Final Child Nursing
A nurse is caring for a 2-day-old infant who has myelomeningocele. Which of the following actions should the nurse take?
monitor the infant's head circumference
A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect?
murmur at the left sternal border
A nurse is caring for a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse perform first?
position the child on his side
A nurse is caring for a 6-month-old infant who has intussusception. Which of the following actions should the nurse take?
prepare the child for a barium enema
A nurse is assessing a 6-year old client at a well-child visit. Which of the following findings requires further assessment by the nurse?
presence of sparse, fine pubic hair
A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following position should the nurse place the infant?
prone
A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include?
provide a high fat diet
A nurse is discussing play activities with a group of parents of toddlers. Which of the following activities should the nurse recommend for this age group?
pushing a toy lawn mower
A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first?
repeat dose should not be given=
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expert?
rigid abdomen
A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend?
scrambled eggs
A nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately?
slurred speech
A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform?
standing on one foot
A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room?
suction equipment
A nurse in an ED is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider?
sudden decrease in wheezing
A nurse is caring for a 2-year-old child who has frequent urinary tract infections. When educating the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include?
teach the child to wipe from front to back
A nurse is teaching the guardians of an infant who has mild gastroesophageal reflux (GER). Which of the following instructions about feeding therapies should the nurse recommend?
thicken feedings with rice cereal
A nurse is assessing a 30-month-old toddler during a well child visit. Which of the following findings requires further assessment by the nurse?
toddler's birth weight is tripled
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is determined. Which of the following responses should the nurse make?
An abdominal ultrasound will confirm the pocket in the intestine
A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider immediately?
An infant with a WBC count of 24,000/mm3
A nurse is providing discharge teaching to the guardian of an infant following a hypospadias repair. Which of the following instructions should the nurse include?
Apply antibacterial ointment to the infant's penis once per day.
A nurse is caring for a child who has episaxis. Which of the following actions should the nurse take?
Apply continuous pressure to the lower part of the childs nose
A school nurse is providing care to a child who has a nosebleed. Which of the following actions should the nurse perform?
Apply pressure to the child's nose using the thumb and forefinger Keep the child calm
A nurse is obtaining a urine sample from a 5-month old infant by applying a urine collection bag. Which of the following actions should the nurse take first?
Wash and dry the genitalia, perineum, and surrounding skin
A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use?
Encourage the child to focus on a recent pleasurable experience
A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority?
Encourage use of incentive spirometer
A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the results of chronic vaso-occlusive phenomena?
Enlarged heart Enuresis Leg ulcers Retinal detachment
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect?
1.035 ↑ = dehydration
A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization?
10 piece wooden puzzle
A nurse in the emergency department is caring for an accompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada". The nurse should make which of the following age assessments for this child?
12 months old
A nurse is performing a nutritional screening for a 12-year-old client who weighs 41 kg (90 lb) and has a height of 1.5 m (60 in). Which of the following values is the client's body mass index (BMI)
18.2 - to calculate the clients BMI, the nurse should divide the clients weight in kilograms by the square of the clients height in meters. Therefore, 41 kg divided by the square of 1.5 m gives a correct BMI of 18.2
A nurse is caring or a toddler and is preparing to administer 0.9% sodium chloride 100mL IV infused over 4 hour. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min
25 Convert hour to minute 100ml/240 min x 60 gtt/ml
A nurse is caring for a school-age child who has glomerulonephritis. The child has decreased urinary output and a blood pressure of 160/78 mmHg and is receiving hydralazine. Which of the following lunch choices should the nurse recommend?
3 oz grilled chicken, 1 cup of pear slices, and 120 ml (4 oz) of apple juice. Moderate sodium restriction and further restriction is given to foods that are high in potassium for children who have decreased urinary output
A nurse is assessing an infant who was born at 32 weeks gestation and is now 8 months old. Which of the following developmental ages should the nurse expect the infant to demonstrate?
6 months
A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include?
A 6-year-old child should be able to count 13 coins
A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?
A client who has DKA and a blood glucose of 375 mg/dL
A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant?
Allow 30 minutes to complete each feeding Gradually increase the caloric density of the formula Position the infant semi-upright during feedings Provide gavage feeding if respiratory rate exceeds 80/ min
A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan to offer which of the following benefits?
Allow the child to manipulate toy medical equipment
A nurse in the emergency department is caring for a child who accidentally ingested an overdose of acetaminophen. Which of the following medications should the nurse expect to administer?
Acetylcysteine
A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). Which of the following pieces of information should the nurse include in the teaching?
Add fortified rice cereal to the infants formula
A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250 mg/dL. Which of the following actions should the nurse take?
Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion
A nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take?
Administer an anti fungal medication after feedings
A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take?
Administer oral analgesics prior to exercises
A nurse is providing teaching to the guardian of an adolescent. The guardian reports that the adolescent sleeps about 10 hour on weekend nights. Which of the following responses should the nurse provide?
Adolescents need more sleep due to rapid growth
A nurse is planning to assess an 8-year-old child who was brought to the clinic by a parent. The parent reports the child has missed school for 3 weeks and refuses to go back due to "not feeling well." Which of the following actions should the nurse perform during the initial interview with the child?
Ask the child to describe what things were like right before not wanting to go to school
A nurse is assessing a toddler who has AIDS. Which of the following findings is an indication of an opportunistic infection?
Candidiasis
A nurse is assessing an infant w ho has acute gastroenteritis. Which of the following findings should the nurse identify as the priority?
Capillary refill 5 seconds - Above 4 seconds is s/s severe dehydration
A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications?
Check for pulse in the affected leg every 4 hours
A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death?
Believes that her own thoughts can cause death
A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take?
Burp the infant at least 2 - 3 times during the feeding
A nurse is planning care for a 3-month-old infant who has ileostomy. Which of the following interventions should the nurse include in the plan?
Check the bag for stool every 4 hours
A nurse is providing dietary teaching to the parent of a toddler who has phenylketonuria. Which of the following foods should the nurse recommend?
Cooked carrots - foods that are low in protein
A nurse is caring for a 6-year-old child who is experiencing encopresis. Which of the following actions should the nurse take?
Determine if there are any recent stressors in the child's environment
A nurse is assessing a 4-year-old child's cognitive development during a well-child visit. Which of the followings should the nurse expect the child to display?
Development of the superego
A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize DKA. Which of the following findings should the nurse identify as a manifestation of this complication?
Deep, rapid respirations
A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before the child can have corrective surgery. The nurse should explain that the parents should wait no longer than 6-12 months for surgery to prevent which of the following outcomes
Difficulty with language acquisition
A nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment?
Dislocated left shoulder revealed by X-ray Thin, frail extremities
A nurse is providing teaching to the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include?
Dry clothing in a hot dryer for at least 20 minutes
A nurse is caring for a school-aged child who begins to have a tonic-clinic seizure when leaving the bathroom. Which of the following actions should the nurse take first?
Ease the child to the floor in Sims' position
A nurse is providing immediate postoperative care for a preschooler who had a tonsillectomy. Which of the following actions should the nurse take?
Eliminate the use of a straw when offering fluids
A nurse is providing teaching about home care to the guardian of an adolescent who has hemophilia. Which of the following pieces of information should the nurse provide?
Encourage the adolescents to participate in non-contact sports
A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take?
Examine the infants throat at the end of the examination
A nurse is providing education for the family of a 6-month-old infant about ways to stimulate language development. Which of the following instructions should the nurse include?
Explain what you are doing to the infant while providing care
A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level?
FACES pain scale
A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use?
FLACC
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take?
Give the medication at the side of the infants mouth
A nurse is performing a visual acuity screening for a school-aged child using the snellen letter chart. Which of the following actions should the nurse take?
Have the child wear his glasses during the vision screening
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well child visit. Which of the following findings should the nurse report to the provider?
Head lagging when the infant is pulled from a lying to a sitting position
A nurse is assessing a 12-month-old male infant's vital signs during a well child visit. The infant is in the 90th percentile for height. Which of the following findings should the nurse report to the provider
Heart rate 175/min
A nurse is caring for a 16-year-old client who reports dysmenorrhea and asks about alternative therapies for treatment. Which of the following statements should the nurse make?
Herbal medication can be effective but should be monitored by your provider
A nurse is developing a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include?
Higher body fat content is associated with earlier onset of menarche
A nurse is teaching the family of a child about hospice care. Which of the following statements should the nurse include in the teaching?
Hospice staff members consider the family's needs to be just as important as those of the child
A nurse is assessing a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect?
Hypertension due to increased production of catecholamines. Other manifestations includes sweating, weight loss, and polyuria
A nurse is caring for a female adolescent who is being treated for frequent urinary tract infections (UTIs). Which of the following statement by the adolescent indicates a possible cause of the UTIs?
I have bowel movements every 4 to 5 days
A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching?
I should eat extra food on busy days when I am more active. I should increase my intake of sugar-free fluids when i am sick I should eat a snack 30 minutes before my baseball games start
A nurse is providing teaching to the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following statements by the parent indicates an understanding of the teaching?
I should give this medication to my child half an hour before breakfast
The nurse is providing teaching to the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching?
I should ignore the stuttering and not interrupt her
A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching?
I should make sure my baby's clothing does not have buttons
A nurse is providing teaching about disease management to the parent of a preschooler who has a new diagnosis of asthma. Which of the following parent statements indicates an understanding of the teaching?
I will encourage my child to participate in sports
A nurse is providing discharge teaching to the parent of a school-aged child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching?
I will inspect my child's mouth every day for sores
A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make?
I will place a pressure dressing over the area after the procedure
A nurse is providing teaching for a parent about pinworm testing. At which of the following times should the nurse advise the parent to perform the tape test?
Immediately after the child wakes up in the morning
A nurse is planning to teach a 9-year-old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-age children are attempting to master which of the following developmental tasks?
Industry vs. inferiority
A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include?
Initiate protective-environment isolation for the child
A home health nurse is developing a plan of care a toddler who has hemophilia. Which of the following instructions for the parents should the nurse include in the plan?
Inspect the toddler's toys for sharp edges
A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterestedness in certain foods." Which of the following statements should the nurse make?
Keep a diary of the goods your child eats each day.
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching
Keep the child away from people who have an infection
A nurse is planning care for a preschooler who is immediately postoperative following the placement of a ventriculoperitoneal shunt. Which of the following interventions should the nurse include in the plan?
Lay the preschooler on the nonoperative side
A nurse is providing teaching about home care to the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include?
Leave the zinc oxide ointment intact and reapply as necessary during diaper changes
A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client?
Longer intestinal tract
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?
Minimize physical contact with the child initially
A nurse is reviewing the laboratory value for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect?
Sodium 125 mEq/L - below the expected range for an infant
A nurse is assessing a 6-month-old infant. The guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infants visual acuity?
Move a brightly colored toy from side to side in front of the infants face
A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching?
My child will likely be irritable for the next few weeks I will ensure my child does not receive any live vaccines for at least 18 months I will keep a record of my childs temperature until she has no fever for several days
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care?
Observe the parents' actions when feeding the child
A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately?
Oxygen saturation 85%
A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should teach the family to expect the preschooler to have which of the following concepts of death?
People can come back to life after they die
A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take?
Place the adolescent in a supine position 30 minutes to 1 hour following a lumbar puncture to decrease the risk of post-dural puncture headache
A nurse is caring for an infant who has tetralogy of F allot and is experiencing a hypercyanotic episode. Which of the following actions should the nurse take?
Place the infant in a knee-chest position
A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take?
Position the child on a cooling blanket and cover her with a sheet
A nurse is reviewing the morning laboratory results of an infant who is receiving digoxin and furosemide for the treatment of heart failure. Which of the following findings should the nurse report to the provider?
Potassium 3.2 mEq/L 4.1 - 5.3 mEq/L
A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse plan to take to help decrease the risk of a vaso-occlusive crisis?
Provide adequate fluid intake throughout the day
During a well-child visit, the guardian of a toddler reports that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make?
Provide the toddler with a favorite stuffed animal at bedtime
A nurse is providing teaching about poisoning prevention top a group of parents with toddlers. Which of the following statements should the nurse make?
Put all cleaning supplies in a locked cabinet
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800 the client describes the pain as a 3on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hour. Which of the following actions should the nurse take?
Reinforce teaching with the client about how to push the button to deliver the medication
A nurse is caring for a toddler who is postoperative following a cleft palate repair. Which of the following actions should the nurse take?
Restrain the toddler's arms at the elbows
A nurse is assessing a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggests a possible delay in development?
Speaking using 2 or 3 word sentences
A nurse is assessing the gross and fine motor behaviors of a toddler. Which of the following behaviors should he nurse identify as an expected achievement for a 3-year-old child?
Standing on 1 foot for several seconds
A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions? -Remove the IV line -Elevate the extremity -Stop the infusion -Notify the provider
Stop the infusion Elevate the extremity Notify the provider Remove the IV line
A nurse is caring or a child who has bacterial endocarditis. The child is scheduled to receive moderate-term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent?
The PICC line will last for several weeks with proper care.
A nurse is taking the history of and performing a physical on a school age child who has attention deficit hyperactivity disorder (ADHD). Which of the following findings in the child's medical record should the nurse identify as a risk factor for ADHD?
The child had prenatal exposure to alcohol on a regular basis
nurse is assessing the dynamic of a family in which child maltreatment is suspected. Which of the following findings should the nurse report to the provider?
The child has several unexplained scars and bruises
A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examinations
The child prefers to sit on the parent's lap during the examination
A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting?
The child reports tightness at the wrist
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child?
The child views death as similar to sleep The child believes his thoughts can cause death The child thinks death is a punishmen
A nurse is assessing a 6-month old infant at a well child visit. Which of the following findings indicates the need for further assessment?
The infant's legs remain crossed and extended when supine
A nurse is providing teaching about immunization to the parents of a severely immunocompromised child who has HIV. Which of the following statements should the nurse include in the teaching?
The pneumococcal and influenza vaccines are recommended for your child
A nurse is providing teaching to the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include?
The tubes should stay in place until they fall out on their own
A nurse is providing teaching about oxycodone to an adolescent who is experiencing a vaso-occlusive crisis. Which of the following pieces of information should the nurse include?
This medication might cause nausea
A nurse at a community health department is discussing the nutritional needs of children with a group of parents and guardians. Which of the following pieces of information should the nurse include?
Toddlers can be given up to 120-180 mL (4-6 oz) of juice per day
A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching?
Toddlers will react to the parents' anxiety and sadness
A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis?
Transposition of the great arteries - reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation
A nurse is talking with a parent of a preschooler. The parent reports that she struggles to get her child to go to bed at a consistent time. She explains that the child gets out of bed, enters his parents room, and cries when they tell him to stay in his own bed. Which of the following instructions should the nurse give the parent?
Use a stable, relaxing routine like a bath and a story time before bed
A nurse is providing teaching to the guardian of a 9-month-old infant who has a new prescription for an oral liquid medication. Which of the following points should the nurse include in the teaching?
Use an oral syringe to measure your infant's medicine accurately
The nurse is preparing to administer an oral medication to an 8-month-old infant. Which of the following actions should the nurse take?
Use an oral syringe to place the medication alongside the infant's tongue
A nurse is planning preoperative teaching for a school-age child who is scheduled for cardiac surgery. Which of the following actions should the nurse plan to take when teaching the child?
Use photographs to help explain the procedure
A nurse is caring for a 15-month-old client who requires droplet precautions. Which of the following actions should the nurse take?
Wear a mask when assisting the toddler with meals
A nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse includ
Withhold the medication if the infant's heart rate is less than 110/min
A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include?
Your child should be able to scribble spontaneously using a crayon at 15 months of age
A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure?
abdominal distention
A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso- occlusive crisis. Which of the following actions should the nurse take?
administer ibuprofen
A nurse in an emergency department is caring for an 8-year-old who is up to date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering?
adult tetanus booster
A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor?
alcohol consumption
A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3. Which of the following medications should the nurse administer?
amoxicillin
A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching?
barking cough
A nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include?
begin after the extrusion reflux has diminished
A nurse is discussing the cause of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption?
celiac disease
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take?
check child's BP q4h
A nurse in the ED is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse
check the child's respiratory status
A nurse is assessing a 6-year-old child who is immediately postoperative following a tonsillectomy. Which of the following findings should the nurse report to the provider?
child is swallowing frequently
A nurse is assessing a child who is postoperative and received a unit of pack RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction?
chills and flank pain
A nurse is assessing a preschooler who has HIV. Which of the following manifestations should the nurse expect?
chronic diarrhea
A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child?
coloring book and crayons
A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first?
demonstrate technique on an orange
A nurse is an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first?
determine the child's breathing
A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm^3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care?
encourage quiet play
A nurse is assessing a child who has stage I Hodgkin disease. Which of the following findings should the nurse expect?
enlarged lymph nodes
A nurse is assessing a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities?
fastening buttons on a shirt
A nurse is caring for a school-aged child who has acute post-streptococcal glomerulonephritis. Which of the following manifestations should the nurse expect?
hematuria
A nurse is assessing an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing
high pitched cry
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make?
increase child's protein intake
A nurse is caring for a toddler who has gastroenteritis caused by Salmonella. Which of the following is the priority action for the nurse?
initiate contact precautions
A nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization?
male
A nurse is caring for a child with a vesicular rash that has been present for 6 days. The nurse should expect that the child has which of the following conditions?
varicella
A nurse is teaching the parents of a 3-year-old child who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching?
we should not smoke around our child
A nurse in an acute pediatric unit is caring for a 2-year-old child who has separation anxiety when her parents to leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair?
withdrawn and refuses to talk
A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take?
Obtain the adolescent's weight prior to the procedure
A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider?
Potassium 2.5 mEq/L
A nurse is assessing the gross motor skills of a 4-year-old preschooler. The nurse should expect the preschooler to perform which of the following activities?
hopping on one foot
A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hour ago and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect?
inactivity and thumb sucking
A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia?
patch the unaffected eye
A nurse is assessing a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect?
periorbital edema
A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following?
speech patterns
A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition
My child should consume 1,000 calories per day
A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further?
My child spends 4 hours per day using online chat rooms
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis?
Nausea Urticaria Stridor
A nurse teaching the parent of a 3-year-old toddler about promoting sleep. Which of the following pieces of information should the nurse include?
Follow a nightly routine and established bedtime
A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching
I need to apply paste to the back of the wafer on my child's appliance
A nurse is teaching the parents of a 4-month-old infant who has gastroesophageal reflex. Which of the following statements by a parent indicates an understanding of the teaching?
I will add 1 teaspoon of rice cereal per ounce to my baby's formula
A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
I will add rice cereal to my baby's feedings.
A nurse is providing postoperative teaching to the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching?
I will fold my baby's diaper away from the incision
A nurse is providing teaching about home care to the guardian of a school aged child who has seizures. Which of the following statements by the guardian indicates an understanding of the teaching?
I will turn my child onto her side when a seizure begins
A nurse is performing a well-child assessment of a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erickson's stage of psychosocial development
Industry vs. inferiority
A nurse is providing teaching to the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include?
Instruct the child to walk the bike through intersections
A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take?
Prepare concentrated sucrose for oral administration
A nurse is caring for a child with cystic fibrosis who has a pulmonary infection. Which of the following findings is the nurse's priority?
inability to clear secretions
A nurse is caring for a 3-year-old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to improve these manifestations?
knee to chest
A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take?
measure the infant's head circumference
A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include?
muscle weakness
A nurse is providing discharge teaching to parents whose infant had a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching?
notify if he has a fever
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
periorbital edema
A nurse is instructing a group of parents and guardians about child development. Which of the following recommendations should the nurse make to promote the developmental task of industry in the school-age child?
assign the child several small chores
A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse take?
provide thorough skin care
A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids?
pruritus
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions
supine
nurse is assessing a 6-month old infant who was recently admitted with acute votmiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration?
tachypnea
A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse provide to foster a rapport and encourage conversation?
tell me about your favorite video game
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take?
test nasal secretions for glucose
A nurse is assessing a 3-year-old child during a well-child examination. Which of the following findings should the nurse report to the provider?
the child cannot walk tiptoe
An 18-month-old infant has pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors?
The infant's mother is likely HIV positive
A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following examples should the nurse use to illustrate a suggestive finding?
Arm cast for a spiral fracture of the forearm
A nurse is cring for a newborn who has spina bifida. The newborn's parents are upset by the diagnosis. Which of the following action should the nurse take?
Encourage the parents to touch and care for the newborn
A nurse is a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include?
Ensure the child's dietary intake of calcium and iron is adequate
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care?
Explain the sounds the child is hearing
A nurse on a pediatric unit is caring for a preschooler who is prescribed an IV medication. Which of the following actions should the nurse take to prepare the child for the procedure
Use role-play activities with the child
A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make?
Your baby can start the pneumococcal vaccine now
A nurse is performing an annual physical assessment of a preschooler. The parent expresses concern about the childs 1.8 kg weight gain over the past year. Which of the following responses should the nurse make?
Your child's weight change is expected for this age group
A nurse is providing Teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions?
hip
A nurse is preparing to administer acetaminophen 240 mg PO daily to a child who has a temperature of 38.9. The amount available is 160/5. How many Ml should the nurse administer per done
7.5
A nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse. Which of the following actions should the nurse take?
Report the suspected abuse to local authorities
A nurse is teaching the parents of an infant about treatment option for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants?
The provide direct stimulation of auditory nerve fiber
A nurse is providing education to the parent of a toddler who is about to receive her first dose of he measles, mumps, and rubella (MMR) immunization. Which of the following statements by the parent indicates an understanding of the teaching?
I can give my child acetaminophen for discomfort associated with the immunization
A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus and pertussis (DTaP) vaccine; The measles, mumps, and rubella (MMR) vaccine; and varicella vaccine, which of the following immunizations should the nurse plan to administer
Inactivated poliovirus vaccine (IPV)
A nurse is caring for a preschool-age child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take?
Instruct the child to use a soft sponge toothbrush when brushing her teeth
A nurse is providing teaching about home safety to the parent of a 2-month-old infant. Which of the following information should the nurse include?
Remove bibs before the infant goes to sleep
A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use the suction the child's tracheostomy?
Remove the catheter while applying intermittent suction
A nurse is evaluating the outcome of surgery for an infant who had a bile duct obstruction which of the following findings should indicate to the nurse that the surgery was successful?
The color of the infants stool is yellowish-brown
A nurse is discussing disciplinary techniques with the guardian of a preschooler. Which of the following actions indicates to the nurse that the guardian is using an age- appropriate disciplinary technique?
The guardian places the child in time-out after misbehaving
A nurse is teaching an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching?
You should drink 4 ox of orange juice if you experience hypoglycemia
A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching?
You will be able to participate in physical exercise
A nurse is assessing the fine motor skills development of a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities?
copying a square
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?
maintain the child on bed rest
