NCLEX: Pediatric Nursing

The nurse has just administered ibuprofen to a child with a temperature of 38.8 C (102 F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours 2. Sponge the child with cold water 3. Plan to administer salicylate in 4 hours 4. Remove excess clothing and blankets from the child

Remove excess clothing and blankets from the child

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure (BP) 4. A weight gain of 1 lb in 1 day

A weight gain of 1 lb in 1 day

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

Checks the amount of urine output

The nurse reinforces home care instructions to the parents of a 3 year old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching? 1. "I will supervise my child closely." 2. " I will pad the corners of the furniture." 3. "I will remove household items that can easily fall over." 4. "I will avoid immunizations and dental hygiene treatments for my child."

"I will avoid immunizations and dental hygiene treatments for my child."

The parents of a newborn have been told that their child was born with bladder exstrophy and the parents ask the nurse about this condition. Which response should the nurse give to the parents about bladder exstrophy? 1. "It is a hereditary disorder that occurs in every other generation." 2. "It is caused by the use of medications taken by the mother during pregnancy." 3. "It is a condition in which the urinary bladder is abnormally located in the pelvic cavity." 4. "It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."

"It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."

The nursing instructor asks a nursing student about sudden infant death syndrome (SIDS). Which statement by the student indicates further teaching is needed? 1. "Some of the interventions that are used to prevent SIDS include having infants sleep in the supine position." 2. "The incidence of SIDS has been found to be higher in breastfed infants and infants that use a pacifier." 3. "Infants exposed to cigarette smoking during pregnancy and after birth are considered at risk for SIDS." 4. "SIDS refers to sudden infant death syndrome that can occur in healthy infants under 1 year of age, and no exact cause is known."

"The incidence of SIDS has been found to be higher in breastfed infants and infants that use a pacifier."

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time? 1. A flat position 2. A prone position 3. On his or her left side 4. On his or her right side

On his or her left side

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? 1. 4 months 2. 9 months 3. 12 months 4. 18 months

9 months

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by impaired muscle movement and posture

A chronic disability characterized by impaired muscle movement and posture

A topical corticosteroid is prescribed by the health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? 1. Apply the cream over the entire body 2. Apply a thick layer over the entire body 3. Avoid cleansing the area before application of the cream 4. Apply a thin layer of cream and rub it into the area thoroughly

Apply a thin layer of cream and rub it into the area thoroughly

Which laboratory result would verify the diagnosis of bacterial meningitis? 1. Clear cerebrospinal fluid with high protein and low glucose levels 2. Cloudy cerebrospinal fluid with low protein and low glucose levels 3. Cloudy cerebrospinal fluid with high protein and low glucose levels 4. Decreased pressure and cloudy cerebrospinal fluid with a high protein level

Cloudy cerebrospinal fluid with high protein and low glucose levels

A nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which clinical manifestation is likely to be reported? 1. Cracked lips 2. A normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

Conjunctival hyperemia

The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 and a platelet count of 20,000 mm3. Which nursing intervention should be incorporated into the plan of care? 1. Encourage naps 2. Encourage a diet high in iron 3. Encourage quiet play activities 4. Maintain strict isolation precautions

Encourage quiet play activities

The mother of a 6 year old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin 2. Come to the clinic immediately 3. Encourage the child to drink liquids 4. Administer an additional dose of regular insulin

Encourage the child to drink liquids

The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

Exercise intolerance

The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching? 1. Stress 2. Trauma 3. Infection 4. Fluid overload

Fluid overload

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching? 1. "I can give my child acetaminophen for fever." 2. "I will watch for any hearing loss that may occur." 3. "I know that I will need to watch for any rash that my child may develop." 4. I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months.

I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months.

A mother brings her 3 week old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL. (0 mcmol/L). The nurse reviews this result and makes which interpretation? 1. It is negative 2. It is a concern 3. It is inconclusive 4. It requires rescreening at age 6 weeks

It is negative

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? 1. Potassium infusion 2. NPH insulin infusion 3. 5% dextrose infusion 4. Normal saline infusion

Normal saline infusion

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible hernial strangulation. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents? 1. Pain 2. Diarrhea 3. Constipation 4. Increased flatus

Pain

The nurse is monitoring for signs of dehydration in a 1 year old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided? 1. Rectal 2. Axillary 3. Electronic 4. Tympanic

Rectal

A child has a basilar skull fracture. Which primary health care provider's prescription should the nurse question? 1. Restrict fluid intake 2. Insert an indwelling urinary catheter 3. Keep an intravenous (IV) line patent. 4. Suction via the nasotracheal route as needed

Suction via the nasotracheal route as needed

The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data should the nurse expect to note during the examination? 1. Full range of motion of the legs 2. Marked asymmetry on the affected side 3. The unstable femoral head pops out of the acetabulum 4. The dislocated femoral head pops back into the acetabulum

The dislocated femoral head pops back into the acetabulum

The nurse observes a mother giving an oral iron supplement to her 6 year old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching? 1. The mother administered the iron with milk 2. The mother administered the iron with water 3. The mother administered the iron with apple juice 4. The mother administered the iron with orange juice

The mother administered the iron with milk

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction? 1. Retractions and coughing 2. Nasal flaring and bradycardia 3. Tripod positioning and dyspnea 4. A low grade fever and complaints of a sore throat

Tripod positioning and dyspnea

After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action? 1. Turn the child to the side 2. Notify the registered nurse (RN) 3. Administer the prescribed antiemetic 4. Maintain NPO (nothing by mouth) status

Turn the child to the side

A parent with a 6 year old child diagnosed with enuresis discusses with the nurse the measures that being taken to help her child. Which statement by the parent indicates a need for further teaching? 1. "I make sure that my child goes potty before going to bed." 2. "I have my child help with changing the wet sheets in the morning." 3. "I take away privileges such as TV time when the bed is wet in the morning." 4. "I make sure that my child does not have anything to drink 2 hours before bedtime."

"I take away privileges such as TV time when the bed is wet in the morning."

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? (select all that apply) 1. Cough 2. Irritability 3. Scalp diaphoresis 4. Tachypnea, tachycardia 5. Slow and shallow breathing

A. Irritability B. Scalp diaphoresis C. Tachypnea, tachycardia

An 18 month old child is being discharged after surgical repair of hyposadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home? 1. Leave diapers off to allow the site to heal. 2. Avoid tub baths until the stent has been removed 3. Encourage toilet training to ensure that the glow of urine is normal 4. Restrict the fluid intake to reduce urinary output for the first few days

Avoid tub baths until the stent has been removed

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding? 1. Hematuria 2. Bacteriuria 3. Glucosuria 4. Proteinuria

Bacteriuria

The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of a tingling in the toes distal to the fracture site. Which action should the nurse take? 1. Elevate the extremity 2. Document the findings 3. Notify the registered nurse (RN) 4. Ambulate the child with crutches

Notify the registered nurse (RN)

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child? 1. Keeping the weights hanging freely. 2. Ensuring that the ropes are in the pulleys 3. Placing the bed linens on the traction ropes 4. Ensuring that the weights are out of the child's reach

Placing the bed linens on the traction ropes

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which priority care measure? 1. Measuring intake and output 2. Administering anticholinergics 3. Preventing infection at the surgical site 4. Applying cold, wet compresses to the surgical site

Preventing infection at the surgical site

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread

Rice

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

Rigid extension and pronation of the arms and legs

A nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Has the child had a sore throat or fever within the past 2 months?"

"Has the child had a sore throat or fever within the past 2 months?"

The nurse is providing discharge instructions to the parents of a 14 year old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching? 1. "I need to watch for diarrhea, so my child does not get dehydrated." 2. "I think that once my child's hair starts to fall out that I can keep a hat on him." 3. "I understand that the radiation will cause nausea and vomiting and I need to keep my child hydrated." 4. "I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

"I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

The nurse is reviewing the postoperative primary health care provider's (PHCP's) prescriptions for a 3 week old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? (select all that apply) 1. Measure abdominal girth daily 2. Monitor strict intake and output 3. Take temperature measurements rectally 4. Start clear liquid diet after 8 hours postoperative 5. Maintain IV fluids until the child tolerates oral intake 6. Monitor the surgical site for redness, swelling, and drainage

A. Take temperature measurements rectally B. Start clear liquid diet after 8 hours postoperative

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate? 1. Reinforce the dressing 2. Notify the registered nurse (RN) 3. Document the findings and continue to monitor 4. Circle the area of drainage and continue to monitor.

Notify the registered nurse (RN)

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching? 1. "I need to wash my hands frequently." 2. "I need to clean the eye, as prescribed." 3. "I need to give the eye drops, as prescribed." 4. "I need to use hot compresses to relieve the eye irritation."

"I need to use hot compresses to relieve the eye irritation."

The nurse is caring for an 18 month old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time? 1. A supine position 2. A side-lying position 3. Prone, with the head elevated 4. Prone, with the face turned to the side

A side-lying position

The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching? 1. "I will insect the skin under the brace for redness or breakdown." 2. "I will encourage my child to do their exercises to maintain strength." 3. "I understand that my child needs to wear this brace for 12 hours a day." 4. "I understand that this brace is not a cure for scoliosis, it only slows the progression of the curvature."

"I understand that my child needs to wear this brace for 12 hours a day."

The nurse reviews the home care instructions with a parent of a 3 year old with pertussis. Which statement by the parent indicates a need for further teaching? 1. "I know that my child will make a loud whooping sound." 2. "I understand this whooping cough is viral and I have to let it run its course." 3. "I understand that I need to watch for respiratory distress signs with pertussis." 4. "I can reduce the environmental factors that can trigger coughing, like dust and smoke."

"I understand this whooping cough is viral and I have to let it run its course."

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range of motion (ROM) exercises at this time. The nurse should make which response to the mother? 1. "Avoid all exercises during painful periods." 2. "The ROM exercises must be performed every day." 3. "Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing the ROM exercises."

"Have the child perform simple isometric exercises during this time."

The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities during which the child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after this surgery."

"I can apply lotion or powder to the incision if it is itchy."

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching? 1. "I need to use proper hand-washing techniques." 2. "I need to take my child's rectal temperature daily." 3. "I need to inspect my child's skin daily for redness." 4. I need to inspect my child's mouth daily for lesions."

"I need to take my child's rectal temperature daily."

The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching? 1. "I need to have my child wear a soft fabric under the brace." 2. "I will apply lotion under the brace to prevent skin breakdown." 3. "I will need to encourage my child to perform the prescribed exercises." 4. "I will need to avoid applying powder under the brace, because it will cake."

"I will apply lotion under the brace to prevent skin breakdown."

The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching? 1. "I will have my child wear long sleeves and long pants to keep covered up." 2. "I will have my child stay on well worn paths and not stray into tall grass." 3. "I will check my child for ticks after being exposed to a high risk tick infected area." 4. "I will have my child wear dark colored clothing so the tick will not be attracted to the colors."

"I will have my child wear dark colored clothing so the tick will not be attracted to the colors."

The nurse is reviewing instructions to a parent of a 6 year old on how to prevent influenza. Which statement by the parent indicates a need for further teaching? 1. "I will get a flu shot and I will have my child get a flu shot too." 2. "I will avoid having my child come into contact with sick children." 3. "I will have my child wash her hands frequently during the flu season." 4. "I will not let my child play with other children who have the flu unless they are taking acetaminophen."

"I will not let my child play with other children who have the flu unless they are taking acetaminophen."

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? (select all that apply) 1. Ascites 2. Anorexia 3. Weight loss 4. Proteinuria 5. Decreased serum lipids 4. Periorbital and facial edema

A. Ascites B. Anorexia C. Proteinuria D. Periorbital and facial edema

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? (select all that apply) 1. Enteric 2. Contact 3. Airborne 4. Protective 5. Neutropenic

A. Contact B. Airborne

The nurse monitors a 5 year old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? (select all that apply) 1. Respiratory impairment 2. Anorexia and weight loss 3. Pallor, weakness, irritability 4. Supraorbital ecchymosis and periorbital edema 5. Firm, nontender, irregular mass in the abdomen 6. Urinary frequency or retention from compression on the bladder

A. Firm, nontender, irregular mass in the abdomen B. Urinary frequency or retention from compression on the bladder

A 6 month old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well baby clinic. The parent return home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate? 1. Monitor the infant for a fever 2. Bring the infant back to the clinic 3. Apply an ice pack to the injection site 4. Leave the injection site alone, because this always occurs

Apply an ice pack to the injection site

The nurse reinforces instructions to the mother about dietary measures for a 5 year old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet? 1. Fats and vitamin A 2. Zinc and vitamin C 3. Calcium and vitamin D 4. Thiamine and vitamin B

Calcium and vitamin D

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears 2. Urine specific gravity is 1.030 3. Capillary refill is less than 2 seconds 4. Urine output is less than 1 mL/kg/hour

Capillary refill is less than 2 seconds

A nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely clinical manifestation of this condition in the medical record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting

Choking with feedings

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take? 1. Document the findings 2. Notify the registered nurse immediately 3. Change the ear tubes so that the do not become blocked 4. Check the ear drainage for the presence of cerebrospinal fluid

Document the findings

The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question? 1. Position the infant on the inoperative side 2. Keep the head of the bed elevated 45 degrees 3. Monitor for signs of infection and check dressings for drainage 4. Observe for irritability, a high shrill cry, lethargy, and poor feeding

Keep the head of the bed elevated 45 degrees

A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox? 1. Macular rash on the trunk and scalp 2. Pseudomembrane formation in the throat 3. Maculopapular or petechial rash on the extremities 4. Small, red spots with a bluish-white center and red base

Macular rash on the trunk and scalp

A child is diagnosed with infectious mononucleosis. The nurse reinforces homecare instructions to the parents about the care of the child. Which instruction should the nurse provide to the parents? 1. Maintain the child on bed rest for 2 weeks 2. Maintain respiratory precautions for 1 week 3. Notify the pediatrician if the child develops a fever 4. Notify the pediatrician if the child develops abdominal or left shoulder pain

Notify the pediatrician if the child develops abdominal or left shoulder pain

A child is diagnosed with scarlet fever. The nurse collects dats regarding the child. Which is characteristic of scarlet fever? 1. Pastia's sign 2. Abdominal pain and flaccid paralysis 3. Dense pseudoformation membrane in the throat 4. Foul smelling and mucopurulent nasal drainage

Pastia's sign

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2 year old child with otitis media. Which should be included in the plan? 1. Wear gloves when administering the eardrops 2. Pull the ear up and back before instilling the eardrops 3. Pull the earlobe down and back before instilling the eardrops 4. Hold the child in a sitting position when administering the eardrops

Pull the earlobe down and back before instilling the eardrops

The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease? 1. Skin rash caused by a virus 2. Skin rash caused by a bacteria 3. Respiratory disease caused by virus involving the lymph nodes 4. Respiratory disease caused by a virus involving the parotid gland

Respiratory disease caused by a virus involving the parotid gland

A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first? 1. begin resuscitation 2. terminate exposure to the poison 3. take measures to prevent absorption of the poison 4. check the circulation, airway, and breathing status of the child

check the circulation, airway, and breathing status of the child

The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis (CF)? 1. veggie salad and caramel apple 2. strawberry jelly sandwich and pretzels 3. plate of nachos and cheese and a cupcake 4. chicken tenders and a baked potato with butter

chicken tenders and a baked potato with butter

An adolescent client with type I diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1) sweating and tremors 2) hunger and hypertension 3) cold, clammy skin and irritability 4)

fruity breath and decreasing level of consciousness

The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching? 1. "I hear that the side effects of the medication that my child will be on can cause overeating." 2. "I know that consistent medication and regular follow up visits are a part of the plan for my child." 3. "I know I need to maintain a consistent home environment because my child is easily distracted." 4. "I understand that I will need to lean some behavioral modification techniques to help my child's impulsivity."

"I hear that the side effects of the medication that my child will be on can cause overeating."

The nurse provides information to the parent of a 2 week old infant who was diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder? 1. "I understand treatment need to be started as soon as possible." 2. "I realize my child will require follow-up care until full grown." 3. "I need to bring my child back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every week with my child for the casting."

"I need to bring my child back to the clinic in 1 month for a new cast."

The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching? 1. "I understand I will need to have my baby on antibiotics for this pneumonia." 2. "I will need to give a cough suppressant before meals if his cough gets too bad." 3. "I will be careful and allow my baby to sleep, so he can conserve energy and fight this infection." 4. "I understand that my baby has viral pneumonia and I need to monitor his temperature because of the risk for febrile seizures."

"I understand I will need to have my baby on antibiotics for this pneumonia."

The nurse is reinforcing home-care instructions to the parents of a 3 year old child with scabies. Which statement by a parent indicates the need for further teaching? (select all that apply) 1. "I understand that I need to leave the scabicide on for 4 hours before washing it off." 2. "I will need to seal up all my child's nonwashable toys in a plastic bag for at least 4 days." 3. "I realize that everyone who has come in contact with my child will need to be treated for scabies." 4. "I know I need to wash all the clothing and bedding in hot water with detergent and dry in a hot dryer."

"I understand that I need to leave the scabicide on for 4 hours before washing it off."

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching? 1. "I will give my child cough syrup if a cough develops." 2. "During an attack, I will take my child to a cool location." 3. "I can give acetaminophen if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluid every day."

"I will give my child cough syrup if a cough develops."

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the nurse indicates the need to further research the disease? 1. "The femur is the most common site of this sarcoma." 2. "The child does not experience pain at the primary tumor site." 3. "If a weight-bearing limb is affected, then limping is a clinical manifestation." 4. "The symptoms of the disease during the early stage are almost always attributed to normal growing pains."

"The child does not experience pain at the primary tumor site."

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statements by a parent indicates a need for further teaching? 1. "Frequent hand washing is important." 2. "I need to provide a well-balanced, high-fat diet to my child." 3. "I need to clean contaminated household surfaces with bleach." 4. "Diapers should not be changed near any surfaces that are used to prepare food."

"I need to provide a well-balanced, high-fat diet to my child."

The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching? 1. "I will make my child wear a medical identification alert bracelet." 2. "I know that my child will need to have a companion when swimming." 3. "I will need to give anti-seizure medications when my child has a seizure." 4. "I will have my child wear a bike helmet when riding a bike or skateboarding."

"I will need to give anti-seizure medications when my child has a seizure."

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching? 1. "I will take my child out into the humid night air." 2. "I will place a steam vaporizer in my child's bedroom." 3. "I will place a cool-mist humidifier in my child's bedroom." 4. "I will place my child in a closed bathroom and allow my child to inhale steam from the running water."

"I will place a steam vaporizer in my child's bedroom."

The nurse assists to create a nursing care plan for the child with an arm cast and should include which interventions in the plan? (select all that apply) 1. Instruct parents to keep the cast clean and dry 2. Monitor the extremity for circulatory impairment 3. Instruct the child not to stick objects down the cast 4. Ensure that rough cast materials are cut off to keep smooth 5. Notify the registered nurse (RN) immediately if circulatory impairment occurs

A. Instruct parents to keep the cast clean and dry B. Monitor the extremity for circulatory impairment C. Instruct the child not to stick objects down the cast D. Notify the registered nurse (RN) immediately if circulatory impairment occurs

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? (select all that apply) 1. Place the infant in a private room 2. Place the infant in a room near the nurses' station 3. Ensure that the infant's head is in a flexed position 4. Wear a mask at all times when in contact with the infant 5. Place the child in a tent that delivers warm, humidified air 6. Position the infant side-lying, with the head lower than the chest

A. Place the infant in a private room B. Place the infant in a room near the nurses' station

A 4 year old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan? 1. Palpate the abdomen for a mass. 2. Check the urine for the presence of hematuria 3. Monitor the blood pressure for the presence of hypertension 4. Monitor the temperature for the presence of a kidney infection

Palpate the abdomen for a mass.

The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first? 1. Assist to administer morphine sulfate 2. Place the child in a knee-chest position 3. Administer 100% oxygen by face mask 4. Prepare to administer intravenous fluids

Place the child in a knee-chest position

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

Projectile vomiting

The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check? 1. Maculopapular lesions behind the ears 2. Lesions in the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area

White sacs attached to the hair shafts in the occipital area

The nurse is reinforcing discharge instructions to the parent of a 2 year old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching? 1. "I'll check his temperature." 2. "I'll give him medication so he'll be comfortable." 3. "I'll let him decide when to return to his play activities." 4. "I'll check his voiding to be sure there are no problems."

"I'll let him decide when to return to his play activities."

The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching? 1. "I will not mix the medication with food." 2. "If more than one dose is missed, I will call the doctor." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."

"If my child vomits after medication administration, I will repeat the dose."

The nurse is instructing a mother of a 1 year old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching? 1. "My child will outgrow this by the time he is 2 years old and be able to see just fine." 2. "I will have my child wear an eye patch over the good eye to help strengthen the weak eye." 3. "If this eye patch does not work I know that we will have to do surgery to correct my child's crossed eyes." 4. "There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance."

"My child will outgrow this by the time he is 2 years old and be able to see just fine."

A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation should the nurse report immediately? (Select all that apply) 1. Fever 2. Ribbon-like stools 3. Increased heart rate 4. Hypoactive bowel sounds 5. Profuse projectile vomiting 6. Change in the level of consciousness

A. Fever B. Increased heart rate C. Change in the level of consciousness

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching? 1. "PKU is an autosomal-recessive disorder." 2. "PKU primarily affects the gastrointestinal system." 3. "Treatment of PKY includes the dietary restriction of phenylalanine." 4. "All 50 states require routine screening of all newborns for PKU."

"PKU primarily affects the gastrointestinal system."

The mother of a child with Marfan syndrome asks the nurse what can be done to help her child. Which are the best responses by the nurse? (select all that apply) 1. "You may need to consider surgery in the future." 2. "You will need to make regular pediatric appointments for your child." 3. "You will need to keep your child indoors and avoid sports." 4. "You will need to make regular eye examination appointments for your child." 5. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." 6. "You will need to let the dentist know that antibiotics should be given before any procedure."

A. "You may need to consider surgery in the future." B. "You will need to make regular pediatric appointments for your child." C. "You will need to make regular eye examination appointments for your child." D. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." E. "You will need to let the dentist know that antibiotics should be given before any procedure."

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis? (Select all that apply) 1. Headache 2. Hypotension 3. Red-brown urine 4. Periorbital edema 5. Increased urine output 6. A low blood urea nitrogen (BUN) level

A. Headache B. Red-brown urine C. Periorbital edema

The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching? 1. "I know that my child will outgrow this problem, just give him time." 2. "I know that I need to be alert for signs of heart failure with this defect until it is repaired." 3. "The doctors tell me that my child has a heart murmur caused by the ductus not closing after birth." 4. "As I understand it, my child may have to have the defect closed, either during a catherization or by surgery."

"I know that my child will outgrow this problem, just give him time."

The nurse caring for a child who sustained a burn injury plans care based on which pediatric consideration associated with this injury? (select all that apply) 1. Scarring is less severe in a child than in an adult 2. A delay in growth may occur after a burn injury 3. An immature immune system presents an increased risk of infection for infants and young children 4. Fluid resuscitation is unnecessary unless the burned are is more than 25% of the total body surface area 5. The proportion of body fluid to body mass in a child increases the risk of cardiovascular problems 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults

A. A delay in growth may occur after a burn injury B. An immature immune system presents an increased risk of infection for infants and young children C. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? (select all that apply) 1. Administer a fleet enema 2. Initiate an intravenous line 3. Maintain nothing by mouth status 4. Administer intravenous antibiotics 5. Administer preoperative medications 6. Place a heating pad on the abdomen to decrease pain

A. Initiate an intravenous line B. Maintain nothing by mouth status C. Administer intravenous antibiotics D. Administer preoperative medications

A 4 year old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? (select all that apply) 1. elevate the right arm 2. Apply warm packs to the right arm 3. check the neurovascular status of the right extremity 4. check the range of motion of the right arm and shoulder 5. determine the level of pain using a pediatric pain assessment tool

A. elevate the right arm B. check the neurovascular status of the right extremity C. determine the level of pain using a pediatric pain assessment tool

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? (select all that apply) 1. Administer regular insulin 2. Encourage the child to ambulate 3. Give the child a teaspoon of honey 4. Provide electrolyte replacement therapy intravenously 5. Wait 30 minutes and confirm the blood glucose reading 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs

A. Give the child a teaspoon of honey B. Prepare to administer glucagon subcutaneously if unconsciousness occurs

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list? (select all that apply) 1. Siblings may also need treatment 2. Use anti-lice sprays on all bedding and furniture 3. Use a pediculicide shampoo and repeat treatment in 14 days 4. Grooming items such as combs and brushes should not be shared 5. Launder all the bedding and clothing in hot water and dry on high heat 6. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

A. Siblings may also need treatment B. Grooming items such as combs and brushes should not be shared C. Launder all the bedding and clothing in hot water and dry on high heat D. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and should which intervention in the plan? 1. Assess hearing loss 2. Monitor urine output 3. Change body position every 2 hours 4. Provide a quiet atmosphere with dimmed lighting

Provide a quiet atmosphere with dimmed lighting

A child is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply) 1. Provide adequate nutrition 2. Restriction of fluids, as prescribed 3. Institute measures to prevent infection 4. Monitoring the arteriovenous (AV) fistula 5. Administer blood products to treat severe anemia 6. Anticipate the child will have central nervous system involvement

A. Provide adequate nutrition B. Restriction of fluids, as prescribed C. Institute measures to prevent infection D. Administer blood products to treat severe anemia E. Anticipate the child will have central nervous system involvement

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? (Select all that apply.) 1. Frequent hand washing is important 2. The child should avoid exposure to other illnesses 3. The child's immunization schedule will need revision 4. Kissing the child on the mouth will never transmit the virus 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention

A. Frequent hand washing is important B. The child should avoid exposure to other illnesses C. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).

A school age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child? 1. Drink a half a cup of orange juice before soccer practice 2. Eat twice the amount that is normally eaten at lunchtime. 3. Take half of the amount of prescribed insulin on practice days 4. Take the prescribed insulin at noontime rather than in the morning

Drink a half a cup of orange juice before soccer practice

The nurse is assisting with gathering admission assessment data on a 2 year old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome? 1. Hypotension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine

Generalized edema

A health care provider has prescribed oxygen as needed for a 10 month old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child? 1. When the child is sleeping 2. When changing the child's diapers 3. When the mother is holding the child 4. When drawing blood for electrolyte levels

When drawing blood for electrolyte levels