Pediatric practice

A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperatures above 38.0º C (100.5º F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100 mg/5 mL. How many mL should the nurse administer to the infant per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL

: Solve for X. X mL/dose = 2 mL/dose

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? "Scold your child when they have a toileting accident." "Award your child with a sticker when they sit on the potty chair." "Play your child's favorite song while teaching them to use the potty chair." "Teach multiple steps of the skill at the same time."

"Scold your child when they have a toileting accident." The parents should use positive reinforcement when teaching their child a new task. Reinforcing positive behaviors, such as remaining dry through the night, will have a greater effect on the child than the negative reinforcement of scolding. ****"Award your child with a sticker when they sit on the potty chair." 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. "Play your child's favorite song while teaching them to use the potty chair." child who has a cognitive impairment has difficulty discriminating between two or more cues or stimuli. The nurse should instruct the parents to eliminate all other stimuli when teaching the child the task of toilet training. "Teach multiple steps of the skill at the same time." Children who have a cognitive impairment have difficulty remembering multiple steps. The nurse should instruct the parents to teach one step at a time to the child. The child should master each step before the parents introduce the next step.

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? "Use a kitchen teaspoon to measure the medication." "Brush the child's teeth after giving the medication." "Double the next dose if the child misses a dose." "Repeat the dose if the child vomits."

"Use a kitchen teaspoon to measure the medication."The nurse should instruct the parents to use the calibrated device that comes with the medication when measuring the medication to avoid accidental overdose. ***"Brush the child's teeth after giving the medication."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. "Double the next dose if the child misses a dose."MY ANSWERThe parent should administer digoxin at regular intervals, usually twice daily, or every 12 hr. The nurse should instruct the parents not to double the medication amount if they miss a dose because this can result in digoxin toxicity. "Repeat the dose if the child vomits."Nausea, vomiting, and decreased appetite are common manifestations of digoxin toxicity in children. The nurse should instruct the parents not to administer a second dose if the child vomits and to notify the provider.

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 instructions should the nurse include in the teaching? "You may bathe your infant in an infant bathtub when you go home." "Apply hydrocortisone cream to your infant's penis daily." "You should clamp your infant's stent twice daily." "Allow the stent to drain directly into your infant's diaper."

"You may bathe your infant in an infant bathtub when you go home."Submerging the stent in water can cause infection at the operative site. The parents should avoid placing the infant in an infant bathtub until after the provider removes the stent. "Apply hydrocortisone cream to your infant's penis daily."Following surgical repair of a hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection. "You should clamp your infant's stent twice daily."MY ANSWERThe stent in place following hypospadias repair allows urine to drain from the body. The nurse should instruct the parents to avoid blocking the stent to prevent urinary stasis and potential injury to the infant. ****"Allow the stent to drain directly into your infant's diaper."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.

A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip.)

** Wheezes MY ANSWER 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. Crackles The nurse should identify crackles as high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted. Pleural friction rub The nurse should identify a pleural friction rub as a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together. Rhonchi The nurse should identify rhonchi as low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed.

A nurse is teaching the parents of a 4-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." "I will place my baby on her side when sleeping." "I will decrease the number of feedings my baby receives per day." "I will give my baby loperamide with each feeding."

**"I will add 1 teaspoon of rice cereal per ounce to my baby's formula." The parents can give the infant thickened feedings with rice cereal to help decrease the reflux. In addition, the added calories can help those infants who are underweight due to the gastroesophageal reflux. "I will place my baby on her side when sleeping." The American Academy of Pediatrics recommends supine sleeping for infants. Infants who have gastroesophageal reflux should be placed in a supine position with the head elevated. "I will decrease the number of feedings my baby receives per day." Decreasing the number of feedings per day is contraindicated. An infant must eat to gain nutrients and caloric intake important for growth and development. "I will give my baby loperamide with each feeding." Loperamide is an antidiarrheal medication that is contraindicated for children less than 2 years of age. An infant who has gastroesophageal reflux can benefit from an H2 receptor antagonist or proton pump inhibitor.

A nurse is teaching parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? "I will administer the iron tablet with orange juice." "I will crush the iron tablet prior to giving it to my child "I will encourage my child to take an antacid with the iron tablet." "I will give my child an iron tablet once each day at bedtime."

***"I will administer the iron tablet with orange juice." The intake of citrus juices with the iron will increase the iron's absorption. "I will give my child an iron tablet once each day at bedtime." The parent should spread the iron doses throughout the day to prevent gastric upset. "I will encourage my child to take an antacid with the iron tablet."Antacids decrease the absorption of iron. "I will crush the iron tablet prior to giving it to my child."Crushing the tablet interferes with its absorption and distribution.

A nurse is providing postoperative teaching for the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching? "I will expect the site to bulge when my baby cries." "I will place a belly band around my child's abdomen." "I will fold my baby's diaper away from the incision." "I will bathe my child in the bath tub daily."

***"I will fold my baby's diaper away from the incision." To prevent infection, the parent should be able to verbalize and demonstrate proper folding of the diaper to protect the surgical incision from contamination. "I will expect the site to bulge when my baby cries."Crying can increase intra-abdominal pressure; however, this does not result in bulging at the site. "I will place a belly band around my child's abdomen." The parent should not use a belly band, because they can lead to bowel strangulation. "I will bathe my child in the bath tub daily."The parent should sponge bathe the infant until the postoperative visit when the provider removes the dressing.

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 offer my child small amounts of fruit juice frequently." "I will avoid giving my child solid foods until the diarrhea has stopped." "I will monitor my child's number of wet diapers." "I will give my child polyethylene glycol daily for 7 days."

***"I will monitor my child's number of wet diapers."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. "I will offer my child small amounts of fruit juice frequently."Children recovering from dehydration should not be encouraged to drink frequent, small amounts of fruit juice because it is high in carbohydrates, low in electrolytes, and has a high osmolality value. "I will avoid giving my child solid foods until the diarrhea has stopped."The nurse should teach the parent to encourage solid foods as soon as the toddler is rehydrated to provide adequate nutrient intake. "I will give my child polyethylene glycol daily for 7 days."Polyethylene glycol is an osmotic agent that will pull fluid into the bowel, increasing the frequency of stools, which will increase the level of dehydration.

A nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? "My child can resume usual activities since this was just an outpatient surgery." "My child will be able to drink the chocolate milkshake I promised to get for them tonight." "I will notify the doctor if I notice that my child is swallowing frequently." "I will have my child gargle with warm salt water to relieve their sore throat."

***"I will notify the doctor if I notice that my child is swallowing frequently." The nurse should instruct the parent that frequent swallowing is an indication of bleeding and, if it is observed, to notify the provider immediately. "My child can resume usual activities since this was just an outpatient surgery."Activity should be limited following a tonsillectomy to decrease the risk of hemorrhage. "My child will be able to drink the chocolate milkshake I promised to get for them tonight."Milk products should be avoided because they coat the child's throat, which can initiate a cough response and increase the risk of bleeding. Brown and red foods should be avoided during the immediate postoperative period so that food and fresh or old blood are distinguishable in the child's emesis. "I will have my child gargle with warm salt water to relieve their sore throat." Gargles are likely to cause irritation and discomfort and can increase the risk of bleeding following a tonsillectomy. The child should receive adequate pain medication following the procedure and can wear an ice collar if tolerated.

A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? "I will give you an antibiotic before your procedure." "I will place you on your side during the procedure." "You might have a headache following the procedure." "I will place a pressure dressing over the area following the procedure."

***"I will place a pressure dressing over the area following the procedure." Applying a pressure dressing over the area following the procedure helps to prevent bleeding from the site. "I will give you an antibiotic before your procedure." The child should not receive an antibiotic prior to a bone marrow biopsy, because the use of an antibiotic might skew the test results. "I will place you on your side during the procedure." The child should be in the prone position because the provider will obtain the specimen from the iliac crest. "You might have a headache following the procedure." Bone marrow aspiration will not affect the brain or its fluids. Lumbar punctures are likely to cause headaches

A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? "My child may take aspirin for his joint pain." "My child will need a blood transfusion prior to discharge." "I will need to wear a gown when in my child's room." "I will apply lotion to my child's peeling hands."

***"My child may take aspirin for his joint pain." Children who have rheumatic fever might take salicylates (aspirin) to control the inflammatory process that occurs in the joints. "My child will need a blood transfusion prior to discharge." A child who has rheumatic fever does not require blood transfusions, because the child does not have blood loss from this disorder. "I will need to wear a gown when in my child's room." A child who has rheumatic fever only needs standard isolation precautions because rheumatic fever is an immune response that occurs after an infection with group A β-hemolytic streptococci. "I will apply lotion to my child's peeling hands." Kawasaki disease causes peeling hands and rheumatic fever does not.

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? "You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy." "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." "When using the peak expiratory flow meter, record your child's average of three readings."

***"Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." 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. "You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing."The nurse should inform the parent that long-acting beta2 agonists are to be used in conjunction with a low- or medium-dosage inhaled corticosteroid, and never used alone. Using this medication alone on an as-needed basis during an acute asthma attack is dangerous and can lead to worsening of the child's condition. "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy."The nurse should instruct the parent that the use of inhaled corticosteroids has not been shown to have any negative effects on growth. The provider might monitor the child's growth for systemic absorption; however, it is not necessary for the parent to weigh the child weekly. "When using the peak expiratory flow meter, record your child's average of three readings."The nurse should instruct the parent to measure the child's airflow using a peak expiratory flow meter. This should be done twice daily, taking three measurements each time and waiting 30 seconds between each measurement. The parent should record the highest of the three readings, rather than the average.

A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? "The infant might be dehydrated." "The infant might be anemic." "The infant might have received too much fluid." "The infant might have leukemia."

***"The infant might be dehydrated." An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration. "The infant might be anemic." The hemoglobin value is within the expected reference range. Clients who have anemia have a decreased hemoglobin level. "The infant might have received too much fluid." Overhydration would result in a decreased hematocrit level. A hematocrit level of 51% is an increased value. "The infant might have leukemia." Leukemia has a high WBC and a low RBC. These hemoglobin and hematocrit levels do not indicate impaired bone marrow production seen in leukemia.

A nurse is teaching the parents of a 3-year-old child who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching? "My child should not play around others who have ear infections." "We should not smoke around our child." "My child should not swim this summer." "I will encourage my child to blow his nose forcefully when he has a cold."

***"We should not smoke around our child." Preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inflammation of the respiratory tract. "My child should not play around others who have ear infections." A child who has an ear infection is not contagious; therefore, the child may play with other children who have ear infections. "My child should not swim this summer." A child who has recurrent ear infections is able to swim; however, wearing earplugs might aid in decreasing the risk of infection. "I will encourage my child to blow his nose forcefully when he has a cold." A child who has recurrent ear infections should not forcefully blow his nose during a cold, because this causes organisms to ascend through the eustachian tubes.

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? "If you take too much insulin, drink a sugar-free cola." "You will need to decrease your insulin dosage when you become a teenager." "You can use a vial of insulin for up to 30 days." "Stop taking your insulin if you are vomiting."

***"You can use a vial of insulin for up to 30 days." The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator. "If you take too much insulin, drink a sugar-free cola." Sugar-free cola will not increase the blood sugar, because it does not contain sugar. Encourage the child to drink juice or milk and eat a complex carbohydrate. "You will need to decrease your insulin dosage when you become a teenager." Insulin requirements increase during puberty due to a decreased sensitivity to insulin, resulting in an increase in the child's insulin dosage. "Stop taking your insulin if you are vomiting." Blood glucose levels rise during times of illness and stress; therefore, the child might need to contact the provider for an increased insulin dosage.

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." "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." "You should restrict your child's calorie intake to 1,200 per day." "You should give your child a multivitamin once weekly."

***"You should offer your child high-protein meals and snacks throughout the day."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. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake."Children who have cystic fibrosis need a diet that is unrestricted in fat. They also require 35% to 40% of their calories to come from fats due to decreased absorption from the intestines. "You should restrict your child's calorie intake to 1,200 per day."Children who have cystic fibrosis require a high-calorie diet and should consume at least 2,000 calories per day. "You should give your child a multivitamin once weekly."Children who have cystic fibrosis should be given a multivitamin once daily.

A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make? "Your baby might pull at their ears when they are teething." "Rub your baby's gums with an aspirin to decrease discomfort." "Place a beaded teething necklace around your baby's neck." "Your baby's upper middle teeth will erupt first."

***"Your baby might pull at their ears when they are teething." The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness. "Rub your baby's gums with an aspirin to decrease discomfort." The guardian should avoid using aspirin or teething powders due to the risk of aspiration, infection, or irritation of the gum tissues. The nurse should recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort. "Place a beaded teething necklace around your baby's neck." Necklaces can result in suffocation and choking. Therefore, the nurse should instruct the guardian to avoid placing these on the infant. "Your baby's upper middle teeth will erupt first." The nurse should inform the guardian that the eruption of an infant's teeth begins with the lower central incisors.

A nurse is providing discharge teaching to the parents of a 3-month-old infant following a cheiloplasty. Which of the following instructions should the nurse include? "Clean your baby's sutures daily with a mixture of chlorhexidine and water." "Expect your baby to swallow more than usual over the next few days." "Inspect your baby's tongue for white patches using a tongue depressor every 8 hours." "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."

****"Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days." 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. "Clean your baby's sutures daily with a mixture of chlorhexidine and water."The nurse should instruct the parents to clean the infant's sutures with sterile water or diluted hydrogen peroxide. "Expect your baby to swallow more than usual over the next few days."The nurse should instruct the parents to notify the provider of excessive swallowing because this can indicate bleeding and the infant's swallowing of the blood. "Inspect your baby's tongue for white patches using a tongue depressor every 8 hours." The nurse should instruct the parents to avoid placing objects, such as tongue depressors, in the infant's mouth to prevent injury to the suture line.

A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following statements should the nurse make? "You should give your child a stool softener daily." "Toddlers gain weight at a rapid pace." "You should have your child assessed for a spinal deformity." "Toddlers do not have well-developed abdominal muscles."

****"Toddlers do not have well-developed abdominal muscles." The abdominal muscles are immature and not well developed at this stage. Therefore, it is common for a toddler to have a "potbellied" appearance. "You should give your child a stool softener daily." Constipation is not the cause of the toddler's protruding abdomen. "Toddlers gain weight at a rapid pace." Toddlers are not growing as rapidly as they did in infancy, and weight gain does not cause a protruding abdomen. "You should have your child assessed for a spinal deformity." A spinal deformity is not the cause of the toddler's protruding abdomen.

A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? "Your child will be unable to eat by mouth." "Your child will be unable to participate in recreational activities." "Your child will need a botulinum toxin A injection to help with muscle spasticity." "Your child will need throw rugs placed over non-carpeted areas."

****"Your child will need a botulinum toxin A injection to help with muscle spasticity." Children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which aid in reducing the spasticity. "Your child will be unable to eat by mouth." Children who have cerebral palsy may eat food by mouth; however, the parents might need to use special feeding techniques. "Your child will be unable to participate in recreational activities."Children who have cerebral palsy are able to participate in recreational activities. Some facilities have specific activities for those children who have disabilities. "Your child will need throw rugs placed over non-carpeted areas." The parents should not use throw rugs, because children who have cerebral palsy have an increased risk of falls

A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following statements should the nurse make? "Your child will need to take estrogen daily when she reaches puberty." "Your child will need monthly blood coagulation studies." "Your child will need surgery to remove the diseased thyroid." "Your child will need to take thyroid hormone replacement for her entire life."

****"Your child will need to take thyroid hormone replacement for her entire life." In congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require life-long thyroid hormonal replacement for normal growth and development. "Your child will need to take estrogen daily when she reaches puberty."The child who has congenital hypothyroidism does not require estrogen replacement. "Your child will need monthly blood coagulation studies." The child who has congenital hypothyroidism does not have a blood coagulation disorder. "Your child will need surgery to remove the diseased thyroid."The child who has congenital hypothyroidism has a thyroid gland that is absent, small, or malfunctioning; however, the child does not require surgical removal of the gland.

A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? Blood glucose 140 mg/dL Oxygen saturation 85% RBC 3.2 million/uL Serum sodium 156 mEq/L

*****Oxygen saturation 85% The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should report this finding to the provider immediately. Blood glucose 140 mg/dL A blood glucose level of 140 mg/dL is above the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately. RBC 3.2 million/uL An RBC of 3.2 million/uL is below the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately. Serum sodium 156 mEq/L A serum sodium level of 156 mEq/L is above the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately.

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. Arrange frequent visits from family members and peers. Give the child a large-piece puzzle. Use puppets to entertain the child.

*****Provide the child with a book about adventure. 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. Arrange frequent visits from family members and peers.The nurse should limit visitors for a child who has neutropenia because this places the child at an increased risk for infection. Give the child a large-piece puzzle.MY ANSWERThe nurse should provide a large-piece puzzle to a preschooler. School-age children tend to be challenged mentally with complex board and video games. Use puppets to entertain the child.The nurse should use puppets to entertain toddlers. School-age children are not typically entertained for very long or challenged mentally with puppets. Instead, they tend to prefer complex board and video games.

A nurse is caring for a child who ahderes to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices as having the highest protein content? Medium baked potato Wheat bagel with 1 tbsp of apricot jam Large orange 1/2 cup of peanut butter with apple slices

****1/2 cup of peanut butter with apple slices Peanut butter and apple slices have a total of 28.91 g of protein. This is a good choice for this client because peanut butter is high in protein, which helps with the healing process. Medium baked potatoA medium baked potato has 4.32 g of protein. Wheat bagel with 1 tbsp of apricot jamA wheat bagel with 1 tbsp of apricot jam has 10.14 g of protein. Large orange One large orange has 1.06 g of protein.

A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A child who has asthma and a pulse oximetry of 94% A child who has nephrotic syndrome and 1+ protein on the urine dipstick A child who has sickle cell anemia and a urine specific gravity of 1.030 A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL

****A child who has sickle cell anemia and a urine specific gravity of 1.030 The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A child who has sickle cell anemia must maintain adequate hydration because dehydration might cause sickle cell crisis that can occlude the child's circulation A child who has asthma and a pulse oximetry of 94% A child who has asthma should have a pulse oximetry reading of 90% or greater; therefore, this is not the nurse's priority finding. A child who has nephrotic syndrome and 1+ protein on the urine dipstick The child who has nephrotic syndrome typically has moderate to large amounts of protein in the urine; therefore, this is not the nurse's priority finding. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL A blood glucose level of 110 mg/dL is within the expected reference range; therefore, this is not the nurse's priority. .

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 An adolescent who has infective endocarditis and reports having a headache An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 A school-age child who has acute glomerulonephritis and brown-colored urine

****A toddler who has a concussion and an episode of forceful vomiting 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. An adolescent who has infective endocarditis and reports having a headacheA report of a headache is nonurgent because it is an expected finding for a child who has infective endocarditis. Therefore, the nurse should assess another child first. An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10A report of moderate pain is nonurgent because it is an expected finding for a child who has a new halo traction device. Therefore, the nurse should assess another child first. A school-age child who has acute glomerulonephritis and brown-colored urineBrown-colored urine is nonurgent because it is an expected finding for a school-age child who has acute glomerulonephritis. Therefore, the nurse should assess another child first.

A nurse is caring for a child who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medications should the nurse plan to administer? Digoxin immune fab Acetylcysteine Naloxone Vitamin K

****Acetylcysteine Acetylcysteine is the antidote for acetaminophen overdose or poisoning. Digoxin immune fab Digoxin immune fab is an antidote for digoxin toxicity. Naloxone Naloxone is the antidote for opioid overdose. Vitamin K Children who have salicylate, or aspirin, poisoning or overdose should receive vitamin K to decrease bleeding.

A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. Give potassium as a rapid IV bolus. Administer 3 units of ultralente insulin subcutaneously. Obtain an HbA1c level stat.

****Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. When the child's blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur. Give potassium as a rapid IV bolus. Giving potassium as a rapid IV bolus is contraindicated because it can result in cardiac arrest. Administer 3 units of ultralente insulin subcutaneously. Ultralente is long-acting insulin that takes 6 to 14 hr to begin working. Regular insulin will be given via IV infusion until the blood sugar reaches 250 to 300 mg/dL. If the regular insulin infusion continues, hypoglycemia can occur. Obtain an HbA1c level stat. MY ANSWER An HbA1c level measures the blood glucose level over the last 2 to 3 months and will not give useful information for the client's current status.

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 the infant's pain? Use a manual lancet to obtain the heel blood sample. Apply an ice pack to the infant's heel prior to obtaining the sample. Allow the mother to breastfeed while the sample is being obtained. Apply a topical lidocaine cream prior to obtaining the sample.

****Allow the mother to breastfeed while the sample is being obtained. 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. Use a manual lancet to obtain the heel blood sample. The use of a manual lancet should be avoided because it can cause more discomfort. Evidence-based practice recommends using an automatic lancet to obtain heel samples because it is safer and less traumatic. Apply an ice pack to the infant's heel prior to obtaining the sample.The nurse should apply a heating pad to the infant's heel prior to obtaining the sample. This will increase blood flow to the site, which will make the sample easier to obtain. Apply a topical lidocaine cream prior to obtaining the sample.The use of topical lidocaine is not an effective pain management technique for a heel stick.

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 18-month-old toddler who has unintelligible speech A 3-month-old infant who has an exaggerated startle response A 4-year-old preschooler who prefers playing with others rather than alone An 8-month-old infant who is not yet making babbling sounds

****An 8-month-old infant who is not yet making babbling sounds 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. An 18-month-old toddler who has unintelligible speech The nurse should refer a toddler who does not possess intelligible speech by the age of 24 months to a provider for a more extensive evaluation of hearing. A 3-month-old infant who has an exaggerated startle response The nurse should refer infants who are under the age of 4 months and lack a startle response to a provider for a more extensive evaluation of hearing. A 4-year-old preschooler who prefers playing with others rather than alone The nurse should refer a preschooler who prefers playing alone and avoids interaction with others to a provider for a more extensive evaluation of hearing.

A nurse in an emergency department is caring for a school-age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? Administer the tetanus toxoid vaccine if more than 1 year since the prior dose. Apply an antimicrobial ointment to the affected area. Leave the burn area open to air. Place an ice pack on the affected area.

****Apply an antimicrobial ointment to the affected area.MY ANSWERThe nurse should apply an antimicrobial ointment to the burned area to prevent infection. Administer the tetanus toxoid vaccine if more than 1 year since the prior dose. The nurse should administer the tetanus toxoid vaccine if it has been more than 5 years since the prior dose. Leave the burn area open to air.The nurse should apply a clean-dry dressing of fine mesh gauze and a light gauze dressing that restricts movement to prevent injury to the wound. Place an ice pack on the affected area.Applying ice to the affected area can impair circulation to the area and increase tissue damage.

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. Refrain from auscultating the child's bowel sounds during the postoperative assessment. Encourage the child to play with other children on the unit prior to surgery. Explain to the child that their pain will be managed after the surgery.

****Avoid palpating the abdomen when bathing the child before surgery.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. Refrain from auscultating the child's bowel sounds during the postoperative assessment.MY ANSWERAuscultation of the child's bowel sounds to monitor for an obstruction is an important part of the postoperative assessment. Therefore, the nurse should auscultate bowel sounds following the surgery. Encourage the child to play with other children on the unit prior to surgery.The child's risk for injury increases with physical activity. Therefore, the nurse should not encourage the child to play with other children on the unit. Explain to the child that their pain will be managed after the surgery.Telling the child about pain prior to surgery will likely increase their fear and anxiety level. Therefore, the nurse should not explain to the child that pain will be managed after surgery.

A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? Diphtheria, tetanus, and pertussis (DTaP) Pneumococcal (PCV) Haemophilus influenza type B (Hib) Hepatitis B (Hep B)

****Diphtheria, tetanus, and pertussis (DTaP) Children should receive booster doses of the DTaP immunization between the ages of 4 and 6. It is around this age that blood titers drop due to decreasing antibodies. Pneumococcal (PCV)The infant should receive the PCV immunization at 2 months, 4 months, and 6 months, and the fourth dose between 12 to 18 months. Haemophilus influenza type B (Hib) The infant should receive the Hib immunization at 2 months, 4 months, and 6 months, and the fourth dose between 12 to 18 months. Hepatitis B (Hep B)The infant should receive the Hep B immunization at birth, 1 to 2 months, and the third dose at 6 to 18 months.

A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety? Provide privacy. Give the child a thorough explanation before providing care. Encourage rooming-in. Tell the child you will help fix her.

****Encourage rooming-in. Rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope in an unfamiliar environment. Provide privacy. Toddlers are not as concerned about privacy as school-age children and adolescents. These children prefer to be with someone during procedures. Give the child a thorough explanation before providing care. A nurse should provide a toddler with short, simple explanations. A long explanation might cause heightened anxiety in the child. Tell the child you will help fix her. When the nurse is speaking to a toddler, she should refrain from using the word "fix" because toddlers assume they are broken. Instead, the nurse should say, "I will help make you feel better."

A nurse is creating a plan of care for a child who has varicella. Which of the following interventions should the nurse include? Maintain the child's room temperature at 80° F Prepare the child for a lumbar puncture. Administer aspirin to the child for a temperature greater than 38.3° C (101° F). Initiate airborne precautions for the child

****Initiate airborne precautions for the child. 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. Maintain the child's room temperature at 80° F. The nurse should ensure that a child who has varicella remains cool. Cooler temperatures decrease pruritis. Maintaining the child's room at a warm temperature will increase the child's discomfort. Prepare the child for a lumbar puncture. The nurse should prepare a child who has bacterial meningitis for a lumbar puncture. Administer aspirin to the child for a temperature greater than 38.3° C (101° F).Guardians should be instructed to avoid the administration of aspirin when the child has a viral varicella infection due to the possibility of causing the development of Reye syndrome, which can be fatal.

A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take? Monitor the infant's head circumference. Position the infant supine. Place the infant under a radiant warmer. Tape a piece of plastic over the protruding membranes..

****Monitor the infant's head circumference. Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference helps to determine any increase. Position the infant supine. The nurse should place an infant who has myelomeningocele in a prone position to minimize risk of trauma or tension to the sac. Place the infant under a radiant warmer. The nurse should not place an infant who has myelomeningocele under a radiant warmer, because of the risk of drying out the lesion and causing cracking. Tape a piece of plastic over the protruding membranes. Placing a piece of plastic over the protruding membranes will exert pressure on the area. The nurse can place wet gauze over the lesion to help provide moisture.

A school nurse is assessing an adolescent child who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? Potential for sustaining abdominal trauma Deficient dietary intake Exposing peers to the illness Straining sore joints

****Potential for sustaining abdominal trauma An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in trauma to the enlarged spleen. Deficient dietary intake Although an adolescent who has mononucleosis might have difficulty swallowing in the early phases of the illness, upon his return to school, he should not have deficient dietary intake. Exposing peers to the illness Epstein-Barr virus causes mononucleosis and is spread primarily through direct contact with the saliva of an infected individual. Casual contact during gym and recess would be no more hazardous than having the child in a classroom. Straining sore joints An adolescent who has mononucleosis will not have joint inflammation.

A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. When planning for the nutritional needs of the child, which of the following actions should the nurse plan to take? Administer pancrelipase to the child prior to each meal. Supplement the child's feedings with enteral feedings. Provide the child with a low-protein meal. Perform dressing changes 10 min prior to the child's meals.

****Supplement the child's feedings with enteral feedings. A child who has burns in excess of 25% of total body surface area requires enteral supplementation to consume enough calories to heal. Administer pancrelipase to the child prior to each meal. Children who have cystic fibrosis require pancrelipase, a pancreatic enzyme to aid in digestion. Children who have cystic fibrosis are unable to have proper digestion without this medication. Provide the child with a low-protein meal.Superficial partial-thickness burns affect both the outer and underlying layer of the skin, causing pain, redness, swelling, and blistering. The child who has a burn needs a high-carbohydrate and protein diet with adequate fat for healing. Perform dressing changes 10 min prior to the child's meals. Dressing changes are painful, so they should not be done close to the time of feeding, since appetite and digestion might be negatively affected.

A nurse is caring for a school-age child who has glomerulonephritis. The child has decreased urinary output, a blood pressure of 160/78 mm Hg, and is receiving hydralazine. Which of the following lunch choices should the nurse recommend? 1 hot dog, 22 potato chips, and 120 mL (4 oz) of orange juice 1 sandwich with lettuce, tomato, and 4 slices bacon, a small apple, and 240 mL (8 oz) of milk 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz) of apple juice 1 cup of cottage cheese, a small banana, and 240 mL (8 oz) of soda

***3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz) of apple juice The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet is the lowest option and consists of 571 g of potassium and 268 g of sodium. 1 hot dog, 22 potato chips, and 120 mL (4 oz) of orange juice The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet consists of 921 g of potassium and 734 g of sodium. 1 sandwich with lettuce, tomato, and 4 slices bacon, a small apple, and 240 mL (8 oz) of milk The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet is the highest option and consists of 1,119 g of potassium and 1,132 g of sodium. 1 cup of cottage cheese, a small banana, and 240 mL (8 oz) of soda The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet consists of 655 g of potassium and 712 g of sodium.

A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? Give the adolescent ibuprofen. Elevate the adolescent's leg on pillows. Place an ice pack on the cast. Assess for manifestations of circulatory impairment.

***Assess for manifestations of circulatory impairment. The nurse should apply the ABC priority setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should first assess for circulatory impairment to ensure there is no vascular compromise. Give the adolescent ibuprofen. The nurse should give the adolescent ibuprofen to manage the client's pain; however, there is another action the nurse should take first. Elevate the adolescent's leg on pillows. The nurse should elevate the adolescent's leg on pillows to prevent edema; however, there is another action the nurse should take first. Place an ice pack on the cast. The nurse might give the adolescent the ice pack to help with pain; however, there is another action the nurse should take first.

A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? Manually move the weights to the floor when the child is experiencing pain. Check for pulses in the affected leg every 4 hr. Cleanse the pins every 12 hr. Inform parents to discourage visitors for the child.

***Check for pulses in the affected leg every 4 hr. Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hr. Manually move the weights to the floor when the child is experiencing pain. The nurse should not move or adjust the weight to ensure proper alignment and correct healing. Cleanse the pins every 12 hr.Buck's traction is skin traction, which works without the use of pins. Inform parents to discourage visitors for the child.The child who is in Buck's traction is not ill and should be encouraged to continue socialization through various means.

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? Maintain the child on strict bed rest. Check the child's blood pressure every 4 hr. Administer albumin to the child every 8 hr. Provide the child with a low-carbohydrate diet.

***Check the child's blood pressure every 4 hr. The nurse should check the child's blood pressure every 4 to 6 hr to monitor for hypertension. Maintain the child on strict bed rest. Glomerulonephritis does not require strict bed rest, because ambulation does not have an effect on the disease. However, a child might experience fatigue with glomerulonephritis and can voluntarily restrict activities when the disease is most active. Administer albumin to the child every 8 hr. A child who has nephrotic syndrome might require albumin to correct hypoalbuminemia and extreme edema. Administering albumin causes serum albumin levels to rise and fluid shifts from the subcutaneous spaces into the bloodstream, which decreases edema. A child who has glomerulonephritis has mild edema, so albumin is not needed. Provide the child with a low-carbohydrate diet. A child who has glomerulonephritis should have limited sodium intake, but there is no restriction on carbohydrate consumption.

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 for a head injury. Observe for oral bleeding. Check the child's respiratory rate. Observe for extremity weakness.

***Check the child's respiratory rate. 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. Check the child for a head injury.A tonic-clonic seizure is characterized by symmetric contraction and intense jerking movements of the child's body. If the child is standing or sitting in a chair, they will fall to the ground and a head injury can potentially occur. Therefore, it is important to check for a head injury following a tonic-clonic seizure; however, this is not the first action the nurse should take. Observe for oral bleeding. During a tonic-clonic seizure, a child can lose muscle control and bite down on their tongue. It is important to check for oral bleeding following a tonic-clonic seizure; however, this is not the first action the nurse should take. Observe for extremity weakness. The client might experience extremity weakness due to intense jerking movements following a tonic-clonic seizure; however, this is not the first action the nurse should take.

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? Deep respirations of 32/min Shallow respirations of 10/min Paradoxic respirations of 26/min Periods of apnea lasting for 20 seconds

***Deep respirations of 32/min 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. Shallow respirations of 10/min The nurse should expect shallow respirations in a child who has respiratory depression related to opioid administration. However, shallow respirations are not an expected finding in a child who has ketoacidosis. Paradoxic respirations of 26/minThe nurse should expect paradoxic respirations in a child who has flail chest. However, paradoxic respirations are not an expected finding in a child who has ketoacidosis. Periods of apnea lasting for 20 secondsThe nurse should expect periods of apnea lasting 20 seconds or more in a child who has sleep apnea. However, periods of apnea are not an expected finding in a child who has ketoacidosis.

A nurse is caring for a toddler who has acute otitis media and a temperature of 40º C (104º F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? Apply a cooling blanket to the toddler. Dress the toddler in minimal clothing. Give the toddler a tepid bath. Administer diphenhydramine to the toddler.

***Dress the toddler in minimal clothing.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. Apply a cooling blanket to the toddler. Applying a cooling blanket can cause shivering and discomfort, which increases metabolic requirements. The nurse should be aware that the use of a cooling blanket is indicated for the treatment of hyperthermia, but not a fever. Give the toddler a tepid bath.A tepid bath is lukewarm, which can cause discomfort to the toddler. The nurse should be aware that the use of a tepid bath is indicated for the treatment of hyperthermia, but not a fever. Administer diphenhydramine to the toddler.Diphenhydramine is an antihistamine indicated for the treatment of an allergic reaction. The nurse should identify that antipyretics, such as acetaminophen, are indicated for the treatment of a fever.

A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? Provide foods high in iron. Avoid people who have infections. Administer PRN oxygen. Encourage quiet play.

***Encourage quiet play. A platelet count of 20,000/mm3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk for injury, thereby reducing the chance of hemorrhage. Provide foods high in iron.Iron is given to a child who has anemia. A platelet count of 20,000/mm3 is not an indication of an anemic condition. Avoid people who have infections.Platelets are the blood component associated with clotting. Administer PRN oxygen. RBCs are the blood component responsible for carrying oxygen to body tissues. The issue in this question is platelet count, which is associated with the blood's ability to clot.

A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? Encourage the parents to bring in the child's stuffed animal. Give the child choices when planning daily activities. Administer phenytoin three times per day. Provide a shared room with another child his age.

***Encourage the parents to bring in the child's stuffed animal. Encouraging parents to bring in a child's favorite stuffed animal helps lessen the disruptiveness of hospitalization. Give the child choices when planning daily activities.Children who have autism have difficulty organizing behaviors; therefore, it is best to not give choices. Administer phenytoin three times per day. Phenytoin is taken by children who have seizure disorders. Provide a shared room with another child his age.Children who have autism need decreasing stimulation and avoidance of auditory or visual distraction. These children should have a private room.

A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Graphic Record Temperature 37.5° C (99.5° F) Heart rate 70/min Respiratory rate 30/min Birth weight 3.2 kg (7 lb) Current weight 5.9 (13 lb) Nurses' Notes 3 episodes of vomiting 6 wet diapers in 24 hr Consumed 3 oz concentrated formula every 3 hr Episodes of vomiting Formula consumption Weight Temperature

***Episodes of vomiting When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. Formula consumptionA 4-month-old infant who has heart failure requires 3 to 4 oz of formula every 3 hr to adequately address caloric needs. A feeding schedule of every 2 hr does not allow sufficient rest time between feedings, and a feeding schedule of every 4 hr requires consumption of a higher volume, which is often not tolerated by the infant. An intake of 3 to 4 oz of formula every 3 hr indicates that the infant is tolerating the current feeding schedule. Therefore, there is another finding that is the nurse's priority. The infant who has heart failure is at risk for inadequate nutrition; therefore, the nurse should closely monitor the infant's intake. WeightMY ANSWERA weight of 5.9 kg (13 lb) is an expected finding for a 4-month-old infant who weighed 3.2 kg (7 lb) at birth. Therefore, there is another finding that is the nurse's priority. The infant should gain 680 g (1.5 lb) per month until the age of 5 months. TemperatureA temperature of 37.5º C (99.5º C) is within the expected reference range of 37º to 37.5º C (98.6º to 99.5º F) for a 4-month-old infant. Therefore, there is another finding that is the nurse's priority.

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 Numeric CRIES Visual analog

***FACESThe 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. Numeric The nurse should use the numeric pain rating scale when assessing the need for pain management in pediatric clients who are 8 years old and older. The nurse should identify that a 3-year-old toddler does not yet possess a concept of numbers and numerical value to effectively use this pain rating scale. CRIESThe nurse should use the CRIES pain assessment scale when assessing the need for pain management in infants who are less than 40 weeks of age. Visual analog MY ANSWERThe nurse should use the visual analog scale to assess pain for a child who is greater than 8 years of age. The visual analog scale allows the child to mark their pain on a centimeter ruler.

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? Until the adolescent is afebrile For 7 days following admission to the facility Until the adolescent has a negative blood culture For 24 hr following initiation of antimicrobial therapy

***For 24 hr following initiation of antimicrobial therapy 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. Until the adolescent is afebrileA temperature within the expected reference range for an adolescent can be achieved with acetaminophen. Therefore, this is not a determinant factor for removing a client from droplet precautions. For 7 days following admission to the facility The adolescent is not contagious for 7 days. Therefore, it is not necessary for the nurse to maintain droplet precautions for that length of time. Until the adolescent has a negative blood cultureBlood cultures should be drawn before the first dose of antibiotics. It usually takes 48 to 72 hr for the organism to grow enough for identification. The test should be repeated after the entire antibiotic regimen is completed to determine if the infection is still present. Therefore, blood cultures are not a determinant factor for removing a client from droplet precautions.

A nurse is caring for a child who has cystic fibrosis and a pulmonary infection. Which of the following findings is the nurse's priority? Blood streaking of the sputum Dry mucous membranes Constipation Inability to clear secretions

***Inability to clear secretions The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the inability to clear secretions is the priority-finding because the child has a compromised airway and the nurse must act in a manner that ensures transportation of oxygen to the body's cells. Blood streaking of the sputumBlood streaking of the sputum is a common finding with children who have cystic fibrosis and a pulmonary infection; therefore, this is not the nurse's priority. Dry mucous membranes Children who have cystic fibrosis might have dry mucous membranes due to malabsorption of sodium and chloride which results in dehydration; this is not the nurse's priority. Constipation Constipation is common in children who have cystic fibrosis because of malabsorption of sodium and chloride resulting in dehydration; this is not the nurse's priority.

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? Administer pancreatic enzymes 2 hr after meals. Discontinue the use of pancreatic enzymes if steatorrhea develops. Limit fluid intake to 750 mL per day. Increase fat content in the child's diet to 40% of total calories.

***Increase fat content in the child's diet to 40% of total calories. 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. Administer pancreatic enzymes 2 hr after meals.MY ANSWERThe nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis. Discontinue the use of pancreatic enzymes if steatorrhea develops.A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves. Limit fluid intake to 750 mL per day.The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration.

A nurse is caring for a preschool-age child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take? Place viscous lidocaine on the child's oral lesions. Instruct the child to use a soft sponge toothbrush when brushing her teeth. Encourage the child to mouth rinse with hydrogen peroxide every 2 to 4 hr. Give the child lemon glycerin swabs to use after each meal.

***Instruct the child to use a soft sponge toothbrush when brushing her teeth. The child should use a soft sponge toothbrush when brushing her teeth because a regular toothbrush might cause further irritation to the mucosal ulcers. Place viscous lidocaine on the child's oral lesions. Preschool-age children should not take viscous lidocaine, because it depresses the gag reflex, increasing their risk of aspiration. Encourage the child to mouth rinse with hydrogen peroxide every 2 to 4 hr. Children who have mucosal ulcers should not use hydrogen peroxide as a mouth rinse, because it causes drying effects of the mucosa and might cause further ulceration. Give the child lemon glycerin swabs to use after each meal. Children who have mucosal ulcerations should avoid the use of lemon glycerin swabs because they are very irritating, especially on eroded tissues.

A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take? Place the infant in a knee-chest position. Administer a dose of meperidine IV. Discontinue administration of IV fluids. Apply oxygen at 2 L/min via nasal cannula.

***Place the infant in a knee-chest position. 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. Administer a dose of meperidine IV. The nurse should administer morphine IV to the infant, instead of meperidine, to decrease infundibular spasms that cause a decrease in pulmonary blood flow and right-to-left shunting. Discontinue administration of IV fluids.The nurse should continue the administration of IV fluids during a hypercyanotic spell to decrease the viscosity of the infant's blood, which decreases the risk of a cerebrovascular accident. Apply oxygen at 2 L/min via nasal cannula. The nurse should apply oxygen at 100% via face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brain.

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? Furosemide Captopril Regular insulin Potassium chloride

***Potassium chloride 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. Furosemide A child who has congestive heart failure might need a diuretic to prevent fluid overload from heart failure. Furosemide is a loop diuretic that excretes potassium. Since the child is exhibiting manifestations of hyperkalemia, this medication is safe to administer. Captopril A child who has congestive heart failure will require medications that cause vasodilation, such as ACE inhibitors, to reduce cardiac afterload. Regular insulin 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 that insulin should be administered to facilitate the movement of potassium into the cells.

A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? Presence of a central incisor tooth Presence of strabismus Presence of an open anterior fontanel Presence of external cerumen

***Presence of strabismusStrabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider. Presence of a central incisor tooth The nurse should recognize that the presence of a central incisor tooth is an expected finding for a 6-month-old infant and is not necessary to report to the provider. Presence of an open anterior fontanelMY ANSWERThe nurse should recognize that the presence of an open anterior fontanel is an expected finding for a 6-month-old infant and is not necessary to report to the provider. The anterior fontanel generally closes around 12 months of age. Presence of external cerumenThe nurse should recognize that the presence of cerumen, which is a soft, yellow-brown waxy substance found in the ear, is an expected finding for a 6-month-old infant and is not necessary to report to the provider.

A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take? Schedule the child for a preoperative visit to the facility. Inform the child he will be put to sleep during the procedure. Read the child a story about a cartoon character having a similar operation. Tell the child the appointment is to have his throat checked

***Schedule the child for a preoperative visit to the facility.A preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure. Inform the child he will be put to sleep during the procedure.After 9 years of age, a child understands concepts of death. The nurse should inform the child that he is taking a "special sleep" not that he is being "put to sleep". Children who have pets might refer to being "put to sleep" as death. Read the child a story about a cartoon character having a similar operation.Reading a cartoon book is developmentally appropriate for a preschool-age child or toddler. Participating in therapeutic play has benefits for those age groups. Tell the child the appointment is to have his throat checked. Children need factual information and explanations about what will happen during hospitalizations.

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? Reports an absence of nausea and vomiting Reports experiencing an onset of loose stools within 15 min of administration Serum potassium level 4.1 mEq/L Blood pressure 86/52 mm Hg

***Serum potassium level 4.1 mEq/L 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. Reports an absence of nausea and vomitingAbsence of nausea and vomiting indicates effectiveness of an antiemetic medication. Sodium polystyrene sulfonate is an antidote, which exchanges sodium ions in the intestine. Therefore, absence of nausea and vomiting is not an indicator of the medication's effectiveness. Reports experiencing an onset of loose stools within 15 min of administrationThe nurse should monitor the adolescent for diarrhea because it is an adverse effect of sodium polystyrene sulfonate. Blood pressure 86/52 mm HgA blood pressure of 86/52 mm Hg is below the expected reference range of 90 to 110 mm Hg systolic and 60 to 80 mm Hg diastolic for an adolescent and does not indicate effectiveness of the medication. The nurse should continue to monitor blood pressure as an indicator of fluid and electrolyte imbalance.

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 insipidus? Urine specific gravity 1.045 Sodium 155 mEq/L Blood glucose 45 mg/dL Urine output 35 mL/hr

***Sodium 155 mEq/LA 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. Urine specific gravity 1.045 Urine specific gravity of 1.045 is above the expected reference range of 1.005 to 1.030. A child who has diabetes insipidus is more likely to have diluted urine and a urine specific gravity below the expected reference range. Blood glucose 45 mg/dL Blood glucose of 45 mg/dL is below the expected reference range of 70 to 110 mg/dL. A child who has diabetes insipidus is expected to have a blood glucose level within the expected reference range. Urine output 35 mL/hr Urinary output of 35 mL/hr is within the expected reference range of 33 to 58 mL/hr for a 10-year-old child. A child who has diabetes insipidus is expected to have polyuria.

A nurse is caring for a child who has a vesicular rash. The parents of the child asks the nurse what illness can cause this rash for 6 days. The nurse should expect that the child has which of the following conditions? Measles Fifth disease Tetanus Varicella

***Varicella Children who have varicella might commence with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over. Measles A child who has measles might develop Koplik spots, a transient cephalocaudal rash of maculopapular eruptions of the upper trunk and face, becoming more confluent as it spreads to the lower areas of the body. Fifth disease A child who has fifth disease usually begins with bright red cheeks producing a "slapped-cheek" appearance. Following this, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance to the rash. Tetanus A child who has tetanus will develop lockjaw and muscle rigidity; however, there is no rash associated with tetanus. Nurses recommend the DTaP immunization to aid in prevention of this disease.

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? Wrist Great toe Index finger Heel

**Great toe 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 temperature, color, and the presence of a pulse. Wrist It is important for the sensor to be positioned in the correct area to obtain an accurate reading. The nurse should avoid placing the sensor on the wrist because this placement will result in an inaccurate reading. Index finger The nurse should secure the sensor to the index finger of a child and then use a self-adhering bandage to hold the sensor in place; however, this site is not recommended for pulse oximetry of an infant. Heel It is important for the sensor to be positioned in the correct area to obtain an accurate reading. The nurse should avoid placing the sensor on the heel of the infant's foot because this placement will result in an inaccurate reading.

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching? "Mononucleosis is caused by an infection with the Epstein-Barr virus." "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." "A Monospot is a throat culture used to diagnosis mononucleosis." "Children who get mononucleosis will need to refrain from sports for 6 months."

**Mononucleosis is caused by an infection with the Epstein-Barr virus." The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics."The nurse should identify that infectious mononucleosis is caused by the Epstein-Barr virus. No known specific treatment is available for mononucleosis. "A Monospot is a throat culture used to diagnosis mononucleosis."The nurse should identify that a Monospot is a blood test that uses a special piece of paper to assist in diagnosing mononucleosis. "Children who get mononucleosis will need to refrain from sports for 6 months."The nurse should identify that a child who has mononucleosis should adjust their activities according to their level of fatigue. It is recommended that contact sports be avoided for about 4 weeks, or until splenomegaly has resolved.

A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? Inform the parents that written consent is required prior to organ donation. Provide written information to the parents about organ donation. Ask the provider to explain misconceptions of organ donation to the parents. Explore the parents' feelings and wishes regarding organ donation.

Inform the parents that written consent is required prior to organ donation.MY ANSWERThe nurse should inform the parents that written consent is required prior to organ donation to document that the parents have consented to organ donation and that the provider has addressed any questions or concerns the parents might have. However, there is another action the nurse should take first. Provide written information to the parents about organ donation.The nurse should provide written information to the parents to enhance their understanding about organ donation. However, there is another action the nurse should take first. Ask the provider to explain misconceptions of organ donation to the parents.The nurse should ask the provider to explain misconceptions of organ donation to the parents, because it is important that they have accurate information before making a final decision. However, there is another action the nurse should take first. ***Explore the parents' feelings and wishes regarding organ donation. 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 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? Insert an indwelling urinary catheter. Measure weight and height. Initiate IV access. Maintain ECG monitoring.

Insert an indwelling urinary catheter. The nurse should insert an indwelling urinary catheter for a child who has early indications of shock. Strict intake and output monitoring is needed because urinary output decreases during shock due to reduced blood flow to the kidneys as the body attempts to conserve body fluids. However, there is another action that the nurse should take first. Measure weight and height. The nurse should measure weight and height of a child who has early indications of shock to calculate weight-based medication dosages. However, there is another action that the nurse should take first. **Initiate IV access. After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume. Maintain ECG monitoring. The nurse should maintain ECG monitoring for a child who has early indications of shock to continually assess for changes in cardiac status. However, there is another action that the nurse should take first.

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? Length of stay Treatment schedule Disease process Self-care ability

Length of stay It is important for the nurse to consider the child's anticipated length of stay because some client rooms might be larger, and thus more comfortable for families during long hospitalizations. However, this is not the nurse's priority consideration. Treatment schedule It is important for the nurse to consider the child's treatment schedule when making room assignments because children requiring frequent monitoring and treatment should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration. **Disease process 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 is important for the nurse to consider the child's self-care ability when making room assignments because children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration.

A nurse is performing a screening for scoliosis on a school-age child. Which of the following instructions should the nurse provide? "Bend your knees and touch your toes." "Stand facing me with your hands on your hips." "Bend forward with your knees straight and your arms dangling." "Lie on your stomach with your arms extended over your head

***"Bend forward with your knees straight and your arms dangling." This position allows for adequate visualization to detect any asymmetry of the spine or rib cage. "Bend your knees and touch your toes." This position does not enable the nurse to inspect the spine for a lateral curvature. "Stand facing me with your hands on your hips." The nurse should inspect the child from behind to note any asymmetry of the hips or shoulders. "Lie on your stomach with your arms extended over your head." The prone position does not allow adequate visualization of any asymmetry of the spine, hips, or shoulders.

A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? "My child has frequent mood swings." "My child has a very messy bedroom." "My child takes 1 to 2 showers per day." "My child spends 4 hours per day in Internet chat rooms."

***"My child spends 4 hours per day in Internet chat rooms." Adolescents might spend time using a computer, but parents should know what they are doing, who they are communicating with, and limit the time. The American Academy of Pediatrics guidelines recommend 2 hr of screen time daily. "My child has frequent mood swings." Adolescents strive for independence and commonly have frequent mood changes. "My child has a very messy bedroom." Many adolescents assert their independence by controlling what they can. Their environment, in this case the bedroom, is one area where they feel they can assert control. "My child takes 1 to 2 showers per day." Adolescents are very preoccupied with their body image and how they appear to others. Therefore, they might shower more than once daily to maintain their self-appearance.

A nurse is teaching about poisoning prevention to a group of parents who have toddlers. Which of the following statements should the nurse make? "Keep medications on a counter that is out of reach of the toddler." "Do not allow live plants in the house." "Put all cleaning supplies in a locked cabinet." "Allow your child to eat from his favorite ceramic bowls."

***"Put all cleaning supplies in a locked cabinet." Parents should lock up cleaning supplies to provide for the safety of toddlers. Toddlers are very inquisitive and are able to open most cabinet doors without difficulty. The toddler cannot open the door of a locked cabinet. "Keep medications on a counter that is out of reach of the toddler." A toddler is able to climb and can obtain many things that are out of reach. Placing medications on a high counter does not ensure the safety of the toddler. "Do not allow live plants in the house." Not all plants are poisonous. Parents should remove any plants that are poisonous. "Allow your child to eat from his favorite ceramic bowls." A toddler should not eat out of ceramic ware due to its high source of lead content.

A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3° C (101° F). Which of the following medications should the nurse administer? Diphenhydramine Furosemide Amoxicillin Ibuprofen

****Amoxicillin A child who has acute otitis media should take an antibiotic to help alleviate the infection. Diphenhydramine Diphenhydramine is an antihistamine used for allergic reactions. Furosemide Furosemide is a diuretic used to decrease edema. Ibuprofen Children less than 6 months old should not take ibuprofen. Acetaminophen is the preferred choice for children of this age.

A nurse is inspecting the thorax of an infant. Which of the following findings should the nurse expect? Primarily thoracic movement during inspiration A barrel-shaped chest in which the anterior-posterior are equal Asymmetrical movement of the chest during respirations A chest circumference that is twice the measurement of the head circumference

***A barrel-shaped chest in which the anterior-posterior are equal A barrel-shaped chest is an expected finding in an infant. As the child grows, the lateral diameter will increase more than the posterior diameter. Primarily thoracic movement during inspiration In an infant, the nurse should expect to observe primarily abdominal movement with respiration. This finding persists until young school-age when children transition to thoracic respirations. Asymmetrical movement of the chest during respirations Asymmetrical chest movement is an unexpected finding at any age and should be reported to the provider. A chest circumference that is twice the measurement of the head circumference During infancy, the chest and head circumferences should be approximately equal in size.

A nurse is performing an abdominal examination on a preschooler. Which of the following actions should the nurse take during the assessment? Instruct the child to take a deep breath and hold it while the nurse palpates. Ask the child to "help" with the exam by placing their hand on top of the nurse's hand. Begin by palpating any identified tender areas. Position the child with legs and arms extended.

***Ask the child to "help" with the exam by placing their hand on top of the nurse's hand. Encouraging the child the assist with the examination will promote distraction and relaxation of the abdominal wall muscles. Instruct the child to take a deep breath and hold it while the nurse palpates. Taking a deep breath and holding will tense the abdominal muscles and hinder the nurse's ability to accurately assess the muscle tone of the abdomen. Begin by palpating any identified tender areas. The nurse should palpate any identified areas of tenderness last. Position the child with legs and arms extended. The nurse should position the child with the knees flexed to promote relaxation of the abdominal wall muscles prior to palpating.

A nurse is performing a cardiac assessment on a preschooler. The nurse should plan to auscultate the apical pulse at which of the following precordial landmarks? Along the sternal border at the third intercostal space At the second intercostal space, to the right of the sternum Left of the midclavicular line at the fourth intercostal space At the fifth intercostal space, left of the midclavicular line

***Left of the midclavicular line at the fourth intercostal space This is the site where the mitral valve is best auscultated in children who are younger than 7 years old. Therefore, the nurse should plan auscultate the child's apical pulse at this site. At the fifth intercostal space, left of the midclavicular line This is the site where the mitral valve is best auscultated in children who are older than 7 years old. The nurse should use this site to auscultate the apical pulse in an older child. Along the sternal border at the third intercostal space This site is where murmurs are best auscultated. It is also referred to as Erb's point. At the second intercostal space, to the right of the sternum This site is where the nurse can best auscultate sounds from the pulmonic valve.

A nurse is inspecting the skin of a toddler. Which of the following findings should the nurse report to the provider? Presence of fine hair on the lower arms and legs Telangiectatic nevi on the back of the neck Mongolian spot across the buttocks Ecchymotic area on the abdomen

***Ecchymotic area on the abdomen Although bruising on the extremities is a common finding in children, bruising in other areas, such as the abdomen, should be investigated to determine the cause. Therefore, the nurse should report this finding to the provider. Presence of fine hair on the lower arms and legs Fine hair on the arms and legs is an expected finding for a toddler. Telangiectatic nevi on the back of the neck Telangiectatic nevi are commonly referred to as stork bites. They are flat and deep pink in coloring and are most commonly observed on the face and head. They are an expected finding for a toddler. Mongolian spot across the buttocks Mongolian spots are a variation of skin coloring commonly present on the skin of toddlers from some ethnic backgrounds. This is an expected finding for a toddler.

A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hr ago and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? Crying and screaming Inactive and thumb sucking Shows interest in toys around him Attempts to escape and find parent

***Inactive and thumb sucking A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair. Crying and screaming The protest stage is the first stage seen in separation anxiety, which includes the child crying and screaming. Shows interest in toys around him Denial, or detachment, is the third stage of separation anxiety, in which the child appears happy and interacts with strangers. Attempts to escape and find parent The protest stage is the first stage seen in separation anxiety, which includes the child attempting to escape the area to find a parent.

A nurse is assessing the reflexes of a 6-month-old infant. Which of the following reflex findings should the nurse expect? Positive extrusion reflex Negative plantar grasp reflex Positive Babinski reflex Negative sucking reflex

***Positive Babinski reflex The Babinski reflex is elicited by stroking up the side of the foot and across the ball of the foot. A positive Babinski reflex is present when this action causes the toes to fan outwards. This is an expected finding through the first year of life, after which it begins to fade. Positive extrusion reflex The extrusion reflex is elicited when the infant's tongue is depressed or touched. A positive extrusion reflex is present when the infant responds by forcing their tongue outwards. This reflex should disappear by 4 months of age. Negative plantar grasp reflex The plantar grasp reflex is elicited by touching the foot at the base of the toes. A positive plantar grasp reflex is present when the toes curl downwards in response to this action. This is an expected finding in a 6-month-old infant. Negative sucking reflex The sucking reflex is elicited by touching the lips. A positive sucking reflex is present when the infant responds to the touch with strong sucking movements if the circumoral area. This is an expected finding throughout the first year of life.

A nurse is performing an annual physical examination on an adolescent. Which of the following should the nurse include in the general survey? The adolescent's deep tendon reflexes are 2+ bilaterally. The adolescent is able to read small print at a distance of 14 inches. The adolescent demonstrates fine motor coordination The adolescent makes good eye contact.

***The adolescent makes good eye contact. The nurse should include this information in the general survey. The general survey includes identifying the client's demeanor, mood, and interactions with others The adolescent's deep tendon reflexes are 2+ bilaterally. Deep tendon reflexes are examined during a neurologic examination. The adolescent is able to read small print at a distance of 14 inches. Visual acuity is examined during an eye examination. The adolescent demonstrates fine motor coordination Fine motor coordination, such as moving the fingers rapidly to each touch the thumb, is examined during a neurologic examination.

A nurse is caring for a group of infants who have congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? Transposition of great arteries Ventricular-septal defect Coarctation of the aorta Patent-ductus arteriosus

***Transposition of great arteriesAn infant who has transposition of great arteries will have severe cyanosis because reversal of the anatomic position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation. Ventricular-septal defect An infant who has a ventricular-septal defect, a hole in the septal wall between the ventricles, can have increased pulmonary vascular resistance but is unlikely to have cyanosis because oxygenation of the blood remains adequate for the systemic circulation. Coarctation of the aorta An infant who has coarctation of the aorta, a constricted segment of the aorta that obstructs blood flow to the body, is unlikely to have cyanosis because even though the left ventricle must generate higher than normal pressures for adequate stroke volume, oxygenation of the blood remains adequate for the systemic circulation. Patent-ductus arteriosus An infant who has a patent-ductus arteriosus will have a blood vessel connecting the pulmonary artery to the aorta. The infant can have increased pulmonary vascular resistance, but oxygenation of the blood remains adequate for the systemic circulation.

A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection? Vastus lateralis Dorsogluteal Deltoid Abdomen 5 cm (2 in) from the umbilicus

***Vastus lateralis The vastus lateralis is a large, developed muscle, even in an infant. The muscle can tolerate the volume of the injection, and there are no important nerves or blood vessels in this muscle. Dorsogluteal Receiving an injection at the dorsogluteal site at 2 months of age is contraindicated because the muscle is pooly developed. Deltoid The deltoid has a small muscle mass, and the proximity of the radial and axillary nerves make it suitable for use only after the age of 18 months. Abdomen 5 cm (2 in) from the umbilicus The abdomen is a site used for subcutaneous injections.

A nurse is caring for a 2-year-old child who has frequent highlight urinary tract infections. When educating the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include in the teaching? Teach the child to wipe from front to back. Give the child frequent bubble baths. Urge the child to urinate every 6 hr. Administer oxybutynin daily.

**Teach the child to wipe from front to back. The child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra. Give the child frequent bubble baths. The child should avoid bubble baths, because they can cause urethral irritation. Urge the child to urinate every 6 hr. The child should urinate at least every 4 hr to prevent stasis of the urine in the bladder, because stasis urine can cause bacteria growth. Administer oxybutynin daily. Oxybutynin is an antispasmodic used for clients ages 6 and older who have neurogenic bladders.

A nurse is preparing to administer acetaminophen 240 mg PO daily to a child who has a temperature of 38.9° C (102° F). The amount available is acetaminophen oral solution 160 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) mL

Have/Quantity = Desired/X 160 mg/5 mL = 240 mg/X mL X = 7.5 mL

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? Platelet count 120,000/mm3 Serum sodium 160 mEq/L Hgb 9 g/dL Serum cholesterol 700 mg/dL

Serum cholesterol 700 mg/dL A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids. Platelet count 120,000/mm3 A platelet count of 120,000/mm3 is below the expected reference range. Children who have nephrotic syndrome have an increased platelet count because of hemoconcentration. Serum sodium 160 mEq/L A serum sodium level of 160 mEq/L is above the expected reference range. Children who have nephrotic syndrome have lower than the expected serum sodium level because of hemoconcentration. Hgb 9 g/dL A hemoglobin level of 9 g/dL is below the expected reference range. Children who have nephrotic syndrome will have hemoglobin levels within the expected reference range or elevated.

A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply.) Increased temperature Gingival hyperplasia Xerophthalmia Bradycardia Cervical lymphadenopathy

✅Increased temperature is correct. Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics. ✅Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. ✅Cervical lymphadenopathy is correct. A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size. Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction.

A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child has allergies to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) Bradycardia Nausea Hypertension Urticaria Stridor

✅Nausea is correct. A common gastrointestinal response to excessive histamine release is nausea. ✅Urticaria is correct. A common skin manifestation of excessive histamine release is hives, also known as urticaria. ✅Stridor is correct. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor. Bradycardia is incorrect. Histamine is a potent vasodilator; therefore, the client who is going into anaphylaxis will exhibit tachycardia. Hypertension is incorrect. Histamine is a potent vasodilator and the child will exhibit hypotension.

A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.) Steatorrhea Vomiting Lethargy Constipation Weight gain

✅Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. ✅Lethargy is correct. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake. Steatorrhea is incorrect. The nurse should expect an infant who has intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis. Constipation is incorrect. The nurse should expect an infant who has intussusception to have mucus-filled and red jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen. Weight gain is incorrect. The nurse should expect an infant who has intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.

A nurse is caring for a 10-year-old child who should reduce his fat intake. Which of the following menu choices should the nurse suggest? A hot dog on a whole wheat bun 3 oz of baked chicken on a whole wheat roll 1/2 cup diced potatoes with scrambled eggs A medium blueberry muffin

***3 oz of baked chicken on a whole wheat roll A baked chicken sandwich on a whole wheat bun has the lowest fat content at 6.2 g. A hot dog on a whole wheat bun A hot dog on a bun contains more than 18.1 g of fat. 1/2 cup diced potatoes with scrambled eggs Diced potatoes with scrambled eggs contain 16.5 g of fat. A medium blueberry muffin A medium blueberry muffin contains 18.2 g of fat.

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? Apply cool compresses to the painful area. Initiate contact isolation precautions. Give the child flavored popsicles. Administer phytonadione.

**Apply cool compresses to the painful area. Cool compresses cause vasoconstriction and might cause further occlusions. Initiate contact isolation precautions. A child who has an infection that she transmits by direct contact, such as Clostridium difficile, requires contact precautions. Give the child flavored popsicles. Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children accept flavored popsicles as a source of fluid. Administer phytonadione. A client who has a warfarin overdose should receive phytonadione. A child who has sickle cell anemia should not receive a warfarin antidote.

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. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A is correct. The nurse should identify that this is the location to tap to elicit the biceps reflex. B is incorrect. The nurse should tap this location to elicit the triceps reflex. C is incorrect. The nurse should tap this location to elicit the brachioradialis reflex.

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 prescribe? Desmopressin Luteinizing hormone-releasing hormone Recombinant growth hormone Levothyroxine

DesmopressinDesmopressin is used to treat hyposecretion of antidiuretic hormones. Luteinizing hormone-releasing hormoneMY ANSWERLuteinizing hormone-releasing hormone is used in the treatment of precocious puberty to slow prepubertal growth in children and in the treatment of advanced prostate cancer in adult clients. ***Recombinant growth hormone 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 prescribe this treatment. LevothyroxineLevothyroxine is used to treat various hypothyroid conditions.

A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? Erythrocyte sedimentation rate 18 mm/hr WBC count 6,200/mm3 C-reactive protein 1.4 mg/L RBC count 4.7 million/mm3

Erythrocyte sedimentation rate 18 mm/hr 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. WBC count 6,200/mm3 The nurse should identify that a WBC count of 6,200/mm3 is within the expected reference range of 5,000 to 10,000/mm3. An elevated WBC count is an indication of osteomyelitis. C-reactive protein 1.4 mg/L The nurse should identify that a C-reactive protein level of 1.4 mg/L is within the expected reference range of less than 10.0 mg/L. An elevated C-reactive protein level is an indication of osteomyelitis. RBC count 4.7 million/mm3 The nurse should identify that an RBC count of 4.7 million/mm3 is within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC count can indicate hemorrhage.

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 plan to increase the amount of homework I assign to students who have ADHD." "I will give students who have ADHD the same amount of time as other students to complete tests." "I will allow students who have ADHD one rest break throughout the day." "I will teach challenging academic subjects to students who have ADHD in the morning."

"I will plan to increase the amount of homework I assign to students who have ADHD." Faculty should decrease the amount of school work and homework given to a child who has ADHD to maintain their attention. "I will give students who have ADHD the same amount of time as other students to complete tests." Students who have ADHD should be given additional time to take tests due to decreased attention. "I will allow students who have ADHD one rest break throughout the day."MY ANSWERFaculty should allow frequent breaks throughout the day for students who have ADHD to modify their learning environment. *****"I will teach challenging academic subjects to students who have ADHD in the morning." 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 obtaining the blood pressure of a school-age child. Which of the following actions should the nurse take? Position the arm at the level of the umbilicus while the child is sitting in a chair. Release the cuff pressure at a rate of 4 to 5 mm Hg per second. Ensure the cuff bladder encircles 50% of the extremity. Select a cuff width that covers 40% of the upper arm.

***Select a cuff width that covers 40% of the upper arm. Using a blood pressure cuff that is too large or too small will lead to inaccurate blood pressure measurement. Therefore, the nurse should inspect the limb size of the child and choose a cuff which covers 40% of the upper arm circumference. Position the arm at the level of the umbilicus while the child is sitting in a chair. The arm should be positioned and supported with the cubital fossa at the level of the heart. Release the cuff pressure at a rate of 4 to 5 mm Hg per second. The cuff pressure should be released at a rate of 2 to 3 mm Hg per second. Ensure the cuff bladder encircles 50% of the extremity. The cuff bladder length should encircle 80 to 100% of the upper arm.

A nurse is preparing to perform a physical examination on a 10-year-old child. Which of the following interventions should the nurse plan to implement? Allow the child to touch and play with the equipment. Play games while performing the physical examination. Explain how the equipment works using correct medical terminology. Discuss the benefits of performing the examination with the child.

**Explain how the equipment works using correct medical terminology. School-age children are interested in learning and building language skills. Therefore, the nurse should explain the function of the equipment using correct medical terminology. Allow the child to touch and play with the equipment. This technique is best used with toddlers, preschoolers, and young school-age children. Play games while performing the physical examination. This technique is best used with toddlers and uncooperative preschoolers because it can help decrease the child's anxiety. Discuss the benefits of performing the examination with the child. This technique is best used with adolescents because discussing the benefits and long-term consequences of the examination requires abstract thinking. This developmental skill does not appear until adolescence.

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. Instruct the adolescent to return with a guardian. Obtain consent from the adolescent's guardian over the phone. Treat the adolescent without a consent form.

**Have the adolescent sign a consent form for treatment. MY ANSWERThe 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. Instruct the adolescent to return with a guardian. Adolescents or emancipated minors can provide their own consent for any medical treatment. Obtain consent from the adolescent's guardian over the phone. Adolescents or emancipated minors can provide their own consent for any medical treatment. Treat the adolescent without a consent form. Adolescents or emancipated minors can provide their own consent for any medical treatment.

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? ½ cup whole milk 1 cup orange juice ½ cup raisins 1 cup raw carrots

½ cup whole milkWhole milk does not contain the highest amount of nonheme iron. However, it does contain high amounts of calcium. 1 cup orange juiceOrange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body. **½ cup raisins MY ANSWERThe nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. 1 cup raw carrotsRaw carrots do not contain the highest amount of nonheme iron.

A nurse is preparing to administer diphenhydramine 5mg/kg/day PO to divide equally every 8 hr to a school-age child who weighs 50 lb. Available is diphenhydramine oral solution 12.5 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL

X= 15.13332

A nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? "Stay home from school for 1 week following the procedure." "Follow a diet that is low in fiber for 1 week." "Wait 3 days before taking a tub bath." "Apply a pressure dressing to the site for 3 days."

***"Wait 3 days before taking a tub bath." The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. "Stay home from school for 1 week following the procedure."The child can attend school the next day but they should avoid strenuous activities to prevent bleeding at the insertion site. "Follow a diet that is low in fiber for 1 week."The child can resume their regular diet after the procedure. "Apply a pressure dressing to the site for 3 days."The parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.

A nurse is caring for a child who has Tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? Platelet count of 20,000/mm3 WBC 4,000/mm3 Thyroid stimulating hormone 7.0 microunits/mL RBC 6.8 million/uL

**RBC 6.8 million/uL A child who has Tetralogy of Fallot causes cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts. Platelet count of 20,000/mm3A platelet count of 20,000/mm3 is below the expected range. A child who has Tetralogy of Fallot will not have a decreased platelet count. WBC 4,000/mm3A WBC count of 4,000/mm3 is below the expected reference range. A child who has Tetralogy of Fallot will not have neutropenia. Thyroid stimulating hormone 7.0 microunits/mL This TSH level is above the expected reference range. A child who has Tetralogy of Fallot will not have changes in the thyroid function levels.

A nurse is caring for a 6-month-old infant who has intussusception. Which of the following actions should the nurse take? Prepare to administer high-dose steroids. Give the child magnesium hydroxide PO. Prepare the child for a barium enema. Educate the parents that the child will need a colostomy.

Prepare the child for a barium enema. The pressure created by a barium enema might force the bowel to resume a normal configuration. Some children are treated with the barium enema and do not require surgical intervention. Prepare to administer high-dose steroids.Intussusception is not an inflammatory process, but a mechanical obstruction. Give the child magnesium hydroxide PO. Abdominal pain observed with intussusception is a contraindication for receiving magnesium hydroxide, a laxative. In addition, children such as these are NPO and should not receive anything by mouth. Educate the parents that the child will need a colostomy. In the event of surgical intervention, the provider will remove the nonviable portion of the bowel so the bowel is anastomosed, with no need for a colostomy.

A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? Platelet count 500,000 mm3 RBC 2.5 million/uL WBC 4,000/mm3 Hct 60%

RBC 2.5 million/uL An RBC of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC. Platelet count 500,000 mm3 A platelet count of 500,000 mm3 is above the expected reference range. A child who has acute lymphocytic leukemia has a low platelet count. WBC 4,000/mm3 A WBC of 4,000/mm3 is below the expected reference range. A child who has acute lymphocytic leukemia has a very high WBC. Hct 60% An Hct of 60% is above the expected reference range. A child who has acute lymphocytic leukemia has a low Hct level.

A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? Word graphic rating scale Color tool FACES pain rating scale Numeric scale

Word graphic rating scale A word graphic rating scale uses a line with words identifying a scale of no pain to worst possible pain. Children ages 4 to 17 place a line on the scale that describes their pain. Children who are 3 years old will have difficulty understanding the words. Color tool The color tool uses four markers for the child to represent pain at various levels. Children ages 4 and older can use this tool. Children who are 3 years old might have difficulty remembering what each marker represents. ****FACES pain rating scale The FACES scale is a scale that looks at various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels. Numeric scale Using a numeric scale from 0 to 10 to rate pain requires the child to understand numbers. This tool is helpful for children ages 5 and older.

A nurse is preparing to obtain a temperature on an 18-month-old toddler during a well child examination. Which of the following actions should the nurse take? Pull the pinna up and back before placing the tympanic thermometer in the ear canal. Insert the lubricated tip of a rectal electronic thermometer 2.5 cm (1 inch) into the toddler's rectum. Place the tip of the oral electronic thermometer under the toddler's tongue in a posterior sublingual pocket. Place the thermometer tip in the center of the toddler's axilla against their skin.

****Place the thermometer tip in the center of the toddler's axilla against their skin. The nurse should us the axillary method to obtain a young child's temperature during a screening assessment. Pull the pinna up and back before placing the tympanic thermometer in the ear canal. A tympanic thermometer should not be used to assess the temperature of a child who is younger than 2 years old due to the small size of the ear canal. Insert the lubricated tip of a rectal electronic thermometer 2.5 cm (1 inch) into the toddler's rectum. Rectal temperature assessment is invasive and upsetting to young children. Therefore, the nurse should not use this method for routine screening. Place the tip of the oral electronic thermometer under the toddler's tongue in a posterior sublingual pocket. The nurse should not use an oral electronic thermometer to assess a toddler's temperature because children younger than 5 years old have difficulty holding the temperature probe under their tongue.

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? Use sterile scissors to remove the dressing from the site. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. Access the site using a noncoring angled needle. Use a semipermeable transparent dressing to cover the site.

**Use a semipermeable transparent dressing to cover the site. The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. Use sterile scissors to remove the dressing from the site. The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. Access the site using a noncoring angled needle. The nurse should use a noncoring angled or straight needle when accessing an implanted port.

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 no longer has an increased temperature." "Three days after you first noticed the rash appear on your child." "When your child's lesions are crusted, usually 6 days after they appear." "Two to three weeks, when your child's lesions completely disappear."

"When your child no longer has an increased temperature."The nurse should inform the parent that an absence of a fever does not indicate the child is no longer contagious. "Three days after you first noticed the rash appear on your child."MY ANSWERThe nurse should inform the parent that the child will remain contagious longer than 3 days after the rash appears. **"When your child's lesions are crusted, usually 6 days after they appear." 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. "Two to three weeks, when your child's lesions completely disappear."The incubation period of varicella is two to three weeks. However, this is not related to the appearance and disappearance of the lesions.

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. Weigh the child daily using the same scale. Assess the child's skin turgor. Observe the child for periorbital swelling.

***Palpate the dorsum of the child's feet.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. Weigh the child daily using the same scale. Weighing the child daily might indicate that the child has retained fluid. However, this is not a method the nurse should use to assess for peripheral edema. Assess the child's skin turgor.Assessing the child's skin turgor measures the elasticity and mobility of the skin. However, this is not a method the nurse should use to assess for peripheral edema. Observe the child for periorbital swelling.Observing the child for periorbital swelling is a method used to assess for generalized edema. However, this is not a method the nurse should use to assess for peripheral edema.

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 guardians to report which of the following findings to the provider? Capillary refill time less than 2 seconds Restricted ability to move the toes Swelling of the casted foot when the leg is dependent Pedal pulse +3 bilateral

**Restricted ability to move the toes 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. Capillary refill time less than 2 seconds Capillary refill time is assessed to determine circulatory status by pressing lightly on the tips of the toes until the skin has blanched. A capillary refill time that is greater than 2 seconds indicates circulatory compromise and should be reported to the provider immediately. Swelling of the casted foot when the leg is dependentSwelling of the casted foot when the leg is dependent is an expected finding. The nurse should instruct the guardians that frequent rest is needed for the next several days, and that the casted foot should not be in a dependent position for more than 30 min. When the toddler is resting, the casted extremity should be elevated on a pillow at chest level to minimize swelling. Pedal pulse +3 bilateral A pulse that is not easily obliterated with pressure is graded as a +3 and is an expected finding that indicates adequate circulation of the extremity. An absent pulse indicates circulatory compromise and should be reported to the provider immediately.

A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? "Limit movement of the child's large joints." "Encourage the child to perform independent self-care." "Provide the child with a soft mattress for sleeping." "Schedule a 2-hour daily nap for the child in the afternoon."

"Limit movement of the child's large joints."Large joints should be exercised regularly to maintain mobility and strengthen muscles. **"Encourage the child to perform independent self-care."MY ANSWERThe 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. "Provide the child with a soft mattress for sleeping."Children who have juvenile idiopathic arthritis should sleep on a firm mattress to provide support in maintaining joints in a functional position. "Schedule a 2-hour daily nap for the child in the afternoon."Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity, and naps can interfere with nighttime sleeping.

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? Hypotension Reports insomnia Difficulty concentrating Tachycardia

HypotensionThe nurse should identify that hypertension is a late manifestation of increased intracranial pressure due to compression of the brain vessels. Reports insomniaThe nurse should identify that somnolence and lethargy are manifestations of increased intracranial pressure. **Difficulty concentratingMY ANSWERThe 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. TachycardiaThe nurse should identify that bradycardia is a late manifestation of increased intracranial pressure.

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? "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." "Choose a waterproof sunscreen with a minimum SPF of 15." "Dress your child in loose weave polyester fabric prior to sun exposure." "Reapply sunscreen every 4 hours."

"Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m."The nurse should instruct parents to avoid allowing their children to play outside during the hours between 1000 and 1400 because the child is at greatest risk for developing a sunburn during this time. ***"Choose a waterproof sunscreen with a minimum SPF of 15."MY ANSWERThe 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. "Dress your child in loose weave polyester fabric prior to sun exposure."The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun exposure to protect the skin from the sun. "Reapply sunscreen every 4 hours."The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.

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 that a padded tongue blade is at the child's bedside. Allow the child to play video games on a tablet computer. Allow the child to take a tub bath independently. Ensure the oxygen source is functioning in the child's room.

Ensure that a padded tongue blade is at the child's bedside.Nothing should be placed in the child's mouth during or after a seizure. Therefore, placing a padded tongue blade at the child's bedside is not an action the nurse should take. Allow the child to play video games on a tablet computer. Bright or flashing lights from video games can trigger seizure activity. The nurse should decrease environmental stimuli and offer other play activities, such as reading a book or playing with a stuffed animal. Allow the child to take a tub bath independently. The nurse should allow the child to take a tub bath with supervision, but not independently. There should be someone available to assist the child if they experience a seizure. ***Ensure the oxygen source is functioning in the child's room. MY ANSWERThe 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 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 Increased abdominal girth Decreased appetite Increased protein in the urine

*****Decreased edema 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. Increased abdominal girth The nurse should expect decreased abdominal girth with prednisone therapy. Decreased appetite Increased, rather than decreased, appetite is an expected manifestation of corticosteroid therapy. Increased protein in the urine The nurse should expect decreased protein in the urine with prednisone therapy.

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. The child should ride their bike 2 feet to the side of other bike riders. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. The child should ride the bike facing traffic when it is necessary to ride in the street.

***The child should be able to stand on the balls of their feet when sitting on the bike. 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. The child should ride their bike 2 feet to the side of other bike riders. To decrease the risk for injury, children should ride their bikes single file rather than side by side. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. To decrease the risk for injury when riding a bike at night, children should wear light-colored clothing that has fluorescent material attached. This measure, along with fluorescent material on the bike itself, makes bike riders more visible to motor vehicle drivers and other bike riders. The child should ride the bike facing traffic when it is necessary to ride in the street. To decrease the risk for injury, bike riders should ride in the direction of the flow of traffic.

A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? "I will not dress my child in one-piece outfits." "I need to buy diapers that are tighter than my infant usually wears." "I need to apply paste to the back of the wafer on my child's appliance." "I will not need to toilet train my child."

***"I need to apply paste to the back of the wafer on my child's appliance." The parent should apply stoma paste to the back of the wafer on the appliance, as well as around the stoma, to act as a sealant to prevent skin breakdown. "I will not dress my child in one-piece outfits."The parent should dress the infant in one-piece outfits to restrict the infant's hands from reaching the pouch. "I need to buy diapers that are tighter than my infant usually wears." The parent should use diapers that are larger than the ones the child usually wears to go over the stoma and help with drainage.

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 buy plastic shoes to wear at the swimming pool." "I should wear sandals as much as possible." "I should place the permethrin cream between my toes twice daily." "I should seal my nonwashable shoes in plastic bags for a couple of weeks."

"I should buy plastic shoes to wear at the swimming pool." The use of plastic shoes increases the occurrence of tinea pedis. The nurse should instruct the adolescent to avoid wearing plastic shoes. ******"I should wear sandals as much as possible." 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. "I should place the permethrin cream between my toes twice daily." Permethrin 5% cream is a scabicide used to treat scabies. This treatment is not indicated for tinea pedis. "I should seal my nonwashable shoes in plastic bags for a couple of weeks." Sealing nonwashable items in plastic bags for 14 days is a recommended practice for clients who have pediculosis. This practice is not indicated for tinea pedis.

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? Nasal flaring WBC count 11,300/mm3 Diarrhea Abdominal distension

**Nasal flaringMY ANSWERWhen 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. WBC count 11,300/mm3The nurse should report a WBC count of 11,300/mm3 because it is above the expected reference range of 5,000 to 10,000/mm3 and indicates infection. However, there is another finding that is the priority for the nurse to report. Diarrhea The nurse should report diarrhea because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report. Abdominal distensionThe nurse should report abdominal distension because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? Apply a warm cloth to the bridge of the child's nose. Tilt the child's head back. Apply continuous pressure to the child's nose for at least 10 min. Administer aspirin for the child's pain.

Apply continuous pressure to the child's nose for at least 10 min. The nurse needs to apply continuous pressure for at least 10 minutes to help stop bleeding. Apply a warm cloth to the bridge of the child's nose. Applying a warm cloth to the bridge of the nose causes vasodilation, which can increase the bleeding. Tilt the child's head back. Tilting the head back allows blood to flow down the back of the throat, which can cause nausea. Administer aspirin for the child's pain. Aspirin can increase bleeding from the site due to its antithrombotic actions. The use of aspirin is contraindicated in children.

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? Heart rate 124/min Increased tear production Sunken anterior fontanel Capillary refill 2 seconds

Heart rate 124/min A heart rate of 124/min is within the expected reference range of 106 to 186/min for a 3- to 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia. Increased tear production An infant who has moderate to severe dehydration is more likely to have absence of tears rather than increased tear production. **Sunken anterior fontanel The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. Capillary refill 2 seconds A capillary refill of 2 seconds is within the expected reference range of 2 seconds or less for a 3-month-old infant. An infant who has moderate to severe dehydration is more likely to have delayed capillary refill of greater than 2 seconds.

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? Obtain a throat culture from the child. Monitor the child's oxygen saturation. Put a warm mist humidifier in the child's room. Place the child in the supine position.

Obtain a throat culture from the child.MY ANSWERObtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing. **Monitor the child's oxygen saturation. 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. Put a warm mist humidifier in the child's room.The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room. Place the child in the supine position. Placing the child in the supine position increases the child's risk for complete airway obstruction. The nurse should allow the child to be in whatever position they feel provides the most help with breathing. This is usually an upright position, and sometimes it is helpful for the child to lean forward to help with breathing.

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? Resists having an axillary temperature taken Exhibits withdrawal behaviors when their parent leaves Has multiple bruises on their knees Poor personal hygiene

Resists having an axillary temperature takenA toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Therefore, this finding is not an indication of physical neglect. Exhibits withdrawal behaviors when their parent leavesSeparation anxiety is an expected finding for a toddler. Toddlers can become fearful and exhibit regressive behaviors when left alone with strangers and separated from their parents. Therefore, this finding is not an indication of physical neglect. Has multiple bruises on their kneesMY ANSWERAn 18-month-old toddler has typically accomplished the gross motor skills of standing and walking, and has likely started trying to run, which can result in them falling and bruising their knees. Therefore, this finding is not an indication of physical neglect. ***Poor personal hygieneA toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision.