hesi peds

D - (Multivitamins, iron, and folic acid supplementation are recommended.)

Therapeutic management of the child with an inflammatory bowel disease (IBD) includes a diet that has which components? A. Low protein B. Low calorie C. High fiber D. Vitamin supplements

C - (Approximately 80% to 90% of children with biliary atresia will require liver transplantation.)

Which should the nurse consider when providing support to a family whose infant has just been diagnosed with biliary atresia? A. Death usually occurs by 6 months of age. B. Prognosis for full recovery is excellent. C. Liver transplantation may be needed eventually. D. Children with surgical correction live normal lives.

D - (Aplastic anemia often follows exposure to certain drugs, D, such as chloramphenicol, sulfonamides, and phenylbutazone, Butazolidin, insecticides such as DDT, and chemicals, especially, benzene.)

The nurse admits a child to the intensive care unit with a diagnosis of acquired aplastic anemia. What is the most common cause of this type of anemia? A. Bacterial infections B. A diet deficient in iron C. Heart-lung congenital defects D. Exposure to certain drugs

D - (Excessive salivation and drooling is indicative of tracheoesophageal fistulas. With a fistula, the child has difficulty managing the secretions causing choking, coughing, and cyanosis.)

The nurse assesses a neonate immediately after birth and suspects a tracheoesophageal fistula. Which should be present? A. Jaundice B. Clubfeet C. Absence of sucking and swallowing D. Excessive amount of frothy saliva in the mouth

C - (The nasogastric tube is used to maintain gastric decompression until the return of intestinal activity.)

A child has a nasogastric tube (NG) after surgery for acute appendicitis. The purpose of the tube is to: A. maintain electrolyte balance. B. prevent spread of infection. C. prevent abdominal distention. D. maintain an accurate record of output.

B, C - (Giving the toddler a choice may increase autonomy in the hospitalized setting, B. Brief but simple explanations are beneficial with the toddler, C.)

Which nursing intervention(s) is (are) therapeutic when caring for a hospitalized toddler? (Select all that apply.) A. Require parents to leave the room when performing invasive procedures. B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures. D. Insert a urinary catheter if bedwetting occurs during hospitalization. E. Do not allow any toys to be brought in from the child's home.

D - (Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson's theory of psychosocial development, D. They enjoy being active and participating in role playing.)

A 4-year-old child has cystic fibrosis. Which stage of Erikson's theory of psychosocial development is the nurse addressing when teaching inhalation therapy? A. Autonomy B. Industry C. Trust D. Initiative

C - (A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making, C, the highest priority. When asked "priority" questions, REMEMBER MASLOW! Physical needs usually have a higher priority than psychosocial needs and an open airway is the highest physiological need!)

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? A) Give small, frequent feedings of fluids. B) Accurately chart observations regarding breath sounds. C) Have a bulb syringe readily available to remove secretions. D) Encourage older siblings to visit.

C - (10 lbs 15 oz = 10.9 lbs. Convert lbs to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954 kg, rounded to 5 kg. An infant requires 108 calories/kg/day, 108 × 5 = 540 calories/day. However, this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day.)

A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The nurse determines the daily caloric need for this child is approximately A) 400 calories per day. B) 500 calories per day. C) 600 calories per day. D) 700 calories per day.

B - (The extremity should be extended to prevent trauma to the femoral catheterization site, B. Only the extremity that was catheterized requires immobilization.)

An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement? A. Teach the parents how to ambulate the child in the room safely. B. Show the parents how to hold the child with the extremity extended. C. Restrain the child's lower extremities for a minimum of 4 hours. D. Place the child in a prone position to apply pressure to the site.

C - (Because of the early sexual maturation of the child, both family and child require extensive teaching. Included in this is the information that the child should be engaged in activities according to chronologic age.)

An important component of discussion with parents of a child in precocious puberty is: A. the child is not yet fertile. B. heterosexual interest is usually advanced. C. dress and activities should be appropriate to chronologic age. D. appearance of secondary sexual characteristics does not proceed in the usual order.

A - (Intercostal retractions result from respiratory effort to draw air into restricted airways, A.)

At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions? A. Inspiration B. Coughing C. Apneic episodes D. Expiration

A - (Food intake should be increased in the summer when the child is more active. Races and other competitions may require more food than other practice times.)

During the summer many children are more physically active. What changes in the management of the child with diabetes are expected as a result of more exercise? A. Increased food intake B. Decreased food intake C. Increased risk of hyperglycemia D. Decreased risk of insulin shock

A - (Type 1 diabetes is characterized by destruction of the insulin-producing pancreatic beta cells.)

The destruction of pancreatic beta cells, which produce insulin, is a characterization of: A. type 1 diabetes. B. type 2 diabetes. C. impaired glucose tolerance. D. gestational diabetes.

B - (Cushing syndrome is a description of the clinical manifestations caused by too much circulating cortisol.)

Which statement best describes Cushing syndrome? A. Treatment involves replacement of cortisol. B. Cushing syndrome is caused by excessive production of cortisol. C. The major clinical features are exophthalmia and pigment changes. D. Diagnosis is suspected with findings of hypotension, hyperkalemia, and polyuria.

A - (Hirschsprung disease is a mechanical obstruction caused by a lack of motility of a segment of the intestine resulting from the lack of innervation by ganglion cells.)

Which statement best describes Hirschsprung disease? A. The colon has an aganglionic segment. B. It results in frequent evacuation of solids, liquid, and gas. C. There is passage of excessive amounts of meconium in the neonate. D. It results in excessive peristaltic movements within the gastrointestinal tract.

C - (A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making, C, the highest priority.)

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? A) Give small, frequent feedings of fluids. B) Accurately chart observations regarding breath sounds. C) Have a bulb syringe readily available to remove secretions. D) Encourage older siblings to visit.

C - (Washing the hair and skin with soap and hot water, C, removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne.)

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? A) Remove all blackheads and follow with an alcohol scrub. B) Use medicated cosmetics only to help hide the blemishes. C) Wash the hair and skin frequently with soap and hot water. D) Encourage her to see a dermatologist as soon as possible.

C - (The nurse is taking a proactive approach. The adolescent is provided with information to facilitate the management of his illness.)

A 17-year-old boy with diabetes mellitus tells the school nurse that he has recently started drinking alcohol with his friends on weekends. The most appropriate action by the nurse is to: A. tell him not to do this. B. ask him why he is drinking alcohol. C. teach him about the effects of alcohol on diabetes and how to prevent problems associated with alcohol intake. D. recommend counseling so that he understands the serious consequences of alcohol consumption.

D - (A 2-year-old child is comforted by consistency, D.)

A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A) Invite other children home to share meals. B) Accept that he will eat when he is hungry. C) Reward the child with a nap after eating. D) Consistently follow a set mealtime routine.

C - (Two-year-old children are egocentric and unable to share, C, with other children. A, B, and D, are behaviors of a preschooler.)

The nurse expects a 2-year-old child to exhibit which behavior? A. Build a house with blocks. B. Ride a small tricycle 6 feet. C. Display possessiveness with toys. D. Look at a picture book for 15 minutes.

A - (A 4-year-old can readily identify with simple pictures, A, to show the nurse how he/she is feeling.)

To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? A) Use a happy-face/sad-face pain scale. B) Ask the mother if she thinks the analgesic is working. C) Assess for changes in the child's vital signs. D) Teach the child to point to a numeric pain scale.

A - (Intercostal retractions result from respiratory effort to draw air into restricted airways, A)

When assessing a child with asthma, the nurse should expect intercostal retractions during A) inspiration. B) coughing. C) apneic episodes. D) expiration.

A (Congenital heart disease occurs in 40% to 50% of children with trisomy 21, Down syndrome. Defects of the atrial or ventricular septum that create systolic murmurs, A, are the most common heart defects associated with this congenital anomaly.)

A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome? A. Presence of a systolic murmur B. New onset of patchy alopecia C. Complaints of long bone pain D. Recent projectile vomiting

B - (The parents should notify the health care provider if the hernia remains irreducible, B, after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release.)

Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery? A. Crying that is unrelieved by comforting measures B. Presence of an inguinal bulge after gentle palpation C. Refusal to take oral feedings D. Straining during defecation

A - (A child's head and neck are proportionately larger to their body than an adult's, A. The standard "Rule of Nines" is inaccurate for determining burned body surface areas with children, and must be modified for use with children.)

A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is calculated as a larger percentage of total body surface than an adult's? A) Head and neck. B) Arms and chest. C) Legs and abdomen. D) Back and abdomen.

C - (The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation, C, is indicated to prevent further exposure to staff and others.)

A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which intervention should the nurse implement first? A. Place a mask on the child before transporting the child outside the room. B. Immunize exposed family members with the varicella vaccine. C. Place the child in strict isolation to prevent an outbreak on the unit. D. Determine which staff have had varicella before making assignments.

B - (The presence of the goiter puts the infant at risk for respiratory failure. Preparations are made for emergency ventilation, including a tracheostomy set at the bedside.)

A neonate with a goiter has just been admitted to the newborn nursery. A priority nursing intervention is to: A. position the infant on its left side. B. have a tracheostomy set at bedside. C. explain transient paralysis to parents. D. suction secretions from the infant at least every 5 to 10 minutes.

C - (Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission, i.e., from the mother during delivery, is a persistent cold or respiratory infection, C)

A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit? A. Shortness of breath B. Joint pain C. Persistent cold D. Organomegaly

A - (The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report, A.)

A nurse is preparing to end the shift and receives a lab report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take? A. Communicate the result to the oncoming nurse and document. B. Tell the oncoming nurse that the level is dangerously high. C. Ask the laboratory to redo the test because the result is faulty. D. Hold the next dose of theophylline based on this finding.

B - (The most effective way to provide emotional support is to acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions, B.)

A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman? A. "You can prevent SIDS if your baby sleeps on the side or back. You will have to monitor the baby carefully." B. "The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?" C. "An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind that you need." D. "My neighbor's baby died of SIDS last year, and she went to a SIDS support group. That really helped her."

B - (Adequate fluid intake, B, decreases the viscosity of the blood which affects the incidence of vasocclusive crisis.)

A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child's care? A) Daily iron supplements should be given. B) Plenty of fluids should be consumed daily. C) Immunizations should be delayed for a few years. D) Protective equipment should be worn for contact sports.

B - (Removing restraints one at a time, B, is safer than removing all of them at once.)

A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child? A) Keep restraints on at all times. B) Remove restraints one at a time and provide range of motion exercises. C) Remove all restraints simultaneously and provide play activities. D) Renew the healthcare provider's prescription for restraints every 72 hours.

C - (The key word in this question is polycythemia. Hydration, C, decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia.)

When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority? A. Administering oxygen therapy continuously B. Restricting fluids as ordered C. Maintaining adequate hydration D. Maintaining digoxin (Lanoxin) levels

B - (More information is needed to interpret these findings, B. The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Because these findings are not completely normal, further assessment of history and related signs and symptoms are needed to interpret the findings accurately.)

During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take? A. No action is required, because this is an expected finding for a school-aged child. B. Ask if the child has had a cold, runny nose, or any ear pain lately. C. Send a note home advising parents to have the child evaluated by a health care provider. D. Call the parents and have them take the child home from school for the rest of the day.

A - (Although fever may occur, non-aspirin-containing medications should be used because of the risk of Reye's syndrome, A.)

Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed? A. "I will give her a baby aspirin every 4 hours as needed for fever." B. "I will call the clinic if her cry becomes high-pitched or unusual." C. "I know I can expect her to be irritable over the next 2 days." D. "I will exercise her legs regularly to decrease the soreness."

D - (Diminished femoral pulses, D, could indicate coarctation of the aorta.)

In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses

B - (All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant's heart rate, B, which may decrease because of vagal nerve stimulation and can occur when the tube is inserted.)

When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement? A. Use a blanket as a mummy restraint. B. Monitor the infant's heart rate. C. Lubricate the catheter with saline. D. Explain the procedure to the parents.

D - (Prevention of stress on the lip suture line, D, is essential for optimum healing and the cosmetic appearance of a cleft lip repair.)

When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it A) increases salivation. B) increases the respiratory rate. C) leads to vomiting. D) stresses the suture line.

A, C, D, E - (A, C, D, and E, are all common assessment findings in the client with cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis, B.)

Which assessment finding(s) should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) A. Steatorrhea B. Obesity C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion

B, D, E - (Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, B, eliminating dairy products, D, and initiating a regular toileting routine, E.)

Which intervention(s) should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) A. Provide a low-fiber diet. B. Administer mineral oil daily. C. Decrease the daily fluids. D. Eliminate dairy products. E. Initiate consistent toileting routine.

A - (Because of the unstable nature of the child's fluid and electrolyte balance, wearing medical identification is an extremely important intervention.)

A nurse is developing a plan of care for a child recently diagnosed with diabetes insipidus. Which should be included? A. Encourage the child to wear medical identification. B. Discuss with the child and family ways to limit fluid intake. C. Teach the child and family how to do required urine testing. D. Reassure the child and family that this is usually not a chronic or life-threatening illness.

B - (Sinus bradycardia, heart rate < 90 to 110 beats/min in an infant, is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority, B.)

An infant is receiving digoxin (Lanoxin) for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab (Digibind) stat.

A - (The respiratory rate should be taken first, A, in infants, since touching them or performing unpleasant procedures usually makes them cry, elevating the heart rate and making respirations difficult to count.)

To take the vital signs of a 4-month-old child, which order provides the most accurate results? A) Respiratory rate, heart rate, then rectal temperature. B) Heart rate, rectal temperature, then respiratory rate. C) Rectal temperature, heart rate, then respiratory rate. D) Rectal temperature, respiratory rate, then heart rate.

A, C, F - (The most accurate calculations of pediatric dosages use the child's height and weight, A. The child's BSA is calculated using the square root of weight in kg times height in cm divided by 3600 or the square root of weight in lb times height in inches divided by 3131, C, then the child's BSA is multiplied by the recommended published dose per BSA. The nomogram, F, is used to plot the child's height and weight, and the point at which they intersect is the BSA mathematical constant used to calculate the child's dose.)

Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.) A) Child's height and weight. B) Adult dosage of medication. C) Body surface area of child. D) Average adult's body surface area. E) Average pediatric dosage of medication. F) Nomogram determined mathematical constant.

A - (The use of an infant seat simulates a supine position with the head elevated, A, and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan's bow and prevent the infant from rubbing the face on the bed surface.)

A 3-month-old infant returns from surgery with elbow restraints and a Logan's bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning. D. Apply water-soluble lubricant to the suture line.

C - (Developmental dysplasia of the hip, DDH, occurs more often in infants who present in the breech position, C)

A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical examination. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors commonly associated with DDH. Which response is accurate? A. Vertex delivery B. Male gender C. Breech presentation D. Second-born child

A - (Cyanosis, A, indicates impaired circulation to fingers and should be reported immediately.)

A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? A) Call the healthcare provider immediately if his nail beds appear blue. B) Check his fingers hourly for the first 48 hours to see that he is able to move them without pain. C) Be sure his arm remains above his heart for the first 24 hours. D) Take his temperature q4h for the next two days and call if an elevation is noted.

A - (A lists the most common presenting symptoms of leukemia. Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor.)

A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit? A. Bone pain, pallor B. Weakness, tremors C. Nystagmus, anorexia D. Fever, abdominal distention

A - (A heart rate of 60, A, is much lower than normal for a 6-month-old and warrants immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM when awake, and a rate of 70 while sleeping is considered within normal limits.)

A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? A) Apical heart rate of 60. B) Sweating across the forehead. C) Doesn't suck well. D) Respiratory rate of 30 breaths per minute.

B - (Removing restraints one at a time, B, is safer than, C. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments.)

A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. Which nursing intervention should be included in this child's plan of care? A. Keep restraints on at all times to prevent unplanned extubation. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities. D. Document the reason for application of the restraints every 72 hours.

A - (Altered daily schedules and loss of rituals are upsetting to children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules, A, and establishing an individual schedule familiarizes the child to the hospital environment and decreases anxiety.)

A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization? A) Explain hospital schedules to the child, such as mealtimes. B) Use terms, such as "honey" and "dear," to show a caring attitude. C) Provide a list of rules that limits visitation of siblings in the hospital. D) Orient the parents to the hospital unit and refreshment areas.

D - (Suctioning supplies, D, should always be readily available for use with any client who has a tracheostomy.)

A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the first time tomorrow. During the school day, which intervention should be implemented for this child? A. Cover the tracheostomy site with clothing so that other children will not notice. B. Apply suction for 30 seconds when inserting a catheter into the stoma. C. Discourage the child from coughing deeply to remove mucous secretions. D. Place suctioning supplies on the back of the wheelchair when transporting.

C - (An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids, C, to rehydrate the infant.)

A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first? A. Obtain a scale to weigh the infant's diapers. B. Instruct the mother to offer Pedialyte regularly. C. Insert an intravenous (IV) line and begin IV fluids. D. Obtain a stool specimen for analysis.

A - (Airway obstruction, A is always a priority when caring for any client.)

A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse? A. "My son often chokes while I am feeding him." B. "Is it normal for my child's legs to cross each other?" C. "He gets stiff when I pull him up to a sitting position." D. "My 4-year-old son is jealous of his little brother."

A - (Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition, A.)

A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take? A. Send the child home with the parents to see the health care provider before returning to school. B. Send the child home with the parents and report this to the health department. C. Cover the lesion with a dry gauze dressing and send the child back to class. D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class.

D - (The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation.)

A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally. Which intervention has the highest priority? A. Determine if the child has any allergies to antibiotics. B. Instruct the parent to give the child tepid baths. C. Instruct the parent to increase the child's fluid intake. D. Tell the parent to take the child to the emergency department.

A - (Photosensitivity is a common side effect of tetracycline HCL, Achromycin V, therapy. Severe sunburn can occur with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen.)

A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan? A) Use sunscreen when lying by the pool. B) Cleanse the skin at least 4 times a day. C) Take the medication with a glass of milk. D) Menstrual periods may become irregular.

C - (Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization ,C, is an invasive procedure.)

Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A. Adjustment of orthodontic appliances or braces B. Loss of deciduous teeth (baby teeth) C. Urinary catheterization D. Insect bites

C - (A trial of HCG,human chorionic gonadotrophic hormone, C, may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes, cryptorchidism, may be found in the inguinal canal due to exaggerated cremasteric reflex. A, is not indicated. Stimulation of the cremasteric reflex causes the testes to ascend rather than descend in the scrotum, B. D, may relax the cremasteric muscle, but may not cause the testes to descend.)

Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? A) A trial of adrenocorticotrophic hormone injections. B) Frequent stimulation of the cremasteric reflex. C) A trial of human chorionic gonadotrophic hormone. D) Frequent warm baths to gently dilate the scrotal area.

B - (Sudden and unexplained weight gain, B, can indicate fluid retention and is a sign of congestive heart failure.)

The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider? A. Sits or squats frequently when playing outdoors B. Exhibits a sudden and unexplained weight gain C. Is not completely toilet-trained and has some accidents D. Demonstrates irritation and fatigue 1 hour before bedtime

A - (Peer acceptance and body image are significant issues in the growth and development of adolescents. A, addresses the problem of a lack of contact with peers stemming from his desire to protect his ego.)

The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further assessment reveals that he is concerned about his edematous facial features. Based on these assessment findings, the nurse should plan interventions related to which nursing diagnosis? A. Social isolation B. Altered health maintenance C. Knowledge deficit D. Ineffective coping

C - (Four-year-old children are aggressive in their behavior and enjoy telling tales, C. A and D, are typical toddler behaviors.)

The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this child to exhibit? A. Throws a temper tantrum when told he must share the toys B. Plays by himself for most of the day C. Boasts aggressively when telling a story D. Cries and is fearful when separated from his parents

A - (A, includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea.)

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? A) Choking, coughing, and cyanosis. B) Projectile vomiting and cyanosis. C) Apneic spells and grunting. D) Scaphoid abdomen and anorexia.

D - (The child should be evaluated as soon as possible for pneumonia, D. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough.)

A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother? A. Watch the boy a few more days and see if the cough begins to produce sputum. B. The full 10-day course of antibiotics must be completed before effectiveness can be evaluated. C. Give the child plenty of fluids and an over-the-counter cough suppressant. D. Bring the child to the clinic today for an examination related to the cough.

C - (Emesis should be induced for the child who drank the large dose of acetaminophen, Tylenol, elixir, C, because this medication is hepatotoxic. Vomiting is contraindicated for: children under 1 year of age.)

A nurse who is working in the Poison Control Center receives several telephone calls from parents whose children have ingested possible poisons. The nurse should recommend inducing vomiting for which child? A) 8-month-old who ate 4 to 6 ibuprofen tablets. B) 3-year-old who drank an unknown amount of charcoal lighter fluid. C) 16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir. D) 2-year-old who ate a handful of automatic dishwasher detergent

B - (The baby is at 35% which is much more than room air, 21%, and at this time the baby should not be moved from under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant, B.)

A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents? A) Studies have shown that handling a sick newborn is not good for the baby and upsets the parents. B) The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her. C) Since your baby has been doing well under oxygen for 24 hours, I can let you hold the baby without oxygen. D) You can hold the baby with the oxygen blowing in the baby's face since the level is very close to room air.

A - (Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises, A, helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant.)

The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? A) Type of reaction to loud noises. B) Any surgeries on the ears since birth. C) Drainage from the infant's ears. D) Number of ear infections since birth.

B - (Celiac disease is characterized by intolerance to gluten, the protein found in wheat, barley, rye, and oats. A low-gluten diet is indicated.)

The most appropriate diet for a child with celiac disease is: A. salt free. B. low gluten. C. phenylalanine free. D. high calorie, low protein, low fat.

A - (Early diagnosis is imperative. Because brain growth is complete by 2 to 3 years of age, the deficiency must be detected and replacement therapy begun as soon as possible.)

The most important nursing consideration related to congenital hypothyroidism is: A. early identification of the disorder. B. facilitation of parent-infant attachment. C. initiating referrals for mental retardation. D. helping parents deal with future prospects for the child.

D - (The best approach for a toddler is to ignore the attention-seeking behavior, D.)

The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother? A) Paddle him gently as soon as the behavior is initiated. B) Immediately put him in "time-out." C) Quietly remind him that others are watching him. D) Walk away from him and ignore the behavior.

D - (Needs of a sibling will be better met with factual information and contact with the ill child, so sibling visitation should be encouraged, D.)

The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's repeated hospitalizations. Which is the best response that the nurse should offer? A) Inform the parent that the child is too young to visit the hospital. B) Suggest that the child visit a grandmother until the sibling returns home. C) Ask the mother if the child asks when the sibling will be discharged. D) Encourage the mother to have the children visit the hospitalized sibling.

C - (In type 1 diabetes the beta cells have been destroyed. It is necessary to supply the insulin no longer produced by the beta cells.)

The mother of a child with type 1 diabetes mellitus asks why her child cannot avoid all those "shots" and take pills as an uncle does. The most appropriate response by the nurse is: A. "The pills work with an adult pancreas only." B. "The drugs affect fat and protein metabolism, not sugar." C. "Your child needs insulin replaced and the oral hypoglycemics only add to an existing supply of insulin." D. "Perhaps when your child is older, the pancreas will produce its own insulin, and then your child can take oral hypoglycemics."

A - (All these are important measures to review with the UAP, but the most important is, A. Improper use of isolation precautions can place other staff and clients at risk for infection.)

The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP? A. Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care. D. Report any pain that the child experiences.

B - (Assessing the client's physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism, B.)

The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? A) Have you lost any weight in the last month? B) Are you experiencing any type of nervousness? C) When was the last time you took your synthroid? D) Are you having any problems with your vision?

A - (Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception, A. It would be best for the nurse to ask a more general question, such as, A. B, is narrow in focus. C and D, are blocks to any further communication.)

The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse? A. "Tell me what you know about birth control." B. "Do you know how to apply a condom?" C. "Teen pregnancy should not be taken lightly." D. "You need to visit with your guidance counselor."

D - (Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes, D, due to tissue hypoxia.)

The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit? A) Bradycardia. B) Machinery murmur. C) Weak pedal pulses. D) Clubbed fingers.

A - (Russell's skin traction is used for fractures of the femur in young children and adolescents whose growth plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can compress the peroneal nerve and arteries that supply the foot. Assessment of adequare circulation, movement, and sensation of the toes and skin distal to the application is made to identify compromised blood flow, so cyanosis, A, should be reported immediately.)

The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider? A) Pale bluish coloration of the toes. B) Skin is warm and dry to the touch. C) Toes are wiggled upon command. D) Capillary refill less than 3 seconds.

B - (The child must be monitored for signs and symptoms of hyponatremia, which creates secondary central nervous system alterations such as changes in level of consciousness, seizure, and coma, B.)

The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication? A) Poor skin turgor resulting from dehydration. B) Changes in level of consciousness. C) Premature aging as the disease progresses. D) Severe edema from an excess of water and sodium.

D - (The child must be monitored for signs and symptoms of hyponatremia, which creates secondary central nervous system alterations such as changes in level of consciousness, seizure, and coma.)

The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication? A) Poor skin turgor resulting from dehydration. B) Changes in level of consciousness. C) Premature aging as the disease progresses. D) Severe edema from an excess of water and sodium.

A - (Passage of a normal stool indicates that the intussusception has resolved. Notification of the physician is essential to determine whether a change in treatment plan is indicated.)

The nurse is caring for a child with probable intussusception. The child had diarrhea before admission, but while waiting for administration of air pressure to reduce the intussusception, the child passes a normal brown stool. The most appropriate nursing action is to: A. notify the physician. B. measure abdominal girth. C. auscultate for bowel sounds. D. take vital signs, including blood pressure.

A - (An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit, A, and then implement, B, C, and D.)

The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement? A. Assess the child's mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child's food likes and dislikes. D. Ask the parents about the child's recent dietary intake.

D - (Joint inflammation and pain are the typical manifestations of an exacerbation of JRA, D.)

The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is the most likely cause of the child's impaired mobility? A. Pathologic fractures B. Poor alignment of joints C. Dyspnea on exertion D. Joint inflammation

A - (A liquid iron preparation administered through a straw may help the child to accept the medication since young children consider drinking from a colorful straw fun, A.)

The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child's cooperation? A) Use a colorful straw. B) Mix the medication in water. C) Administer the medication using an oral syringe. D) Ask the pharmacy to provide an enteric tablet.

D - (Outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration, D.)

The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A) I will read all the literature you gave me before surgery. B) I have had surgery before when I broke my wrist in a bike accident, so I know what to expect. C) All the things people have told me will help me take care of my back. D) I understand that I will be in a body cast and I will show you how you taught me to turn.

B - (Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children, usually occurs between 3 months and 5 years of age. Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception, B, thereby negating the need for surgical intervention.)

The nurse is preparing a child with an intussusception for a prescribed barium enema. What is the main purpose of conducting this procedure prior to surgical intervention? A. Evacuate the bowel of impacted feces. B. Reduce the invaginated bowel segment. C. Locate the presence of diverticula. D. Identify the area of esophageal atresia.

B - ( The only reliable way to prevent poisonings in young children is to make them inaccessible, B. Teaching children not to taste is important, A, but ineffective for young children. C and D, will not control a child's curiosity.)

The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction? A) Tell children they should not taste anything but food. B) Store all toxic agents and medicines in locked cabinets. C) Provide special play areas in the house and restrict play in other areas. D) Punish children if they open cabinets that contain household chemicals.

B - (The only reliable way to prevent poisonings in young children is to make the items inaccessible, B.)

The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about the prevention of accidental poisonings. It is most important for the nurse to include which instruction? A. Tell children that they should not taste anything but food. B. Store all toxic agents and medicines in locked cabinets. C. Provide special play areas in the house and restrict play in other areas. D. Punish children if they open cabinets that contain household chemicals.

B - (A child with celiac disease is managed on a gluten-free diet, B, which eliminates food products containing oats, A, wheat, C, rye, D, or barley.)

The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease? A. Turkey salad, milk, and oatmeal cookies B. Baked chicken, coleslaw, soda, and frozen fruit dessert C. Tuna salad sandwich on whole wheat bread, milk, and ice cream D. Turkey sandwich on rye bread, orange juice, and fresh fruit

D - (Environmental exposure to allergens, milk, and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis, D, because milk allergies can contribute to the child's outbreaks.)

The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child? A. "Our first child was born with a cleft lip." B. "We are very careful not to get sunburns in our family." C. "My first child sometimes got a diaper rash." D. "My husband and our daughter are both lactose-intolerant."

A - (Signs and symptoms of diabetes or hyperglycemia, A, need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance.)

The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family? A) Polyuria and polydipsia. B) Lethargy and fatigue. C) Increased facial hair. D) Facial bone structure changes.

A - (The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene, A.)

The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client? A. Remove the brace 1 hour each day for bathing only. B. Remove the brace only for back range-of-motion exercises. C. Wear the brace against the bare skin to ensure a good fit. D. Wearing the brace will cure the spinal curvature.

C - (Four-year-old children are aggressive in their behavior and enjoy "tale telling", C)

The nurse observes a 4-year-old boy in a daycare setting. Which behavior would the nurse consider normal for this child? A) Has a temper tantrum when told he must share his toys. B) Plays by himself most of the day. C) Demonstrates aggressiveness by boasting when telling a story. D) Begins to cry and is fearful when separated from his parents.

C - (Assuming a knee-chest position with the head and chest slightly elevated, C, will help restore hemodynamic equilibrium.)

The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs? A. Place the child's head flat, with the knees on pillows above the level of the heart. B. Have the child lie on the right side, with the head elevated on one pillow. C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated. D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths.

A - (A description of the vomiting episodes, A, will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant.)

The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? A) Description of vomiting episodes in past 24 hours. B) Number of wet diapers in last 24 hours. C) Feeding and sleep schedule. D) Amount of formula consumed during the past 24 hours.

A - (Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat, and barley. The child should avoid any products containing these ingredients to avoid symptoms such as diarrhea. A, is the selection which avoids all of these ingredients.)

Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations? A) Oven-baked potato chips and cola. B) Peanut butter and banana sandwich. C) Oatmeal-raisin cookies and milk. D) Graham crackers and fruit juice.

B - (Altered comfort, pruritus, B, has the highest priority because itching will cause the infant to scratch, creating complications such as scarring or infection.)

Which nursing diagnosis has the highest priority when planning care for an infant with eczema? A. High risk for altered parenting related to feelings of inadequacy B. Altered comfort (pruritus) related to vesicular skin eruptions C. Altered health maintenance related to knowledge deficit of treatment D. Risk for impaired skin integrity related to eczema

D - (Projectile vomiting, D, the classic sign of pyloric stenosis, contributes to metabolic alkalosis.)

Which preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? A. Monitor for signs of metabolic acidosis. B. Estimate the quantity of diarrhea stools. C. Place in a supine position after feeding. D. Observe for projectile vomiting.