NUR1025 Module 6 EAQs

A child with acute glomerulonephritis (AGN) with edema and oliguria is hospitalized. Which sign does the nurse remain alert for in the child?

Hypertension A child with AGN in the edema or oliguria phase is at risk for acute hypertension. Therefore the nurse needs to take blood pressure measurements every 4 to 6 hours.

The nurse is providing care for a child with enuresis. What medication does the nurse expect to be prescribed to the child to inhibit urination?

Imipramine (Tofranil) Imipramine (Tofranil) causes an anticholinergic action in the bladder and inhibits urination

The nurse observes erythema, pain, and edema at a child's intravenous (IV) site with streaking along the vein. What should the nurse do first?

Immediately stop the infusion. This describes an extravasation/infiltration. The IV must be stopped to prevent further damage to the child

The health care provider has ordered both tetanus immunoglobulin (TIG) and tetanus toxoid for a child suffering from tetanus. Which is the most accurate method of administration?

Intramuscularly using separate syringes at separate sites TIG is responsible for treatment of the condition, and tetanus toxoid provides immunization and protection against future attacks of the C. tetani bacteria.

Why would the use of lower-extremity bracing be recommended for a child with a spinal cord injury (SCI)?

It is necessary for ambulation.

A child with acute kidney injury is provided nourishment by an intravenous (IV) route. What is the most important action of the nurse in this case?

Monitor for fluid overload

What is an important nursing consideration when caring for a child with end-stage renal disease (ESRD)?

Multiple stresses are placed on the child and family with ESRD because the child's life is maintained by drugs and artificial means.

An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, what should the nurse consider?

Muscle function will gradually return, and recovery is possible in most children. Supportive nursing care is essential. Most patients regain full muscle strength. The return of function is in reverse order of onset. The paralysis is progressive, but most children have full recovery. It is an immune-mediated disease associated with viral and bacterial infections.

The parents brought their child to the emergency department after a needle penetrated the child's eye. Which action should the nurse perform while caring for the child?

Observe for hyphema and reaction of the pupil to light. If a child has a penetrating eye injury of any kind, the nurse should examine the eye to determine whether any aqueous humor has leaked from the penetration site. The nurse should observe the presence of hyphema, or bleeding from the eye. The nurse should also assess for pupillary reaction to light because it helps assess the functioning of the pupil.

The nurse is discussing bed-wetting with the parents of an 8-year-old patient suffering from enuresis. What are the different aspects of caring that the nurse should make the parents aware of? Select all that apply.

Observe for side effects of any medication Reinforce the desired behavior in a positive way Assure the parents that the condition has nothing to do with upbringing

A 5-year-old male child has bilateral eye patches that were put in place after surgery yesterday morning. Today he can be allowed to get out of bed. What is the most important nursing intervention?

Orient him to his immediate surroundings. Because the child is being allowed to move about while both eyes are patched, the immediate safety concern for him is ensuring familiarity with his immediate surroundings. Orientation to the room now that he is out of bed is essential.

The primary health care provider prescribes tetanus immunoglobulin (TIG) and tetanus toxoid and proposes immediate care of the wound. What is the most appropriate step for taking care of such a wound?

Performing surgical debridement and cleansing of the wound Surgical debridement should be done, and the wound must be cleaned. This ensures reduction in the number of proliferating organisms, which cause tetanus, at the site.

A child with renal failure is prescribed dialysis. The parents tell the nurse that they would like to initiate home care because the medical facility is very far from their house. Which type of dialysis is likely to be prescribed for the child?

Peritoneal dialysis Peritoneal dialysis is performed at home as the dialysis solution can be instilled into the peritoneal cavity through a surgically implanted indwelling catheter.

What is the most important complication associated with the use of peripheral venous catheters?

Phlebitis Phlebitis is an inflammation of the vessel wall.

The nurse is doing preoperative teaching with a child and his parents. The parents say that he is "dreading the shot" for premedication. What should the nurse's response be based on?

Preanesthetic medication should be atraumatic, using oral, existing intravenous, or rectal routes.

External defects of the genitourinary tract such as hypospadias are usually repaired as early as possible to do what?

Promote development of normal body image Promoting the development of normal body image is extremely important. Surgery involving sexual organs can be very upsetting to children, especially preschoolers who fear mutilation and castration

A child with spina bifida has developed a latex allergy from numerous bladder catheterizations and surgeries. What is a priority nursing intervention?

Provide a latex-free environment.

What do the major goals of therapy for children with cerebral palsy include?

Recognizing the disorder early and promoting optimal development Because cerebral palsy is currently a permanent disorder, the goal of therapy is to promote optimal development

The nurse is planning care for a child with anemia due to chronic renal failure. Which treatment is likely to be prescribed for the child?

Recombinant human erythropoietin (rHuEPO) injections Anemia in children with chronic renal failure is caused by decreased production of erythropoietin. Therefore thrice-weekly or weekly subcutaneous injections of recombinant human erythropoietin (rHuEPO) are prescribed.

A young child is diagnosed with vesicoureteral reflux. The nurse should know that this usually is associated with what?

Recurrent kidney infections Reflux allows urine to flow back to the kidneys. When the urine is infected, this contributes to kidney infections.

The nurse is admitting a 12-year-old female patient with severe muscle weakness and a differential diagnosis of Guillain-Barré. Upon interviewing the mother regarding the child's recent injuries and illnesses, which finding would be most important?

A flu-like illness Guillain-Barré syndrome (infectious polyneuritis) is an uncommon disease of the peripheral nervous system, caused by a malfunction in the body's own immune system. A significant finding with Guillain-Barré syndrome is the onset of symptoms, which occurs days or even weeks after a flu-like illness.

The nurse is preparing a plan to teach a mother how to administer 1.5 teaspoons of medicine to her 6-month-old child. What should the nurse recommend using?

A plastic syringe (without needle) calibrated in milliliters A plastic syringe offers the most accurate measurement.

What is a common postoperative complication of anesthesia?

Respiratory tract infections Respiratory tract infections are a potential complication of anesthesia, so the nurse makes every effort to aerate the lungs and remove secretions.

A week-old newborn is assessed for body weight, birth marks, and height. The birth weight is lower than what it should be for height. Which physical feature of the newborn makes the nurse conclude that the newborn is affected by Down syndrome?

Short and broad neck

The nurse is assessing a child with a hearing impairment. The child has no speech defect but has difficulty hearing low voices. What would be the hearing level of the child based on the Classification of Hearing Impairment System?

Slight hearing impairment

A pregnant patient visits the primary health care provider for a prenatal checkup. The patient reveals that she occasionally smokes and drinks alcoholic beverages. The nurse expects the health care provider will instruct the patient to stop drinking and smoking. What is the rationale for these instructions?

Smoking and alcohol impair the baby's cognitive development.

Autism is a complex developmental disorder. Diagnostic criteria for autism include delayed or abnormal functioning in which area(s) before 3 years of age? Select all that apply.

Social interaction Inability to maintain eye contact Language as used in social communication

Early detection of a hearing impairment is critical because of its effect on areas of a child's life. The nurse should evaluate further for effects of the hearing impairment on what?

Speech development The ability to hear sounds is essential for the development of speech. Babies imitate the sounds that they hear. The child will have greater difficulty learning to read, but the primary issue of concern is the effect on speech.

What is a neural tube defect that is not visible externally in the lumbosacral area?

Spina bifida occulta

A patient reports severe pain in the eye. Further assessment shows that the patient also has photophobia and eye redness. What treatment would the nurse expect the health care provider to prescribe for this patient?

Surgical treatment to open the outflow tract for aqueous humor Severe pain in the eye is caused by elevated intraorbital pressure, caused by the accumulation of aqueous humor in the eye. This is manifested as glaucoma, and the treatment involves surgical intervention to increase the outflow of aqueous humor.

The primary health care provider asks the nurse to watch for signs of developing hydrocephalus in a toddler with spina bifida. The nurse should look for what signs?

Temperature instability, irritability, and lethargy, and elevated intracranial pressure Early signs of hydrocephalus include signs of infection, such as temperature instability (axillary), irritability, and lethargy, and elevated intracranial pressure. Children with spina bifida are placed in an incubator so their temperature can be maintained without clothing.

What does the nurse keep in mind while administering an enema to a child?

The buttocks of the child should be held together briefly. Infants and young children are unable to retain the solution after it is administered, so the buttocks must be held together for a short time to retain the fluid.

The parent of a 2-year-old child tell the nurse that the child likes to play alone and asks people to repeat questions several times. The parent also says that the child uses gestures to communicate. What should the nurse infer from this?

The child has difficulty hearing. Children 2 to 3 years old understand the common language used at home, and they try to communicate with family members in the same language. If the child has difficulty understanding and responding after the parent repeats a statement several times, this may indicate the child has a hearing problem.

A child is diagnosed with a conductive hearing loss after reporting difficulty in hearing. How should the nurse help the parents cope with the situation?

The nurse explains that conductive hearing loss can be treated successfully. Conductive hearing loss can be treated by both medical and surgical procedures. Reassurance provided by the nurse about the available treatments can help the parents cope with the condition.

A visually impaired child is hospitalized for eye surgery. What nursing intervention should be included in the plan of care to encourage the child to be independent?

The nurse instructs the cleaner not to move the furniture around.

The nurse is caring for a 10-year-old patient after surgery. The nurse gives the patient an inhaled anesthetic for pain relief. What is an important consideration for the patient?

The patient may develop tachycardia. In susceptible children inhaled anesthetics and the muscle relaxant succinylcholine trigger malignant hyperthermia (MH), producing hypermetabolism.

The nurse is caring for a teenager scheduled for surgery. What criteria does the nurse use to obtain valid consent from the patient? Select all that apply.

The patient should act voluntarily. The patient should be well-informed. The patient should be over the age of majority.

The relative of a child receiving oxygen therapy brings the child a remote-controlled airplane as a gift. What safety risk does the toy present to the patient?

The toy can cause fire. Electrical or friction toys are not safe because sparks can cause oxygen to ignite.

The parents find that their son has X-linked Duchenne muscular dystrophy (DMD). They also have a daughter and are concerned about their daughter's well-being. Neither parent has muscular dystrophy. Their daughter has not shown any symptoms. Which are the most appropriate statements to address their concerns? Select all that apply.

"It can be a new mutation, and the mother need not be a carrier." "Your daughter may be a carrier and could develop cardiomyopathy." "It is a genetic disease caused by mutation of the gene that encodes dystrophin."

A child in the hospital complains about difficulty raising the arms over the head, lack of facial mobility, and a forward slope of the shoulders. The primary health care provider identifies facioscapulohumeral condition in the child. Which response from the nurse is most appropriate in explaining the condition to the child's parents?

"It is an autosomal dominant disorder, with slow progression and unaffected life span."

It is time to give a 3-year-old boy his medication. Which approach is most likely to receive a positive response?

"It's time for your medication now. Would you like water or apple juice afterward?"

The nurse is removing the tape of an intravenous catheter in a child. What is the most appropriate instruction given by the nurse?

"Let's remove the tape together." When it is time to discontinue an intravenous infusion, many children are distressed by the thought of catheter removal. Encouraging children to remove or help remove the tape from the site provides them with a measure of control and often fosters their cooperation

A child with Duchenne muscular dystrophy (DMD) is also suffering from obesity. What advice does the nurse give the parents so that they can manage the child's weight more appropriately? Select all that apply.

"Obesity can lead to premature loss of ambulation and functional independence." "It is important to increase the physical and recreational activities in your child's life." "Proper dietary intake and a diversified recreational program help reduce the likelihood of obesity."

A 4-month-old child shows signs of being infected with Clostridium botulinum, such as mild constipation, loss of neurologic function, and respiratory failure. The nurse asks the senior nurse about the child's care. What are the appropriate responses by the senior nurse? Select all that apply.

"Observe and report signs of poor feeding, constipation, and muscle impairment." "Educate the parents about stool softeners, fatigue after recovery, and feeding."

The parent of a child hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. What is the nurse's best reply?

"Acute hypertension (or high blood pressure) must be anticipated and identified." Vital signs, in particular blood pressure, provide information about the severity of the disease and early signs of complications. Acute hypertension is anticipated and requires frequent monitoring for early intervention.

The nurse is assessing a newborn with Down syndrome. The newborn's parent tells the nurse, "We are having a hard time holding our baby. We didn't have this hard of a time with our other children." What would be the nurse's best response?

"Children with Down syndrome have lower muscle tone." Newborns with Down syndrome have joint hyperflexibility and low muscle tone. This can make it difficult to hold the newborn because he or she can go limp like a rag doll. This makes it difficult for the parents to embrace and provide warmth to their newborn.

A child with spina bifida presents with a rash and is also sneezing and coughing continuously. Which are the most appropriate questions to confirm whether the child has a latex allergy? Select all that apply.

"Does your child have a history of allergic reaction to anything?" "Did your child come in contact with any rubber product recently?" "Has your child ever had any allergy testing at a certified clinic?" "Has your child ever had an allergic reaction during surgery?"

The primary health care provider has prescribed blood polymerase chain reaction (PCR) for the dystrophin gene mutation. The newly graduated nurse is inexperienced and asks the senior nurse to explain. What is the most appropriate response?

"Duchenne muscular dystrophy (DMD) is diagnosed by PCR test." The diagnosis of DMD is primarily established by PCR for the dystrophin gene mutation.

A child has been diagnosed with Guillain-Barré syndrome (GBS). Which is the most appropriate explanation of this condition?

"GBS is a rare, acute immune-mediated disease with a progressive ascending flaccid paralysis."

The nurse is caring for a child with cognitive impairment. Which statement made by the nurse to the parents is a reason for concern?

"I do not know what is going on with this child's health."

A parent of a child with enuresis tells the nurse that they often scold the child for bed-wetting, but it has not made any difference in the child's behavior. How does the nurse respond?

"I would suggest you use positive reinforcement"

The parents of a child with glomerulonephritis tell the nurse that the child has asked them to bring pretzels for snacks. How does the nurse respond?

"Pretzels should be avoided completely." Pretzels are high in salt, so they are avoided if the child has glomerulonephritis. Asking the parents to get low-salt pretzels is not appropriate as the child may have increased proteinuria even with small amounts of salt intake. Telling the parents to bring pretzels once a week is not advisable as salt is restricted. Water and salt is restricted in the child to decrease proteinuria.

An inadequately immunized child sustains a wound contaminated with dirt, feces, soil, and saliva. Primary symptoms of tetanus are noted in the child. The child's mother asks the nurse for assistance. What is the most appropriate response by the nurse?

"TIG and tetanus toxoid at separate sites will treat and provide future protection."

A child is identified as having strabismus. The parents ask the nurse what would be the consequence if they left this condition untreated. What should the nurse tell these parents?

"The child may have amblyopia."

The nurse is reviewing a child's medical reports and notes that the child has suffered a spinal cord injury and has tetraplegia. What does the nurse expect the health care provider to tell the parents about the child's condition?

"The child will have loss of functional use of the four extremities." A higher damage without any functional use of the four extremities is called tetraplegia. The complete or partial paralysis of the lower extremities of the body is known as paraplegia.

A patient who is 6 weeks pregnant tells the nurse that she is worried that the baby might have spina bifida because of a family history. What is the nurse's best response?

"The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally." Fetal ultrasound and elevated concentrations of alpha-fetoprotein in amniotic fluid may indicate the presence of anencephaly or myelomeningocele.

A 10-year-old child is diagnosed with an autism spectrum disorder (ASD). The parents ask the nurse about the cause of the disorder. Which answer given by the nurse is most appropriate?

"The exact cause of autism spectrum disorders is unknown." Although the exact cause of ASD is not known, the nurse should always help parents understand that they are not responsible for the child's condition. There are many theories about the cause of ASD, but nothing is definitive.

The child is admitted to the intensive care unit after suffering a spinal cord injury. The primary health care provider prescribes an assessment of neurologic function. The report suggests level D according to the American Spinal Injury Association Impairment Scale. What explanation does the nurse expect the primary health care provider to give to the parents?

"The motor functions are preserved in at least half of the key muscles."

The genetic testing of a child with Down syndrome (DS) showed that it was caused by translocation. The parents ask about further genetic testing. What is the nurse's best response for the parents?

"The parents can be tested themselves because the child's condition might be hereditary." The parents and any siblings should be tested. Down syndrome resulting from a translocation may be inherited. This type of chromosome abnormality presents issues for future pregnancies.

A child with nephrotic syndrome is being treated with corticosteroids. The child's parents tell the nurse that the child has suddenly gained weight and the child's face has become round. How does the nurse respond?

"These side effects will diminish after completing the therapy."

The nursing instructor is teaching a group of students about the use of enemas in children. The instructor says, "We usually do not use Fleet enemas for children." What statement by the student indicates a need for additional teaching?

"They are hypotonic." Plain water is hypotonic, not the Fleet enema. The Fleet enema is not advised for children because of the harsh action of sodium biphosphate and sodium phosphate.

The nurse is assessing a female adolescent for urinary problems. On further assessment the nurse finds that the patient is sexually active. What instructions does the nurse give the patient?

"Urinate soon after having intercourse."

Parents of a child with spinal muscular atrophy (SMA) are concerned their child is not receiving enough oxygenation during sleep. The nurse knows that inadequate oxygenation can lead to hypoxemia. How does the nurse respond to the parent's concerns?

"Use home pulse oximetry."

The mother of a 7-year-old child with acute poststreptococcal glomerulonephritis (APSGN) is expecting her second child. The concerned mother asks the nurse whether the next child may suffer from the same disease. What should be an appropriate response by the nurse?

''The reason is not genetic; it is not acquired or cannot be inherited from parents.'' APSGN is not a genetic disease, so it cannot be passed from parents to offspring. This disease is caused by an immune complex disorder occurring after the patient suffers from streptococcal throat infection.

A 13-year-old patient with an ankle injury requires minor surgery. The parents of the patient have given their consent but are unable to wait during the procedure. What is the best nursing action in this context?

Adhere to the parents' wishes of not participating. The nurse should support parents who do not want to be present in their decision and encourage them to remain close by so they can be available to support the child immediately after the procedure.

What is an advantage of continuous cycling peritoneal dialysis (CCPD) or continuous ambulatory peritoneal dialysis (CAPD) for adolescents who require dialysis?

Adolescents can carry out procedures themselves

An 8-year-old female child is diagnosed with moderate cerebral palsy (CP). She recently began participation in a regular classroom for part of the day. Her mother asks the school nurse about having her daughter join the after-school Girl Scout troop. On what knowledge should the nurse's response be based?

After-school activities often provide children with CP opportunities for socialization and recreation. Recreational outlets and after-school activities should be considered for the child who is unable to participate in athletic programs. Most activities can be adapted for children. The child, family, and activity director should assess the degree of activity to ensure that it meets the child's capabilities. A supportive environment will add to the child's self-esteem.

A child in the clinic exhibits reduced visual acuity in one eye despite appropriate optical correction. What does the nurse expect the child's health care provider to diagnosis the child with?

Amblyopia

Which antipyretic is associated with Reye syndrome in children?

Aspirin (Bayer) Aspirin should not be given to children because of its association in children with influenza virus or chickenpox and Reye syndrome.

A 9-year-old patient is scheduled for a surgical procedure next week. What teachings will the nurse include to ensure the patient's assent? Select all that apply.

Assess patient understanding. Tell the patient what can be expected. Solicit an expression of the patient's willingness. Inform the patient about the nature of the condition.

The nurse is implementing therapeutic techniques in a child's plan of care to manage nocturnal enuresis. Which technique does the nurse include in the care plan?

Avoid caffeinated beverages after 4 PM.

A child with a hearing impairment is prescribed a hearing aid. What is the most important thing the nurse has to tell the parents about the hearing aid?

Batteries should be stored out of reach of children. The batteries should be stored out of reach of children because ingestion of batteries is a medical emergency.

When is bronchial (postural) drainage generally performed?

Before meals and at bedtime

What is an important consideration for the patient receiving gavage feeding?

Careful hand washing is necessary. The nurse should practice meticulous hand washing during the procedure to prevent bacterial contamination of the feeding, especially during continuous-drip feedings. Infection of the mouth is not a risk; contamination of feeding is the concern.

The nurse is administering an antipyretic medication to a child with a high fever. What action does the nurse take in the first hour after giving the medication?

Check the temperature again. The temperature is usually retaken 30 minutes after the antipyretic is given to assess its effect but should not be measured repeatedly. Another dose is not administered before 4 hours and no more than five times in 24 hours.

The nurse is asked to obtain a urine sample from a school-age child for a urine culture to detect bacteriuria. Which intervention does the nurse implement?

Collect an early morning urine specimen The nurse collects an early morning urine sample as it provides an accurate organism count.

A third-grade student is diagnosed with autism. What should the nurse instruct the teacher to expect the child to have difficulty doing?

Coordinating with other students during projects A child with autism may have difficulty with nonverbal social interactions such as eye-to-eye contact, facial expressions, body posture, and gesture.

The nurse is assessing a child with nephrosis. The medical history indicates that there have been relapses even after steroid therapy. Which medication is likely to be prescribed for the child?

Cyclophosphamide (Cytoxan) Cyclophosphamide (Cytoxan) is an immunosuppressant medication prescribed for children who do not respond to steroid therapy.

A child with glomerulonephritis is instructed to restrict fluid intake. On assessment, the nurse finds that the child has lost weight. Which condition does the nurse suspect?

Dehydration When fluids are restricted and the child has lost weight, the nurse needs to assess the child for dehydration and report it promptly.

The primary health care provider prescribed a genetic analysis of circulating fetal cells in the maternal blood and muscle electromyography of a pregnant patient. Which response from the nurse best explains the reason for the test?

Detection of spinal muscular atrophy (SMA) type 1 in the prenatal stage Prenatal diagnoses are done by genetic analysis of circulating fetal cells in the maternal blood or circulating fetal cells in amniotic fluid. Diagnostic studies also include muscle electromyography—which demonstrates a denervation pattern—and muscle biopsy.

The nurse is assessing a newborn and notices the infant has a shortened rib cage, Brushfield spots, and broad, short hands with stubby fingers. What can the nurse interpret that the newborn may have?

Down syndrome

The nurse is caring for a child recovering from ankle surgery. The child was administered an anesthetic for pain relief. What does the nurse do to prevent respiratory complications during the postoperative care?

Encourage respiratory movement with incentive spirometers.

A 10-year-old child falls down the stairs at school and shows symptoms of major spinal injury. The school nurse needs to take care of the child before emergency medical technicians arrive. What should be included as part of the initial nursing actions? Select all that apply.

Ensure that the child has adequate initial stabilization of the entire spinal column. Provide a cervical collar with supportive blocks on a rigid backboard to support the spine.

A 10-year-old female child requires daily medications for a chronic illness. Her mother tells the nurse that she is always nagging the child to take her medicine before school. What is the most appropriate nursing action to promote the child's compliance?

Establishing a contract with her, including rewards For school-age children, behavior contracting associated with desirable rewards is an effective method for achieving compliance.

The parents of a child with fragile X syndrome want to have another baby. They tell the nurse they worry that another child might be similarly affected. What is the most appropriate nursing action?

Explain that prenatal diagnosis of the syndrome is now available. Fragile X syndrome can now be detected prenatally. The family should be referred for genetic counseling. The syndrome is inherited on the X chromosome.

The nurse finds that a child under care for a gastrostomy experienced fecal incontinence. What is a priority intervention by the nurse?

Gently clean the skin and remove moisture. Fecal incontinence, especially when mixed with urine, wound drainage, or gastric drainage around gastrostomy tubes can erode the epidermis.

A child has been prescribed desmopressin acetate (DDAVP) nasal spray for enuresis. The nurse observes that two sprays before bedtime cause nasal irritation in the child. Which intervention does the nurse implement?

Give a tablet form of the medication The nurse substitutes the sprays with the tablet form of desmopressin acetate to prevent the irritation caused by the nasal sprays.

What is included in standard precautions for infection control?

Gloves are worn to change diapers when there are loose or explosive stools. Gloves are not indicated unless there is potential for contact with body substances.

The nurse is charting the amount of food that a child ate at breakfast. The child had 2 oz of orange juice out of 4 oz, and two slices of bread out of the three slices. What is an appropriate way to record the information?

Had 2 oz orange juice and 2 slices of bread.

An 18-month-old patient suffering from cryptorchidism is scheduled for orchiopexy. The parents want to inquire about the outcome of the surgery. What should be the ideal response of the nurse to the parents' concern?

The undescended testicle will be saved from further damage. Cryptorchidism is a defect in which one or both the testes fail to descend into the scrotal sac.

A child with strabismus is undergoing treatment for impaired vision of the left eye. The nurse covers the child's right eye with an occlusion patch. Why does the nurse do so?

To increase vision in the left eye While caring for a child with strabismus, the nurse should cover the unaffected eye with an occlusive patch because it helps stimulate vision and movement in the weaker eye.

The nurse is assessing growth and development in an infant and suspects the child has infantile autism. What observations led the nurse to come to this conclusion?

Unresponsiveness to sounds Functional hearing loss is associated with infantile autism. The child has central auditory imperceptions and is unresponsive to sounds as a result of hearing loss. The child may have reduced development and reduced increase in height and weight relative to other children.

The parents of a school-age child tell the nurse that the child goes to the toilet frequently and the urine smells strong. For which condition is the nurse likely to evaluate the child?

Urinary tract infection

What action does the nurse take to prevent ventilator-associated pneumonia for the patient receiving mechanical ventilation?

Use aggressive hand hygiene. Ventilator-associated pneumonia is a complication that can be prevented through the use of aggressive hand hygiene. The nurse ensures oral care as oral care prevents the development of harmful bacteria in the mouth.

The nurse is taking care of a 14-month-old child with nephrotic syndrome. What is the ideal method by which the nurse can monitor fluid retention or excretion?

Use diapers and weigh wet pads Continuous monitoring of fluid retention and excretion is an important duty of the nurse. The best method of monitoring fluid intake and output for a 14-month-old child is using diapers and weighing wet pads. This pad keeps an accurate tab on the fluid dynamics.

The nurse is assessing a child with autism. What characteristic features of autism does the nurse expect to find in the child? Select all that apply.

Verbal impairment Stereotyped behavior patterns Decreased involvement in play