Chapter 1
neutropenic precautins
Discouraging fresh flowers in the child's room Placing a mask on the child when outside the room Avoiding rectal exams, suppositories, and enemas
An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is:
Ineffective breathing pattern related to airway inflammation and increased secretions
A physician orders a medication dosage that is above the normal dosage. The nurse administers the medication without questioning the dosage. What error did the nurse make?
The nurse violated one of the "rights" of medication administration.
10-year-old is recently diagnosed with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching?
"He can resume participation in football in 2 weeks."
Which of the following statements by the mother of a child diagnosed with asthma indicates more teaching is needed?
"I should cut back on his dairy intake because it coats his throat"
The nurse is counseling the parents of a 9-year-old boy who is receiving morphine for postoperative pain. Which statement from the nurse accurately reflects the pain experience in children?
"It is very rare that children become addicted to narcotics."
Baby X was born yesterday with a CHD and needs surgery. The parents seem very stoic. What is the most therapeutic statement for the nurse to make?
"Let's go into the consultation room and talk about what you're thinking"
The nurse is consulting with a child life specialist (CLS) to help minimize the stress of hospitalization for a child. Which services would the CLS provide? Select all that apply
Activities to support normal growth and development Grief and bereavement support Emergency room interventions for children and families
The nurse explains that a ventricular septal defect will:
Allow blood to shunt left to right, causing increased pulmonary flow and no cyanosis
At Suzie's 6 month well visit, the pediatrician notes asymmetry and unequal number of skin fold on posterior thigh, positive Ortolani test and positive Barlow test. What should be done next?
An X-ray
A nurse is caring for a child who has contact dermatitis due to poison ivy. Which of the following actions should the nurse take? Select all that apply
Apply calamine lotion to the skin Remove the clothing over the rash
The nurse is providing atraumatic care to children in a hospital setting. What are principles of this philosophy of care? Select all that apply.
Avoid or reduce physical distress Use core primary nursing Avoid or reduce painful procedures
Which of the following vital signs for a 1 year old would be most concerning?
BP 120/76
Which of the following tasks are appropriate to delegate to the Licensed Practical Nurse?
Bathing and measuring i & o, administering meds, taking vital signs
A nurse is teaching a group of parents about preventing insect bites. Which of the following information should the nurse include in the teaching?
Check house pets frequently Avoid areas of tall grass Wear insect repellent
The nurse contacts a child life specialist (CLS) to work with children on a pediatric ward. What is the primary goal of the CLS?
Decrease anxiety and fear during hospitalization and painful procedure.
The nurse is caring for a 4-year-old boy with Ewing sarcoma who is scheduled for a computed axial tomography (CAT) scan tomorrow. Which is the best example of therapeutic communication?
Describing what it is like to get a CAT scan using words he understands
4 month vaccine
DTaP (diphtheria, tetanus and pertussis) Hib (haemophilus influenzae type b) IPV (inactivated poliovirus)
6 month vaccine
Diphtheria, tetanus, and whooping cough (pertussis) (DTaP) (3rd dose) Haemophilus influenzae type b disease (Hib) (3rd dose) Polio (IPV) (3rd dose)
The nurse is reviewing the medical record of a child with infective endocarditis. What would the nurse expect to find? Select all that apply.
Electrocardiogram with prolonged PR interval Microscopic hematuria with urinalysis Petechiae on palpebral conjunctiva
Based on Erikson's developmental theory, what is the major developmental task of the adolescent?
Finding an identity
The nurse is educating the parents of a 7-year-old girl who has just been diagnosed with epilepsy. Which teaching technique would be most appropriate?
Giving the parents and child information in small amounts at a time
The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a whisper, has auditory inspiratory wheezes, and sits up with her neck thrust forward. Based on these findings, what interventions would you expect the nurse to perform?
Have child sit forward Have tracheostomy kit at bedside Give 100% oxygen Auscultate lung sounds
The nurse is teaching a new mother about the drastic growth and developmental changes her infant will experience in the first year of life. Which statement describes a developmental milestone occurring in infancy?
Heart doubles in size in the first year
The statement that best corresponds to a preschoolers understanding of hospitalization is:
I got sick because I was mad at my brother.
The nurse is designing a nursing care plan for a toddler with lymphoma, who is hospitalized for treatment. What is a priority intervention that the nurse should include in this child's nursing plan?
Monitoring the toddler for developmental delays
Which of the following causes neurological deficits?
Myelomeningocele
Compared to the adult, the infant's
Nasal passages are narrower Larynx is more funnel shaped Trachea and chest wall are more compliant Bronchi and bronchioles are shorter and narrower Alveoli are significantly fewer in number Respiratory rate is fast (decreases as the child matures)
Which tool would be the least appropriate scale for the nurse to use when assessing a 4-year-old child's pain?
Numeric pain intensity scale
A nurse is teaching the parents of a child diagnosed with cystic fibrosis about medication therapy. Which would the nurse instruct the parents to administer orally?
Pancreatic enzymes
What activity would the nurse expect to find in a 3 year old?
Pedaling a tricycle
A child is diagnosed with scarlet fever. The nurse is reviewing the child's medical record, expecting which medication to be prescribed for this child?
Penicillin
The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). Significant information would be to:
Place infants on their back or side for sleep.
What four heart defects are associated with tetralogy of fallot?
Pulmonary Stenosis, VSD, Ventricular Hypertropgy, and Enlarged Aortic Valve
The nurse is examining a 5-year-old boy. Which sign or symptom is a reliable first indication of respiratory illness in children?
Rapid, shallow breathing
A nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool-age child?
Relating fears to magical thinking
The nurse working in the emergency room monitors the admission of children. Statistically, for which disorder would children younger than 5 years most commonly be admitted?
Respiratory disorders
The nurse is explaining to parents that the preschooler's developmental task is focused on the development of initiative rather than guilt. What is a priority intervention the nurse might recommend for parents of preschoolers to stimulate initiative?
Reward the child for initiative in order to build self-esteem.
The pediatric nurse is planning quiet activities for hospitalized 18-month-old. What would be an appropriate activity for this age group?
Stacking blocks
The nurse is preparing a teaching plan for the parents of a child who has been diagnosed with a congenital heart defect. What would the nurse be least likely to include?
Strict bedrest
A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis are:
The heart muscle and the mitral valve
The nurse caring for infants in the neonatal intensive care unit (NICU) relies on the use of behavioral and physiologic indicators for determining pain. Which examples are behavioral indicators? Select all that apply.
The infant grimaces. The infant is crying uncontrollably. The infant flails his arms and legs.
The nurse caring for infants in the neonatal intensive care unit (NICU) relies on the use of behavioral and physiologic indicators for determining pain. Which examples are behavioral indicators? Select all that apply.
The infant grimaces. The infant flails his arms and legs. The infant is crying uncontrollably.
The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? Select all that apply.
The nasal passages are narrower. The larynx is more funnel shaped. There are significantly fewer alveoli.
The nurse is performing an admission of a 10-year-old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family? Select all that apply.
The nurse should initiate introductions. The nurse should only communicate with the child and ask the family to step out.
An appropriate nursing action related to the administration of Lanoxin to an infant would be:
Withholding a dose if the apical heart rate is less than 100 beats/min
Diphtheria, tetanus, and whooping cough (pertussis) (DTaP) (3rd dose) Haemophilus influenzae type b disease (Hib) (3rd dose) Polio (IPV) (3rd dose)
frued 8
Which of the following would require immediate intervention?
inspiratory wheeze
pinworm
make sure child washes hands
newborn vs
pulse,120-140
What is the recommended treatment plan for asthma?
stepwise
