Pediatric Nursing Exam 2 8-11
A 13-year-old student has cerebral palsy but is able to communicate well with others. The parents support their child being mainstreamed into a school setting even though self-care is limited. The school nurse likely needs to arrange for which type of care for this student? Select all that apply. 1. Tracheostomy suctioning 2. Straight catheterizations 3. Colostomy management 4. Oral or enteral feedings 5. Medication administration
2. Straight catheterizations 4. Oral or enteral feedings rationale: 2) This is correct. Patients with cerebral palsy may have an indwelling catheter or need straight catheterization because of a lack of bladder control and limited self-care. 4)This is correct. Due to limited self-care, the student is likely to need assistance with either oral or enteral feedings.
The nurse in a pediatric office is performing physical assessments on multiple patients. Which patient will the nurse specifically report to the physician because of physical assessment findings? 1. The 4-year-old patient with a blood pressure of 110/75 mm Hg, pulse of 98 beats/minute. 2. The 3-year-old patient with a history of prematurely closed fontanels who has a headache. 3. The 2-year-old patient with asthma who exhibits abdominal breathing at 26 breaths per minute. 4. The 3-year-old patient with a soiled diaper, at the 70th percentile of weight and height.
2. The 3-year-old patient with a history of prematurely closed fontanels who has a headache. The 3-year-old patient with a history of prematurely closed fontanels has a condition that will affect the growth of the head. The presence of a headache is an indicator of possible increased intracranial pressure. Because there is a potential for brain damage, the nurse will report this finding specifically (and immediately) to the physician.
The nurse is providing postoperative teaching to the parents of a preschool child after a tonsillectomy. For which events does the nurse prompt the parents to contact the physician? Select all that apply. 1. The child keeps an emesis basin close by. 2. The child is frequently swallowing without food or fluids. 3. Bright red blood is noticed in the child's mouth. 4. The child is asking for ice chips and popsicles. 5. The child refuses pain pills because it hurts to swallow.
2. The child is frequently swallowing without food or fluids. 3. Bright red blood is noticed in the child's mouth. 5. The child refuses pain pills because it hurts to swallow. rationale: 2. This is correct. Frequent swallowing without the presence of food or fluid is an indication of bleeding; the parents are instructed to call the physician if this occurs. 3. This is correct. Bright red blood in the child's nose or mouth is indicative of bleeding, and the physician needs to be called. 5. This is correct If the child refuses to take pain pills because it hurts to swallow, the doctor needs to be contacted. It is likely the prescription can be changed to a liquid.
The nurse on a pediatric acute care unit is providing care for an infant who is 11 months of age. The infant is diagnosed with a lower respiratory infection that produces large amounts of thick secretions the infant cannot cough up. When planning to suction the infant, which factor is important to remember? 1. The parents are likely to become angry about the procedure. 2. The infant will respond negatively to a temporary loss of breath. 3. The nurse should apologize after the procedure for stress related to the procedure. 4. The nurse should have assistance to immobilize the infant during the procedure.
2. The infant will respond negatively to a temporary loss of breath. During the suctioning, the nurse will hold the infant tightly and the infant will temporarily experience a loss of breath.
The nurse is caring for a newborn diagnosed with esophageal atresia and tracheoesophageal fistula. Which information does the nurse provide to the parents? Select all that apply. 1. Prenatal conditions that contribute to the problem 2. The manifestation supporting the diagnosis 3. Diagnostic tests performed since the birth 4. Methods of treating the condition 5. Actions for promoting recovery
2. The manifestation supporting the diagnosis 3. Diagnostic tests performed since the birth 4. Methods of treating the condition 5. Actions for promoting recovery Rationale: 2. This is correct. The parents need to know the manifestations that support the diagnosis. The newborn is likely to experience respiratory distress within minutes, days, or weeks of birth; excessive oral secretions; cyanosis; coughing spells; abdominal distention; and upper airway instability. 3. This is correct. The nurse will inform the parents that x-rays, tracheoscopy, echocardiography, and ultrasound was performed after the birth and with the onset of manifestations. 4. This is correct. The nurse will inform the parents that the newborn will require surgery for the repair of the defect. After the physician acquires an informed consent, the nurse will ask about questions and concerns. 5) This is correct. Parent teaching aimed at recovery of the newborn will include information about preventing aspiration, feeding, positioning, and the importance of adherence to frequent follow-up appointments.
A school-aged child is being treated for an overdose of cough medicine administered by the parent. The child is 12 years of age and weighs 98 pounds. The label on the bottle states not to give the medication to children younger than 6 years, and provides a dosing chart that indicates an adult dose for children over 50 kg. For which reason does the nurse suspect the overdose occurred? 1. The cough continued after being medicated. 2. The parent misunderstood weight parameters. 3. The parent measured with a household spoon. 4. The parent attempted to induce sleep in the child.
2. The parent misunderstood weight parameters. The nurse suspects that the parent misunderstood the weight parameters for the medication. The parent may have thought 50 kg was another way of indicating 50 pounds and given the child an adult dose. Multiple doses caused an overdose.
The nurse is asking a parent of a toddler at age 18 months if there are any particular parenting challenges at this time. Which advice will the nurse offer if the parent shares issues with separation anxiety? 1. The parent needs to just leave quickly and ignore the toddler's protests. 2. The parent needs to keep reassuring the toddler that the parent will return. 3. The toddler is to be left only with family members until the fear subsides. 4. The parent needs to plan leaving times to coincide with the toddler's naps.
2. The parent needs to keep reassuring the toddler that the parent will return. rationale: The nurse will advise the parent to repeatedly reassure the toddler that the parent will be back. After the toddler is reassured, the parent needs to leave quickly.
The nurse is evaluating the motor development of a preschooler at age 5 years. Which assessment finding is essential in order for the child to be considered ready for preschool? 1. Dress independently 2. Use the toilet without assistance 3. Draw stick figures with two or more body parts 4. Throw overhand and catch a bounced ball
2. Use the toilet without assistance Before entering preschool, the preschooler needs to be able to use the toilet without assistance.
The nurse in a pediatric office is preparing to remove stitches from an 8-year-old child's arm. Which approach by the nurse before the procedure is most effective? 1. Provide information in advance of how the procedure is performed. 2. Tell the patient, "I will be back in fifteen minutes to take out your stitches." 3. Have a coworker in the room to assist if the patient becomes uncooperative. 4. Bring the instruments to the room and announce, "Let's get those stitches out."
4. Bring the instruments to the room and announce, "Let's get those stitches out." If a procedure must be performed, have the instruments ready and inform the child immediately before the procedure. The action will keep the patient from becoming more anxious. The nurse needs to use a friendly and calm manner to help reduce patient stress.
The nurse is providing care for a school-age patient who received a head injury while playing sports. Which initial assessment finding causes the nurse greatest concern? 1. Confusion and disorientation 2. Headache with periods of nausea 3. Immediate loss of consciousness 4. Changes in breathing and heart rates
4. Changes in breathing and heart rates Normal breathing is involuntary; the central nervous system controls rate and volume of respiration. Adjustments are made in respiration rate, heart rate, and cardiac output to maintain adequate gas exchange. The finding will alert the nurse to either hypoxia in the brain or injury to the part of the brain that controls respiratory function. The scenario does not specify an increase or decrease in the rates.
The school nurse is presenting information on the importance of exercise to children in the fifth and sixth grades of school. Which reason does the nurse cite as being the best reason for being physically active? 1. Sports provide an opportunity to bond with peers. 2. Normal childhood activities make exercise fun. 3. Physical activity needs to replace technology hours. 4. Early exercise will carry over as good habits for adults.
4. Early exercise will carry over as good habits for adults. As with nutrition, early education and experience with exercise can help to form good habits that can last a lifetime. This is the best reason for the nurse to promote physical activity, along with proven health benefits.
The nurse is gathering assessment information from the parent of a 5-year-old child. The parent states, "I am very frustrated. She insists on doing things alone even if it is a struggle to do it right, and gets angry if I redo the task." Which information will the nurse share with the parent to promote greater understanding? 1. Assure the parent that the child will become more compliant as she matures. 2. Suggest how the parent can critique the child's actions without hurting feelings. 3. Encourage the parent to set aside time each week to teach the child the correct way to do things. 4. Explain the child's interest in new things, the need to be independent, and pride in her abilities.
4. Explain the child's interest in new things, the need to be independent, and pride in her abilities. The behavior of this preschooler reflects the milestones related to social and emotional development. The nurse should explain behaviors in a positive way and encourage the parent to support expected growth and development.
The pediatric nurse is preparing a teaching plan for new mothers with small infants. Which is a key point for the nurse to include in the teaching plan? 1. Infants are obligatory mouth breathers for the first month. 2. All sinuses are formed and aerating within 2 months of birth. 3. Infants are abdominal breathers until they are 12 months old. 4. Infant airways get blocked more easily than those in older children.
4. Infant airways get blocked more easily than those in older children. Newborn airways are approximately 4 mm in diameter compared with 20 mm for the average adult's airway. Inflammation 1 mm in circumference would decrease a child's airway diameter 50% but only 20% for an adult.
The nurse is visiting the home of a family who is providing care for a school-age child with profound disabilities. The nurse notes that the primary caregiver looks tired and thin. The caregiver admits to feeling overwhelmed and then guilty about negative feelings. Which intervention by the nurse is most helpful? 1. Arrange for a counselor to meet with the family and assess for well-being. 2. Suggest a means of child management so the parents can plan a short getaway. 3. Provide literature about extended-care facilities where the child can be cared for. 4. Recommend the caregiver to a support group where feelings can be shared.
4. Recommend the caregiver to a support group where feelings can be shared. To combat the effects of caregiver fatigue, caregivers must have a good support network and ability to participate in activities that promote stress relief. The nurse's recommendation for a support group is the best intervention to address the caregiver's immediate needs.
The nurse is providing care for an adolescent patient who is hospitalized following a grand mal seizure. The condition has existed for 5 years and resulted in multiple hospitalizations. Which nursing intervention is appropriate for this client? 1. Ask the patient and family to consider homeschooling. 2. Arrange for home care and regular nursing visitations. 3. Explain methods to minimize the chronic medical events. 4. Refer patient and family to applicable internet resources.
4. Refer patient and family to applicable internet resources. The adolescent patient is likely to have an interest and the ability to do research on the internet. In order to promote understanding through valid and applicable resources, the nurse needs to refer the patient and family to reliable websites.
The nurse works in the pediatric unit of a hospital and is currently providing care for a 1-year-old patient. Which action by the nurse is most important for maintaining the safety of this patient? 1. Question about the presence of smoke and carbon monoxide detectors in the home. 2. Check the temperatures of water, food, and drinks in order to prevent burns. 3. Provide caregiver education on basic home, outdoor play, and car safety measures. 4. Regularly check equipment in the crib environment for potential safety hazards.
4. Regularly check equipment in the crib environment for potential safety hazards. The nurse in an acute care setting is most focused on safety during the hospitalization of a pediatric patient. The nurse needs to check equipment regularly, with special attention to wire and cord placement to minimize entanglement, suction availability at crib side, and minimal equipment and crib attachments to decrease choking and suffocation hazards.
The nurse is evaluating the language skills of a 2-year-old patient. Which assessment finding causes the nurse to suspect a developmental delay? 1. States, "Want mommy!" 2. Points to objects named by the nurse 3. Converses using two short sentences 4. Repeats sounds but not words said by the nurse
4. Repeats sounds but not words said by the nurse Toddlers like to repeat words that are overheard. The expectation is for the toddler at 2 years of age to repeat a single word spoken by the nurse. The inability to perform this action may cause the nurse to suspect a developmental delay or a hearing defect.
The nurse is examining a 10-year-old child brought to the clinic because of episodes of shortness of breath, headaches, and stomach upset. The nurse notices bruises in various stages of resolution on the upper arms and upper legs. Which additional information is most important for the nurse to obtain? 1. Ask about the duration of the presenting symptoms. 2. Ascertain if there is a change in school performance. 3. Notify the physician of physical or sexual abuse. 4. Seek information about the cause of the bruises.
4. Seek information about the cause of the bruises. The most important information for the nurse to obtain is the source of the bruising. The child may have a valid explanation, or the explanation may increase the nurse's concern. The nurse will evaluate the child's response and act accordingly.
The nurse is preparing to perform a physical examination of an adolescent who is 13 years of age. Which action by the nurse will decrease the adolescent's anxiety during the examination? 1. Teaching the anatomical names of body parts 2. Verbalizing findings of physical abnormalities 3. Referring patient concerns to the physician 4. Telling the patient what to expect and why
4. Telling the patient what to expect and why The most effective way to decrease an adolescent's anxiety about a physical examination is to inform the adolescent of the nurse's actions and explain the rationales.
The nurse in an acute care pediatric facility is preparing to assume care of multiple patients at the change of shift. Which patient will the nurse plan to assess first? 1. The toddler who exhibits clubbing of the fingertips 2. The preschooler with pneumonia who has poor skin turgor 3. The infant who can sleep only with the head of the bed elevated 4. The infant who prefers a tripod position instead of lying down
4. The infant who prefers a tripod position instead of lying down When an infant prefers to sit in a tripod position, exhibits a jaw thrust, or is insistent on sitting upright, the indications are relevant to air hunger and oxygen deficiency. This is the patient the nurse will assess first.
The nurse in a pediatric clinic is performing assessments on multiple infants. Which infant does the nurse recognize as being at greatest risk for a respiratory disorder? 1. The infant born at 36 weeks who exhibited respiratory problems at birth 2. The infant who was born at term and recently adopted from another country 3. The infant who sleeps all night, exhibits eczema, and has a family history of asthma 4. The infant with recurrent sore throats and both pets and smokers in the house
4. The infant with recurrent sore throats and both pets and smokers in the house . The infant with recurrent sore throats and exposure to environmental irritants such as pets and smokers in the household is at greatest risk for developing a respiratory disorder. This patient is recognized by the nurse as having three risk factors.
The nurse is caring for a 1-year-old patient after surgery for an intracranial shunt replacement. The nurse selects the FLACC scale for assessment because of the toddler's inability to participate in pain evaluation. The nurse will recognize which assessment finding as an indication of some level of pain? Select all that apply. 1. Constantly frowns, clenched jaw, quivering chin 2. Squirms, shifting back and forth, tense 3. Cries steadily and loudly, sometimes screams or sobs 4. Legs are positioned normally and appear relaxed 5. Answers to name, sucks thumb, and holds toy
1. Constantly frowns, clenched jaw, quivering chin 2. Squirms, shifting back and forth, tense 3. Cries steadily and loudly, sometimes screams or sobs Rationale: 1)Constantly frowning, with clenched jaw and quivering chin are in the face category on the FLACC pain scale, and the score is 2. 2)Squirming, shifting back and forth, and appearing tense are in the activity category on the FLACC pain scale, and the score is 1. 3)Crying steadily and loudly, sometimes screaming or sobbing, are in the cry category on the FLACC pain scale, and the score is 2.
The nurse is conducting a class for parents of children with asthma. After covering the topic of asthma triggers, the nurse asks for feedback on the information. Which statements indicate the parents understand actions to reduce asthma triggers? Select all that apply. 1. "I think that we will need to stop using the fireplace." 2. "We will be rethinking the possibility of a family pet." 3. "Now may be the time for relocating to a warmer climate." 4. "No more going outside without a mask from now on." 5. "Reorganizing our schedules will definitely reduce stress."
1. "I think that we will need to stop using the fireplace." 2. "We will be rethinking the possibility of a family pet." 5. "Reorganizing our schedules will definitely reduce stress." rationale: 1) This is correct. Smoke from any source is a commonly recognized trigger for asthma; understanding the need to stop using the fireplace is indicative of an appropriate action. 2. This is correct. Pet dander is a commonly recognized trigger for asthma; voicing the need to reconsider getting a family pet is indicative of an appropriate action. 5. This is correct. Stress is a commonly recognized trigger for asthma; reorganizing schedules may be an effective way to reduce stress.
The nurse is collecting health data from a 16-year-old male patient. The patient states, "I need to tell you, I had sex with another boy, and I am very confused." Which comment by the nurse is most therapeutic? 1. "Share your thoughts and feelings with me." 2. "Maybe you should speak with your parents." 3. "Tell me what was appealing about this person." 4. "Let's explore your feelings toward the opposite sex."
1. "Share your thoughts and feelings with me." The goal is to create an environment that makes the adolescent feel comfortable to discuss their concerns with the nurse. Therapeutic communication avoids opinions and judgments and attempts to explore the patient's thoughts and feelings.
The nurse in the newborn unit of a pediatric hospital is providing care for a neonate born at 34 weeks' gestation. The nurse is aware that the immediate risk to the neonate is which condition? 1. A lack of a phospholipid in the alveoli 2. Inability to maintain body temperature 3. Delay in closure of cardiac foramen 4. A decrease in renal function
1. A lack of a phospholipid in the alveoli The nurse's immediate concern is related to respiratory function. A premature neonate is likely to have a low level of surfactant, which is a phospholipid in the alveoli that keeps alveoli pliable, preventing them from collapsing completely at the end of each expiration.
The nurse in a pediatric clinic is gathering physical assessment information during a yearly visit on a 6-year-old child. Which finding does the nurse expect during the assessment? 1. A weight gain of 6-1/2 pounds 2. A height increase of 5 inches 3. A blood pressure of 108/72 mm Hg 4. A pulse rate of 85 beats per minute
1. A weight gain of 6-1/2 pounds Children in this age group should gain 3 kg/year in weight, which is comparable to 6.6 pounds.
A 4-year-old patient is on a regular regimen of medications for a chronic condition. The parent expresses frustration because of the difficulty in administering the medications. Which advice will the nurse provide to the parent for managing the process? 1. Ask if the child wants pills or a liquid form of medicine. 2. Inquire if the child prefers the medication at a certain time. 3. Make sure the medicine is sweet and refer to it as candy. 4. Put the medication in juice or milk as preferred by the child.
1. Ask if the child wants pills or a liquid form of medicine. rationale: Allowing a 4-year-old to have some choices regarding medication is likely to foster some cooperation. When possible, the child can decide if the medication is desired in a pill or liquid form.
The nurse in a pediatric clinic is assessing a toddler brought in by a parent who states, "I have noticed some increasing incidents of coughing and wheezing over the last few weeks." Auscultation by the nurse reveals some adventitious breath sounds in the upper right lobe. Which questions does the nurse ask the parent? Select all that apply. 1. "Have you noticed any missing small toys?" 2. "How often is the child allowed to self-feed?" 3. "Is there an older child who gives this child food?" 4. "Can you recall a specific time of gagging or cyanosis?" 5. "Have you noticed any foreign objects in the child's stool?"
1. "Have you noticed any missing small toys?" 3. "Is there an older child who gives this child food?" 4. "Can you recall a specific time of gagging or cyanosis?" rationale: 1. This is correct. The nurse needs to ascertain if and what type of foreign object the toddler may have aspirated. This is an appropriate question if it is suspected that the child aspirated a foreign object. 3. This is correct. The nurse is appropriate in asking if there is another child who may have given the toddler food that could be aspirated. The parent may not be aware but needs to consider the possibility. Of greatest concern is peanuts, tree nuts, hard candies, etc. 4. This is correct. At the time, if the parent noticed the toddler gagging or appearing cyanotic, the nurse may have a better timeline, and the parent's memory may be jogged about a cause.
A parent tells the nurse a toddler is exhibiting signs of being ready to potty train. Which action by the parent will draw the nurse's approval? Select all that apply. 1. "I am initially teaching my son to urinate sitting down." 2. "He has to sit on the potty 10 minutes each hour." 3. "We are still using diapers in order to avoid messes." 4. "Accidents result in the loss of a favorite toy for the day." 5. "We are using treats, stickers, and new underwear as incentives."
1. "I am initially teaching my son to urinate sitting down." 5. "We are using treats, stickers, and new underwear as incentives." Rationale: 1)The nurse will approve of the parent initially teaching a boy to sit to urinate. Once mastered, then move on to standing. The parent or caregiver may use flushable toilet targets for teaching purposes. 5)Incentives are appropriate, and the nurse will approve of providing encouragement in the form of praise and celebration, along with rewards and incentives such as treats, stickers, and new underwear.
The nurse is screening adolescents for substance abuse. Which comment by an adolescent will require additional assessment by the nurse? 1. "I don't smoke cigarettes." 2. "My grandpa died of lung cancer," 3. "I can't afford any kind of smoking." 4. "If I smoke, I pay my own way to college."
1. "I don't smoke cigarettes." The nurse needs to perform additional assessment on the adolescent who specifically states not smoking cigarettes. The NAPNAP paper specifically examines the serious health hazards associated with smoking, smokeless (electronic) cigarettes, and secondhand smoke.
The nurse is providing care for an infant with an inner ear infection. The nurse is aware that the condition has occurred multiple times in a 3-month period. Which comment by the parent indicates to the nurse that specific teaching is needed regarding the incidences of infection? 1. "I now put her to bed with a bottle." 2. "I clean her ears with cotton swabs." 3. "She likes her ears submerged while bathing." 4. "Her older brother brings colds home from school."
1. "I now put her to bed with a bottle." Eustachian tubes are shorter and more horizontal in children than adults and are more prone for migration of substances in the mouth to the inner ear, causing an inner ear infection. The migration of milk is enhanced by putting an infant to bed with a bottle. The nurse will present teaching on this topic.
The nurse is preparing to teach a class of adolescents about the increasing numbers of young people being sexually assaulted. Which advice by the nurse will promote adolescent safety from sex crimes? Select all that apply. 1. Go out with groups of friends. 2. Avoid alcohol and substance use. 3. Remain in public places. 4. Bring a friend along on a date. 5. Research a date's background.
1. Go out with groups of friends. 2. Avoid alcohol and substance use. 3. Remain in public places. rationale: This is correct. Nurses should reinforce safety strategies for avoiding sexual assault, such as going out with a group of friends. The group needs to stay together and should not let a member go off with someone alone. This is correct. Nurses should reinforce safety strategies for avoiding sexual assault, such as avoiding alcohol and substance use, which This is correct. Nurses should reinforce safety strategies for avoiding sexual assault, such as remaining in public places. In addition, the public places should be well lit, well used, and in a safe area.
The nurse is advocating for a transition to home care from a medical inpatient facility for an adolescent patient with a complex medical condition. Which assessment findings/information supports a transition to home for this patient? Select all that apply. 1. Home care is covered by the adolescent's primary and secondary health-care plan. 2. During home care a goal for mainstreaming the adolescent into school is set. 3. The adolescent's parents are older and will benefit from home-care assistance. 4. Home care allows for collaboration and management of care by a medical team. 5. A family member is concerned about the adolescent's complex medication regimen.
1. Home care is covered by the adolescent's primary and secondary health-care plan. 4. Home care allows for collaboration and management of care by a medical team. rationale Home care decreases financial costs and travel costs. When the adolescent has primary and secondary health-care plans that cover home care, the nurse is assured that the transition will not be a financial burden Home care allows collaboration with the adolescent's medical team and increases family satisfaction. The adolescent will be followed by a medical team that is set up to meet the adolescent's medical and psychosocial needs.
15. The nurse is interviewing an adolescent patient 17 years of age who was diagnosed with cystic fibrosis (CF) as an infant. The patient shares feelings of frustration about needing to always live with parents. Which information provided by the nurse is likely to be most important to the patient? 1. How chest physiotherapy (CPT) can be performed independently 2. The availability of home meal delivery to those needing a therapeutic diet 3. Organizations that will provide transportation for persons with chronic illness 4. A list of social organizations available for young persons who have special needs
1. How chest physiotherapy (CPT) can be performed independently Chest physiotherapy is necessary three to four times daily for the patient with CF. The nurse can inform the patient about equipment and techniques. Some suggestions will include handheld massager and an oscillating vest. The nurse will use a multidisciplinary approach to promote independence for the patient.
The school nurse is attending a meeting with the teachers, school counselors, and parents of a student who has recently refused to attend school. The parents share that the student is either pretending to be ill or being untruthful about going to classes. Which initial intervention by the nurse is best? 1. Inquire about the student's feelings regarding school. 2. Ask the parents if they have noticed physical injuries. 3. Explain the impact of missing school to the student. 4. Suggest homeschooling until the problem is resolved.
1. Inquire about the student's feelings regarding school. Initially, the reasons for the student's behavior needs to be identified and addressed, and a good approach is to ask about the student's feelings. The nurse is particularly interested in psychological issues.
The nurse is performing a routine physical assessment on a 7-year-old child. Which specific approaches does the nurse use for this child? Select all that apply. 1. Listen to information shared by the child. 2. Start the exam with obtaining vital signs. 3. Expect the child to be undressed and in a gown. 4. Visually inspect the child's general appearance. 5. Share which immunizations will be given today.
1. Listen to information shared by the child. 4. Visually inspect the child's general appearance. rationale: 1)This is correct. The nurse needs to listen to any information the child provides, especially if it pertains to any recent history or problems. 4)This is correct. The nurse can gather initial assessment data by visually examining the child for general appearance, muscle tone, and skin condition.
A new nurse on a pediatric unit is learning to use EMLA cream in preparation for painful procedures. A school-age patient is scheduled to receive IM medication. Which behavior by the nurse indicates an understanding about the use of EMLA? 1. Medication is applied 2 hours before the IM. 2. The cream is covered with a section of gauze. 3. A thin layer of medication is applied to the area. 4. Cream remaining on the skin is gently rubbed in.
1. Medication is applied 2 hours before the IM. It is most effective to apply EMLA to the site for an IM at least two hours before the procedure. The longer the medication is in place, the deeper it will penetrate.
The nurses at a community pediatric clinic are preparing a presentation about nutrition for the school-age child. Which information is important for the nurses to include? Select all that apply. 1. Over 35% of school-age children are considered to be obese or overweight. 2. Overweight children have an increased likelihood of being overweight adults. 3. Children with high BMIs have increased levels of lipids, insulin, and blood pressure. 4. Notably higher health risks exist for adults who were obese during childhood. 5. School-age children need comparatively more calories than infants or adolescents.
1. Over 35% of school-age children are considered to be obese or overweight. 2. Overweight children have an increased likelihood of being overweight adults. 3. Children with high BMIs have increased levels of lipids, insulin, and blood pressure. 4. Notably higher health risks exist for adults who were obese during childhood. rationale 1. This is correct. Approximately 17.4% of school children are obese, with a BMI defined as greater than the 95th percentile by the CDC, and another 18% are overweight. 2. This is correct. It is a fact that overweight children have a greater risk of being overweight adults. The health consequences of obesity in children will have a negative effect on their morbidity and mortality as adults. 3. This is correct. A high BMI in children is linked with increased lipid levels, insulin levels, and blood pressure; these can lead to higher risks for atherosclerosis and obesity in adulthood. 4. This is correct. The health consequences of obesity in children will have a negative effect on their morbidity and mortality as adults.
The health department informs the school nurse that a high school student has been identified with active TB, and students are to be given a TB skin test. Which consideration does the nurse make in regards to student testing? Select all that apply. 1. Permission for testing is obtained from parents or guardians. 2. Students and parents/guardians are assured of confidentiality. 3. Only students who were in physical contact with the infected student are tested. 4. Students are informed the test administration will cause minor pain. 5. The rationale for the testing is explained to students and parents/guardians.
1. Permission for testing is obtained from parents or guardians. 2. Students and parents/guardians are assured of confidentiality. 4. Students are informed the test administration will cause minor pain. 5. The rationale for the testing is explained to students and parents/guardians. rationale: 1. This is correct. In a high school setting, a majority of students may be minors, and it is necessary for the nurse to obtain parent/guardian permission to administer a TB test. 2. This is correct. As in all situations of medical care, confidentiality is assured. 4. This is correct. The nurse must be honest about any pain during a medical procedure; the nurse will inform the students of expected minor pain. 5. This is correct. Before seeking parent/guardian permission, the nurse must explain the reasons the testing is being performed. Adolescents also need to know the rationales so they will be compliant and assent to the process.
The school nurse is discussing a student's reasons for leaving school to be home schooled. The student has a chronic condition that causes mobility and strength deficits. The student states, "I want to stay in school, but I am always late for class. I can't manage getting around fast enough with all my books." Which suggestion by the nurse will best meet the needs of the student? Select all that apply. 1. Place the designated textbook in each class the student attends. 2. Plan for the student to leave class early to get to the next class. 3. Arrange for a set of textbooks to be left in the student's home. 4. Set up closed-circuit TV so the student "attends" from a set location. 5. Inquire if the parents are able to purchase a motorized wheelchair.
1. Place the designated textbook in each class the student attends. 3. Arrange for a set of textbooks to be left in the student's home. rationale: 1) This is correct. The problem the nurse is attempting to solve is the student's inability to get to class because of difficulty carrying heavy textbooks. The student will benefit if a textbook is left in each assigned class. 3)This is correct. Arranging for a set of textbooks to remain in the student's home will eliminate the need to carry heavy books back and forth from school to home.
The school nurse attends a workshop focusing on the identification and prevention of bullying among school-age children. The nurse will be better able to identify both bullies and victims due to knowledge of which factors? Select all that apply. 1. Poor academic achievement 2. Jealousy over sexual attention 3. Lower education level of caregivers 4. Leader or follower personality types 5. Poor health status or increased health needs
1. Poor academic achievement 3. Lower education level of caregivers 5. Poor health status or increased health needs rationale: 1)This is correct. The nurse will be able to associate poor academic achievement as a cause for either the bully or the victim. 3) This is correct. The nurse will recognize that bullies and victims frequently have parents and caregivers with a high school or lower educational level. 5)This is correct. The nurse will recognize that poor health status, increased health needs, and mental health issues can be a factor in a child becoming either a bully or a victim.
The community pediatric nurses are making home visits to families who have children either above or below the normal ranges in weight and/or height. One nurse visits a home with three qualifying children under the age of 5 years who are all below the standards for their ages. Which interventions will the nurse introduce to the caretakers? Select all that apply. 1. Prepare food for a toddler to eat seven times a day. 2. Serve generous portions and insist on a clean plate. 3. Encourage grazing throughout the day. 4. Physically feed the children to assure better intake. 5. Serve a variety of foods to provide varied nutrients.
1. Prepare food for a toddler to eat seven times a day. 3. Encourage grazing throughout the day. rationale: 1) The nurse will suggest the caregivers make food available for toddlers to eat approximately seven times a day, consuming more meals than snacks. 3)Children should be allowed to graze throughout the day, as toddlers may not sit for three meals.
The nurse is providing teaching to the parent of a toddler 2 years of age diagnosed with otitis media. The toddler presented with a fever of 100.9°F (38.3°C) and does not indicate symptoms related to pain. Which information does the nurse give the parent when the physician orders 48 to 72 hours of supportive care? Select all that apply. 1. Provide age-appropriate analgesics as needed. 2. Administer all of the prescribed antibiotic. 3. Support hydration with fluid increases. 4. Monitor temperature and report increases. 5. Apply topical steroid preparations as instructed.
1. Provide age-appropriate analgesics as needed. 3. Support hydration with fluid increases. 4. Monitor temperature and report increases. rationale: 1)This is correct. The nurse will instruct the parent to administer age-appropriate analgesics as needed. This supportive care is recommended if a child older than 23 months is not in severe discomfort and fever is lower than 102.2°F. Observation for 48 to 72 hours is an important option. 3)The nurse will instruct the parent to avoid dehydration in the child by frequently offering fluids. 4)The nurse will instruct the parent to monitor the child's temperature and report increases, especially if it is 102.2°F or higher.
During a routine pediatric visit the nurse evaluates the cognitive skills of a toddler. The nurse draws a circle on paper and places the crayon in the toddler's right hand. The toddler shifts the crayon to the left hand and draws a circle. Which advice does the nurse provide to the parent? 1. Respect the toddler's preference of one hand over another. 2. Watch the toddler's tendency to alternately use both hands. 3. Reassure the parent that hand preference is not established until age 5 years. 4. Gently insist drawing instruments be placed in the right hand.
1. Respect the toddler's preference of one hand over another. The nurse advises the parent to respect the toddler's preference of using one hand over the other.
A community center is offering classes taught by pediatric nurses on summer safety for toddlers and preschoolers. Which topics will the nurses include in the teaching plan? Select all that apply. 1. Safety near swimming areas 2. Dangers of toys being left in a pool 3. Safety related to flotation devices 4. Bicycle safety for riders or passengers 5. Safety during trampoline play
1. Safety near swimming areas 2. Dangers of toys being left in a pool 3. Safety related to flotation devices 4. Bicycle safety for riders or passengers Rationale: 1)Child-proof all swimming areas, including access to pools, ponds, and lakes. Never leave children unattended near swimming areas, even if they can swim. 2)Toys left in a pool are a dangerous temptation, because children may be tempted to retrieve them. 3)Use flotation devices specifically designed for child safety. Floating toys, rafts, and rings do not provide adequate safety. 4)Trampolines are a safety risk for children of all ages, but toddlers and preschoolers should not be permitted to play on trampolines.
The parent of a toddler at age 2 years and a preschooler at age 4 years is sharing a concern about sibling rivalry. The parent states, "It is so upsetting to see them fighting with each other. I am afraid one of them will hurt the other." Which interventions will the parent and nurse design together in a plan for management? Select all that apply. 1. Set rules defining acceptable behavior. 2. Separate them to opposite sides of the room. 3. Teach children to be kind to each other. 4. Recognize the toddler has increased risk for injury. 5. Assist with appropriate expression of feelings.
1. Set rules defining acceptable behavior. 3. Teach children to be kind to each other. 5. Assist with appropriate expression of feelings. rationale: 1)Together the nurse and parent develop a plan that will set the rules for acceptable behavior. Rules will cover such behaviors such as no name calling, no pushing, and no slamming things. 3)The nurse and parent will identify ways to teach the children to be kind to each other by encouraging apologizing, sharing, and comforting each other when hurt. This intervention will foster positive feelings and behaviors. 5)Children may be unable to express the proper feelings of anger and frustration. The nurse and parent will identify therapeutic methods designed for self-expression.
The nurse works in a pediatric emergency department (ED) and frequently sees adolescents who are victims of sexual abuse. Which assessment findings does the nurse recognize as placing an adolescent at greater risk for sexual assault? Select all that apply. 1. Sexual promiscuity and alcohol/substance use 2. An adolescent with developmental disabilities 3. Adolescents with a history of depression and anxiety 4. Frequent visits to the ED to seek attention 5. A female adolescent who dates older men or boys
1. Sexual promiscuity and alcohol/substance use 2. An adolescent with developmental disabilities 5. A female adolescent who dates older men or boys rationale: the nurse recognizes that adolescents with a history of sexual abuse are more likely to engage in risky behaviors such as sexual promiscuity and alcohol/substance use. The behaviors place the adolescent at risk for additional sexual abuse. The nurse recognizes that adolescents with developmental disabilities are more likely to become victims of sexual abuse. There is an increasing ability to obtain date-rape drugs, such as flunitrazepam (Rohypnol), hydroxybutyrate (GHB), and ketamine. As a result, the use of these substances in adolescent acquaintance-rape assaults is on the rise. An adolescent dating older men or boys is at increased risk
The nurse is aware that the prefrontal cortex of the adolescent brain is still developing. The processes of critical thinking and decision making are in a stage of development. Which change does the nurse expect in the adolescent's thinking? 1. Some awareness of personal limitations 2. Disinterested in politics and social issues 3. Capable of identifying and setting short-term goals 4. Exhibits confidence by not comparing self to peers
1. Some awareness of personal limitations During adolescence, the nurse is aware there is beginning to be some awareness of personal limitations.
The nurse is performing a physical examination on a male who is 15 years of age. The nurse notices the presence of gynecomastia. The patient states, "I hate these breasts and won't even take my shirt off in front of my friends." Which information does the nurse provide for this patient? 1. The condition is self-limiting. 2. Surgical removal is recommended. 3. It indicates the patient is overweight. 4. The male hormone testosterone is deficient.
1. The condition is self-limiting. Gynecomastia refers to abnormal breast development in boys. This is a self-limiting condition.
The nurse is providing care for a 5-year-old patient whose tonsils were removed this morning. The nurse identifies the patient is in pain but not willing to speak. The nurse uses the Wong-Baker FACES scale for pain evaluation. Which indicator does the nurse expect the patient to use to describe the level of pain? 1. The frowning face out of a series of faces 2. A number between 7 and 10 from a scale of 0 to 10 3. An intense red color on a range from pink to deep red 4. The word that identifies the degree of pain (i.e., ouch, hurts bad)
1. The frowning face out of a series of faces The Wong-Baker FACES pain scale is a self-reporting rating scale that assigns a number value to a facial expression that is chosen by a child.
The nurse is preparing information for an adolescent patient regarding a prescribed medication regimen. Which information does the nurse present to the patient? 1. The nurse directly verbalizes medication warnings to the patient. 2. The patient will receive administration clarification by the pharmacist. 3. Most medications are metabolized faster by adolescent patients. 4. Symbols or phrases are sufficient to warn adolescents of medicine-related risks.
1. The nurse directly verbalizes medication warnings to the patient. Adolescents have the best understanding of medication warnings when directly informed verbally by health-care personnel.
A toddler who is 2 years old is playing in the playroom at the hospital and suddenly begins to choke and cough. The nurse attending the toddler places the child in which position to dislodge a possibly inhaled object? 1. Head down and on the left side 2. Head down and on the right side 3. Head horizontal to the floor and supine 4. Head in a neutral position and prone
2. Head down and on the right side In children, the bifurcation of the right and left bronchi occurs higher in the airway, and the right bronchus enters the lung at a steeper angle than does the bronchi of an adult. Placing the child head down and on the right side will help to dislodge the object.
The nurse is invited to present a program on child safety to parents of school-age children in the fourth and fifth grades. Considering the age, which information does the nurse include in the teaching plan? 1. Immunization schedule 2. Head injury prevention 3. Age-appropriate toys 4. Symptoms of illnesses
2. Head injury prevention Unintentional injury, including head injury, is the leading cause of death in this age group. Studies show that parents' knowledge of head injuries is limited. This information and the ages of the children makes this an important topic for the nurse to cover.
Parents bring a toddler who is 2-1/2 years old to the hospital because of observed difficulty with breathing. In addition, they share that at bedtime the toddler has a barky cough. The toddler is diagnosed with laryngotracheobronchitis, commonly referred to as croup. Which assessment finding does the nurse expect related to the diagnosis? 1. Fever accompanied by a congested cough 2. Inspiratory stridor heard in the upper airway 3. Elevated temperature and diaphoresis 4. Snoring sounds throughout respirations
2. Inspiratory stridor Inspiratory stridor, hoarseness, and air hunger are attributed to croup.
The pediatric nurse is reviewing anatomy and physiology in order to have a better understanding of the pediatric respiratory system. The nurse is aware that fluid in the chest cavity can be normal. Which application of this knowledge is correct? 1. Pleural fluid is abundant at birth and decreases over the lifetime. 2. Only enough fluid is present to promote painless movement. 3. Fluid will accumulate in the plural cavity from immobility. 4. Infections such as pneumonia cause fluid in the plural cavity.
2. Only enough fluid is present to promote painless movement. There are two pleural membranes: one around the lungs and one covering the inside of the pleural cavity. The two pleural membranes are normally separated by only enough fluid to lubricate the surfaces for painless movement.
A 6-year-old patient is being assessed by the pediatrician for breathing difficulties. The pediatrician expresses a need for diagnostic tests to identify or rule out asthma. Which tests does the nurse anticipate ordering? 1. Throat culture 2. Pulmonary function tests 3. Electrocardiogram 4. Peak flow meter
2. Pulmonary function tests Pulmonary function tests measure the volumes of inhalation and exhalation, normal and forced. The test evaluates the effectiveness of the lungs.
The nurse is preparing to perform a physical examination on a female who is 15 years of age. The patient states, "I am anxious about having my pelvic organs examined." Which statement does the nurse make? 1. "Slow breaths and relaxation will manage the pain." 2. "I will only briefly examine your external genitalia." 3. "Pelvic exams are recommended after your periods begin." 4. "The instruments are small and the examination is brief."
2. "I will only briefly examine your external genitalia." The first gynecological examination should occur between ages 13 and 15 years for external examination only; pelvic examinations are performed on an adolescent when problems arise such as pain or abnormal bleeding,
Nurses in pediatric emergency departments attend an educational program about identifying victims of human trafficking. Which characteristics have the nurses learned to identify? Select all that apply. 1. Women 2. Age less than 18 years 3. Frequent UTIs and STIs 4. Minors who are pregnant 5. Appearing relaxed and calm
2. Age less than 18 years 3. Frequent UTIs and STIs 4. Minors who are pregnant This is correct; 33% of human trafficking victims are minors. The average age is 12 to 15 years. This is correct. Poor health conditions among this population include STIs; urinary tract infections; multiple pregnancies, abortions, and/or miscarriages; and mental health issues with depression, anxiety, and suicide attempts. This is correct. Many young women will have had multiple pregnancies, abortions, and miscarriages.
****The nurse in a pediatric clinic is performing a routine assessment on a preschool child. The nurse plans to evaluate some of the child's growth and development by interacting directly with the child. Which level of language does the nurse expect if the child is 4 years of age? 1. Sate full name and address without prompting 2. Appropriately converse using two to three sentences 3. Answer questions consistently with a "yes" or "no" 4. Speak clearly enough to be understood
2. Appropriately converse using two to three sentences
The nurse in an acute pediatric care setting is providing care for a 15-year-old patient. The patient is recovering from abdominal surgery. Which nursing intervention is appropriate for this patient? 1. Use FACES pain scale to show the patient a sense of humor. 2. Ask if the patient wants to learn how to care for the incision. 3. Tell the patient that IM injections will feel like a small pinch. 4. Discourage long visits by peers by reinforcing the need for rest.
2. Ask if the patient wants to learn how to care for the incision. It is appropriate for the nurse to encourage the adolescent's active participation in meeting health-care needs. Because the patient may be involved in wound care after discharge, this is a prime time for the nurse to provide appropriate patient education.
During admission of an adolescent to the hospital for an acute illness, the nurse asks about the use of complementary and alternative medicine (CAM). In which manner does the nurse approach the topic to obtain an accurate answer? 1. Tells the adolescent that unreported CAM is a major cause of complications 2. Asks the adolescent what kind of CAM is used in the home and among friends 3. Informs the adolescent that CAM must be completely avoided when hospitalized 4. States that CAM is actually a primitive type of modern medication therapy
2. Asks the adolescent what kind of CAM is used in the home and among friends Adolescents are often reluctant to discuss their use of CAM. Start out by asking the adolescent about family and peer use of CAM. If the adolescent reports use by a close family member or peer, then the adolescent is most likely also using CAM. The nurse can use therapeutic communication skills to acquire additional information.
The parents of an adolescent are distressed about the psychological changes in their child. Which example does the nurse validate as being a source of concern? 1. Constantly compares their body with others 2. Comfortable with doing what the crowd does 3. Regularly tests family limits and rules 4. Presents self in a constantly changing personae
2. Comfortable with doing what the crowd does Because of impulsiveness and a sense of invincibility are common characteristics of the adolescent, the nurse will validate the parents' concern when the adolescent is comfortable doing what the crowd does.
The parents of three children aged 4, 6, and 9 years are preparing to travel abroad as missionaries. The children are in good health and up to date for immunizations; however, the parents are concerned about the high level of TB in the area to which they are assigned. Which recommendation does the nurse make for the protection of the children? 1. Protect the children with good nutrition. 2. Have the children receive the BCG vaccine. 3. Arrange for monthly TB testing for the family. 4. Start the children on preventive medication.
2. Have the children receive the BCG vaccine. Before traveling abroad, the children should get a BCG vaccine, which is a live attenuated strain of Mycobacterium bovis. The vaccine is not widely used in the United States because there is less risk for infection in the United States. It provides incomplete protection, and other precautions are warranted. The BCG vaccine does provide better protection for children than adults.
The nurse is gathering assessment data on a child who is 8 years of age and newly diagnosed with type 1 diabetes mellitus. The caregiver shares a reluctance to allow the child to return to school because the child's glucose levels need to be checked several times daily. Which information is most important for the nurse to share? 1. The caregiver may consider personally attending school with the child. 2. The child's medical condition is manageable in school and other places. 3. The school nurse can care for the special needs of children in school. 4. The caregiver is interrupting psychosocial development in the child.
3. The school nurse can care for the special needs of children in school. Most children can be cared for at school by a school nurse. Medications for asthma and diabetes are commonly administered by the school nurse. This information will be most beneficial to both the child and the caregiver.
A parent has brought a toddler to a new pediatric clinic for a routine visit. The nurse will obtain a health history from the parent. Which information is most important for the nurse to gather? 1. Chief complaint 2. Family medical history 3. Toddler medical history 4. Social history
3. Toddler medical history The most important health history information is the toddler's medical history, which will include childhood illnesses, hospitalizations, surgeries, immunizations, and results of vision/hearing/developmental screens.
The nurse finishes a series of parenting classes on the topic of tantrums and discipline. Which comment by an attending parent causes the nurse concern? 1. "We have learned to ignore her and she stops." 2. "I will give snack and a nap if he is that grumpy." 3. "He plays and then suddenly screams for no reason." 4. "She is learning that a tantrum means a time-out alone."
3. "He plays and then suddenly screams for no reason." rationale: The nurse is aware that some tantrum triggers may indicate a problem related to mental, physical, or emotional issues. The child that is playing and suddenly screams for no reason will cause the nurse concern.
he nurse is gathering health data on an adolescent who is 16 years of age. Which comment by the adolescent will cause the nurse to seek additional information? 1. "I have to be the clumsiest kid in the world. Always tripping over my own feet." 2. "Some days I just hate school. I want to get out and on to a job or college." 3. "I try to keep my distance from a kid in my class who coughs all day long." 4. "I know that I have always been a skinny kid, but wish I could gain weight."
3. "I try to keep my distance from a kid in my class who coughs all day long." When the adolescent expresses trying to stay away from someone who is constantly coughing, the nurse seeks additional information and may recommend TB testing for the patient.
The nurse is providing care for an infant who is 2 months old. Which assessment finding will cause the nurse to suspect an upper respiratory infection? 1. A raspy cry and occasional cough 2. Adventitious lung sounds bilaterally 3. A stuffy nose and reddened eardrums 4. A fever, lethargy, and skin pallor
3. A stuffy nose and reddened eardrums The upper respiratory tract is a passageway that includes the nasopharynx and oropharynx and is connected to the ears by the eustachian tubes. Because of the stuffy nose and reddened eardrums, the nurse suspects an upper respiratory infection.
The nurse in a pediatric clinic is assessing a female adolescent who is 15 years of age. When the nurse performs a sexuality assessment, the patient states, "I have never had anything but safe sex." Which approach does the nurse take next? 1. Provide birth-control options. 2. Ascertain the number of sex partners. 3. Ask the patient to define "safe sex." 4. Inquire about treatment of an STI.
3. Ask the patient to define "safe sex." Given the patient's comment about having only safe sex, the nurse needs to determine the patient's definition of the term. Engagement in oral/anal sex is often considered "safe" by adolescents. If this defines the patient's sexual practice, the nurse needs to educate the patient about risks such as acquiring STIs via oral and anal routes.
The emergency department nurse manager receives a call that a school-age patient will be arriving shortly. The nurse is instructed to have a chaplain and social worker available for the family. The nurse manager is likely to anticipate which possible conditions of the arriving patient? Select all that apply. 1. Pneumonia 2. Terminal cancer 3. Car accident 4. Child abuse 5. Sports injury
3. Car accident 5. Sports injury rationale: 3)The nurse is aware that unintentional injuries and cancer are the leading causes of death for children between the ages of 5 to 14 years. A car accident can be a source of serious body and head injuries, prompting the need for a chaplain and the services of a social worker. 5)School-age children are at risk for unintentional injuries; sports are activities that can result in injuries requiring emergency medical attention. The request for a chaplain and social worker may be indicative of serious injury.
The nurse is preparing to administer medications to school-aged patients. The nurse is aware the pediatric patient doses are different than medication doses for adults. Which factor does the nurse apply to administering pediatric medications? 1. Children's bodies are smaller and need half of the adult dose. 2. The metabolic rate of a child is slower and can cause overdosing. 3. Doses of medications are ordered according to the child's weight. 4. The first dosage consideration is based on the age of the child.
3. Doses of medications are ordered according to the child's weight. Basing medication dosage on weight gives an accurate and safe dose for each patient.
The nurse in a pediatric clinic is assessing the motor development of a 3-year-old patient. The nurse reviews the toddler's last assessment results prior to determining changes. Which new development does the nurse expect to find during assessment? 1. Climbs on furniture unassisted 2. Rides a bicycle with training wheels 3. Independently builds a tower of seven blocks 4. Climbs stairs while holding the railing
3. Independently builds a tower of seven blocks A toddler by age 3 is expected to build a tower with six blocks or more; a 2-year-old will build a tower of four blocks or more.
The nurse in a pediatric clinic is preparing to assess an adolescent who is 12 years of age. Which behavior by the adolescent prompts the nurse to ask if the parent should leave the room? Select all that apply. 1. Acknowledges that the parent is aware of adolescent's sexual activity 2. Refers some of the nurse's questions about health history to the parent 3. Makes attempts to keep their body covered during physical assessment 4. Looks tense and anxious when asked about body functions and changes 5. Does not respond to questions relating to thoughts, feelings, and opinions
3. Makes attempts to keep their body covered during physical assessment 4. Looks tense and anxious when asked about body functions and changes 5. Does not respond to questions relating to thoughts, feelings, and opinions Rationale 3)When the nurse notices the adolescent's attempts to keep their body covered, the nurse should inquire if the patient wants the parent to leave the room. 4) This is correct. When the adolescent looks tense and anxious at any time during the examination, the nurse should inquire if the patient wants the parent to leave the room. 5) This is correct. When the nurse notices the adolescent's lack of response to questions related to thoughts, feelings, and opinions, the nurse should ask if the patient wants the parent to leave the room.
The nurses in a local health department are scheduled to perform screenings at a public elementary school. Which printed information will the nurses most likely send home with the students after the screening? 1. Importance of keeping immunizations up to date 2. Procedure for handwashing to prevent illnesses 3. Methods of treating and avoiding lice infestation 4. Proper way to cover up when coughing or sneezing
3. Methods of treating and avoiding lice infestation Infestations of head lice are prevalent among school-age children. The health department nurses will perform on-site screenings for the presence of the problem. Infected students will receive notifications about positive identification. All students will receive printed material about the treatment and prevention of lice infestation.
The nurse working in the emergency department of a pediatric care facility is receiving an adolescent patient with a gunshot wound to the head. The patient is unconscious but exhibiting signs of life-threatening deterioration. Which action does the nurse take? 1. Keep attempting to reach the parents. 2. Determine if the patient is emancipated. 3. Prepare the patient for surgery. 4. Call the facility's legal advisor.
3. Prepare the patient for surgery. Under the Emergency Medical Treatment and Active Labor Act of 1986, adolescents who require emergency care may be treated regardless of whether caregiver consent has been obtained. The nurse will prepare the patient for surgery.
An adolescent who is 12 years of age is a year into treatment for a malignant brain tumor. For which psychosocial and spiritual care will the nurse plan? Select all that apply. 1. Remind the patient that achieving a vocation/career is not likely. 2. Encourage parents to remain hopeful about the adolescent's future. 3. Promote self-esteem and confidence with praise for accomplishments. 4. Assess the patient for indications of fear from facing a premature death. 5. Use developmental age because there may be some developmental delays.
3. Promote self-esteem and confidence with praise for accomplishments. 4. Assess the patient for indications of fear from facing a premature death. 5. Use developmental age because there may be some developmental delays. rationale: 3. This is correct. The nurse needs to allow for the adolescent's completion of tasks as able. Then, the nurse needs to promote self-esteem and confidence with sincere praise of accomplishments. 4. This is correct. The possibility of a premature death can be especially difficult for an adolescent patient. The nurse needs to assess for fear of facing their own premature death. 5. This is correct. The nurse needs to use developmental rather than chronological age when caring for chronically ill adolescents, because there may be some developmental delays.
The nurse is making a home visit for a child who is 9 years of age and currently unable to attend school because of an illness causing immunosuppression. The child seems depressed and tells the nurse, "I miss my friends and all the fun we had." Which interventions will the nurse add to the plan of care to meet the child's psychosocial needs? Select all that apply. 1. Have the parents take videos of friends for the child to view. 2. Allow friends to visit from the doorway of the child's room. 3. Provide instructions on how to visit friends on a computer. 4. Suggest that the child and friends send letters to each other. 5. Ask parents to arrange daily time for telephone visiting with friends.
3. Provide instructions on how to visit friends on a computer. 5. Ask parents to arrange daily time for telephone visiting with friends. rationale: 3)School-age children are very technology savvy and most of them have access to computers. Providing instructions about how the child and friends can visit safely in current time will help meet the child's psychosocial needs. 5)Verbal communication is a good way to help the isolated child keep in touch with friends. Daily telephone conversations will help meet the child's psychosocial needs.
The nurse is providing care for a preschooler who is 5 years of age. The patient is hospitalized for treatment of a broken femur from a fall. Which behavior by the caregiver is of most concern to the nurse? 1. Requests updates on and changes in the patient 2. Frequently asks questions and expresses concerns 3. Remains adamant about staying at the bedside 4. Insists in reviewing all changes in the plan of care
3. Remains adamant about staying at the bedside rationale: The nurse needs to remind caregivers to care for themselves—reassure them that it is fine to go home for a while, whether to relieve stress, take a shower, go to sleep, and/or take care of other responsibilities. The caretaker's insistence on staying at the bedside is of greatest concern to the nurse.
The nurse is involved in a clinic screening for the kindergarten readiness of preschoolers. Primarily the children being screened are between the ages of 4 and 5 years. Which child does the nurse recognize as being ready to attend school?
3. The 4-year-old who counts to 10, recalls part of a story, and asks questions about the screening. A 4-year-old who can count to 10, recall part of a story, and asks questions about the screening exhibits a readiness for school.
The nurse in a pediatric clinic is assessing an infant who is 3 months old during a well-baby visit. Which assessment finding will be of greatest concern to the nurse? 1. The infant mouth breathes when crying. 2. The infant's eardrums are pink in color. 3. The infant exhibits 15-second periods of apnea. 4. The infant's respiratory rate is fast and irregular.
3. The infant exhibits 15-second periods of apnea. Periods of apnea (the absence of respiration) that last up to 15 seconds are typical of newborns; however, at 3 months of age this patient is considered an infant. The finding is not expected and causes the nurse concern.