pediatric practice questions 2
a nurse is assessing a 6 mo infant, the guardian reports that th eindant does not appear interested in the brightly colored mobile hanging above the crib at home, which of the following techniques should the nurse use to check the infant's visual acuity?
b- move a brightly colored toy from side to side in front of the infant's fact infant should track item, can also use a human face
practice drip rates for IV
do it
a nurse is reviewing lab values for 6 mo infant who has acute renal failure, which of the following findings should the nurse expect?
a- BUN 5mg/dl b- creatinine 0.2 mg/dl c- sodium 125 mEq/L d- potassium 4.2 mEq/L correct - c rationale: nurse should expect infant with acute renal failure to have hyponatremia, a sodium level of 125 is below the range should expect ELEVATED BUN and creatinine should expect hyperkalemia
a nurse is assessing an infant who is at risk for increased intracranial pressure, which of the following findings should indicate to the nurse that this complication is developing?
a- high pitched cry b- sunken fontanel c- tachycardia d- increased awake time correct - a rationale: other indications include bulging fontanel, a high pitched cry, and increased sleeping
a nurse is reviewing the lab results of a child who has experienced diarrhea for the past 24 hours, which of the following values for urine specific gravity should the nurse expect?
a - 1.010 b- 1.035 c- 1.020 d- 1.005 correct - b rationale: 1.035 is a concentrated specific gravity, which is an expected value for a child who is dehydrated, thus also for a child who has experienced diarrhea for 24 hours
a nurse is assessing a 3 year old preschooler, which of the following developmental milestones should the nurse expect the preschooler to demonstrate?
a-stacking 10 blocks b- printing 1 letter c- tying shoelaces d- using 7-word sentences correct - a rationales: b- 5, c- 5, d- 5
a nurse is planning to teach a 9 year old child who has a new diagnosis of DM, the nurse should identify that school-age children are attempting to master which of the following developmental tasks?
b- industry vs inferiority rationale: when planning to teach, the nurse should identify that school-age children are attempting to master the developmental task of industry versus inferiority, during this stage, children enjoy learning new skills and experiencing the sense of accomplishment that comes with master of the skill
a nurse is assessing a toffee who has measles, which of the following findings should the nurse expect?
a - Koplik spots b- parotitis c- strawberry tongue d- paroxysmal coughing correct - a rationale: koplik spots are small, irregular oral lesions with a bluish-white center, they are characters of measles, they appear about 2 days before the maculpapular rash and are accompanied by fevers raise, conjunctivitis, and other cold manifestations
a nurse is providing teaching to the parent of a toddler who has bacterial conjunctivitis, which of the following instructions should the nurse include?
a - clean secretions from the infected eye by wiping the outer Cantus and upward b- keep the infected eye covered with warm compresses for the first 24-48 hours c- notify the provider immediately if the clear becomes inflamed d- apply pressure to the outer Cantus of the eye for 1 min after administering eye drops correct - c rationale: although the conjuctiva becomes inflamed during this infection, the sclera should remain clear and white, if the sclera becomes inflamed, if can indicate the presence of a serious conjunctival infection, and the child should be assessed immediately
a nurse is assessing a school-ages child who has celiac disease, which of the following findings should the nurse expect?
a - elevated sweat chloride b- steatorrhea c- clubbing of the fingers d- jaundice correct - b rationale: foul, fatty, stools as steatorrhea are a manifestation of celiac disease, which is a malabsorption syndrome
a nurse is planning care for a school-aged child who has juvenile idiopathic arthritis (JIA), which of the following actions should the nurse include in the plan?
a - encourage the child to sleep for 1 hr each afternoon b- apply cold compresses to the child's affected joints each morning c- encourage the child to participate in physical activities d- limit the child's intake of foods that are high in uric acid correct- c rationale: the nurse should encourage the child to remain physically active to promote mobility and joint function
a nurse in an emergency department is asking a school-aged child who is experiencing an acute asthma exacerbation, which of the following findings is the priority for the nurse to report to the provider?
a - excessively prolonged expiration b- increased diaphoresis c- increased production of frothy sputum d- sudden decrease in wheezing correct- d rationale: a sudden decrease in wheezing (silent chest), indicates ventilatory failure and imminent respiratory arrest
a nurse at a pediatric clinic is assessing a 5 mo old infant during a well-child visit, which of the following should the nurse report to the provider?
a - head lagging when the infant is pulled from a lying to sitting position b- absence of startle and crawl reflexes c- inability to pick up a rattle after dropping it d- rolling from back to side correct - a rationale: the age of 5 mo, the infant should have no head lag when pulled to a sitting position, thus this should be reported to the provider
a nurse is caring for a 16 year old client who reports dysmenorrhea and asks about alternative therapies for treatment, which of the following statements should the nurse make?
a - herbal medication can be effective but should be monitored by your doctor b- you should place a cold compress on your lower abdomen to decreased inflammation c- you should limit your exercise, which can increased the pain d- avoid touching the painful areas because this can increased you discomfort correct - a rationale: herbal is helpful for menstruation pain, but can risk for toxicity and other drug interactions if wrong dose of polypharmacy
a nurse is te4aching a newly hired nurse about caring for an infant who is postoperative following myelomeningocele repair, the nurse should teach the newly hired nurse to monitor the infant for which of the following complications?
a - hydrocephalus b- congenital hypotonia c- oitis media d- osteomyelitis correct - a rationale: in the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered, the infant is at risk of hydrocephalus and the nurse should monitor for this condition
a nurse is assessing a school aged child who has acute glomerulonephritis, which of the following manifestations should the nurse expect?
a - hypokalemia b- decreased BP c- increased urine volume d- periorbital edema correct-d rationale : swelling is usually worse in the mornings and spreads throughout the day to the genitalia, abdomen, and extremities
a nurse in the ED is assessing an infant who recently started taking digoxin to treat a supra ventricular arrhythmia, which of the following findings should the nurse identify as an indication of digoxin toxicity?
a - irritability b- diaphoresis c- voting d- tachycardia correct- c rationale: the nurse should identify, when unrelated to feedings, is a manifestation of digoxin toxicity, the nurse should report to provider immediately
a nurse is performing a neurological examination on a 15 mo old toddler, which of the following finding should the nurse expect?
a - negative babinski sign b- presence of a moro reflex c- absense of corneal reflexes d- positive palmar grasp correct -a. rationale: the nurse should expect this for a 15 year old because the babinski reflex disappears around 12 mo of age
a nurse is caring for an infant who has a tracheophageal fistula, which of the following actions should the nurse take?
a - place the infant in a lateral position b- perform oropharyngeal suctioning c- administer ranitidine orally d- thicken the infant's formula correct - b rationale: when caring for an infant with a tracheosophageal fistula, the nurse should perform frequent oropharyngeal suctioning to decrease the infant's risk of aspiration
a nurse is assessing a 30 month old toddler during a well-child visit , which of the following findings requires further assessment by the nurse?
a - primary dentition is complete b- the toddler is unable to hop on 1 feet c- the toddler's birth weight is tripled d- the toddler is able to state her first and and last name correct-c rationale: the toddler's birth weight triple by 12 months of age, by 30 months of age, the toddlers, birth weight should be quadrupled
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?
a - provide privacy b- give the child a thorough explanation before providing care c- encourage rooming in d- tell the child you will help fix her correct - c rationale: 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 with an unfamiliar environment
a nurse is caring for a toddler who has otitis media and a temp of 102.4 F (39.1 C), which of the following actions should the nurse take first?
a - reduce the temperature of the child's room b- redress the child in minimal clothing c- apply cool compresses to the child's forehead d- administer an antipyretics to the child correct - d rationale: urgent versus non urgent
a nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac, in which of the following positions should the nurse place the infant?
a - side lying b- supine c- prone d- semi-fowlers's correct - c rationale: when providing preoperative care for an infant who has a myeloningocele, the nurse should maintain the undone in a prone position, this position reduces pressure and the risk of trauma to the sac
a nurse is reviewing the morning lab results of an infant who is receiving digoxin and furosemide for the treatment fo heart failure, which of the following findings should the nurse report to the provider?
a - sodium 140 mEq/l b- calcium 10.2 mg/dl c- chloride 100 mWq/l d- potassium 3.2 mEq/l correct -d rationale: range is 4.1.-5.3 mEq/l for an infant
a nurse is providing teaching about foods high in fiber to the to the guardian of a child who has chronic constipation, which of the following foods should the nurse recommend?
a- 1/2 cup whole milk b- 1/2 cup cooked pinto beans c- 1 cup green leaf lettuce d- 1 cup apple juice correct -b rationale: the nurse should recommend foods high in fiber for a child who has chronic constipation, a half cup of cooked pinto beans contains approximately 5 g of fiber, therefore the nurse should instruct the guardian to include this food in the child's diet.
the nurse is assessing an infant who was born at 32 weeks gestation and is now 8 months old, which of the following developmental ages should the nurse expect the infant to demonstrate?
a- 2 mo b- 4 mo c- 6 mo d- 8 mo correct -c rationale: because the infant was born 8 weeks prematurely, the nurse should use this data to determine that the infant's setback age is 9 months, the nurse should expect the infant to have achieved at a developmental level of 6 months of age
a nurse is preparing to administer recommended immunizations to a 2 mo infant, which of the following immunizations should the nurse plan to administer?
a- HPV and hep A b- MMR and TdaP c- Hib and IPV d- VAR AND LAIV correct- c rationale: 2 mo old includes HiB and IPV; HiB consists of a 3-4 dose series, depending on type, 2,4, and 12-15 mo. IPV immunization series consists of 4 doses and is admin at 2, 4, 6-18 mo, and 4-6 years of age
a nurse is teaching the parent of a toddler about home safety, which of the following statements by the parent indicates an understanding of the teaching?
a- I will lock my medications in the medicine cabinet b- I will keep my child's crib mattress at the highest level c- I will turn pot handles to the side of the stove while cooking d- I will give my child syrup of ipecac if she swallows something poisonous correct - a rationales: prevent access to poison, lowest level, turn handles back, call poison control
a nurse is planning care for a child who has hyperthermia, which of the following actions should the nurse take?
a- admin antipyretics to the child every 4-6 hours b- position the child on a cooling blanket and cover her with a sheet c- place the child in a tub filled with water cooled to 26.7 -29.4 degrees Celsius (80-85 degrees F) d- assess the child's temp every 2 hours during the cooling process correct - b rationale: a cooling blanket will lower the temp of the circulating blood at the skin's surface, the cooler blood will circulate to the viscera and lower the temp of the organs and tissues, heat form the internal organs will be circulated to the skin and dispensed to the cooler outside surface
a nurse is caring for a child who received penicillin IM 15 minutes ago, the child is now irritable and restless, which of the following actions should the nurse take first?
a- admin diphenhydramine b- assess for laryngeal edema c- initiate hourly urine output monitoring d- give epinephrine IV push correct - b rationale: the greatest risk to this child is bronchoconstriction due to an anaphylactic reaction to penicillin, the first action should be to assess for laryngeal edema and implement interventions to maintain a patent airway
a nurse is caring for a child who has epistaxis, which of the following actions should the nurse take?
a- administer aspirin b- tilt the child's head back and apply pressure c- have the child lie down and rest d- apply continuous pressure to the power part of the child's nose correct - d rationale: when the child setting up and breathing through the mouth, the nurse should apply continuous pressure with the thumb and forefinger to the soft lower area of the nose for 10 minutes, most bleeding from the nose stops within this period
a nurse is caring for a 4 year old child who has superficial partial thickness burns over 50% of his body, to meet the nutritional needs of the child, which of the following actions should the nurse plan to take?
a- administer pancrelipase to the child prior to each meal b- supplement the child's feedings with enteral feedings c- provide the child with a low -protein meal d- perform dressing changes 10 min prior to the child's meals correct - b rationale: a child who has excess burns on 25% of total body surface area requires enteral supplemental to consume enough calories to heal
a nurse is preparing to administer an enema to a 10 mo infant, which of the following actions should the nurse plan to take?
a- administer the enema using room-temp tap water b- inset the tubing 7.5 cm into the rectum c- position the infant sitting upright on a bedpan while administering the enema d- fold the infant's buttocks together after administering the fluid correct - d rationale: because the infant is incontinent, the nurse should hold the buttocks together for assort time to maintain retention of the enema
a nurse is planning care for a child who has meningococcal meningitis, which of the following isolation precautions should the nurse plan to implement?
a- airborne precautions b- contact precautions c- protective environment d- droplet precautions correct - d rationale: nurse should maintain droplet precautions for a client who has meningococcal meningitis for 24-72 hours after the initiation of antibiotic therapy, disease transmission can occur through large-droplet particles when the client is talking, there is no drainage of infected body fluids with meningitis, so contact precautions are not necessary
a nurse is planning to implement relaxation strategies with a young child prior to a painful procedure, which of the following actions should the nurse take?
a- ask the child to hold a breath and blow it out slowly b- ask the child to describe a pleasurable event c- bounce the child gently while holding him upright d- rock the child using long, rhythmic movements correct- d rationale: the nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest and rocking or swaying back in forth in long wide movements
a nurse is caring for a child with CF, who has a pulmonary infection, which of the following findings is the nurse's priority?
a- blood streaking of the sputum b- cry mucous membranes c- constipation d- inability to clear secretions correct - d rationale: the inability to clear secretions is the priority findings because the child has a compromised airway, think ABCs, the nurse must act in a manner that ensures transportation of oxygen to the body's cells
a nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy, which of the following adverse effects should the nurse include?
a- bradycardia b- muscle weakness c- diarrhea d- dry skin correct - b rationale: muscle weakness is a common adverse effect of baclofen, other common adverse effects include dizziness, drowsiness, and nausea
a nurse is a pediatric clinic is caring for a 3 year old child who has a blood lead level of 3mcg/dL, when teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include?
a- decrease the child vitamin C intake until the blood level of lead decreases to zero b- administer a folic acid supplement to the child each day c - give pancreatic enzymes to the child with meals and snacks d- ensure the child's dietary intake of calcium and iron is adequate correct - d rationale: a child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption of and effects from the lead, dietary recommendations should include milk, as a good source of calcium
a nurse is assessing a child who has a ventricular septal defect, which of the following findings should the nurse expect?
a- diastolic murmur b- murmur at the left sternal border c- cyanosis that increases with crying d- widened pulse pressure correct - b rationale: a ventricular septal defect is a hole in the septal wall between the ventricles, it is an cyanotic heart defect. a systolic murmur can be heard best at the lower left sternal border, the sound is transmitted in the direction of blood flow, so any back flow of blood for the left to the right ventricle through the septal defect is best heard in this area
a nurse is instructing a group of parent and guardians about child development, which of the following recommendations should the nurse make to promote the developmental task of industry versus inferiority?
a- have an after school snack ready for the child at the end of each day b- assign the child to several small chores c- talk with the child about what future goals as an adult d- talk openly about the family's value system correct - b rationale: the completion of each chore is a short amount of time offers the child a sense of accomplishment and promotes the achievement of the developmental task of industry
a nurse is caring for a preschooler who is immediately postoperative following the removal of a brainstem tumor, which of the following actions should the nurse take?
a- have the child deep breath and cough every our b- offer the child clear liquids 4 hours after the procedure c- monitor the child's temperature every 30 minutes d- place the child in Trendelenburg position correct - c rationale: the nurse should monitor the child's temperature every 15-30 minutes, surgery on the brainstem can cause hyperthermia
a nurse is developing a health education program for the parents of school-aged females, which of the following pieces of information regarding sexual maturation should the nurse include?
a- higher body fat content is associated with earlier onset of menarche b- pubic hair is typically present prior to breast development c- ovulation begins after sexual maturation is complete d- menarche signals the beginning of puberty correct- a rationale: the nurse should inform the parents that the onset of menarche is expected to occur around to 10.5 to 15.5 years of age, females who have a higher body fat content have been shown to have an earlier onset of menarche
a nurse is providing teaching to a parent fo a preschooler who has impetigo, which of the following statements by the parent indicates an understanding of the teaching?
a- impetigo is caused by a virus b- impetigo is contagious for 48 hours after vesicles rupture c- I will wash my child's clothes in hot water d- my child not had immunity against impetigo correct - c rationale: the parent should wash the child's clothes in hot water to kill bacteria, the parent should also keep the child's towels and washcloths separate from those of other members of the household
a nurse is assessing an adolescent who has a new diagnosis of anorexia nerves, which of the following findings should the nurse expect?
a- increased blood pressure b- lanugo over the back c-oily skin with acne d- elevated body temperature correct - b rationale: the result of impaired metabolic activity, other manifestations of anorexia nervosa include hypotension, hypothermia, and dry skin
a nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old, which of the following pieces of information should the nurse include in the teaching?
a- initial vaccines should be administered between birth and 2 weeks of age b- your child will need to being the vaccination series over again if subsequent does in the series are missed c- an allergic reaction to a vaccine is due to the active ingredient in the vaccine d- a vaccination should be postponed if your child has aerial temp of 99.5 F and head congestion correct- a rationale: the first dose of the hep B should be administered within the first 2 weeks after birth, the dose should be given before discharge from the hospital if the mother is hep B surface antigen negative
a nurse is creating a plan of care for child who has aplastic anemia, which of the following interventions should the include?
a- initiate protective environment isolation for the child b- apply pressure for 1-2 min at the puncture site following blood specimens collection c- mix the child's ferrous sulfate elixir twice per day into a glass of milk for administration d - check the child's blood glucose level every hour correct - a rationale: the nurse should suggest protective environment isolation for the child, which consists of a private room with positive air pressure and no live flowers, nurses must don a respirator mask, gloves, and gown prior to entering the child's room, a child who has aplastic anemia has decreased RBCs, platelets, and WBCs, causing immune suppression and increasing susceptibility to infection
a nurse is caring for a child who has a tracheostomy, which of the following techniques should the nurse use to suction the child's tracheostomy?
a- inset the catheter to 2 cm beyond the end of the tracheostomy tube b- remove the catheter while applying intermittent suction c- instill 0.9% sodium chloride irrigation to loosen secretions while suctioning d- continues suctioning until the secretions are removed correct - b rationale: the nurse should insert the catheter without suction and then withdraw the catheter while applying intermittent pressure
a nurse is caring for a child who has acute glomerulonephritis, which of the following actions should the nurse take?
a- maintain the child on strict best rest b- check the child's BP every 4 hours c- admin albumin to the child every 4 hours d- provide the child with a low carb diet correct - b rationale: the nurse should check the child's BP every 4-6 hours to monitor for hypertension
a nurse on a pediatric unit is caring for a child who is not eating well, which of the following suffusions should the nurse offer to the parents. to promote the child's food intake?
a- make dietary selection for you child b- offer foods that have strong flavors or smells c- let you child eat with others when possible d- make sure your child was most of the food on his plate correct - c rationale: socialization with others promotes nutrition by making the child feel more comfortable in his surrounding and enhancing the enjoyment of meal times
a nurse is providing education to the parent of toddler who is about to receive a MMR immunization, which of the following statements by the parent indicates an understanding of the teaching?
a- my child should play with other children for 2 days b- I will need to return in 2 weeks tfor my child to receive the varicella immunization c- I will help my child to blow bubbies during the injection d- my child may have some drainage from the injection site correct - c rationale: providing distraction, such as helping or allowing a child to make bubbles while receiving an injection, is a technique that can minimize pain and discomfort for the child
a nurse is caring for an 18 mo infant who has chronic otitis media, the nurse should recognize the chronic otitis media will affect which of the following?
a- olfaction b- visual acuity c- speech patterns d- hand-eye coordination correct-c rationale: chronic otitis can result in hearing loss, which can affect speech development
a nurse is providing teaching to the parents of a child who has strabismus, which of the following instructions should the nurse include to prevent the development of amblyopia?
a- patch the unaffected eye b- administer mydriatic eye drops daily c- obtain prescription eyeglasses d- administer antihistamines correct - a rationale: amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another problem such as strabismus, with this, muscle weakness allows an ey to wander so that he child cannot focus on an object with both eyes at the same time, if this does not receive treatment by 6 , it will result in central blindness, to strengthen weak muscles, the parent should patch the unaffected or good eye or main eye
a nurse is caring for the family of a preschooler who had a terminal illness, the nurse should teach the family to expect the preschooler to have which of the following concepts of death?
a- people can come back to life after they die b- death eventually occurs for all people c- death is a scary monster that causes people to die d- people are unable to be anything but alive correct- a rationale: a preschooler typically views death as temporary and interchangeable with life
a nurse is assessing a child who sustained a head injury, during the assessment, the nurse observes clear drainage leaking from the child's nose which of the following actions should the nurse take?
a- perform nasotracheal suctioning b- test the nasal secretions for glucose c- maintain direct lighting on the child d- lower the head of the bed correct - b rationale: the nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are a leakage of cerebrospinal fluid (CSF), the leakage of CSF is positive for glucose and occurs if the child has a skull fracture
a nurse is assessing the visual acuity of a group of school aged children, which of the following actions should the nurse take?
a- position each child with their heels at a line that 20 ft away from a snellen chart b- allows each child to wear his or her glasses during the exam c- start the screening by covering each child's right eye d- being by having each child read the largest line of letters at the top of the snellen chart correct - b
a nurse is planning care for a 6 year old child who is receiving chemotherapy, the child has a highlight platelet count of 20,000mm3, based on this lab value, which of the following interventions should the nurse include in the plan of care?
a- provide foods high in iron b-avoid people who have infections c- administer PRN oxygen d- encourage quiet play correct - d rationale: a platelet count of 20,000 will predispose the client to excessive bleeding, quiet play will lessen the client's risk of injury, reducing the chance of hemorrhage
a nurse is admitting a child who has a history of tonic-clonic seizures, which of the following items is the priority to have in the child's room?
a- pulse oximeter b- oxygen therapy c- bag value mask d- suction equipment correct -d rationale: use abcs, this child is at risk for aspiration and airway obstruction due to secretions, food, or fluids, the nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bog value if needed
a nurse is caring for an infant who has a cleft palate, the parents ask the nurse how long they should wait before the child can have corrective surgery, the nurse should explain that the parents should wit no longer than the 6-12 for surgery to prevent which of the following outcomes?
a- repeated ear infections b- nutritional deficits c- immune system deficits d- difficulty with language acquisition correct -d rationale: clients who have a cleft palate can have difficulty acquired language because they need to use the palate for vocalizing sounds, because of the cleft in the palate, these infants could develop poor speech habits
a nurse is creating a plan of care for a 6 mo infant who requires continuous pulse oximetry monitoring, which of the following interventions should the nurse include?
a- reposition the sensor to anew site once every 24 hrs b- secure the oximetry sensor to the infant's wrist c- apply conduction gel to the skin before attaching the sensor d- cover the oximetry sensor with clothing correct - d rationale: cover with clothing to prevent outside light from causing an altered or false reading
a nurse is teaching group of parents and guardians about Otitis media, which of the following should the nurse identify as a risk factor for this illness?
a- summer months b- breastfeeding c- ages 7-10 years d- passive smoking correct - d rationale: exposure to secondhand smoke promotes the attachment of pathogens to the middle ear, extends to the inflammatory response, and impairs drainage through the Eustachian rube, each of these effects increased the risk for development of otitis media
a nurse is assessing a 6 year old child who is immediately postoperative following a tonsillectomy, which of the following findings should the nurse report to the provider?
a- the child has a small amount of dark brown blood between the teeth b- the child is swallowing frequently c- the child has a heart rate of 118/min d- the child refuses the application of an ice collar correct - b rationale: frequent swallowing indicates bleeding and should notify the provider immediately
a nurse is assessing a 7 year old's psychosocial development, which of the following findings should the nurse recognize as an indicator for further evaluation?
a- the child prefer playmates of the same sex b- the child is competitive when playing board games c- the child complain daily about going to school d- the child enjoys spending time alone correct - c rationale: complaint every day about going to school is an unexpected findings for a 7 year old in the inferiority versus industry stage in which the child should want to learn and master new concept, if the child complains like this, ask
a nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing, which of the following findings is the priority for the nurse to report to the provider?
a- the child's temperature is 39 C (102 F) b- the child's skin is sallow c- the child is drooling d- the child's voice is hoarse correct - c rationale: urgent versus nonurgent because drooling could indicate the child might have developed epiglottis, a medical emergency that when left untreated can develop into a complete pulmonary obstruction
a nurse is providing teaching to the parent of a toddler who is undergoing insertion of tympanovstomy tubes, which of the following statements should the nurse include?
a- the doctor will replace the tubes routinely about every two years b- if your child gets water in her ears will not cause any further problems c- the tubes should stay in place until they fall out on their own d- now that the tubes are in place, she should not have any further problems with hearing correct - c rationale: tympanostomy tubes allow drainage from and ventilation to the middle ear, they usually fall out on their own within 6-12 months after insertion
a nurse is a provider's office enters an examination room to assess an 8 mo old infant for the first time, which of the following reactions by the infant should the nurse expect?
a- the infant gives the nurse a social smile b- the infant turns away when the nurse approaches c- the infant reaches out to the nurse to be held d- the infant is responsive and alert as the nurse comes closer correct - b rationale: the nurse should expect an 8 month old to have a heightened fear of strangers
a nurse is caring for a 4 week old infant who is 2 weeks postoperative following surgical correction of biliary atresia, which of the following is an indication that the surgery was successful?
a- the infant has lost 2.2 kg since the surgery b- the infant has a total bilirubin level of 0.3 mg/dl c- the infant has an aspartate aminotransferse AST level of 120 units/L d- the infant's stools are gray in color correct - b
a nurse is preparing to obtain an antistreptolysin (ASO) titer from a child who has acute glomerulonephritis, the child's parent asks the nurse to explain the purpose of the test, which of the following responses should the nurse provide?
a- the test determines the level of antibiotics in you child's blood b- the test tells us if your child ever had measles c- the test verifies the amount of albumin in your child's blood d- the test shows us if your child had a recent strep infection correct - d rationale: an ASo titer indicates the child had a recent strep infection, when determining a definitive diagnosis for acute glomerulonephritis, this must be documented because the condition is usually the result of this type of infection
a nurse is providing teaching about disease-management strategies to a 9 year old client who has cystic fibrosis, which of the following statements should the nurse include?
a- thorough and effective pulmonary clearance can help prevent the need for along transplant when you get older b- you should eat these kinds of foods because they will help you grow big and strong c- you mucus is thick because CF interferes with how your glands work d- you medication follows a certain schedule to help you sleep better correct - c rationale: a 9 year old should understand the production of thick mucus is a part of the disease process
a nurse is assessing an adolescent who has appendicitis, which of the following manifestations should the nurse expect?
a- upper with quadrant abdominal pain b- right abdomen c- hyper active bowel sounds d- bradycardia correct - b rationale: the rigid abdomen is an expected finding of appendicitis
a nurse is providing discharge teaching to parents whose infant has a ventriculoperitoneal shunt placement for the treatment for hydrocephalus, which of the following statements but he parents indicates an understanding of the teaching?
a- we will check his abdomen daily for signs of fluid accumulation b- we will notify the doctor right away if he has a fever c- we should keep a helmet on him when he's awake d- we can expect him to have occasional seizure episodes correct- b rationale: infection is a risk after ventriculoperitoneal shunt insertions, especially 1-2 months after placement, the parents should report fevers, committing, seizure activity, and decreased responsiveness, as these findings can indicate infection
a nurse is teaching an adolescent client who has type 1 DM about managing hypoglycemia, which of the following statements should the nurse include in the teaching?
a- you should drink 8 oz of a regular soft drink if you experience hypoglycemia b- you should drink 4 oz of orange juice if you experience hypoglycemia c- you should take 2 glucose tablets if you experience hypoglycemia d- you should take 3 tsp of sugar if you experience hypoglycemia correct- b
a nurse is teaching a parent of a 12 mo infant about development during the toddler years, which of the following statements should the nurse include?
a- your child should be referring to himself using the appropriate pronoun by 18 mo of age b- a toddler first shows signs interest in looking at pictures at 20 mo of age c- a toddlers should have daytime control of his bowel and bladder by 24 mo of age d- your child should be able to scribble spontaneously using a crayon at 15 mo of age correct - d rationale: 15 is scribbles, 18 the toddler should be able to make stroke imitatively
a nurse is caring for a 2 year old child who has CF, the nurse is planning to take the child to the playroom, which of the following activities would be appropriate for the child?
a-cutting figures from colored paper b- drawing stick figures using crayons c- riding a bicycle d- building towers with blocks correct - d rationales: building blocks is good for 2 year old at their developmental level as it promotes fine-motor development, also knocking down blocks can be stress relieving in the hospitals setting
a nurse is caring for an 8 year old who has acute glomerulonephritis, which of the following findings should the nurse expect?
a-hypotension b- stomatitis c- bloody diarrhea d- periobital edema correct- d rationales periorbital edema is an expected finding in a child who has glomerulonephritis a - elevated blood pressure is correct b- stomatitis is expected with chronic renal failure c- bloody diarrhea is an expected finding with hemolytic uremic syndrome
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?
a-place viscous lidocaine on the child's oral lesions b- instruct the child to use a soft-sponge toothbrush when brushing their teeth c- encourage the child to rinse there mouth with hydrogen peroxide every 2-4 hours d- give the child limo glycerin swabs to use after each meal correct- b rationale: because regular tooth brush may cause further irritation to the mucous ulcers
