-old child with obesity. What information should the nurse review with the child? Select all that apply. Consume a mix of dark-green, red, and orange vegetables. Select a mix of protein foods such as seafood, lean meat, beans, and peas. Increase fruit and vegetable intake. Eat at least a quarter of all grains as whole grains. Eat at least 150 mg of dietary cholesterol daily.
Increase fruit and vegetable intake. Consume a mix of dark-green, red, and orange vegetables. Select a mix of protein foods such as seafood, lean meat, beans, and peas. Explanation: The nurse should instruct the child to increase fruit and vegetable intake; consume a mix of dark-green, red, and orange vegetables; and select a mix of protein foods such as seafood, lean meat, beans, and peas. All of this information is included in the general recommendations from the American Academy of Pediatrics Bright Futures. The child should be instructed to eat at least half of all grains as whole grains, and to limit dietary cholesterol intake to under 300 mg daily.
The nurse admits a pediatric client with bronchiolitis to the unit. What is the most important intervention the nurse should perform? Wear gloves when entering the room. Have a skin test done every 6 months. Maintain strict handwashing. Do not care for other children with bronchiolitis at the same time. SUBMIT ANSWER
Maintain strict handwashing. Explanation: Handwashing is the most effective way to prevent the spread of infection. Wearing gloves can help to stop the spread of infection but is not the most important intervention. Having the skin test done every 6 months will not stop infection, but it helps to identify others who may pass on an infection. Not caring for another child with bronchiolitis at the same time will help to not cross-spread the infection but is not the single most important intervention.
The nurse is performing an assessment on a 12-year-old client with a history of long-term acetaminophen use. Which consideration is appropriate for this client? Monitor for increased bruising and bleeding. Monitor for liver toxicity. Monitor intake and output. Monitor for gastrointestinal irritation.
Monitor for liver toxicity. Explanation: Monitoring for liver toxicity is appropriate for this client, as this is associated with long-term acetaminophen use. Acetaminophen is metabolized by the liver. Monitoring for intake and output, increased bruising and bleeding, and gastrointestinal irritation is appropriate for a client who uses ibuprofen.
The nurse is caring for a 16-year-old client who has recently started therapy with levetiracetam for generalized tonic-clonic seizures. Which consideration should the nurse take into account while caring for the client? Monitor for hypotension during administration. Monitor for signs of drug-related rash. Monitor for suicidal thoughts and behavior. Monitor liver function.
Monitor for suicidal thoughts and behavior. Explanation: The nurse should monitor for suicidal thoughts and behaviors, because these may occur in the client who is on levetiracetam therapy. Liver function and hepatotoxicity are considerations for phenobarbital and divalproex sodium, respectively. Carbamazepine may lead to Stevens-Johnson syndrome, the first sign of which is a drug-related rash. Rapid administration of fosphenytoin can lead to hypotension and cardiac arrhythmias.
The nurse is creating a plan of care for an 11-year-old child with obesity. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply. Teach the family how to incorporate healthy food options. Refer for bariatric surgery. Monitor blood pressure. Monitor weight. Administer prescribed antidiabetic medications.
Monitor weight. Monitor blood pressure. Teach the family how to incorporate healthy food options. Explanation: The nurse's plan of care should include monitoring weight, monitoring blood pressure, and teaching the family how to incorporate healthy food options. The nursing plan of care has a goal of preventing the need for complex weight management modalities such as medication and bariatric surgery.
The nurse is caring for a 16-year-old client admitted to the hospital after experiencing a prolonged generalized tonic-clonic seizure. During the shift, the client exhibits seizure activity lasting more than 5 minutes. Which action should the nurse take first? Notify the health care provider. Administer lorazepam 2 mg IV. Place padding on the side rails of the bed. Ensure suction equipment and oxygen are readily available.
Notify the health care provider. Explanation: Common prescriptions for lorazepam given in the event of a prolonged generalized tonic-clonic seizure require notifying the health care provider prior to administration. Ideally, suction equipment, oxygen, and padded side rails will already be in place before a seizure occurs.
The nurse is caring for a 4-year-old child newly diagnosed with acute lymphoblastic leukemia. What action(s) should the nurse take to support education about the child's condition and treatment? Select all that apply. Cover educational materials when the parents are ready. Sit in on meetings with the family and health care provider. Review the information more than once. Give multiple opportunities for questions. Provide complete, comprehensive information.
Sit in on meetings with the family and health care provider. Review the information more than once. Give multiple opportunities for questions. Cover educational materials when the parents are ready. Explanation: Sitting in on meetings with the family and health care provider, reviewing the information more than once, giving multiple opportunities for questions, and covering educational materials when the parents are ready are actions that support the learning process during a time of high anxiety. Providing complete, comprehensive information does not support education about the child's condition, because it is more effective to provide information a little at a time to allow opportunities for thinking and questions.
The intensive care unit nurse is caring for a 7-year-old child with a diagnosis of diabetic ketoacidosis who is receiving an insulin infusion. The child's last blood glucose level is 68 mg/dl (3.77 mmol/l). What action should the nurse take first? Notify the health care provider. Perform a neurologic assessment. Stop the insulin infusion. Repeat the blood glucose test.
Stop the insulin infusion. Explanation: A blood glucose level less than 70 mg/dl (3.89 mmol/l) is a warning value and means that insulin doses should be adjusted. Performing a neurologic assessment, notifying the health care provider, and repeat testing may be necessary, but should not be performed first.
The nurse is reviewing safety with the parent of a 2-year-old client during an annual well-child visit. The client's parent is reviewing several day-to-day activities with the nurse to determine if the parent should be doing anything to promote the client's safety. Which activity requires further follow-up by the nurse? Not allowing the client to climb on furniture and other elevated surfaces. Supervising the client while riding a tricycle in the street. Keeping all medications out of reach of the client. Tightening loose screws and covering sharp edges of outdoor playground equipment
Supervising the client while riding a tricycle in the street. Explanation: While it is appropriate to supervise the client while the child rides a tricycle, the client's parent should be instructed to keep the child away from the street to ensure an accident involving a car does not occur. Tightening loose screws and covering sharp edges of outdoor playground equipment, keeping all medications out of reach, and not allowing the client to climb on furniture and other elevated surfaces are all appropriate actions that promote safety
While the nurse is caring for a 7-year-old child hospitalized for diabetic ketoacidosis, the nurse notes that the child is experiencing shakiness, sweatiness, and irritability. The child reports feeling nauseated. Which action should the nurse take first? Administer fast-acting insulin. Start IV bolus of normal saline. Test blood glucose level. Monitor for changes in cognitive status.
Test blood glucose level. Explanation: The nurse should test the child's blood glucose level, because the child is exhibiting signs and symptoms of hypoglycemia. Administering fast-acting insulin without blood glucose testing is unsafe. An IV bolus of normal saline may be required, but it is not the action the nurse should perform first. Monitoring for changes in cognitive status will be important after obtaining the child's blood glucose results.
The nurse teaches the parents of a child with respiratory syncytial virus (RSV) about the infection. The parents ask how they can prevent their other children from contracting RSV. Which statement indicates the parents' need for further teaching? "We will insist that anyone with a respiratory illness avoid contact with my children until they are well." "We will make sure that all our children receive palivizumab injections for the remainder of the year." "We will keep our infected child away from our other children until recovered." "We will insist that anyone who comes in contact with our children wash their hands before playing with them."
We will make sure that all our children receive palivizumab injections for the remainder of the year." Explanation: Palivizumab injections are for primary prevention, not for the child who already has RSV. It is administered for a period of 3 to 5 months only to high-risk infants within the first 2 years of life. RSV is contracted through direct contact with respiratory secretions. It is a good idea to keep the ill child away from the healthy children, to have all people coming in contact with the child to wash their hands, and have ill persons avoid contact with the child until they are well.
The nurse is conducting a well-child visit for a 10-year-old child with attention deficit hyperactivity disorder (ADHD). The nurse is providing anticipatory guidance to the child and family regarding ADHD. What should the nurse emphasize? Be lenient and understanding of the child's behavior. Work on behaviors that help the child stay organized in the classroom. Involve the child in structured play activities. Have the child take medication for the disorder just before bed time.
Work on behaviors that help the child stay organized in the classroom. Explanation: Anticipatory guidance should include teaching the parents and child about behaviors that will help the child focus in the classroom. Because a side effect of the medication for ADHD is insomnia, the drug should be administered early in the day, not at night. Children will need firm, consistent limits, not leniency. Activities for the child with ADHD include running or bike riding, not structured activities.
The nurse is teaching a client and family about asthma. The parent of the client asks, "What is asthma?" What is the nurse's explanation? a lower respiratory infection a sudden infection of the airways a reversible, diffuse, obstructive pulmonary disease a thinning and destruction of the alveoli in the lung
a reversible, diffuse, obstructive pulmonary disease Explanation: Asthma is a reversible, diffuse, obstructive pulmonary disease that causes a hyperresponsive reaction to an allergen, exercise, or environmental change. The lower respiratory tract includes the bronchial tubes and the lungs. Bronchitis and pneumonia are infections of the lower respiratory tract. Bronchitis is a sudden infection of the airways caused by a virus. Emphysema is a lower respiratory infection.
The nurse is caring for a 16-year-old client being evaluated for a new diagnosis of a seizure disorder. While collecting the client's medical history, the client and parents report episodes in which the client stares blankly and is unresponsive for several seconds. For which type of seizure disorder should the nurse anticipate treatment? myoclonic absence atonic generalized tonic-clonic
absence Explanation: The client and parents are describing absence seizures, in which the client stares blankly, does not remember, and does not respond during the episode; the seizure lasts a few seconds. Atonic seizures refer to episodes when the client's muscles suddenly go limp; the client is at high risk of injury from falling or dropping items. Generalized tonic-clonic seizures cause the body to shake, stiffen, and jerk. Myoclonic seizures are when the client's muscles suddenly jerk.
The nurse is preparing to discharge a 3-year-old client who has undergone treatment for dehydration secondary to a urinary tract infection. Which topic(s) should the nurse include in the discharge instructions? Select all that apply. intravenous (IV) site care upcoming appointment schedule antibiotic dosing instructions perineal hygiene technique home infusion therapy administration
antibiotic dosing instructions perineal hygiene technique upcoming appointment schedule Explanation: Discharge instructions should include antibiotic dosing instructions, perineal hygiene technique, and the upcoming appointment schedule. Home infusion therapy and IV site care are not topics that the nurse would anticipate for a client discharged from a hospital stay for dehydration secondary to a urinary tract infection.
The nurse is performing an assessment on a 7-year-old child prior to seeing the health care provider during an office visit. Based on the above data, which action should the nurse anticipate first? blood glucose testing basic metabolic panel urinalysis antibiotic therapy
blood glucose testing Explanation: Based on the data provided, the child is experiencing polyphagia, polydipsia, and polyuria as well as dehydration and weight loss. These findings are characteristic of type 1 diabetes, and the nurse should anticipate blood glucose testing as the next step in the child's plan of care. A basic metabolic panel and urinalysis will likely be needed as well, but should not be anticipated first. The above data should not cause the nurse to anticipate antibiotic therapy unless there are other findings consistent with infection.
The nurse is caring for a 2-year-old child in the emergency department with a severe burn injury covering 32% of the body surface area. Which finding listed above requires immediate action by the nurse? blood pressure respiratory rate pain rating oxygen saturation
blood pressure Explanation: The client is at risk for acute systemic responses known as burn shock, which involves increased capillary permeability; increased hydrostatic pressure across the microvasculature; fluid and proteins moving from the intravascular space to the interstitial space; increased systemic vascular resistance; reduced cardiac output; and hypovolemia. The client's abnormal blood pressure reading is a sign that burn shock may be imminent and requires immediate action by the nurse. The client's pain rating, respirations, and oxygen saturation do not require immediate action by the nurse.
The nurse is caring for a 4-year-old child undergoing chemotherapy treatment for acute lymphoblastic leukemia. Based on the above data, what should the nurse recommend when contacting the health care provider? admission to intensive care unit supplemental oxygen therapy bloodwork and antibiotics anxiolytic treatment
bloodwork and antibiotics Explanation: The nurse should recommend bloodwork to determine whether and what kind of infection is present, and antibiotics to treat any infection that may be there as quickly as possible. The nurse should not recommend supplemental oxygen therapy, anxiolytic treatment, or admission to the intensive care unit based on the given data, because these interventions do not address a suspected infection.
The nurse is performing an assessment of a 2-year-old client whose parents suspect a urinary tract infection. Which assessment finding(s) should the nurse report to the parents as reassuring? Select all that apply. pain in the lower abdomen odorless urine clear, slightly yellow urine irritability increased appetite
clear, slightly yellow urine odorless urine increased appetite Explanation: Clear, slightly yellow urine; odorless urine; and increased appetite are expected findings that are not consistent with a urinary tract infection. Pain in the lower abdomen and irritability, however, may indicate that a urinary tract infection is present
The emergency department nurse is reviewing medication prescriptions for a 12-year-old client with an ulnar fracture. Which prescription requires further follow-up by the nurse? acetaminophen codeine ibuprofen hydrocodone
codeine Explanation: The nurse should follow up on the prescription for codeine, because ongoing investigations have shown a large variation in the conversion of codeine to morphine in the pediatric population. This places the client at risk for unanticipated respiratory depression. Ibuprofen, acetaminophen, and hydrocodone are prescriptions that may be carried out safely for the 12-year-old client.
The nurse is reviewing techniques for how to encourage adequate nutrition with the parent of a 2-year-old child. Which technique(s) should the nurse review? Select all that apply. introducing one new food at a time providing a 6-ounce glass of milk with each meal consistency with mealtimes ensuring every meal is completely finished offering a variety of foods with meals
consistency with mealtimes offering a variety of foods with meals introducing one new food at a time Explanation: The nurse should review the techniques of consistency with mealtimes, offering a variety of foods with meals and introducing one new food at a time. Ensuring the client completely finishes every meal is not a technique that encourages adequate nutrition at this stage in the client's development. Consuming too much milk can lead to an iron deficiency by hindering iron absorption; therefore, the nurse should not advise the parent to provide a glass of milk with each meal for the client.
The nurse has performed a point-of-care test for a 3-year-old client with a suspected urinary tract infection. Based on the above listed urinalysis results, which action should the nurse anticipate? cystoscopy antibiotic therapy culture and sensitivity testing none; the results are within normal limits.
culture and sensitivity testing Explanation: The nurse should anticipate culture and sensitivity testing to confirm the presence of bacteria and determine which type of bacteria is present. It is premature to begin antibiotic therapy before determining the type of infection that may be present. A cystoscopy is not anticipated based on the given results.
The nurse is performing an assessment on an 11-year-old child during an annual exam. Based on Erikson's theory of psychosocial development, the nurse should make which consideration while performing the psychosocial assessment? developing a sense of pride and accomplishment in schoolwork, sports, social activities, and family life initiating activities and asserting control over the world through social interactions and play controlling actions, showing clear preferences to certain elements in the environment establishing meaningful and lasting relationships with others
developing a sense of pride and accomplishment in schoolwork, sports, social activities, and family life Explanation: According to Erikson's theory of psychosocial development, the 11-year-old child is resolving the developmental conflict of identity versus role confusion, in which the child is developing a sense of pride and accomplishment in schoolwork, sports, social activities, and family life. Initiating activities and asserting control over the world through social interactions and play is part of resolving the conflict of initiative versus guilt, which occurs during ages 3 through 6 years. Controlling actions and showing clear preferences to certain elements in the environment is part of resolving the developmental conflict of autonomy versus shame and doubt, which occurs during ages 1 through 3 years. Establishing meaningful and lasting relationships is part of resolving the developmental conflict of intimacy versus isolation, which occurs in the 20s through early 40s.
The nurse is assessing a 3-year-old client's pain according to the FLACC scale. What should the nurse include in the assessment? Select all that apply. leg position and movement numerical pain rating facial expression overall activity presence and degree of crying
facial expression leg position and movement overall activity presence and degree of crying Explanation: The FLACC scale is a behavioral scale that contains five indicators: face, legs, activity, cry, and consolability. While the FLACC scale utilizes a numerical score, it does not include the client's numerical pain rating.
The nurse is preparing to teach a 12-year-old client and the client's parents about self-care related to casting following an ulnar fracture. What should the nurse include in the teaching? Select all that apply. applying powder to protect the skin using appropriate tools to relieve itching how to minimize swelling identifying impaired circulation keeping the cast dry
how to minimize swelling identifying impaired circulation keeping the cast dry Explanation: The nurse should include the following in the teaching: how to minimize swelling, identifying impaired circulation, and keeping the cast dry. Powder should not be applied to the skin as this can cause skin irritation. The client and parents should be instructed to never stick anything down the cast, as this can lead to skin irritation, open areas of skin, and infection
The nurse is creating a plan of care for an 11-year-old child with obesity. Which consideration should the nurse make to support successful outcomes for the child? strict adherence to prescribed medications expected weight loss of 1 to 2 lb (0.5 to 1 kg) per week referral to a therapist or counselor involvement of the entire family
involvement of the entire family Explanation: The nurse should involve the entire family when implementing the plan of care to facilitate successful outcomes for the child. Without the involvement of the family, the child may continue to struggle emotionally and physically. Strict adherence to prescribed medications, referral to a therapist or counselor, and weight loss of 1 to 2 lb (0.5 to 1 kg) per week may be elements of the plan of care, but are not considerations the nurse should make without additional data.
A 4-month-old infant presents to the emergency department (ED) with course crackles, cough, intercostal retractions, tachypnea, and a suspected diagnosis of bronchiolitis. The nurse should anticipate that treatment will include which intervention(s)? Select all that apply. oxygen nasal suctioning cerebrospinal fluid (CSF) analysis computed tomography (CT) scan IV fluids
nasal suctioning oxygen IV fluids Explanation: Nasal suctioning removes thickened secretions from the nasal pharynx, allowing for ease of breathing. Oxygen is applied when the oxygen saturation is below 92%. IV fluids are administered to replace fluid lost by not eating and to liquify and mobilize mucus. CSF analysis may include tests to diagnose infectious diseases of the brain and spinal cord, including meningitis and encephalitis. CT scans are special x-ray tests that produce cross-sectional images of the body using x-rays and a computer. Neither CSF analysis nor CAT scans are applicable.
The community health nurse is teaching a seminar on preventing choking in children aged 2 to 3 years. Which food(s) should the nurse review in the teaching as a choking risk? Select all that apply. hot dogs whole grapes hard candies bananas nuts
nuts hard candies hot dogs whole grapes Explanation: To prevent choking in young children aged 2 to 3 years, parents and caretakers should avoid giving children foods that can cause choking, which include nuts, hard candies, hot dogs, whole grapes, and marshmallows. Bananas are not considered a food that can cause choking in children in this age group.
The nurse instructs the parent of a child with sickle cell anemia about factors that may precipitate a pain crisis in the child. Which factor identified by the parent as being able to cause a pain crisis indicates a need for further teaching? overhydration emotional stress infection cold environment
overhydration Explanation: Common sickle cell crisis triggers in children include sudden change in temperature, which can make the blood vessels narrow; very strenuous or excessive exercise, due to shortage of oxygen; dehydration, low blood volume; infections; stress; high altitudes due to low oxygen concentrations in the air; alcohol use; smoking; and pregnancy. Overhydration, if identified as a factor by the parent, indicates a need for further teaching.
The nurse is performing an assessment on a 3-year-old client whose parents believe that the client has a urinary tract infection. What should the nurse include in the assessment? Select all that apply. body temperature reflexes palpation of the abdomen lower extremity strength urine odor and appearance
palpation of the abdomen body temperature urine odor and appearance Explanation: The nurse's assessment should include assessing for abdominal pain, especially in the area of the bladder. Assessment of body temperature may reveal the presence of a fever if a urinary tract infection is present. A urinary tract infection may cause foul-smelling, cloudy, and/or blood-tinged urine. Altered reflexes and lower extremity strength are not signs of a urinary tract infection.
The nurse is caring for a newborn client with a ventricular septal defect (VSD) experiencing heart failure and receiving treatment with furosemide. Based on the data above, what should the nurse anticipate in the client's plan of care? monitoring for cough potassium replacement reviewing over-the-counter medications for interactions apical pulse monitoring
potassium replacement Explanation: The nurse should anticipate potassium replacement for the newborn client with a VSD who is experiencing heart failure and receiving furosemide treatment. The client's potassium level is low and may require supplementation. Apical pulse monitoring is required for digoxin. Cough is an adverse effect of enalapril, which may also interact with over-the-counter medications.
While caring for a 2-year-old child with dehydration, the nurse assesses the client's percentage of dehydration in preparation for fluid replacement therapy. What should the nurse include in this assessment? blood pressure pre-illness weight and current weight serum creatinine capillary refill
pre-illness weight and current weight Explanation: To calculate the client's percentage of dehydration, the nurse will subtract the client's current weight from the client's pre-illness weight and multiply the result by 100. Serum creatinine, blood pressure, and capillary refill are useful assessments for determining the client's hydration status but are not used to assess the client's percentage of dehydration.
The nurse is creating a plan of care for an 11-year-old child with obesity and elevated cholesterol and triglycerides. What should the nurse include in the plan of care? Select all that apply.
recommending foods to the family suggesting activities to increase exercise referring to a dietitian Explanation: The plan of care for an 11-year-old child with obesity and elevated cholesterol and triglycerides should include recommendations for dietary changes, activities to increase exercise, and referral to a registered dietitian. Oral and subcutaneous medication administration should not be anticipated for the child at this time.
The nurse is reviewing the laboratory results with an 11-year-old child with obesity. Based on the above results, which action should the nurse include in the plan of care? recommending recipes with low amounts of low-density lipoproteins (LDLs) to the family tools for adhering to oral cholesterol-lowering agent regimen instructions for subcutaneous injection administration reviewing food choices high in high-density lipoproteins (HDLs)
recommending recipes with low amounts of low-density lipoproteins (LDLs) to the family Explanation: The child's LDL result is elevated; therefore, the nurse should include recommending recipes low in LDLs to the family in the plan of care. In addition to addressing the child's elevated LDL levels, involving the entire family in the plan of care will increase the plan's chances for success. Total cholesterol, HDL, and triglyceride levels are within normal range for the child's age.
The nurse is caring for a child whose parent is concerned the child has asthma. The child is overweight, has had multiple respiratory infections, gets congested when outside, and has a family history of asthma. Which risk factor(s) suggests that the client may have asthma? Select all that apply. seasonal allergies physical activity obesity family history respiratory infections
respiratory infections seasonal allergies family history obesity Explanation: The most common risk factors for developing asthma are family history of asthma, having a severe respiratory infection as a child, having an allergic condition, or being exposed to certain chemical irritants or industrial dusts. Physical activity is not a risk factor; moderate physical activity can help strengthen the child's lungs.
The nurse is performing an assessment on a 6-month-old infant for a well-child visit. Which finding requires further follow-up by the nurse? occasionally fusses supports himself with arms while sitting rolls to one side grasps food with his whole hand
rolls to one side Explanation: At 6 months of age, the infant should be able to roll back and forth. This finding may mean that the infant is not meeting developmental milestones and requires further follow-up by the nurse. Supporting oneself with the arms while sitting (tripod position) and grasping food with the whole hand are both expected developmental milestones and require no further follow-up by the nurse. Being generally happy is expected for the infant's emotional and social development, but occasional fussing is an expected finding.
The nurse is caring for an 8-year-old child whose parent states the child is exhibiting impulsiveness, distraction, risk taking, and inability to follow directions, per the above nurse's note. What is the priority concern for the nurse to address with this child and parent? safety self-esteem social isolation
safety Explanation: Around the age of 8 years, children are developing a greater sense of independence and are beginning to give in to peer pressure, so safety issues must be addressed at home. Safety is a particularly important concern for children with attention deficit hyperactivity disorder (ADHD), the sign and symptoms of which this child exhibits. Children with ADHD have an increased incidence of accidents, children are more likely to have higher rates of unintentional injuries, emergency room visits, smoking, drug use, and alcohol consumption. The 8-year-old child could experience some social isolation if the behavior is very disruptive and other children do not want to be around the child. Chronic low self-esteem and disturbed personal identity are more likely to happen to the adolescent child.
The nurse is performing a routine physical assessment on an 11-year-old child during an outpatient visit. Which age-related screening should the nurse include in the assessment? psychosocial scoliosis reproductive cardiac
scoliosis Explanation: The nurse should include scoliosis screening for an 11-year-old child during a well visit. Reproductive, psychosocial, and cardiac assessments are routine aspects of a physical examination at any age.
The emergency department nurse is assessing a 2-year-old child with a burn injury covering 42% of the body surface area. Which consideration(s) related to the client's age should the nurse take? Select all that apply. shorter airway smaller tonsils more communicative thinner skin immature immune system
shorter airway immature immune system thinner skin Explanation: The nurse should take into consideration that the client's stage of growth and development means the client has a shorter airway, an immune system that is not completely developed, and thinner skin, all of which affect the physiological adaptations to burn injuries and treatments. Children in the client's stage of growth and development have larger tonsils, making intubation more difficult. Children have less-developed communication skills, which results in greater difficulty assessing pain.
The nurse is performing a focused assessment for a 16-year-old client with epilepsy who takes divalproex and levetiracetam. Based on the above data, what seizure risk should the nurse review with the client? weight alcohol use diet sleeping habits
sleeping habits Explanation: The client reports irregular sleeping habits, which increases the client's risk of experiencing a seizure. Based on the given assessment data, the client is not at significant risk for seizure based on weight (which is within the acceptable range for a 16-year-old), diet, or alcohol use.
While performing an assessment on a 2-year-old child, the nurse asks the client's parents about developmental milestones. Which finding requires further follow-up by the nurse? speaks in single-word statements has temper tantrums plays alongside other children without interacting imitates both children and adults
speaks in single-word statements Explanation: Speaking in single-word statements requires further follow-up by the nurse, because the nurse should anticipate that a 2-year-old would have the ability to speak in two- to four-word sentences. Playing alongside other children without interacting is called parallel play and is an expected finding. Temper tantrums and imitating both children and adults are also anticipated behaviors.
The nurse is preparing to assess a 12-year-old client in the emergency department for a wrist injury. Which method should the nurse use to assess the client's pain? the numerical pain rating scale FLACC pain rating scale mPAT pain assessment tool FACES pain rating scale
the numerical pain rating scale Explanation: The numerical rating scale is appropriate for the cognitive development of the 12-year-old client. The FACES pain rating scale; the Face, Legs, Activity, Cry, Consolability (FLACC) scale; and the modification of the original Pain Assessment Tool (mPAT) are appropriate tools to use at earlier stages of human development.
The nurse is reviewing the risks for obesity with an 11-year-old child during an annual exam. Which risk(s) should the nurse review with the child? Select all that apply. gout hypertension type 2 diabetes sleep apnea hyperthyroidism
type 2 diabetes sleep apnea hypertension Explanation: The nurse should review the risks for type 2 diabetes, sleep apnea, and hypertension with the 11-year-old child with obesity. Other risks include musculoskeletal issues and other cardiovascular problems. Gout and hyperthyroidism are not considered health problems for which obesity places the child at risk.
A 3-month-old infant is admitted to the hospital with a diagnosis of bronchiolitis. What should the nurse monitor to assess hydration status? Select all that apply. skin turgor fontanels (fontanelles) urine output emesis digital clubbing heart rate
urine output fontanels (fontanelles) emesis skin turgor heart rate Explanation: The fontanels (fontanelles) should feel flat and firm. If dehydrated, the fontanel will be soft and sunken. In addition to monitoring intake, output should also be monitored. When fluid is balanced, skin will be elastic and mobile. Heart rate is expected to increase as the body attempts to increase circulation. Digital clubbing happens over years and is usually the result of low oxygen in the blood or chronic lung infections.
The nurse is reviewing the supplies required to perform an insulin injection with a 7-year-old child with type 1 diabetes and the child's parents. Which supplies should the nurse instruct the child and parents to gather to prepare for insulin administration? Select all that apply. vial of correct insulin two alcohol pads syringe butterfly needle sharps disposal container
vial of correct insulin two alcohol pads syringe sharps disposal container Correct response: syringe vial of correct insulin two alcohol pads sharps disposal container Explanation: The nurse should instruct the child and parents to gather the syringe, the vial containing the correct insulin, two alcohol pads, and a sharps disposal container. A butterfly needle is not needed for a subcutaneous injection.
The nurse is performing an assessment on a 2-year-old child prior to seeing the primary health care provider for an annual exam. Which finding requires further follow-up by the nurse? height of 34.0 in (86.36 cm) head circumference of 19.0 in (48.26 cm) blood pressure of 92/54 mm Hg weight gain of 1.5 lb (0.68 kg) since last year's exam
weight gain of 1.5 lb (0.68 kg) since last year's exam Explanation: A weight gain of 1.5 lb (0.68 kg) since last year's exam requires further follow-up by the nurse, because an increase in weight of 3 to 5 lb (1.36 to 2.27 kg) per year is typical for the client's age group. The client's head circumference, height, and blood pressure are within expected parameters.
