Pediatrics HESI Practice Exam (evolve)

A 4-year-old child who is ventilator-dependent is receiving tube feedings in the home setting. The family wants to begin oral feeding of the child and asks the home health nurse to orally feed the 4-year-old baby food. What steps should be taken? (Rank in priority order.) 1. Acknowledge the request. 2. Explore available options. 3. Explain the risk of aspiration. 4. Contact the healthcare provider (HCP) and discuss suggested new options for further orders and additional discussion.

1. Acknowledge the request. 2. Explain the risk of aspiration. 3. Explore available options. 4. Contact the healthcare provider (HCP) and discuss suggested new options for further orders and additional discussion. The request for oral feeding should be acknowledged, risk of aspiration should be discussed, and then options should be explored. These options and suggested changes must be presented to the HCP and new orders must be written before implementation. All education and outcomes should be thoroughly documented.

The nurse notices that the skirt hem on a preadolescent girl is uneven. What procedure should the nurse follow to examine the girl for scoliosis? (Arrange the examination process from the first step to the last step.) 1. Examine for scapular prominence. 2. Ask the girl to remove her shirt but leave on her bra or swimsuit top. 3. Instruct the girl to bend at the waist so her back is parallel to the floor. 4. Look for asymmetry in the hip area.

1. Ask the girl to remove her shirt but leave on her bra or swimsuit top. 2. Look for asymmetry in the hip area. 3. Instruct the girl to bend at the waist so her back is parallel to the floor. 4. Examine for scapular prominence. To screen for scoliosis, the girl should first be asked to remove her shirt and wear her bra or a swimsuit top. Then, as she stands erect, observe for asymmetry of the shoulders, back, and hips while standing behind the girl. Next, ask her to bend forward so that her back is parallel to the floor. Finally observe her from the side and the back, noting asymmetry or prominence of the rib cage and scapulae.

The nurse is caring for a client with scoliosis who had a posterior spinal fusion and is in a body jacket cast. Which assessment finding indicates to the nurse that the client is developing superior mesenteric artery syndrome? a. Abdominal distention. b. "Hot spot" felt on cast. c. Diminished pulses in the foot. d. Musty, unpleasant odor to cast.

a. Abdominal distention. Superior mesenteric artery syndrome occurs when the cast is applied too tightly and is compressing the superior mesenteric artery against the duodenum. Abdominal distention, pain, nausea, and vomiting may result.

A 2-year-old is receiving care in the emergency department (ED) for a deep laceration on the head. What action should the nurse implement to facilitate the child's cooperation? a. Allow the child to hold a favorite toy or blanket. b. Direct the parents to remain outside the treatment room. c. Keep the child physically restrained during nursing care. d. Let the child decide whether to sit up or lie down for procedures.

a. Allow the child to hold a favorite toy or blanket. Allowing a child to hold a favorite toy or blanket provides familiarity and comfort that should facilitate the child's cooperation during treatment. Parents should remain with the child to calm and reassure the child who may perceive the ED environment as threatening.

While assessing the apical pulse of a 13-year-old, the nurse determines that the rate is 88 beats/minute, and the rhythm is irregular. The heart rate is phasic with respirations, increasing during inspiration and decreasing with expiration. Which action should the nurse take? a. Continue the cardiac examination. b. Inquire about daily caffeine intake. c. Reassess the apical pulse in 15 minutes. d. Schedule a consultation with a cardiologist.

a. Continue the cardiac examination. Sinus arrhythmia is characterized by phasic irregularity of the heart rate that occurs with changes in intrathoracic pressure during respiration and is a common phenomenon during childhood and adolescence. No intervention is required. The nurse should continue with the cardiac exam.

The nurse is assessing the coping behaviors of the parents whose child has been recently diagnosed with a chronic illness. What reaction by the parents is a positive step in the ability to cope with this new situation? a. Endowing the illness with meaning. b. Refusing to believe the child is ill. c. Entertaining an unrealistic future plan for the child. d. Placing complete faith in religion to the point of relinquishing responsibility.

a. Endowing the illness with meaning. Coping mechanisms are behaviors directed at reducing the tension elicited by a crisis. Approach behaviors are coping mechanisms resulting in movement toward adjustment and resolution of the crisis. The parents' ability to assign the illness meaning within an existing medical, scientific, or spiritual philosophy of life is a long-term coping strategy significantly related to successful family functioning.

A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless, and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? a. Experiencing culture adaptation. b. Lacks the maturity needed in school. c. Refuses to participate in school activities. d. Going through minority group discrimination.

a. Experiencing culture adaptation. An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Adapting culturally describes feelings of discomfort and disorientation when adapting to new cultural settings. Language barriers inhibit effective communication. A child who is unable to communicate in the spoken language in the school environment lacks the skills necessary to participate.

The nurse is examining a neonate at age 10 minutes. Which site should the nurse expect to see nonpathologic cyanosis? a. Feet and hands. b. Bridge of nose. c. Circumoral area. d. Mucous membranes.

a. Feet and hands. Acrocyanosis, nonpathologic cyanosis of the hands and feet, is an expectant finding in a newborn.

Which neurological test should the nurse implement to assess cerebellar function in a 5-year-old with symptoms of hyperactivity? a. Finger-to-nose. b. Quadriceps reflex. c. Two-point discrimination. d. Ability to follow directions.

a. Finger-to-nose. The cerebellum controls balance and coordination and is significant in children with symptoms of hyperactivity or learning difficulties. Difficulty performing a finger-to-nose test indicates poor sense of position (especially with the eyes closed) and incoordination (especially with the eyes opened).

The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis. The infant has had continuous loose stools since surgery yesterday. Which nursing problem has the highest priority given the infant's condition? a. Fluid volume deficit. b. Alteration in bowel elimination. c. Pain due to postoperative condition. d. Anxiety of parents due to newborn's condition.

a. Fluid volume deficit. All stated nursing problems are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern for any infant and is even more of an issue for a postoperative infant. Newborns are extremely vulnerable to fluid imbalances due to immature body systems and a larger percentage of body weight consisting of fluid. At birth, the total weight of an infant is 73% fluid compared with 58% in an adult. Infants have a proportionately higher ratio of extracellular fluid than adults. An important aspect of fluid balance is its relationship to other systems. An infant's rate of metabolism is twice that of an adult in relation to body weight. As a result, twice as much acid is formed, leading to more rapid development of acidosis. In addition, immature kidneys cannot sufficiently concentrate urine to conserve body water. These factors make infants more prone to dehydration, acidosis, and fluid imbalances.

The nurse is caring for an irritable, lethargic 18-month-old child who swallowed several over-the-counter (OTC) antihistamine tablets an hour ago. Which intervention should the nurse implement? a. Initiate gastric lavage. b. Administer naloxone. c. Give a dose of ipecac syrup. d. Encourage oral intake of water or milk.

a. Initiate gastric lavage. Gastric lavage should be implemented within 2 hours of ingestion to ensure gastric removal of a noncorrosive substance, such as an OTC antihistamine.

The nurse at the well-child clinic is advising the parents of an 8-month-old child about health and safety. What information should the nurse provide? a. Install stair guards or gates in the home. b. Use of a car seat is optional if a lap and shoulder belt is in place. c. Start toilet training with a child-sized potty. d. Give syrup of ipecac in case of accidental ingestion or poisoning.

a. Install stair guards or gates in the home. By the age of 8 months, a child is crawling and may be able to pull up to a standing position. The use of a stair guard or gate is necessary to prevent accidents, which are the most common cause of injury among children of this age.

The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention? a. Prolonged exhalations. b. Thick yellow rhinorrhea. c. Frequent nonproductive cough. d. Oxygen saturation of 95% by pulse oximeter.

a. Prolonged exhalations. Prolonged exhalation indicates breathing difficulty and requires immediate intervention. According to the American Heart Association's Pediatric Advance Life Support (PALS) algorithm, a prolonged expiration in a pediatric client is indicative of lower airway obstruction.

When caring for a child who is in the paroxysmal stage of pertussis, which intervention should the nurse implement to support the child's nutritional needs? a. Provide small, frequent meals. b. Increase protein intake. c. Maintain a liquid diet. d. Offer the child a regular diet.

a. Provide small, frequent meals. The paroxysmal stage of pertussis is characterized by coughing with vomiting. Frequent small meals are vomited less often than larger meals.

The nurse is developing a plan of care for a school-aged boy with a chronic disability. The child frequently complains about being different from his siblings and wants others to do things for him that he is capable of doing for himself. To assist the family in coping with this child's chronic illness, which intervention is most important for the nurse to implement? a. Recommend the use of consistent discipline and reward for acceptable behavior. b. Allow the child to act out since he is chronically ill. c. Suggest that all the children are included in family decision-making. d. Evaluate the proper use of equipment that is provided to improve the child's lifestyle.

a. Recommend the use of consistent discipline and reward for acceptable behavior. Focusing on the child, and not the condition, is essential in assisting the child to adapt to a chronic disability or illness. Consistent family rules should be used with a chronically ill child, such as setting boundaries for acceptable behavior, requiring participation in household activities, and fulfilling school responsibilities. Children need solid boundaries, even if chronically ill.

A 14-year-old returns to the pediatric unit after corrective surgery for scoliosis. In the immediate postoperative period, the nurse should include which action in this client's plan of care? (Select all that apply.) a. Record intake and output every 8 hours. b. Elevate the head of the bed 30 degrees. c. Assess bowel sounds every 4 hours. d. Initiate a logrolling schedule every 2 hours. e. Ambulate for 5 minutes, 12 hours postoperative. f. Give morphine sulfate, 2 mg IV every 4 hours PRN.

a. Record intake and output every 8 hours. c. Assess bowel sounds every 4 hours. d. Initiate a logrolling schedule every 2 hours. f. Give morphine sulfate, 2 mg IV every 4 hours PRN. Recording intake and output and assessing bowel sounds are critical when determining if the body systems are recovering from the effects of anesthesia. Using a logrolling technique to turn the client maintains spinal alignment postoperatively and prevents complications of immobility. Since this is a painful surgery, the nurse should maintain pain control as prescribed. The pain associated is not just due to the incisions of surgery, but also to the manipulation and placement of the spinal hardware and muscular pain as the involved muscles adjust to the corrective realignment of the spine. Following corrective surgery for scoliosis, a client should be immobilized without spinal flexion for 24 to 48 hours, and then ambulated by the physical therapist.

A child is brought to the emergency department with sweating, chills, and snake fang-like puncture marks on the calf. What action should the nurse implement after the type of snake is identified? a. Secure the antivenom. b. Ambulate the child. c. Apply a tourniquet to the leg. d. Reassure the child and parent.

a. Secure the antivenom. A snake's venom contains neurotoxins, which causes muscle paralysis and depression of the respiratory system. Antivenom is essential to the child's survival because the child is showing signs of envenomation. When a bite or envenomation is located on an extremity, the extremity should be immobilized. The use of a tourniquet is not recommended. Envenomation is a potentially life-threatening condition.

A nurse reviews the methods for preventing recurring urinary tract infections (UTI) with the parent of a female child. Which response by the parent indicates that further teaching is needed in caring for the child? a. States they will buy the child only nylon underclothes. b. Increases oral fluids and encourages the child to void frequently. c. Provides the child with cotton underwear for daily use. d. Teaches the child to cleanse the perineal area from front to back.

a. States they will buy the child only nylon underclothes. Nylon underwear traps moisture and can contribute to bacterial growth, thus the parent's statement indicates the need for further teaching.

A newborn who is breastfeeding is diagnosed with galactosemia. Which action should the nurse implement? a. Stop the infant breastfeeding. b. Add amino acids to breast milk. c. Give galactokinase with breast milk. d. Substitute a lactose-containing formula.

a. Stop the infant breastfeeding. Galactosemia is a rare genetic disorder that involves an inborn error of carbohydrate metabolism in which a hepatic enzyme, galactokinase, involved in the conversion of galactose to glucose is absent. Treatment consists of eliminating all lactose-containing foods, including breast milk, so the infant should stop breastfeeding. Soy protein formula is the feeding of choice during infancy.

The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? a. Tachycardia. b. Bradycardia. c. Dry mucous membranes. d. Increased skin turgor.

a. Tachycardia. In early dehydration (during the first 2 days), fluid loss occurs first from the extracellular and intravascular fluid spaces. Blood pressure falls and heart rate increases in response to a diminished blood volume.

The nurse is caring for a premature infant who needs an IV access restarted. Which action should the nurse take when using adhesive tape? a. Use solvents such as water, mineral oil, or petrolatum to remove adhesives instead of pulling on the skin. b. Avoid using tape and adhesives until the skin is more mature. c. Use scissors carefully to remove the tape instead of pulling the tape off. d. Use alcohol to remove the adhesives.

a. Use solvents such as water, mineral oil, or petrolatum to remove adhesives instead of pulling on the skin. The use of adhesives should be minimized as much as possible in the treatment of preterm neonates. They should be removed using water, mineral oil, or petrolatum. The skin of the premature infant is fragile, delicate, and thinner compared to a full-term infant, and is easily traumatized. Alcohol should not be used to remove adhesives.

When conducting a hygiene class for adolescent girls, it is important for the nurse to include which instruction about preventing toxic shock syndrome? a. Wash your hands before inserting a tampon. b. Use super absorbent tampons. c. Wear cotton underwear. d. Douche following menstruation.

a. Wash your hands before inserting a tampon. The single most effective means of preventing infection is handwashing.

A mother brings her 6-month-old infant to the clinic for a well-baby routine exam. Which vaccine should the nurse verify the infant has received? (Select all that apply.) a. Meningococcal polysaccharide vaccine (MPSV4). b Haemophilus influenzae type b conjugate vaccine (Hib). c. Inactivated poliovirus vaccine (IPV). d. Hepatitis B virus vaccine (HepB). e. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP). f. Measles, mumps, and rubella vaccine (MMR).

b Haemophilus influenzae type b conjugate vaccine (Hib). c. Inactivated poliovirus vaccine (IPV). d. Hepatitis B virus vaccine (HepB) e. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP) .According to the Centers for Disease Control's guidelines for immunizations, a 6-month-old infant should have received doses 1 and 2 of Hib, IPV, HepB, and DTap vaccines.

An infant weighs 7 pounds (3.18 kg) at birth. How much would the nurse expect the infant to weigh at age 6 months of age? a. 12 lb (5.44 kg). b. 14 lb (6.35 kg). c. 17 lb (7.71 kg). d. 21 lb (9.53 kg).

b. 14 lb (6.35 kg). Due to growth spurts, a healthy infant should double their birth weight in 4 to 6 months and triple it in one year.

A mother tells the nurse that her children are asking questions about divorce, but one child tells her that he is sorry that he caused the divorce of the parents. Which age group is most likely to experience feelings of punishment or responsibility for the divorce of parents? a. 1 year b. 4 years. c. 8 years. d. 13 years.

b. 4 years. Divorce constitutes a major disruption for children of all ages. Behaviors and feelings differ based on children's developmental stages and cover a wide spectrum, with overlap between stages. A preschool-aged child often feels frightened, confused, and may blame themselves for the divorce or feel it is their personal punishment.

The mother of a 2-month-old reports that she often lets the baby cry in the middle of the night instead of going to pick up or sooth the infant. What information should the nurse provide the mother? a. Picking up the infant in the middle of the night fosters dependency on the mother. b. A sense of trust is developed in an infant when others respond to the infant's cry. c. An infant is learning to manipulate others when the infant is picked up unnecessarily. d. A 2-month-old who does not sleep through the night should be evaluated further.

b. A sense of trust is developed in an infant when others respond to the infant's cry. According to Erikson, a crucial element in the developmental stage of the infant is "Trust versus mistrust", which is nurtured when the mother or the primary caregiver is responsive and consistent in responding to the infant's needs and cries.

The parents of a 14-year-old girl tell the nurse that their daughter dresses as a tomboy and plays baseball one day and the next day dresses in feminine clothes and becomes a teenage "drama queen." What information should the nurse use to respond to the parents? a. Teenagers need a strong role mode to emulate. b. Adolescents try on different roles while seeking their identity. c. Such erratic behavior needs further investigation. d. Fourteen-year-olds often try to please parents with their role choices.

b. Adolescents try on different roles while seeking their identity. As teenagers seek their own identity, they "try on" different roles to see if they fit and which feels more natural and comfortable.

Which site should the nurse use to obtain the pulse rate for a 1-year-old child? a. Radial. b. Apical. c. Carotid. d. Femoral.

b. Apical. An apical pulse rate should be obtained in children less than 2 years of age to assess cardiac function.

The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose? a. Syrup. b. Applesauce. c. Orange juice. d. Formula or milk.

b. Applesauce. In order to prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications.

The nurse is caring for a 9-year-old female child who asks, "What does it mean when a girl says they started their period?" How should the nurse respond? a. Ask the child whether she was sexually abused. b. Ascertain what the child knows about changes that a female undergoes during puberty, then simply and factually present the information in a way that the child will understand. c. Inquire where the child heard this. d. Involve the child in teaching about puberty with their peers.

b. Ascertain what the child knows about changes that a female undergoes during puberty, then simply and factually present the information in a way that the child will understand. School-age children are curious about bodily changes. Education on puberty should be presented in an honest, factual, age-appropriate manner.

The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client? a. Anemia. b. Cardiac arrhythmias. c. Gastrointestinal reflux. d. Heightened neurologic reflexes.

b. Cardiac arrhythmias. An adolescent with bulimia who purges by frequent self-induced vomiting, using diuretics, or abusing laxatives can experience potassium depletion, which increases the risk for cardiac arrhythmias.

When plotting a 20-week-old infant's weight on a standardized growth chart, the nurse determines that the child's weight is between the 2nd and 3rd percentiles. Based on this finding, which action should the nurse take? a. Teach the parents about interventions for failure to thrive syndrome. b. Compare this weight with previous weights recorded in the child's record. c. Evaluate the parent's body build in relation to the infant's weight. d. Obtain a 24-hour nutritional history before making any conclusions.

b. Compare this weight with previous weights recorded in the child's record. Evaluation of weight using a growth chart requires comparison of current weight with previous weight measurements. An infant is defined as having "failure to thrive" if their height or weight falls below the 3rd percentile, but first the nurse should review the infant's health record to assess the infant's weight history.

While assessing an 18-month-old during a well-child visit, the nurse notes that the toddler has a rounded potbelly abdomen, marked lordosis or swayback, short and slightly bowed legs, and a large head. Based on these findings, what action should the nurse implement? a. Refer the findings to the healthcare provider for diagnostic studies for hydrocephalus. b. Document general physical appearance of a normally developed toddler. c. Plot the findings on the growth chart within the parameters of delayed physical maturation. d. Review the dietary intake for indications of a vitamin deficiency or malnutrition.

b. Document general physical appearance of a normally developed toddler. "Toddler lordosis" describes the normal upright posture found at this age, which is characterized by a potbelly, swayback, and short, slightly bowed legs.

Per the healthcare provider's orders, the nurse is preparing to catheterize an 8-year-old child. Before gathering supplies and starting the procedure, which action should the nurse take first? a. Obtain the parent's consent before initiating the procedure. b. Explain to the child and parents why the procedure is being done and what will occur. c. After talking with the parents about the procedure, ask them to leave the room. d. Provide the child with privacy by conducting the procedure in the treatment room.

b. Explain to the child and parents why the procedure is being done and what will occur. An 8-year-old uses concrete operational thought (Piaget), can cooperate, and should be included in the explanation of the plan of care. Explaining why the procedure is needed and what will occur will enhance the child's understanding and cooperation. A separate consent does not need to be obtained and signed. The parents should be allowed to stay in the room while the nurse still protects the child's privacy. There is no need to move to a treatment room unless the nurse or parents feel it is needed. More invasive procedures that can cause pain, such as IV insertion or blood draws, can be done in a treatment room so the child's room remains a safe place.

Which is a priority nursing problem for a child in the subacute stage of Kawasaki disease (KD)? a. Alterations in skin integrity. b. High risk for altered tissue perfusion, cardiopulmonary. c. Risk for imbalanced body temperature, hyperthermia. d. High risk for fluid volume deficit.

b. High risk for altered tissue perfusion, cardiopulmonary. KD is an acute systemic vasculitis that places the child at risk for coronary artery aneurysm, which is most likely to occur during the subacute phase resulting in reduced cardiac output. KD causes a rash and desquamation of the hands and feet. This is not as life-threatening as cardiac involvement.

Which research finding provides evidence-based practice for an infant's risk for sudden infant death syndrome (SIDS)? a. Breastfeeding reduces the risk for and the incidence of SIDS. b. Infants should be positioned supine or supported laterally to sleep. c. The prone position should be used when an infant sleeps after feeding. d The peak incidence occurs between the ages of 1 and 2 months.

b. Infants should be positioned supine or supported laterally to sleep. Research has shown that placing babies on their backs for sleep reduces the risk of SIDS. A population-based study found the prone sleep position was associated with twice (2.4% odds ratio) the rate of SIDS compared with infants placed supine (on their backs) to sleep.

An 8-year-old boy who was recently diagnosed with diabetes mellitus is admitted to the intensive care unit with diabetic ketoacidosis (DKA). Which nursing action has the highest priority? a. Place on a cardiac monitor. b. Initiate an intravenous infusion. c. Collect a specimen for serum electrolytes. d. Obtain fingerstick glucose.

b. Initiate an intravenous infusion. The priority for a child with DKA, an emergency life-threatening situation, is to obtain venous access for administration of fluids, electrolytes, and insulin. The child should be placed on a cardiac monitor and have serum electrolytes and glucose levels obtained, but not before initiating venous access.

A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. Which action should the nurse implement? a. Postpone the abdominal palpation until the next examination. b. Place the child's hand under the examiner's hand while palpating. c. Touch the abdomen firmly as the child takes short, quick breaths. d. Press the abdomen with the child bearing down and holding the breath.

b. Place the child's hand under the examiner's hand while palpating. Placing the child's hand on the abdomen with the examiner's hand on top of the child's hand gives the child control and reduces the sensation of tickling. Abdominal palpation is an integral part of the physical assessment and should not be postponed.

The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding? a. Adequate hydration. b. Poor skin turgor. c. Normal skin elasticity. d. Assessment inconclusive.

b. Poor skin turgor. Tissue turgor refers to the amount of elasticity in the skin and is one of the best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes its normal position without residual marks or creases. In a child with poor turgor, the skin remains tented or suspended for a few seconds before returning to a normal position.

When administering a gavage feeding to a school-age child, which action should the nurse implement? a. Administer feedings over 5 to 10 minutes. b. Position the child on the right side after administering the feeding. c. Check the placement of the tube by inserting 20 mL of sterile water. d. Lubricate the tip of the feeding tube with petroleum jelly to facilitate passage.

b. Position the child on the right side after administering the feeding. The child should be positioned on the right side with the head of the bed elevated 30 degrees after administering the feeding to facilitate gastric emptying and prevent gastric reflux. Gavage feedings should be given to allow slow gastric filling over 15 to 30 minutes.

A 3-year-old boy is brought to the emergency department because of a possible diazepam overdose. He is lethargic and confused. His vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30 mmHg. Which nursing intervention has the highest priority? a. Insert an orogastric tube for gastric lavage. b. Prepare a set-up for an endotracheal intubation. c. Draw blood for stat chemistries and blood gases. d. Insert a Foley catheter to monitor renal functioning.

b. Prepare a set-up for an endotracheal intubation. Diazepam causes respiratory depression. Preparation for endotracheal intubation to protect the airway is the priority intervention at this time.

A crying toddler has a blood pressure measurement of 120/70 mmHg. Which action should the nurse implement? a. Notify the healthcare provider of the measurement. b. Quiet the child and retake the blood pressure. c. Ask the parent if the child has a history of hypertension. d. Document the finding and recheck in 4 hours.

b. Quiet the child and retake the blood pressure. When a child is crying, intrathoracic and abdominal pressures increase and are reflected in an elevation of systemic blood pressure. The nurse should quiet the child before retaking the blood pressure.

An adolescent female's susceptibility to vaginitis could be related to which causative factor? a. Swimming pool chlorine. b. Sexual activity. c. Urinary incontinence. d. Menarche.

b. Sexual activity. Vaginitis can result from irritation, foreign objects, allergens, and sexual activity.

The nurse calculates a 4 mL dose of prescribed digoxin to a 9-month-old infant. Which action should the nurse implement? a. Mix the dose with juice to disguise its taste. b. Suspect a dosage error and do not give the dose. c. Check the infant's heart rate and administer the dose by placing it to the back and side of the mouth. d. Check the infant's heart rate and administer the dose by letting the infant suck it through a nipple.

b. Suspect a dosage error and do not give the dose Digoxin's narrow margin of safety for an infant should not exceed 1 mL (50 mcg) in one dose. The nurse's calculation indicates a dosage error and should not be given. Digoxin is given without mixing with any other fluids or foods because the infant may refuse to consume the total amount, which results in an inaccurate drug dose. Generally, pediatric digoxin elixir is available as 0.05 mg/mL. Great care must be taken in dosage calculation and should be double-checked with another nurse prior to administration.

Which sign of malignant hyperthermia should the nurse assess for during the perioperative period in a child receiving general anesthesia? a. Apnea. b. Tachypnea. c. Bradycardia. d. Decreased blood pressure.

b. Tachypnea. Malignant hyperthermia, a potentially fatal autosomal genetic myopathy, can cause a change in vital signs that demands immediate attention in the perioperative period when these individuals are exposed to anesthetic agents. Early symptoms of the disorder include tachycardia and tachyarrhythmia, tachypnea, hypercarbia, and metabolic and respiratory acidosis. An elevated temperature is a late sign of the disorder.

A mother expresses concern to the nurse about the behavior of her 15-year-old who is frequently finding fault and criticizing her. What information should the nurse provide? a. The family value system may need to be changed to meet the teen's changing needs. b. Teens create psychological distance from parents in order to separate from them. c. Parents should relinquish their relationship with their teen to the teen's peers. d. Conflicts in the parent-teen relationship are to be expected during adolescence.

b. Teens create psychological distance from parents in order to separate from them. Although a mutually respectful parent-adolescent relationship is important, an adolescent may use critical and fault-finding behavior as a mechanism to separate from the parent. Between the ages of 15 to 17 years, adolescents tend to have conflicts with their parents as they struggle with issues of independence and control, and mature towards late adolescence of 18 to 20 years of age.

During a well-child assessment, the parents of a 4-year-old express concern that their child often chatters while playing alone. What information should the nurse provide the parents? a. The child is attempting to formulate a secondary language. b. This is an attempt by the child to form an imaginary social base. c. "Private speech" is normal at this age and serves as a problem-solving tool. d. Concern for psychological development is warranted, so further testing is required.

c. "Private speech" is normal at this age and serves as a problem-solving tool. Children chatter to themselves between the ages of 4 and 6 years. This "private speech" serves as a problem-solving tool as children try new tasks or work through unfamiliar situations.

The parents of a child with autism ask the nurse if they could help them to better understand the disorder. Which information best describes autism spectrum disorder? a. Obsession with moving objects. b. Repetitive patterns of behavior. c. A neurobehavioral disorder diagnosed after assessment in two areas: social communication and interaction and restricted, repetitive behavior. d. Stereotypic movements and speech patterns.

c. A neurobehavioral disorder diagnosed after assessment in two areas: social communication and interaction and restricted, repetitive behavior. Autism spectrum disorder is a neurodevelopmental disorder of unknown origin. Diagnosis is based on two behavioral domains: difficulties in social communication and social interaction and unusually restricted, repetitive behavior, interest, or activities.

A 6-year-old child is brought to the emergency department with a systolic blood pressure of 58 mmHg. What action should the nurse take first? a. Comfort the child. b. Assess responsiveness. c. Alert the healthcare provider. d. Initiate IV fluid replacement.

c. Alert the healthcare provider. The lower limit for systolic blood pressure for a child older than 1 year of age is 70 mmHg plus 2 times the child's age in years. The healthcare provider should be notified immediately of the child's hypotension and anticipate a prescription for IV fluids.

An infant with developmental dysplasia of the hip is placed in a Pavlik harness. Which instructions should the nurse include in a teaching plan for the parents? a. Apply lotion or powder to minimize skin irritation. b. Put clothing over the harness for maximum effectiveness. c. Check for red areas under the straps two to three times a day. d. Use a thin absorbent disposable diaper over the harness.

c. Check for red areas under the straps two to three times a day. The Pavlik harness, which maintains the hips in abduction, is the most widely used device for developmental dysplasia of the hip. An infant who continuously wears a Pavlik harness is at risk for skin breakdown, so parents should be instructed to check two to three times a day for red areas under clothing and harness straps. To avoid direct contact with the skin, clothing and diapers should be placed under the straps.

The parents of a toddler brought to the clinic for a well-child visit tell the nurse that the child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents? a. A child is insecure because trust is not fostered and developed during infancy. b. A toddler should be exposed to different routines to promote adapting to new experiences. c. Children of this age are comfortable with ritualism and display global thinking. d. Objects should be frequently moved in the environment to teach the child to acclimate to change.

c. Children of this age are comfortable with ritualism and display global thinking. A 2-year-old is ritualistic and wants consistency and routine. Changes in the toddler's environment or schedule is upsetting. Another mark of the toddlers' sensitivity to change is global thinking. When there is a change in one small part of the environment, such as a minor shift in room arrangement, or changes in the whole environment, the 2-year-old's composure disintegrates.

During the well-child assessment of an 18-month-old toddler, the nurse determines the child does not hold on to furniture while walking but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which nursing problem should the nurse identify? a. Alteration in nutrition. b. Alteration in parenting. c. Delayed growth and development. d. Alteration in health maintenance.

c. Delayed growth and development. This child does not demonstrate gross motor or psychosocial skills typical of an 18-month-old toddler, which best supports delayed growth and development.

A 7-month-old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child's growth and development, which intervention is most important for the nurse to implement? a. Encourage the parents to participate in a planned program of play with the infant. b. Refer the parents for psychological counseling to identify parental detachment. c. Demonstrate feeding strategies and infant cues that indicate hunger and satiation. d. Provide instructions about formula preparation and feeding schedules.

c. Demonstrate feeding strategies and infant cues that indicate hunger and satiation. NFTT most often occurs due to inadequate parental knowledge or a disturbance in parental-child attachment, but the first goal for infants with NFTT is to provide nutrition to promote "catch-up" growth. The nurse should demonstrate positive feeding strategies that reduce parent and infant frustration, such as recognizing the infant's cues indicated by vigorous sucking and satiation.

Which intervention should the nurse implement to help keep a 6-month-old infant calm during a physical assessment? a. Give the infant a soft cuddly toy to hold. b. Remove the pacifier from the infant's mouth. c. Encourage the parent to hold the infant. d. Distract the infant with noise or bright lights.

c. Encourage the parent to hold the infant. Parents should be encouraged to participate by holding the infant as much as possible during an examination to calm the infant and help the infant feel secure.

A mother brings her 6-month-old infant to the clinic for a wellness checkup. She comments, "I want to go back to work, but I don't want my baby to suffer because I'll have less time at home." How should the nurse respond to the mother? a. Stay home until the child starts school. b. Find a good babysitter close to home. c. Let's talk about the child care options that are best for the child. d. Go back to work now so the infant will get used to being with others

c. Let's talk about the child care options that are best for the child. It is common for mothers to feel torn between their work and child and to have feelings of guilt. The nurse should assist the mother to explore her feelings on the subject while focusing on the optimal, appropriate, safe, and available options for her child.

The low birthweight (LBW) infant requires a neutral thermal environment. Which action should the nurse implement? a. Use wool blankets for covers. b. Avoid using disposable diapers. c. Maintain a temperature-controlled, high-humidity atmosphere. d. Continue cool oxygenation via a hood.

c. Maintain a temperature-controlled, high-humidity atmosphere. A temperature-controlled neutral thermal environment with high humidity provides adequate warmth so the LBW infant can maintain a normal core temperature with minimum oxygen consumption and caloric expenditure. LBW infants are especially vulnerable to temperature instability since they are usually premature and neurologically have difficulty maintaining their temperature. Their skin has not matured enough to provide adequate protection from heat and water loss. A high-humidity atmosphere in an incubator contributes to body homeostasis by reducing evaporative heat loss and insensible water loss. The three primary methods for maintaining a neutral thermal environment are the use of an incubator, a radiant warmer, and an open bassinet with cotton blankets. Microenvironments for humidification can include items such as food-grade plastic bags or plastic wrap, humidified reservoirs for incubators, and humidified plastic heat shields covered with plastic wrap.

The mother of a 2-month-old infant who just received the first DTaP asks the nurse what symptoms to expect. What is the best response for the nurse to provide? a. Most children do not experience any reaction. b. Seizures are common and require anticonvulsant medication. c. Mild reactions are common and most frequently include low-grade fever. d. The most common reaction is a whole-body rash that develops into itchy vesicles.

c. Mild reactions are common and most frequently include low-grade fever. The most common mild reactions to DTaP include low-grade fever, drowsiness, anorexia, local pain, swelling, and redness. They are usually managed symptomatically with acetaminophen. Uncommon reactions following DTaP administration may occur. Uncommon reactions to DTAP, which include seizures and rash, are more likely to occur after the varicella virus vaccine and should be reported to the healthcare provider.

During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing? a. Associative play. b. Object apprehension. c. Object permanence. d. Separation anxiety.

c. Object permanence. Object permanence, learning that objects and people continue to exist even when they are no longer in sight, starts around the age of 7 months.

A 5-year-old child who is one day postoperative has bilateral eye patches in place and should be out of bed. Which nursing intervention should be implemented first before leaving the bedside? a. Speak to the child when entering the room. b. Allow the child to assist in eating. c. Orient the child to the immediate surroundings. d. Allow the parents to stay in the room with the child.

c. Orient the child to the immediate surroundings. When sighted children temporarily lose their vision, many aspects of the environment becomes bewildering and frightening. To minimize the effects of temporary loss of vision, the child should be oriented immediately to the surroundings and should be told about the nurse's actions and any experiences that are felt or heard during procedures. The child and family should be reassured throughout every phase of treatment and encouraged to be independent (with assistance) in self-care activities such as eating and bathing.

The nurse is assessing a child for neurological soft signs. Which finding is most likely demonstrated in the child's behavior? a. Presence of vertigo. b. Loss of visual acuity. c. Poor coordination and sense of position. d. Inability to move the tongue in all directions.

c. Poor coordination and sense of position. There is a gray area in neurological assessment known as soft signs, which are findings that are a mild or slight abnormality that is difficult to detect or interpret. Poor coordination and sense of position are classic signs that are consistent with the failure to perform age-specific tasks and represent the persistence of a more primitive neurological response.

A 14-year-old is brought to the emergency department after a biking accident. How should the nurse interact with the adolescent? a. Furnish rewards for cooperation during procedures. b. Have the parents remain with the adolescent at all times. c. Provide clear explanations while encouraging questions. d. Limit the number of choices to be made by the adolescent.

c. Provide clear explanations while encouraging questions. Adolescents are capable of abstract thinking and understand explanations, so the opportunity to ask questions should be provided. Since an adolescent's modesty should be respected, the presence of the parents at the bedside should be a choice made by the adolescent. An adolescent's ability to think abstractly engages problem-solving, therefore the 14-year-old should be allowed to verbalize decisions about their care.

After discussing the introduction of solid foods with the mother of a 6-month-old infant, the nurse determines that the mother understands the information when she states that the first food she will give the infant is from which food group? a. Fruits. b. Egg yolks. c. Rice cereal. d. Yellow vegetables.

c. Rice cereal. Solid food is usually introduced at about 6 months of age starting with rice cereal, which is the least allergenic. New food items should be introduced one at a time with about 5 days between each different type. If the infant has a sensitivity to a particular food, it will be easier to identify it by spacing out the introduction of each new food.

How should the nurse measure the length of a 14-month-old child? a. Standing height. b. Prone recumbent position. c. Supine recumbent position. d. Side-lying position.

c. Supine recumbent position. Children younger than 24 to 36 months of age should be measured for length in the supine position from crown to heel, known as recumbent length.

Which finding should the nurse in the emergency department identify as an indicator that a 3-year-old child has been mistreated? a. The toddler does not remember how the injury occurred. b. The parents are extremely calm in the emergency department. c. The injury sustained is highly unusual for a 3-year-old child. d. The child was doing something unsafe when the injury occurred.

c. The injury sustained is highly unusual for a 3-year-old child. An injury that is highly unusual or inconsistent with the age and condition of the child should raise suspicion of child abuse. If the description of the incident provided by the caregivers does not match the injury sustained or there are inconsistencies, the nurse should be vigilant in the assessment and documentation while maintaining professionalism with the parents.

Which should the nurse assess last when examining a 5-year-old child? a. Heart. b. Lungs. c. Throat. d. Abdomen.

c. Throat. Examination of the mouth, throat, and perineum is considered to be more invasive than other parts of a physical examination. Invasive procedures should be left for the end of the examination for a preschooler.

A nurse who is working in the Poison Control Center receives a telephone call from a parent of a 16-month-old child who drank 2 ounces of acetaminophen elixir. Which action should the nurse recommend to the parent? a. Administer oral syrup of ipecac. b. Give the child a glass of whole milk. c. Transport the child to the emergency department for gastric decontamination. d. Obtain oral activated charcoal tablets from the pharmacy.

c. Transport the child to the emergency department for gastric decontamination. Each 5 mL of elixir contains 160 mg of acetaminophen. This child has ingested twice the maximum recommended 24-hour dose, which can cause acetaminophen toxicity. The parent should transport the child to the emergency department for gastrointestinal decontamination and the possible administration of the antidote, acetylcysteine. Overdosing of acetaminophen can cause serious liver damage.

A 12-year-old male client tells the nurse that he is happy to be taking growth hormones because now he can grow to be as tall as his friends. What response is best for the nurse to provide? a. "You must remember that this treatment regimen is not always effective." b. "Although being tall is important to you, remember there are far more important characteristics than height." c. You will grow with this medicine, and are likely to be taller than anyone in your family." d. "Being taller is important to you and taking your injections will help achieve that goal."

d. "Being taller is important to you and taking your injections will help achieve that goal."

A 15-year-old girl tells the school nurse that she wants to have a baby. How should the nurse respond? a. "Will you be able to support the baby?" b. "Do you have plans to continue school?" c. "Have you talked with your parents about this?" d. "Can you tell me how your life will be if you have an infant?"

d. "Can you tell me how your life will be if you have an infant?" Developing a dialogue with the teen is important. By using an open-ended question the nurse will encourage communication and explanation. This question directs the teen to consider real life experiences and allows the nurse to assess the teen's perception and reality orientation.

The community health nurse teaches the parents of school-age children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching? a. "Excessive amounts of fluoride will make teeth turn brittle and yellow." b. "Having our children brush with fluoride toothpaste is not effective." c. "Use of fluoride in water is mostly effective during initial tooth formation." d. "Dental caries can be prevented through fluoridation of public water."

d. "Dental caries can be prevented through fluoridation of public water." Dental caries can be prevented through fluoridation of public water.

Which is the priority nursing intervention for a 12-year-old client newly diagnosed with bacterial meningitis? a. Continue pain management and provide comfort measures. b. Maintain seizure precautions to protect the client from injury. c. Monitor for increased intracranial pressure and do frequent neural vital sign checks. d. Administer broad-spectrum antibiotics before results of culture and sensitivity tests are returned.

d. Administer broad-spectrum antibiotics before results of culture and sensitivity tests are returned. Although culture and sensitivity results identify the most effective treatment, prescribed broad-spectrum antibiotic therapy should be initiated once the culture is obtained to provide an immediate anti-infectant regimen against the risk of mortality due to bacterial meningitis.

The nurse is collecting a blood sample from a newborn for a phenylketonuria (PKU) screening test. When should the nurse obtain the blood sample? a. At birth from cord blood. b. Fourteen days after birth. c. Before oral feedings are initiated. d. After ingestion of a source of protein.

d. After ingestion of a source of protein. PKU is a genetic disease caused by the absence of the enzyme needed to metabolize the essential amino acid phenylalanine. The Guthrie blood test is used for early detection of this condition in order to prevent mental retardation as a result of this disease. The blood sample should be collected between 1 to 7 days after birth, with fresh heel blood only, and no sooner than 24 hours after the infant has ingested a source of protein (breast milk or infant formula). Premature infants and/or sick neonates who haven't been introduce to breast milk or formula due to medical reasons will have the PKU test taken after they are able to ingest breast milk or formula regardless of method of delivery (nippling or gavage fed).

When assessing the breath sounds of an 18-month-old child who is crying, what action should the nurse take? a. Ask the parent to quiet the child so breath sounds can be auscultated. b. Auscultate and document breath sounds, noting that the child was crying at the time. c. Document that the assessment was not available because the child was crying. d. Allow the child to initially play with the stethoscope, and distract the child during auscultation.

d. Allow the child to initially play with the stethoscope, and distract the child during auscultation. Engaging the child with an interesting activity, such as playing with the stethoscope before its use, often distracts the child long enough to stop crying so that breath sounds can be auscultated accurately.

A child with a penetrating eye injury comes to the school clinic. Which action should the nurse implement? a. Remove the object impaled in the eye and then apply a regular eye patch. b. Place an ice bag over the eye until the healthcare provider is seen c. .Irrigate the affected eye copiously with a cool sterile saline solution. d. Apply a Fox shield to the affected eye and any type of patch to the other eye.

d. Apply a Fox shield to the affected eye and any type of patch to the other eye. The treatment for a penetrating eye injury is not to remove or manipulate the impaled object, but to apply a Fox shield over the eye, if available (not a regular eye patch). Place an eye patch over the unaffected eye to prevent bilateral eye movement. The child should be transported to the emergency department immediately. If a Fox shield is not available, tape a paper cup over the eye and object.

A 4-year-old is brought to the emergency department with a laceration on the right foot. Which action should the nurse implement to help the child cope with the emergency department experience? a. Avoid the use of bandages to keep wounds open to air. b. Remind the preschooler how big children should act. c. Give the child some time after explaining procedures. d. Avoid using jargon, such as "shot," when giving care.

d. Avoid using jargon, such as "shot," when giving care. Using positive terms and avoiding words (jargon) that the child may perceive in a frightening way can assist the child cope with the emergency department experience.

The parents of an adolescent male with Ewing sarcoma ask the nurse what is the most significant factor contributing to their son's prognosis. Which factor should the nurse include when answering the parent's concern? a. Age of onset. b. Gender of child. c. Appearance on x-ray. d. Degree of metastasis.

d. Degree of metastasis. Ewing sarcoma is the second most common malignant bone tumor of children. Prognosis is most significantly related to the degree of metastasis during the early course of the disease.

When assessing a preschooler, which finding warrants further assessment by the nurse? a. Able to ride a tricycle. b. Talks about an imaginary friend. c. Dresses independently. d. Gains 2 pounds (0.9 kg) in 12 months.

d. Gains 2 pounds (0.9 kg) in 12 months. Preschool children gain an average of 5 pounds (2.3 kg) per year. Therefore, a gain of 2 pounds (0.9 kg) is less than half of the expected weight gain and should be investigated further.

What is the best action for the nurse to take when initiating contact with a toddler for the first time? a. Ask the toddler to point to where it hurts. b. Tell the child your name and that you are the nurse. c. Call the child by name while picking up the toddler. d. Kneel in front of the toddler and speak softly.

d. Kneel in front of the toddler and speak softly. The toddler perceives the nurse as a stranger. A more positive interaction occurs when the toddler perceives the meeting in a nonthreatening way. Placing oneself at the toddler's eye level and speaking softly can be less threatening for the child.

A 4-month-old breastfeeding infant is at the 80th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding? a. Milk allergy. b. Failure to thrive. c. Inadequate milk supply in mother. d. Normal growth curve of a breastfed infant.

d. Normal growth curve of a breastfed infant. When plotting weights and heights on a standard growth chart both breastfed and formula-fed infants, the breastfed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breastfed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breastfed differ from those who are formula fed.

The nurse observes the interactions of a 2-year-old child who says, "No" even when "Yes" is what the child really wants to say. The parent says to the nurse, "We are such positive people. Why is our child so negative?" How should the nurse respond? a. A 2-year-old often acts in the opposite way to get attention. b. A child at this age is testing the limits of the parent's patience. c. The toddler is exhibiting an example of ritualistic behavior. d. The child is trying to assert autonomy through negativism.

d. The child is trying to assert autonomy through negativism. As a toddler tests autonomy and ego boundaries, sometimes they clash with parental restrictions and respond with recital of prompts that parents often say. "No" is a favorite repeated word and is the child's way of exploring autonomy through negativism.

The father of an 8-year-old child tells the nurse that he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to the father? a. The father should decrease his expectations to give his son a chance to succeed. b. The child has an introverted personality and should be encouraged to play isolated games. c. The father should encourage his son to participate in team sports instead of less physical activities. d. The child should be given opportunities to achieve a sense of competency in an area he chooses.

d. The child should be given opportunities to achieve a sense of competency in an area he chooses. According to Erikson, the developmental stage "Industry versus inferiority" builds feelings of confidence, competence, and industry if there is achievement in an area of interest. If a child believes that he or she cannot measure up to society's expectations, the child loses confidence and may not find pleasure in the activity. Children should be encouraged to do the things they enjoy and succeed in. The father who wants his son to play soccer does not need to decrease his expectations, but should be encouraged to shift the expectations to an activity the child takes pleasure in.

Which clinical finding should the nurse expect a child with nephrosis to exhibit? a. Elevated blood pressure. b. Blood-tinged urine. c. Elevated temperature. d. Urine protein 3+ to 4+.

d. Urine protein 3+ to 4+. In nephrosis, renal tubules become permeable to proteins, causing massive proteinuria.

A 4-year-old boy is brought to the emergency department by his parent who reports that the child has been pointing at his stomach and saying, "It hurts so bad." Which pain assessment tool should the nurse use? a. Descriptor Scale. b. Brief Pain Inventory. c. A numeric rating scale. d. Wong-Baker FACES Scale.

d. Wong-Baker FACES Scale. A pain rating scale using pictures, such as the Wong-Baker FACES Scale, allows the child to choose a facial expression that shows "how much hurt you have now" and should be used for a preschool-aged child.