Nursing Care of Children-B ati
A nurse is providing discharge teaching to he parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include?
"Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days." Rationale: The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.
A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching?
"Award your child with a sticker when they sit on the potty chair." Rationale: A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair.
A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching?
"Brush the child's teeth after giving the medication." Rationale: The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste.
A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?
"Choose a waterproof sunscreen with a minimum SPF of 15." Rationale: The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn.
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching?
"Encourage the child to perform independent self-care." Rationale: The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem.
**** A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?
A: Deep respirations of 32/min. r: The nurse should expect deep and rapid respirations in a child who has diabetic ketoacidosis. This respiratory rhythm is the body's attempt to blow off excess carbon dioxide and achieve a state of homeostasis. The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis.
****A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority when making a room assignment?
A: Disease process. R: The transmission of infectious diseases is the greatest risk to this child and other children on the unit; therefore, the child's disease process is the nurse's priority consideration. Self-care ability
*** A nurse is caring for a toddler who has acute otitis media and a temp of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler/s temp?
A: Dress the toddler in minimal clothing. R: The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature.
*** A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?
A: Epinephrine. r: This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
Q: A nurse is admitting a 4 month old infant who has heart failure. Which of the following findings is the nurse's priority?
A: Episodes of vomiting. r: When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention; therefore, this is the priority finding.
*** A nurse is reviewing lab results of a school age child who is 1 week postoperative following an open fracture repair. Which of the following values should the nurse identify as an indication of a potential complication?
A: Erythrocyte sedimentation rate 18 mm/hr. Rationale: The nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis.
Q: A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycling accident. Which of the following actions should the nurse take first?
A: Explore the parents' feelings and wishes regarding organ donation. Rationale: The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family.
** A school nurse is assessing a school age child who has erythema infectiosum (fifth disease). Which of the following findings should the nurse expect?
A: Facial rash.
**** A nurse is caring for a school age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
A: Flank pain. R: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.
Q: A nurse in an ED is caring for a school age child who has appendicitis and rates his abdominal pain at 7/10. Which of the following actions should the nurse take?
A: Give morphine 0.05 mg/kg IV. *A pain level of 7 on a 0 to 10 scale is considered severe and the nurse should administer an analgesic medication for pain relief.
**** A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant?
A: Great toe. r: The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for pulses, temperature, and color.
***A nurse is reviewing the lab report of a 6 year old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
A: Hgb 8.5g/dL. R: The child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range for a 6-year-old child and should be reported to the provider.
Q: A nurse is providing teaching to the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statement by the parent should the nurse identify as understanding the teaching?
A: I should keep my child indoors when I mow the yard.
****A nurse is teaching a school age child who has anew diagnosis of type 1 diabetes mellitus. The nurse should identify which of the following statements by the child as understanding the teaching?
A: I will give myself a shot of regular insulin 30 minutes before I eat breakfast. r: The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.
Q: A nurse is providing discharge teaching to the parent of a school age child who has undergone a tonsillectomy. Which of the following statements by the parent should the nurse identify as understanding the teaching?
A: I will notify the Dr if I notice that my child is swallowing frequently. r: The nurse should instruct the parent that frequent swallowing is a sign of bleeding and, if it is observed, to notify the primary care provider immediately.
Q: A nurse is teaching the parent of an infant who has a Pavlik harness to treat developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?
A: I will place my infant's diapers under the harness straps. r: To prevent soiling of the harness the parent should apply the infant's diaper under the straps.
**A nurse is planning care for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?
A: Increase fat content in the child's diet to 40% of total calories. R: A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to equal 40% of total caloric intake.
**** A nurse is reviewing the lumbar puncture results of a school age child suspected of having bacterial meningitis. which of the following results should the nurse identify as a finding associated with bacterial meningitis?
A: Increased protein concentration. r: The nurse should recognize that an increased protein concentration in the spinal fluid is a finding associated with bacterial meningitis.
*****A nurse in the ED is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select All)
A: Increased temp Xerophthalmia Cervical lymphadenopathy. R: Kawasaki disease is an acute illness associated with a fever lasting more than 4 days that is unresponsive to antipyretics or antibiotics. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. The child who has Kawasaki disease may develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.
Q: A nurse is assessing an 8 year old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next?
A: Initiate IV access. R: Since the child's airway is established and respirations are stabilized, the next action the nurse should take using the airway, breathing, circulation approach to client care is to establish IV access to maintain the child's circulatory volume.
Q: A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?
A: Initiate droplet precautions for the child.
****A nurse is planning care for a school age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?
A: Initiate seizure precautions for the child. R: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions in order to maintain the child's safety.
Q: A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make?
A: Let's talk about some of the ways you have handled previous stressors in your life.
Q: A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
A: Loud, harsh murmur. r: The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.
****A nurse is caring for a school age child who has acute rheumatic fever. Which of the following actions should the nurse take?
A: Maintain the child on bed rest. R: The nurse should maintain the child on bed rest as well as limit the child's activity during the acute phase of rheumatic fever to assist with the prevention of cardiac damage.
***A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent should the nurse identify as understanding the teaching?
A: Mono is caused by an infection with the Epstein-Barr virus. r: Mononucleosis is a mildly contagious illness that occurs sporadically or in groups and is primarily caused by the Epstein-Barr virus.
Q: A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?
A: Oral re-hydration solution. R: oral rehydration solution to replace electrolytes and water and promote recovery from dehydration.
Q: A nurse is caring for a school age child who has experience a tonic clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?
A: Place the child in a lateral position. r: to prevent aspiration.
Q: A nurse is caring for an infant who is receiving IV fluids for the treatment of tetralogy of allot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take?
A: Place the infant in a knee-chest position. Rationale: The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.
*** A community health nurse is assessing an 18 month old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect?
A: Poor personal hygiene. R: Poor personal hygiene in a toddler is a potential indication of physical neglect. Because toddlers are still dependent on their parents for help with hygiene needs, poor personal hygiene indicates a lack of supervision.
*** A nurse in an ED suspects that a toddler has epiglottis. Which of the following actions should the nurse take?
A: Prepare the toddler for nasotracheal intubation. r: When epiglottitis is suspected the nurse should prepare for nasotracheal intubation or a tracheostomy, which might be required if the toddler begins to experience severe respiratory distress.
Q: A nurse is assessing a 6 month old infant at a well infant visit. Which of the following findings should the nurse report to the provider?
A: Presence of strabismus. r: Strabismus, or crossing of the eyes, disappears at 3 to 4 months of age. Therefore, the nurse should report this finding to the provider.
Q: A nurse is creating a plan of care for a school age child who has heart disease and has developed heart failure. Which of they following interventions should the nurse include in the plan?
A: Provide small, frequent meals to the child.
Q: A nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to recommend to the parents for treating the child's condition?
A: Recombinant growth hormone. r: Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to recommend this treatment to the child's parents. The nurse's role is to provide emotional support for the parents as they make a decision about the treatment they feel is best for their child.
Q: A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the parents to report which of the following findings to the provider?
A: Restricted ability to move the toes. Rationale: The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours.
Q: A nurse is caring for a school age child who is receiving chem and is severely immunocompromised. Which of the following actions should the nurse take?
A: Screen the child's visitors for indication of infection.
Q: A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?
A: Serum creatinine 3.0 mg/dl. r: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the normal reference range and may indicate rejection of the kidney.
Q: A nurse is preparing to suction an infant who has a tracheostomy. Which of the following actions should the nurse take?
A: Suction for 5 seconds or less. r: to prevent hypoxia.
Q: A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first?
A: Tachypnea.
**** A nurse is planning an educational program for school age children and their parents about bicycle safety. Which of the following information should the nurse plan to include?
A: The child should be able to stand on the balls of her feet when sitting on the bike. r: To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar.
Q: A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?
A: The toddler received tobramycin during a hospitalization 2 weeks ago. r: The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
Q: A nurse is assessing a toddler who has leukemia and is receiving his first round of chemo. Which of the following findings is the priority for the nurse to report to the provider?
A: Urticaria. r: The greatest risk to a toddler who is receiving his first round of chemotherapy is an anaphylactic reaction; therefore, urticaria is the priority finding for the nurse to report to the provider. The nurse should monitor the child for anaphylaxis during and up to 1 hr after the infusion is complete, and immediately report associated findings, such as urticaria, rash, angioedema, and wheezing to the provider.
**** A nurse is teaching a school age child who has a severe allergy to bee venom and his parent about epinephrine. Which of the following
A: Use a second dose if the first does of epi does not completely reverse the symptoms. r: A biphasic response, in which the child will appear to recover and then experience a recurrence of symptoms, is possible with some allergic reactions. The nurse should instruct the parent and child to use a second dose if the first dose does not resolve all the symptoms.
Q: A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan?
A: Use a semipermeable transparent dressing to cover the site. Rationale: The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.
Q: A nurse in an ED is caring for a school-age child who has sustained a minor superficial burn from fireworks on his forearm. Which of the following actions should the nurse take?
A: Use an antimicrobial ointment on the affected area. Rationale: The nurse should apply an antimicrobial ointment to the burned area to prevent infection.
*** A nurse is admitting an infant who has intussusception. Which of the following finding should the nurse expect? Select all that apply.
A: Vomiting, Lethargy. R: have bloody stools that are currant jelly-like in appearance The nurse should expect the infant with intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably leading to exhaustion and decreased nutritional intake. vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel.
****A nurse is teaching a school age child and his parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include?
A: Wait 3 days before taking a tub bath. R: The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. He should not take a tub bath for 3 days to avoid immersion of the incision in water.
Q: A nurse in an ED is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following?
A: Wheezes. Rationale: The nurse should identify the sound during auscultation as wheezes, which are high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways.
*****A nurse is teaching the mother of a 6 month old infant about teething. Which of the following statements should the nurse make?
A: Your baby may pull at her ears when she is teething. R: The nurse should inform the mother that teething can result in discomfort for the infant. Therefore, the mother should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness.
Q: A nurse is providing anticipatory guidance to the parents of an 8 month old infant during a well-child visit. Which of the following statements should the nurse make?
A: Your baby should be able to sit unsupported.
Q: A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should teach the parent to apply which of the following to the affected area?
A: Zinc Oxide. r: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include?
Expresses likes and dislikes Rationale: The nurse should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions.
A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use?
FACES Rationale: The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management.
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?
For 24 hr following initiation of antimicrobial therapy Rationale: The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.
A nurse is creating a plan of care for a child who has varicella. which of the following interventions should the nurse include?
Initiate airborne precautions for the child. Rationale: The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear.
A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes incipidus?
Sodium 155 mEq/L Rationale: A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L.
A nurse is planning an educational program for school age children and their parents about bicycle safety. Which of the following information should the nurse plan to include?
The child should be able to stand on the balls of their feet when sitting on the bike. Rationale: To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar.
Q: A nurse is assessing a school age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
A: Decreased attention span. Rationale: The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem.
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?
"I should wear sandals as much as possible." Rationale: Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection.
A nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?
"I will monitor my child's number of wet diapers." Rationale: The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status.
A school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching?
"I will teach challenging academic subjects to students who have ADHD in the morning." Rationale: Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective.
A nurse is providing dietary teaching to the guardian of a school age child who has cystic fibrosis. Which of the following statements should the nurse make?
"You should offer your child high-protein meals and snacks throughout the day." Rationale: The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection.
A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include?
"Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." Rationale: The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly.
A nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make?
"When your child's lesions are crusted, usually 6 days after they appear." Rationale: The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron?
1/2 cup raisins Rationale: The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron.
A nurse is receiving change of shift report for four children. Which of the following children should the nurse assess first?
A toddler who has a concussion and an episode of forceful vomiting Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.
Q: A nurse is providing anticipatory guidance to the parents of a 2 week old infant about risk factors for sudden infant death syndrome (SIDS). Which of the following risk factors should the nurse include in the teaching?
A: Covering the sleeping infant with a blanket. R: The use of quilts or blankets to cover the sleeping infant increases the risk of SIDS due to the potential for suffocation. The nurse should recommend the parents dress the infant warmly and increase the temperature in the home.
***A nurse is assessing a 4 year old child at a well child visit. Which of the following developmental milestones should the nurse expect to observe?
A: Cuts a shape using scissors.
Q: A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?
A: 1 capsule.
****A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?
A: A unilateral rib hump. r: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.
Q: A nurse is assessing a school age child who has appendicitis with possible perforation. The nurse should identify which of the following as a manifestation of peritonitis?
A: Abdominal distention.
Q: A nurse is caring for a 2 week old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain?
A: Administer sucrose to the infant prior to the procedure.
Q: A nurse is providing discharge teaching to the parents of a 6 month old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instruction should the nurse include in the teaching?
A: Allow the stent to drain directly into your infants diaper. r: The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow.
Q: A nurse is preparing to administer a hep B vaccine to a 1 month of infant. The nurse should plan to inject the medication at which of the following locations?
A: C vastus lateralis.
A nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize that infant's pain?
Allow the mother to breastfeed while the sample is being obtained. Rationale: The nurse should allow the mother to breastfeed the infant prior to or during the procedure. Evidence-based practice indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants.
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?
An 8-month-old infant who is not yet making babbling sounds Rationale: The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing.
A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include?
Avoid palpating the abdomen when bathing the child before surgery. Rationale: The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site.
A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first?
Check the child's respiratory rate. Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths.
A nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective?
Decreased edema Rationale: A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema.
A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority?
Disease process Rationale: The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration.
A nurse is planning care for a newly admitted school age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include?
Ensure the oxygen source is functioning in the child's room. Rationale: The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure.
A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take?
Have the adolescent sign a consent form for treatment. Rationale: The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent.
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?
Increase fat content in the child's diet to 40% of total calories. Rationale: A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.
A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the biceps reflex.
Inner elbow Rationale: the inner elbow will elicit the biceps reflex
A nurse in an emergency department is caring for a school age child who has epiglottitis. Which of the following actions should the nurse take?
Monitor the child's oxygen saturation. Rationale: The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment.
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider?
Nasal flaring Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress.
Nursing Care of Children-B
Nursing Care of Children-B
A nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?
Palpate the dorsum of the child's feet. Rationale: The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema.
*****A nurse is caring for an infant who is receiving IV fluids for the treatment of Tertralogy of Fallot and begins to have cyanotic spell. Which of the following actions should the nurse take?
Place the infant in knee-chest position R: The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.
A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider?
Potassium chloride Rationale: The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia.
A nurse is planning developmental activities for a newly admitted 10 year old child who has neutropenia. Which of the following actions should the nurse plan to take?
Provide the child with a book about adventure. Rationale: The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read.
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?
Serum potassium level 4.1 mEq/L Rationale: The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication.
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?
Sunken anterior fontanel Rationale: The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid.
