PEDS DYNAMIC QUIZZES part 2

Correct Answer: C. Children who were born prematurely are more likely to be maltreated. ** Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often have increased care needs, which increases the risk of caregiver fatigue and can lead to an increased potential for maltreatment. Incorrect Answers: A. While child maltreatment occurs in all age groups, infants from birth to 1 year of age have the highest rate of maltreatment. B. In single-parent families, the parent is more often the abuser than the nonbiological partner. D. While child maltreatment does occur across all socioeconomic groups, the most cases occur in families of lower income and education level. These families often have a greater number of additional stressors and restricted access to available support systems.

A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? A. Preschoolers have the highest rates of maltreatment. B. In single-parent families, the parent's non-biological partner is typically the abuser of the child. c. Children who were born prematurely are more likely to be maltreated. D. Child maltreatment occurs equally across all socioeconomic groups.

Correct Answer: C. "A 6-year-old child should be able to count 13 coins." ** A 6-year-old child should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands. Incorrect Answers: A. A 7-year-old child prefers playing with groups of friends of the same gender. B. A child who is 8 to 9 years old understands the concept of cause and effect. D. A child who is 10 to 12 years old should be able to wash his or her hair independently. An 8-year-old child should be able to brush his or her own hair,

A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include? A. "A 7-year-old child prefers to play with children of a different gender." B. "A 6-year-old child should understand the concept of cause and effect." C. "A 6-year-old child should be able to count 13 coins." D. "An 8-year-old child should be able to wash his or her own hair independently."

Correct Answer: B. Inspect the toddler's toys for sharp edges. ** The nurse should instruct the parents to inspect the toddler's toys for sharp edges or parts to decrease the risk of injury and bleeding to the toddler. Incorrect Answers: A. The nurse should not instruct the parents to administer aspirin or medications that contain aspirin, as this could increase the toddler's risk of bleeding. C. The nurse should instruct the parents to elevate and rest the toddler's affected joint during a bleeding episode. D. The risk of infection is a concern for a toddler who has an immunodeficiency disorder, not hemophilia.

A home health nurse is developing a plan of care a toddler who has hemophilia. Which of the following instructions for the parents should the nurse include in the plan? A. Administer low-dose aspirin for pain. B. Inspect the toddler's toys for sharp edges. C. Perform passive range-of-motion of the affected joint during a bleeding episode. D. Avoid contact with people who have respiratory infections.

Correct Answer: A. Toddlers will react to the parents' anxiety and sadness. ** The nurse should identify that toddlers have little understanding of death. Their reaction is related to changes in routine and the parents' emotions. Incorrect Answers: B. Preschoolers might perceive death as punishment for bad behavior. C. A recognition of the permanence of death is often not achieved until age 9 or 10. D. A realistic concept of death is often not achieved until age 9 or 10.

A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching? A. Toddlers will react to the parents' anxiety and sadness. B. Toddlers view death as punishment for bad behavior. C. Toddlers view death as permanent and irreversible. D. Toddlers have a realistic concept of death.

Correct Answer: B. The infant turns away when the nurse approaches. ** The nurse should expect an 8-month-old infant to have a heightened fear of strangers. The infant is expected to cling to her parent and turn away when approached by a stranger. Incorrect Answers: A. The nurse should expect social smiles to begin at 6 weeks of age; however, the nurse should not expect this from an 8-month-old infant upon initially entering the room due to the infant's expected fear of strangers. C. The nurse should not expect an 8-month-old infant to reach out as the nurse enters the room due to the infant's expected fear of strangers. D. Once the infant is 12 months old, the nurse should expect an alert response to strangers once again.

A nurse in a provider's office enters an examination room to assess an 8-month-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 Answer: A. Tell the guardian that a repeat dose of medication should not be given ** The greatest risk to this infant is an injury from digoxin toxicity. Therefore, the priority action for the nurse to take is to instruct the guardian not to administer another dose of medication. The nurse should follow-up with the guardian frequently to determine if the child has further episodes of vomiting. If so, the nurse should notify the provider immediately because vomiting is a possible indication of digoxin toxicity. Incorrect Answers: B. The nurse should verify the prescribed digoxin regimen and the accuracy of home administration, However, there is another action the nurse should take first. C. The nurse should attempt to identify possible causes of the infant's vomiting. However, there is another action the nurse should take first. D. The nurse should determine if the infant's urinary output is adequate to evaluate the effectiveness of the digoxin in managing the infant's heart failure. However, there is another action the nurse should take first.

A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first? A. Tell the guardian that a repeat dose of medication should not be given B. Verify the prescribed medication regimen C. Determine if the infant has been exposed to others who are ill D. Ask the guardian about the infant's urinary output

Correct Answer: B. The child is withdrawn and refuses to talk. ** Separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stage of despair. Incorrect Answers: A. Physical attacks are a manifestation of the stage of protest. C. Attempts to run away to find her parents is a manifestation of the stage of protest. D. Screaming and loud crying are manifestations of the stage of protest.

A nurse in an acute pediatric unit is caring for a 2-year-old child who has separation anxiety when her parents to leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. The child tries to bite the nurse. B. The child is withdrawn and refuses to talk. C. The child attempts to run away to find her parents. D. The child screams and cries loudly.

Correct Answer: D. Sudden decrease in wheezing ** When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose a larger risk to the client. A sudden decrease in wheezing can indicate that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilatory failure and imminent respiratory arrest. Incorrect Answers: A. The nurse should report excessively prolonged expiration to the provider; however, there is a different finding the nurse should report first. B. The nurse should report increased diaphoresis to the provider; however, there is a different finding the nurse should report first.

A nurse in an emergency department is assessing 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 Answers: A. Identify how much cleaner was in the bottle D. Insert an IV for morphine administration E. Apply a pulse oximeter ** The nurse should ask the parent or guardian about the size of the container, its contents prior to ingestion, and its contents remaining following ingestion. This information provides an estimate of the amount of cleaner the child ingested and can assist the provider in directing treatment. A child who ingests a corrosive agent is likely to have intense pain due to burns in the gastrointestinal system. The nurse should administer morphine as prescribed via IV to provide pain relief. The child is also at risk for airway occlusion due to edema following ingestion of a corrosive agent. Monitoring the child's oxygen saturation level will help the nurse recognize if the child's airway is becoming obscured, Incorrect Answers: A. A child who has asthma should have a pulse oximetry reading of 90% or greater; therefore, this is not the nurse's priority finding. B. A child with nephrotic syndrome typically has moderate to large amounts of protein in the urine; therefore, this is not the nurse's priority finding.

A nurse in an emergency department is assisting with the care of a 4-year-old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the nurse perform? (Select all that apply.) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Perform immediate gastric lavage D. Insert an IV for morphine administration E. Apply a pulse oximeter

Correct Answer: D. Determine the child's breathing pattern ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Hence, determining the child's breathing pattern is the first action the nurse should take. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Incorrect Answers: A. The nurse should cover the child's wounds with a clean, dry cloth; however, there is a different action the nurse should take first. B. The nurse should establish IV access for the child using a large-bore catheter; however, there is a different action the nurse should takefirst. C. The nurse should provide reassurance to the child's parents; however, there is a different action the nurse should take first.

A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following should the nurse take first? A. Cover the child's wounds with a clean, dry cloth B. Establish Iv access with a large-bore catheter C. Provide reassurance to the child's parents D. Determine the child's breathing pattern

Correct Answer: D. Adult tetanus booster (Td) ** Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age. Incorrect Answers: A. DTAP is used to provide immunity against diphtheria, tetanus, and pertussis in infants and children under the age of 7 years. DTAP is not recommended for wound prophylaxis. B. TIG and DT may be given concurrently for wound prophylaxis, but the nurse should administer these immunizations separately using different muscles. DT is given as wound prophylaxis to children under the age of 7 years. C. Tdap is given to adults and adolescents who have completed the initial DTAP immunization series but have not yet received an adult tetanus booster (Td). The minimum age for TdaP is 10 years; however, children between the ages of 7 and 10 years who have not received all recommended doses of DTAP should be given a dose of Tdap. Tdap is not recommended for wound prophylaxis.

A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? A. Diphtheria, tetanus, and acellular pertussis (DTAP) vaccine B. Single injection of tetanus immune globulin (TIG) mixed with pediatric tetanus booster (DT) C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine D. Adult tetanus booster (Td)

Correct Answer: D. Bruises at various stages of healing ** The nurse should recognize that bruises at various stages of healing are a manifestation of physical abuse. Incorrect Answers: A. Depriving a child of medical and dental care is a manifestation of physical neglect. B. Malnutrition is a manifestation of physical neglect. C. Frequent urinary tract infections are a manifestation of sexual abuse.

A nurse in the emergency department is assessing a preschooler for indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Frequent urinary tract infections D. Bruises at various stages of healing

Correct Answer: C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." ** The coating action of liquids permits larger areas of contact with tissues and results in more extensive injury. Incorrect Answers: A. The absence of oral or pharyngeal burns does not eliminate the possibility of esophageal burns. The existence and extent of burns depend on the substance and the length of time it has been in contact with tissues. A burn may be present in the esophagus but not in the mouth. B. Neutralization can result in heat injury to tissues due to an exothermic reaction. This might cause both chemical and thermal burns of tissues. D. Activated charcoal is not administered to an adolescent who has ingested a corrosive substance because it can infiltrate any tissue that is burned.

A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? A. "The absence of oral burns excludes the possibility of esophageal burns." B. "Treatment focuses on neutralization of the chemical." C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted."

Correct Answer: B. Check the child's respiratory status ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. This child's lips are edematous and inflamed, and he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway. Incorrect Answers: A. The nurse should remove the child's contaminated clothing to prevent further exposure to the substance; however, a different action is thepriority. C. The nurse may administer an antidote if available for the substance ingested; however, a different action is the priority. D. The nurse should establish IV access because shock is a complication of some poisons; however, a different action is the priority.

A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing B. Check the child's respiratory status C. Administer an antidote to the child D. Establish IV access for the child

Correct Answer: D. Acetylcysteine ** The nurse should expect to administer acetylcysteine to the child because it is an antidote to acetaminophen. Incorrect Answers: A. The nurse should expect to administer naloxone if the child is experiencing respiratory depression resulting from an opioid; however, naloxone is not indicated as a treatment for an overdose of acetaminophen. B. The nurse should expect to administer diphenhydramine if the child is experiencing an allergic reaction to a medication; however, diphenhydramine is not indicated as a treatment for an overdose of acetaminophen. C. The nurse should expect to administer glucagon if the child is experiencing hypoglycemia; however, glucagon is not indicated as a treatment for an overdose of acetaminophen.

A nurse in the emergency department is caring for a child who accidentally ingested an overdose of acetaminophen. Which of the following medications should the nurse expect to administer? A, Naloxone B. Diphenhydramine c. Glucagon D. Acetylcysteine

Correct Answer: B. 12 months old ** The nurse should know that this infant must be less than 18 months old because her anterior fontanel is still open. The infant is approximately 12 months old due to the presence of 6 teeth. Her skills-sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say 2 words (12 months)-should also help the nurse estimate the infant's age as 12 months. Incorrect Answers: A. At 6 months, an infant would not have 6 teeth or demonstrate these skills. C. The infant must be younger than 18 months old since her anterior fontanel is still open. In addition, an infant of this age should have 12 teeth. D. At 24 months, an infant should have all of her primary teeth and be able to speak in 2-word phrases.

A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada." The nurse should make which of the following age assessments for this child? A. 6 months old B. 12 months old C. 18 months old D. 24 months old

Correct Answer: C. An infant with a WBC count of 24,000/mm3 ** The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. This WBC count is high and indicates infection and possibly sepsis, which poses the greatest The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy. Incorrect Answers: A. A slightly elevated specific gravity can indicate dehydration; however, it is not a reliable measure in children. While this child requires evaluation for influenza manifestations, another client's immediate needs are the priority. B. Although this toddler's BUN is slightly elevated, the creatinine is within the expected reference range. These findings indicate dehydration, which is expected with influenza manifestations. While the toddler requires evaluation, another client's immediate needs are the priority. D. This finding indicates pregnancy. This client does require care and counseling; however, another client's immediate needs are the priority.

A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider immediately? A. A school-age child with a urine specific gravity of 1.035 B. A toddler with a BUN of 25 mg/dL and a creatinine of 0.5 mg/dL C. An infant with a WBC count of 24,000/mm3 D. An adolescent with a positive beta human chorionic gonadotropin test

Correct Answer: A. Attach a latex allergy alert identification band ** Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk of latex allergy; therefore, the nurse should avoid the use of common medical products containing latex such as latex gloves for this client. Incorrect Answers: B. UTI is a common complication of myelomeningocele. However, neither myelomeningocele nor UTI requires contact precautions. C. UTI is a common complication of myelomeningocele. Straining urine is essential for urolithiasis (urinary calculi) or stones in the urinary system, not for myelomeningocele or UTI. D. Women should take folic acid during pregnancy to reduce the risk of neural tube defects such as myelomeningocele.

A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the client's bathroom to strain the client's urine D. Administer folic acid with meals

Correct Answer: B. RBCS 2.5 million/ul ** An RBC count of 2.5 million/ul is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC count. Incorrect Answers: A. A platelet count of 500,000 mm^3 is above the expected reference range. A child who has acute lymphocytic leukemia has a low platelet count. C. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has acute lymphocytic leukemia has a very high WBC count. D. An Hct level of 60% is above the expected reference range. A child who has acute lymphocytic leukemia has a low Hct level.

A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelets 500,000 mm^3 B. RBCS 2.5 million/ul c. WBCS 4,000/mm^3 D. Hct 60%

Correct Answer: C. A blue coloring of the sclera ** This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding. Incorrect Answers: A. This discoloration is known as a nevus simplex, or stork bite. It typically blanches with pressure and becomes more prominent with crying. This finding does not require notification of the provider. B. This discoloration is known as a Mongolian spot. It is typically observed in infants who have increased skin pigmentation (e.g., those of African, Asian, or Hispanic descent) and does not require notification of the provider. D. This discoloration is known as erythema toxicum, or newborn rash. It is a benign, transient finding and does not require notification of the provider.

A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. A blue coloring of the sclera D. A patchy, red rash with raised centers

Correct Answer: A. Weight gain of 1.8 kg (4 lb) A 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider. Incorrect Answers: B. A heart rate of 125/min is an expected finding in a 2-month-old infant. C. A soft, flat fontanel is an expected finding in a 2-month-old infant. D. A systemic murmur is an expected finding in an infant who has a ventricular septal defect.

A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg (4 lb) B. Heart rate of 125/min C. Soft, flat fontanel D. Systemic murmur

Correct Answer: C. The child cannot walk on tiptoe ** The nurse should identify that a child should be able to take a few steps on tiptoe by 30 months of age. Therefore, the nurse should report this finding to the provider. Incorrect Answers: A. The nurse should identify that bedwetting during sleep is an expected finding for a 3-year-old child. Nighttime bladder control can take months to a few years to achieve following daytime bladder control. B. The nurse should identify that the ability to catch a ball occurs when a child is 4 to 5 years old. A 3-year-old child does not have the gross motor skills necessary to perform this skill. D. The nurse should identify that building a tower of 10 cubes is an expected finding for a 3-year-old child. The child should also have the fine motor skills to copy a circle when drawing and place beads into a small bottle.

A nurse is assessing a 3-year-old child during a well-child examination. Which of the following findings should the nurse report to the provider? A. The child wets the bed when sleeping B. The child cannot catch a ball C. The child cannot walk on tiptoe D. The child builds a tower of 10 cubes

Correct Answer: C. The toddler's birth weight is tripled. The toddler's birth weight should triple by 12 months of age. By 30 months of age, the toddler's birth weight should be quadrupled. Incorrect Answers: A. This is an expected finding in a 30-month-old toddler. At this age, the toddler should have all 20 deciduous teeth. B. The skill of hopping on 1 foot is not developed until around the age of 4 years. D. This is expected finding in a toddler at the age of 30 months. At this age, the toddler should be able to state her first and last name.

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 foot. C. The toddler's birth weight is tripled. D. The toddler is able to state her first and last name.

Correct Answer: B. Development of the superego ** This is the development of a conscience. Preschoolers begin to develop an understanding of right from wrong. While they might be unable to understand the "why" of acceptable vs unacceptable behaviors, they learn the concept through punishment and reward and the principles to which their parents adhere. Incorrect Answers: A. Conservation is the ability to understand that quantity does not change if shape changes. The ability to understand conservation typically develops in a school-age child. C. This is the ability to use previous experiences to solve current problems, which typically develops in the school-aged child. D. Preschoolers are typically able to tolerate brief periods of separation from their parents and interact with unfamiliar persons. Separation anxiety typically develops in infants around 10 months of age.

A nurse is assessing a 4-year-old child's cognitive development during a well-child visit. Which of the following should the nurse expect the child to display? A. Conservation B. Development of the superego C. Concrete operational thought D. Separation anxiety

Correct Answer: A. Fastening buttons on a shirt The nurse should expect a 4-year-old child to have the fine motor ability to fasten buttons on a shirt; however, the child may have difficulty if the buttons are small. Incorrect Answers: B. The nurse should expect a 4-year-old child to have the fine motor ability to lace shoes; however, tying shoelaces is a fine motor skill expected of a 5-year-old child. C. The nurse should expect a 7-year-old child to have the fine motor ability to part and comb his/her hair without the need of assistance. D. The nurse should expect a 7-year-old child to have the fine motor ability to cut tender pieces of meat with a table knife.

A nurse is assessing a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Fastening buttons on a shirt B. Tying shoelaces C. Parting and combing hair D. Cutting the meat at dinner

Correct Answer: C. BP 86/40 mmHg ** A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider. Incorrect Answers: A. This temperature is within the expected reference range for a 6-month-old infant. B. This apical pulse level is within the expected reference range for a 6-month-old infant. D. This respiratory rate is within the expected reference range for a 6-month-old infant.

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? A. Temperature 37.5°C (99.5°F) B. Apical pulse rate 140/min C. BP 86/40 mmHg D. Respiratory rate 32/min

Correct Answer: B. Heart rate 118/min ** The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia. Incorrect Answers: A. The nurse should identify that dullness with chest percussion is an indication of consolidation of infection. Therefore, this finding does not indicate that treatment has been effective. C. The nurse should identify that conjunctival discharge is a manifestation of allergic rhinitis or conjunctivitis. This finding does not indicate effective treatment of pneumococcal pneumonia. D. The nurse should identify that a respiratory rate of 28/min is above the expected reference range for a 6-year-old child. A child who has pneumococcal pneumonia will exhibit tachypnea and shallow respirations.

A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. Dullness with chest percussion B. Heart rate 118/min c. Conjunctival discharge D. Respiratory rate 28/min

Correct Answer: C. The child complains daily about going to school. ** Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children at this stage want to learn and master new concepts. If the child complains daily about going to school, further evaluation is warranted. Incorrect Answers: A. Male and female children who are 7 years old prefer to play with peers who are the same gender. B. School-age children enjoy engaging in various types of competitive games and are learning about the concept of winning. D. A 7-year-old child does not require the same level of companionship as older school-age children; therefore, the fact that this child spending time alone is an expected finding.

A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.

Correct Answer: B. Requiring support to sit for prolonged periods ** An infant should be able to sit unsupported by the age of 8 months. The nurse should report this finding to the provider because it is an indication of a delay in gross motor development. Incorrect Answers: A. The use of a pincer grasp usually begins to appear at the age of 8 months and becomes more refined by the age of 9 months. This is an indication that the infant's fine motor skills are on track with expected findings. C. An infant begins to localize sounds by the age of 3 months. By 9 months of age, the infant should be able to turn the head toward the location of the sound. This is an indication that the infant's sensory skills are on track with expected findings. D. An infant begins to vocalize chained syllables such as "dada" by the age of 7 months of age. By 10 months of age, the infant associates meaning with words such as "mama." This is an indication that the infant's vocalization skills are ahead of expected findings.

A nurse is assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a delay in development? A. Using a pincer grasp to pick up blocks B. Requiring support to sit for prolonged periods C. Turning the head toward the parent's voice D. Reaching for the mother and saying "mama"

Correct Answer: B. Dropping a cube when passing from 1 hand to the other ** The ability to pass a cube from a hand to the other is a fine motor skill expected of a 7-month-old infant. Therefore, the nurse should identify the 9-month-old infant's inability to perform this task as a possible developmental delay and should report this finding to the provider. Incorrect Answers: A. The pincer grasp is an expected fine motor skill for a 9-month-old infant. C. Falling down to a sitting position from a standing position is an expected gross motor skill for a 9-month-old infant. D. A 9-month-old infant should have the gross motor ability to maintain balance while leaning forward in a sitting position; however, the infant does not yet have the ability to maintain balance while leaning sideways.

A nurse is assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? A. Grasping a small object with just the thumb and index finger B. Dropping a cube when passing from 1 hand to the other C. Falling from a standing position to sitting D. Losing balance when leaning sideways while sitting

Correct Answer: B. Murmur at the left sternal border ** A ventricular septal defect (a hole in the septal wall between the ventricles) is an acyanotic heart defect. A systolic murmur can be heard at the lower left sternal border, The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area. Incorrect Answers: A. A diastolic murmur is an expected finding in a child who has an atrial septal defect. C. Cyanosis that increases with crying is an expected finding in a child who has an atrioventricular canal defect. D. Widened pulse pressure is an expected finding in a child who has patent ductus arteriosus.

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 Answer

Correct Answer: A. Hypertension **The nurse should expect a child who has pheochromocytoma to exhibit hypertension due to the increased production of catecholamines. Other manifestations include sweating, weight loss, and polyuria. Incorrect Answers: B. The nurse should expect a child who has pheochromocytoma to exhibit anorexia and weight loss. C. The nurse should expect a child who has pheochromocytoma to exhibit tachycardia. D. The nurse should expect a child who has pheochromocytoma to exhibit constipation.

A nurse is assessing a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect? A. Hypertension B. Abdominal obesity C. Bradycardia D. Loose stools

Correct Answer: B. Enlarged lymph nodes ** Manifestations of stage I Hodgkin disease include painless enlargement of lymph nodes. Incorrect Answers: A. Generalized petechiae are not a manifestation of Hodgkin disease. C. Chronic vomiting is not a manifestation of Hodgkin disease. D. Dependent edema is not a manifestation of Hodgkin disease.

A nurse is assessing a child who has stage I Hodgkin disease. Which of the following findings should the nurse expect? A. Generalized petechiae B. Enlarged lymph nodes c. Chronic vomiting D. Dependent edema

Correct Answer: B. Respiratory depression ** The nurse should monitor the child's respiratory status postoperatively and plan to administer naloxone if respiratory depression is present. Naloxone is an opioid antagonist used to reverse the effects of opioids administered perioperatively. Incorrect Answers: A. The nurse should monitor the child's lung sounds postoperatively. Crackles in the lung bases can indicate atelectasis, which indicates the need to promote lung expansion. However, this is not an indication for the administration of naloxone. C. The nurse should monitor the child for nausea and vomiting postoperatively. This postoperative complication can occur as a result of abdominal distention or pain and as an adverse effect of medications. However, this is not an indication for the administration of naloxone. D. The nurse should monitor the child's heart rate and vital signs postoperatively. Tachycardia can be an indicator of pain, hemorrhage, or hypoxemia indicating the need for further assessment. However, tachycardia is not an indication for the administration of naloxone.

A nurse is assessing a child who is postoperative. Which of the following findings should the nurse identify as an indication that naloxone should be administered? A. Crackles in the lung bases B. Respiratory depression C. Nausea and vomiting D. Tachycardia

Stop the infusion Elevate the extremity Notify the provider Remove the IV line

A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Stop the infusion Notify the provider Remove the IV line Elevate the extremity

Correct Answer: C. 9 ** Apgar scoring is an evaluation of a newborn's heart rate, respiratory effort, muscle tone, reflexes, and color. A maximum score of 2 is assigned for each parameter. This infant lost 1 point for the presence of acrocyanosis. Incorrect Answers: A. A newborn who has a score of 7 would have at least 3 areas lacking in peak response or1-2 areas of additional deficiency. The only deficiency this infant has is cyanosis of the hands and feet, which results in a loss of 1 point. B. A newborn who has a score of 8 would have at least 2 areas lacking in peak response or 1 area of additional deficiency. The only deficiency this infant has is cyanosis of the hands and feet, which results in a loss of 1 point. D. An infant who has an Apgar score of 10 would have earned the maximum for each parameter, but this infant has a deficiency in circulation indicated by acrocyanosis.

A nurse is assessing a newborn at birth to assign Apgar scores. At 1 min of age, the newborn is crying vigorously with limbs flexed and has a heart rate of 120/min. The newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant? A.7 B. 8 c.9 D. 10

Correct Answer: D. Chronic diarrhea ** Chronic diarrhea is an expected finding for a preschooler who has HIV. Incorrect Answers: A. Generalized petechiae are not a manifestation of HIV in a preschooler. B. Jaundice is not a manifestation of HIV in a preschooler. C. Failure to thrive and weight loss are expected findings for a preschooler who has HIV.

A nurse is assessing a preschooler who has HIV. Which of the following manifestations should the nurse expect? A. Generalized petechiae B. Jaundice C. Obesity D. Chronic diarrhea

Correct Answer: B. "Does anyone smoke around or in the same house as your child?" ** Otitis media is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear space and prolongs the inflammation and impedes drainage from the ear. Incorrect Answers: A. Otitis media is an infection of the middle ear and is not caused by exposure to cold weather. C. Although aspirin has some implications for Reye's syndrome if taken during a viral illness, aspirin itself does not cause otitis media. D. Although gluten has some association with a variety of gastrointestinal and allergic disorders, it does not cause otitis media.

A nurse is assessing a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? A. "Does your child wear a hat outdoors in cold weather?" B. "Does anyone smoke around or in the same house as your child?" C. "Have you given your child any aspirin recently?" D. "Is your child's diet high in gluten?"

Correct Answer: B. Steatorrhea ** Foul, fatty, frothy stools known as steatorrhea are a manifestation of celiac disease, which is a malabsorption syndrome. Incorrect Answers: A. Children with cystic fibrosis have an elevated sweat chloride. C. Children who have cardiovascular disorders develop clubbing of the fingers and toes due to chronic hypoxemia of the tissues. D. Jaundice results from liver dysfunction, not celiac disease.

A nurse is assessing a school-age 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 Answer: C. Thin, frail extremities ** The nurse should identify that thin, frail extremities are related to malnourishment and can indicate child maltreatment. The nurse should investigate this finding further and report the results to the provider. Incorrect Answers: A. Bruising of the right elbow is consistent with horseback riding injuries. B. A dislocated shoulder is consistent with horseback riding injuries. D. Abrasions on the wrists are indications consistent with horseback riding injuries, possibly caused by the reins wrapping around the wrists.

A nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A. Bruising of the right elbow B. Dislocated left shoulder revealed by X-ray C. Thin, frail extremities D. Abrasions on both wrists

Correct Answer: A. Abdominal distention ** A VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus. Incorrect Answers: B. This complication can occur following a cardiac catheterization. It is not associated with the insertion of a VP shunt. C. The inability of the shunt to drain due to a blockage will increase intracranial pressure. This can result in pressure on the oculomotor nerve, which causes dilation of the pupils. D. Frontal bossing can be observed in infants with hydrocephalus. Open cranial sutures allow for excess cerebral spinal fluid to cause head enlargement. Frontal bossing describes the protruding frontal skull bones that can occur in severe cases of hydrocephalus.

A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing

Correct Answer: C. Deep, rapid respirations ** This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia. Incorrect Answers: A. This finding indicates mild dehydration. A toddler experiencing severe dehydration would exhibit intense thirst. B. This finding indicates mild to moderate dehydration. A toddler experiencing severe dehydration would exhibit a capillary refill of 4 seconds or greater and skin tenting. D. This finding indicates moderate dehydration. A toddler experiencing severe dehydration would exhibit an absence of tears and sunken eyeballs.

A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production

Correct Answer: A. Koplik spots Koplik spots are small, irregular oral lesions with a bluish-white center. ** They are characteristic of measles (rubeola). Koplik spots appear about 2 days before the maculopapular rash and are accompanied by fevers, malaise, conjunctivitis, and other cold manifestations. Incorrect Answers: B. Swollen parotid glands are an expected finding in a child who has mumps. C. Strawberry tongue is an expected finding in a child who has scarlet fever. D. Paroxysmal coughing is an expected finding in a child who has pertussis.

A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? A. Koplik spots B. Parotitis C. Strawberry tongue D. Paroxysmal coughing

Correct Answer: C. FLACC ** The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. Incorrect Answers: A. The nurse should identify that the FACES pain scale is used for children aged 3 years and older. The scale is composed of 6 cartoon faces that range from smiling to crying with tears. B. The nurse should identify that the CRIES pain scale is used for preterm newborns. CRIES is an acronym for crying, requires increased oxygen, increased vital signs, expression, and sleeplessness. D. The nurse should identify that the Premature Infant Pain Profile (PIPP) is used for preterm newborns.

A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP

Correct Answer: A. The toddler is unable to remove his shoes ** An 18-month-old toddler should be able to remove his or her own shoes, socks, and gloves. The nurse should report this finding to the provider. Incorrect Answers: B. The nurse should identify that a 30-month-old toddler should be able to draw a plus sign. C. The nurse should identify that a 30-month-old toddler should be able to jump off a step or small chair. D. The nurse should identify that an 18-month-old toddler should be able to turn 2 to 3 pages in a book. The child should be able to turn a single page in a book at 24 months of age.

A nurse is assessing an 18-month-old toddler during a well-child examination. Which of the following findings should the nurse report to the provider? A. The toddler is unable to remove his shoes B. The toddler is unable to draw a plus sign C. The toddler is unable to jump off a step D. The toddler is unable to turn 1 page of a book at a time

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

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

Correct Answer: B. Capillary refill 5 seconds ** When using the urgent vs nonurgent approach to client care, the nurse should identify that the priority finding is a capillary refill of 5 seconds. A capillary refill above 4 seconds is an indication of severe dehydration and requires immediate intervention to prevent progression to hypovolemic shock. Incorrect Answers: A. Decreased skin turgor is nonurgent because it is a manifestation of moderate dehydration. Therefore, there is another finding that is the nurse's priority. C. A heart rate of 150/min is nonurgent because it is an expected finding for an infant. Therefore, there is another finding that is the nurse's priority. D. Dry mucous membranes are a nonurgent finding and an early manifestation of mild dehydration. Therefore, there is another finding that is the nurse's priority.

A nurse is assessing an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority? A. Decreased skin turgor B. Capillary refill 5 seconds C. Heart rate 150/min D. Dry mucous membranes

Correct Answer: D. Standing on 1 foot ** The nurse should expect a 3-year-old child to have the gross motor ability to stand on 1 foot for a few seconds. Incorrect Answers: A. Skipping is a developmental task expected of a 4-year-old child. B. Hopping on 1 foot is a developmental task expected of a 4-year-old child. C. Throwing a ball overhead is a developmental task expected of a 4-year-old child.

A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot

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

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

Correct Answer: B. Allow each child to wear his or her glasses during the exam ** The nurse should allow each child to wear his or her glasses during a screening for visual acuity. Incorrect Answers: A. The nurse should position each child so that the heels are at a line that is 3 m (10 ft) away from the Snellen chart C. The nurse should start the screening by testing each child's right eye first. D. The nurse should start the screening by having each child read the 20/20 line of letters on the chart. If they are unable to do so, the nurse should move up to the next larger line of letters on the chart until the child can read at least 4 out of 6 letters correctly.

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 is 6 m (20 ft) away from the Snellen chart B. Allow each child to wear his or her glasses during the exam C. Start the screening by covering each child's right eye D. Begin by having each child read the largest line of letters at the top of the Snellen chart

Correct Answer: C. A plastic mirror ** A 4-month-old infant can recognize herself and will also attempt to play with "the baby in the mirror." A mirror is a bright object that provides appropriate visual stimulation for this age group. For the infant's safety, however, the mirror must be unbreakable. Incorrect Answers: A. This would be an appropriate choice for a 6- to 12-month-old infant. A 4-month-old infant cannot understand the pictures on a board book or hold the book by herself. B. This would be an appropriate choice for a 6- to 12-month-old infant. A 4-month-old infant would not be able to manipulate the toy's movable parts. D. This is an appropriate toy for a 9- to 12-month-old infant. A 4-month-old infant would not be able to perform the actions of pushing and pulling the toy.

A nurse is caring for a 4-month-old child who is hospitalized. Which of the following toys should the nurse provide for the child? A. A board book with large pictures B. A toy with movable parts C.A plastic mirror D. Push-pull toy

Correct Answer: A. Place the infant in knee-chest position ** The nurse should identify that a hypercyanotic spell occurs when a vascular spasm reduces pulmonary blood flow and forces blood to shunt from the right ventricle to the left ventricle through the ventricular septal defect. The nurse should place the infant in a knee-chest position to increase systemic vascular resistance, which will help force more blood through the pulmonary artery. Incorrect Answers: B. The nurse should identify that a hypercyanotic spell is a temporary period of hypoxia that can occur in response to crying, feeding, or straining during a bowel movement. The nurse should not initiate CPR because the infant is still breathing and has a pulse. C. The nurse should administer 100% oxygen via facemask to treat the hypoxia that occurs during a hypercyanotic spell. D. The nurse should not administer adenosine to an infant experiencing a hypercyanotic spell. Adenosine is an antiarrhythmic used in the treatment of supraventricular tachycardia.

A nurse is caring for a 4-month-old infant who has tetralogy of Fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse take? A. Place the infant in knee-chest position B. Begin CPR C. Prepare to intubate the infant D. Administer IV adenosine

Correct Answer: B. Inactivity and thumb sucking ** A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which despair. Incorrect Answers: A. Protest is the first stage of separation anxiety, which includes crying and screaming. C. Denial or detachment is the third stage of separation anxiety, in which the child appears happy and interacts with strangers. D. Protest is the first stage of separation anxiety, which includes attempting to escape the area to find a parent.

A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hours ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb sucking C. Showing interest in nearby toys D. Attempting to escape and find the parent

Correct Answer: B. Small, frequent bottle feedings of electrolyte solution ** Feedings begin 4 to 6 hours after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water. Incorrect Answers: A. Small, incremental formula feedings will resume 24 hours after surgery if small frequent feedings of electrolyte solution are retained by the infant. C. Nasoduodenal tube feedings are indicated for children who have brain injuries or are on mechanical ventilation. D. Gastrostomy feedings are indicated for children who cannot have any foods or fluid by mouth or for whom the passage of a tube through the esophagus is contraindicated.

A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure? A. Bottle formula with added protein B. Small, frequent bottle feedings of electrolyte solution C. Continuous nasoduodenal tube feedings D. Bolus feedings via gastrostomy tube

Correct Answer: C. Determine if there are any recent stressors in the child's environment ** Encopresis can be caused by stress or changes in the child's environment. Incorrect Answers: A. Treatment for encopresis includes emptying the bowel of impacted stool, followed by the administration of daily stool softeners for 2 to 3 months. B. The nurse should encourage the child to attempt to have a bowel movement twice daily. This will help the child establish a regular pattern of defecation, D. The guardian should pay as little attention as possible to bowel accidents and offer praise when encopresis does not occur.

A nurse is caring for a 6-year-old child who is experiencing encopresis. Which of the following actions should the nurse take? A. Instruct the child's guardian to limit stool softener use to no more than twice per week B. Encourage the child to attempt to have a bowel movement 4 times per day C. Determine if there are any recent stressors in the child's environment D. Urge the child's guardian to provide negative consequences when the child has a bowel accident

Correct Answer: D. Chapter books **The nurse should offer chapter books as an appropriate diversional activity for a school-age child who has limited movement due to skeletal traction. Incorrect Answers: A. The nurse should offer a puzzle with large pieces as a diversional activity for a preschooler. B. The nurse should offer building blocks as a diversional activity for a preschooler. C. Although school-age children enjoy crafts such as painting, finger painting is a diversional activity the nurse should offer a toddler.

A nurse is caring for a 7-year-old child who is in skeletal traction following complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books

Correct Answer: A. "An abdominal ultrasound will confirm the pocket in the intestine." ** Intussusception is the invasion of a part of the intestine into another, creating a pocket. The presence of an intussusception is confirmed by an abdominal X-ray, ultrasound, or CT scan. Incorrect Answers: B. Genotyping is performed to determine a child's gene composition and is used for hereditary disease identification. C. A biopsy is done to identify a defect of nerve innervation in the colon and is used for the diagnosis of Hirschsprung's disease. D. An upper gastrointestinal series focuses on an area that is too high to allow visualization of an intussusception and is used diagnosis of pyloric stenosis.

A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is determined. Which of the following responses should the nurse make? A. "An abdominal ultrasound will confirm the pocket in the intestine." B. "Genotyping will be done to identify this condition." C. "A biopsy will be done on a small amount of tissue from the colon." D. "An upper GI series should identify the area involved."

Correct Answer: B. Semi-Fowler's ** Maintaining a semi-Fowler's position promotes adequate ventilation. Flexing the knees slightly will likely be the most comfortable position for the child. Additionally, this promotes drainage of the cecum downward into the pelvis instead of upward toward the lungs. Incorrect Answers: A. Maintaining a supine position will not promote adequate ventilation and can cause painful tugging on or stretching of the incisional area. C. Maintaining Sims' position will not promote adequate ventilation, and the degree of flexion required by the upper leg can cause painful compression of the incisional area. D. This position is used for clients who have difficulty breathing and can cause painful pressure on or compression of this client's incisional area.

A nurse is caring for a child who has a ruptured appendix. Which of the following positions should the nurse encourage the child to maintain? A. Supine B. Semi-Fowler's C. Sims' D. Orthopneic

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

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

Correct Answer: D. Apply continuous pressure to the lower part of the child's nose ** With the child sitting 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. Incorrect Answers: A. Aspirin can increase bleeding from the site due to its antithrombotic actions. B. Tilting the head back allows blood to flow down the back of the throat, causing nausea. C. Lying down increases the risk of aspirating blood.

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 lower part of the child's nose

Correct Answer: B. Administer oral analgesics prior to exercises ** Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause the child discomfort. Incorrect Answers: A. The nurse should implement contact precautions for a client with poliomyelitis. This virus is spread by direct contact with feces and oropharyngeal secretions. C. Respiratory complications from poliomyelitis are due to paralysis of the respiratory muscles. The nurse should assess the child for signs of weak respiratory effort such as difficulty talking, ineffective coughing, and shallow and rapid respirations. D. Seizures are not an expected complication of a poliomyelitis infection.

A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? A. Implement droplet precautions B. Administer oral analgesics prior to exercises c. Use humidified oxygen to thin secretions D. Initiate seizure precautions

Correct Answer: A. Administer ibuprofen ** The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic. Incorrect Answers: B. The nurse should encourage the child to increase daily fluid intake to reduce blood viscosity and prevent sickling of red blood cells. C. Cold compresses increase vasoconstriction and increase pain. Therefore, the nurse should apply warm compresses to painful joints. D. The nurse should ensure the child receives all immunizations to prevent infection. Infection is a major cause of death in children who have sickle cell anemia.

A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints D. Withhold live virus immunizations

Correct Answer: D. Serum cholesterol 700 mg/dL ** A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids. Incorrect Answers: A. A platelet count of 120,000/mm^3 is below the expected reference range. Children with nephrotic syndrome have an increased platelet count because of hemoconcentration. B. A serum sodium level of 160 mEg/L is above the expected reference range. Children who have nephrotic syndrome have a serum sodium level that is lower than expected because of hemoconcentration. C. A hemoglobin level of 9 g/dL is below the expected reference range. Children who have nephrotic syndrome will have hemoglobin levels that are within the expected reference range or elevated.

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelets 120,000/mm^3 B. Serum sodium 160 mEg/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL

Correct Answer: D. RBC 6.8 million/uL ** A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts. Incorrect Answers: A. A platelet count of 20,000/mm^3 is below the expected range. A child who has tetralogy of Fallot will not have a decreased platelet count. B. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has tetralogy of Fallot will not have neutropenia. C. This hormone level is above the expected reference range. A child who has tetralogy of Fallot will not have changes in thyroid function levels.

A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/ul

Correct Answer: D. Encourage the child to use an incentive spirometer ** The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Encouraging the child to use an incentive spirometer will promote adequate oxygenation and is the priority nursing action. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Incorrect Answers: A. The nurse should perform passive range of motion for unaffected joints; however, a different action is the nurse's priority. B. The nurse should massage the child's pressure areas; however, a different action is the nurse's priority. C. The nurse should increase the child's fluid intake; however, a different action is the nurse's priority.

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints B. Massage the child's pressure areas C. Increase the child's fluid intake D. Encourage the child to use an incentive spirometer

Correct Answer: B. Acetylcysteine ** Acetylcysteine is the antidote for acetaminophen overdose or poisoning. Incorrect Answers: A. Digoxin immune fab is an antidote for digoxin toxicity. C. Naloxone is the antidote for opioid overdose. D. Children who have salicylate (aspirin) poisoning or overdose should receive vitamin K to decrease bleeding.

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

Correct Answer: C. Frequent swallowing ** When applying the urgent versus non-urgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. Frequent swallowing can be an indication of bleeding and must be addressed. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Incorrect Answers: A. Nausea is a common adverse effect of anesthesia; therefore, this is not the nurse's priority. B. A hoarse voice is an expected finding following a tonsillectomy; therefore, this is not the nurse's priority. D. A sore throat is an expected finding following a tonsillectomy; therefore, this is not the nurse's priority.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? A. Nausea B. Hoarse voice C. Frequent swallowing D. Sore throat

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

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

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

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

Correct Answer: D. Pad the rails of the toddler's bed ** When caring for a toddler who has manifestations of bacterial meningitis, the nurse should implement seizure precautions, which includes padding the side rails of the bed. Incorrect Answers: A. When caring for a toddler who has a fever, the nurse should administer acetaminophen rather than aspirin because aspirin is associated with the development of Reye syndrome. B. When caring for a toddler who has a fever, the nurse should avoid giving the toddler a cold bath because it can cause shivering and discomfort. C. When caring for a toddler who has manifestations of bacterial meningitis, the nurse should keep the head of the bed slightly elevated to decrease intracranial pressure.

A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take? A. Administer 81 mg of aspirin to the toddler B. Give the toddler a cold bath C. Place the toddler in a supine position D. Pad the rails of the toddler's bed

Correct Answer: A. Transposition of the great arteries ** An infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation. Incorrect Answers: B. An infant who has a ventricular septal defect (a hole in the septal wall between the ventricles) can have increased pulmonary vascular resistance but is unlikely to have cyanosis because oxygenation of the blood remains adequate for systemic circulation. C. An infant who has coarctation of the aorta (constricted segment of the aorta that obstructs blood flow to the body) is unlikely to have cyanosis. Even though the left ventricle must generate higher than normal pressures for adequate stroke volume, oxygenation of the blood remains adequate for the systemic circulation. D. An infant who has a patent ductus arteriosus will have a blood vessel connecting the pulmonary artery to the aorta. The infant can have increased pulmonary vascular resistance, but oxygenation of the blood remains adequate for systemic circulation.

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

Correct Answers: A. The child views death as similar to sleep. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. ** Preschool-age children may think of death like sleep. Preschool-age children also believe that their thoughts and wishes can make things happen since they are egocentric. This is part of why the death of a family member can be difficult for a child at this age. Finally, preschool- age children sometimes believe that death is the result of guilt or a punishment for something they did, said, or thought. Incorrect Answers: B. A school-age child will be interested in post-death services and what happens to the body after death due to an improved ability to comprehend what is happening.

A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to the body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.

Correct Answers: A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water E. Wash hands before and after contact with the affected area ** Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on teaching the child's parents about topical application of an antibacterial ointment. The parents should wash their hands before and after contact with the affected area and wash the child's bed linens daily in hot water to decrease the risk of reinfection or transmission.

A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate illness? (Select all that apply.) A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water C. Administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area

Correct Answer: C. The child reports tightness at the wrist ** The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome. Incorrect Answers: A. The nurse should expect the child to have mild to moderate pain due to the fracture; therefore, a pain level of 5 on a scale of 0 to 10 is an expected finding. If the pain becomes severe and is unrelieved by analgesics, it could indicate an impairment in circulation. B. The nurse should monitor the child for indications of impaired circulation after a cast is applied. The nurse should be concerned if only the casted extremity is cool but not if the finding is bilateral. D. The nurse should expect the child to have impaired function such as a weak grasp due to the fracture. However, if the child develops paralysis of the extremity, it could indicate an impairment in circulation.

A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of 0 to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak

Correct Answer: D. Hematuria ** Hematuria can be detected visually in clients who have acute post-streptococcal glomerulonephritis. Incorrect Answers: A. Elevated blood pressure is a manifestation of acute post-streptococcal glomerulonephritis. B. Serum lipid levels are not elevated for clients who have acute post-streptococcal glomerulonephritis. The levels are within the expected reference range. C. Serum potassium levels are within the normal expected reference range or elevated for clients who have acute post-streptococcal glomerulonephritis.

A nurse is caring for a school-aged child who has acute post-streptococcal glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypotension B. Elevated serum lipid levels C. Decreased serum potassium levels D. Hematuria

Correct Answer: A. Position the child on his side ** Using evidence-based practice, the nurse should first position the child on his side. Salivation increases and the swallowing reflex is lost during a tonic-clonic seizure, placing the child at risk for aspiration. It is essential to maintain the airway during a seizure. Incorrect Answers: B. The nurse should measure the child's vital signs during the postictal period, which occurs just after the seizure has ended; however, evidence-based practice indicates that the nurse should take a different action first. C. The nurse should loosen restrictive clothing to reduce the possibility of further injury during the seizure; however, evidence-based practice indicates that the nurse should take a different action first. D. The nurse should check the child for head injuries during the postictal period; however, evidence-based practice indicates that the nurse should take a different action first.

A nurse is caring for a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse perform first? A. Position the child on his side B. Measure the child's vital signs C. Loosen any restrictive clothing D. Check the child for head injuries

Correct Answer: B. Initiate contact precautions ** Salmonella is a type of bacteria that is transmitted via contaminated feces, making contact precautions essential for preventing transmission. This client is at greatest risk for transmission of Salmonella to others; therefore, contact precautions are the nurse's priority. Incorrect Answers: A. Throughout the course of gastroenteritis, the nurse should monitor the child's weight so essential nutrition support can be provided. The nurse should weigh the child to evaluate the degree of weight loss; however, another action is the nurse's priority. C. Throughout the course of gastroenteritis, the child's skin must be protected. The nurse should establish a skin care routine for the child; however, another action is the nurse's priority. D. The nurse should obtain a recent food history to determine how the child acquired the infection and the source of the Salmonella transmission; however, another action is the priority.

A nurse is caring for a toddler who has gastroenteritis caused by Salmonella. Which of the following is the priority action for the nurse? A. Weigh the child B. Initiate contact precautions C. Establish a skin care routine D. Obtain a recent food history

Correct Answer: D. Administer an antipyretic to the child ** When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Incorrect Answers: A. Reducing the room temperature is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take. B. Redressing the child in minimal clothing is an effective method of reducing the toddler's temperature when implemented about 1 hour following the administration of an antipyretic. Therefore, this is not the first action the nurse should take. C. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take.

A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). 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 antipyretic to the child

Correct Answer: C. Creatinine 0.9 mg/dL ** The expected reference range for a toddler is a creatinine level of 0.3 to 0.7 mg/dL. This child's level is above the expected reference range and should be reported to the provider. Incorrect Answers: A. The expected reference range for a toddler is BUN 5 to 18 mg/dL. B. The expected reference range for a toddler is a uric acid level of 2.0 to 5.5 mg/dL. D. The expected reference range for a toddler is a urine specific gravity of 1.001 to 1.030.

A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the provider? A. BUN 8 mg/dL B. Uric acid 3.0 mg/dL c. Creatinine 0.9 mg/dL D. Urine specific gravity 1.010

Correct Answer: D. 10-piece wooden puzzle ** Age-appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow manipulation and exploration and meet the child's developmental and diversional activity needs. Incorrect Answers: A. Some dolls have accessories that are small and could present a choking hazard for the child. This selection is better for a preschooler or a school-age child. B. Most toddlers are not ready to read and learn the alphabet. This selection is better for a preschooler. C. Video games do not address a toddler's developmental and diversional activity needs. This selection is better for a preschooler or school- age child.

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A. Small plastic doll with clothes and accessories B. Alphabet flash cards C. Handheld video game D. 10-piece wooden puzzle

Correct Answer: B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis (which affects the brain) and meningococcemia (which affects the blood). Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention issued a recommendation that all incoming college students receive the meningococcal immunization. Incorrect Answers: A. The pneumococcal polysaccharide immunization is administered to children between the ages of 2 and 18 years who have a specific high- risk condition that places them at risk for an infection with Streptococcus pneumococci, a bacterium that causes meningitis, otitis media, and pneumonia. C. The final dose of the rotavirus immunization is administered prior to the age of 8 months. An additional booster dose is notrecommended. D. The herpes zoster immunization is recommended for adults over the age of 60 to prevent an episode of shingles.

A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should recommend which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster

Correct Answer: C. Give the child flavored popsicles ** Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children often accept flavored popsicles a source of fluid. Incorrect Answers: A. Cool compresses cause vasoconstriction and might prompt further occlusions. B. A child who has an infection transmitted by direct contact (e.g. Clostridium difficile) requires contact precautions. D. A client who has a warfarin overdose should receive phytonadione. A child who has sickle cell anemia should not receive a warfarin antidote.

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

Correct Answer: D. Pruritus ** Pruritus is an adverse effect of opioids. Constipation, respiratory depression, nausea, vomiting, agitation, orthostatic hypotension, and hallucinations are also adverse effects of opioids. Incorrect Answers: A. Dilated pupils a emanifestations of withdrawal from opioids. B. Tremors are manifestations of withdrawal from opioids. C. Yawning is a manifestation of withdrawal from opioids.

A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? A. Dilated pupils B. Tremors C. Yawning D. Pruritus Answer

Correct Answer: B. Place the adolescent in a supine position ** The nurse should place the adolescent in a supine position for 30 minutes to 1 hour following a lumbar puncture to decrease the risk of a post-dural puncture headache. Incorrect Answers: A. The nurse should encourage the adolescent to consume fluids following a lumbar puncture to promote replacement of cerebrospinal fluid, C. The nurse should assist the provider in applying an adhesive bandage to the puncture site following the procedure. The nurse should avoid the application of heat because it promotes blood flow to the site, which increases the client's risk for bleeding. D. The nurse should apply EMLA cream to the puncture site at least 1 hour prior to the lumbar puncture to decrease the adolescent's pain during the procedure.

A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take? A. Initiate NPO status for the adolescent B. Place the adolescent in a supine position C. Place a moist, warm pack on the adolescent's lower back D. Apply a eutectic mixture of local anesthetics (EMLA) to the adolescent's puncture site

Correct Answers: A. Enlarged heart B. Enuresis C. Leg ulcers E. Retinal detachment ** Chronic vaso-occlusive phenomena result from the obstruction of organs by red blood cells, leading to stasis and enlargement of the organs, infarction due to ischemia, and scarring. An enlarged heart, enuresis, leg ulcers, and retinal detachment are manifestations of chronic vaso- occlusive phenomena. Incorrect Answer: D. Intrahepatic cholestasis is a manifestation of chronic vaso-occlusive phenomena. Extrahepatic cholestasis is caused by the blockage of

A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment

Correct Answer: D. Reinforce teaching with the client about how to push the button to deliver the medication ** The appropriate action at this time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, verify that the client knows how to use the equipment, and emphasize the importance of using it regularly to manage pain effectively. Incorrect Answers: A. A PCA device allows the adolescent to be in charge of pain management and is an effective method of controlling pain. It is inappropriate for the nurse to suggest discontinuing the PCA. B. One of the principles of PCA is that no one other than the client or the nurse pushes the button to deliver the medication. An adolescent is capable of maintaining effective pain control using a PCA. C. Moderate (5 to 6) or severe pain (7 to 10) requires the use of opioids for effective pain management. A PCA delivers an appropriate amount of opioid to treat moderate pain, and the client should be encouraged to push the PCA button to deliver the medication at this time.

A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10 D. Reinforce teaching with the client about how to push the button to deliver the medication

Correct Answer: B. Perform oropharyngeal suctioning ** When caring for an infant who has a tracheoesophageal fistula, the nurse should perform frequent oropharyngeal suctioning to decrease infant's risk of aspiration. Incorrect Answers: A. When caring for an infant who has a tracheoesophageal fistula, the nurse should position the infant supine on an inclined plane with the head elevated to decrease the risk of aspiration. C. When caring for an infant who has a tracheoesophageal fistula, the nurse should maintain the infant on NPO status due to the risk of aspiration. D. When caring for an infant who has a tracheoesophageal fistula, the nurse should maintain the infant on NPO status due to the risk of aspiration.

A nurse is caring for an infant who has a tracheoesophageal 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 Answers: A. Yellow sclerae D. Abdominal distention E. Dark urine ** Biliary atresia is a progressive process that leads to the destruction of the biliary tree. Yellow sclerae are an early manifestation of biliary atresia caused by obstruction of the biliary tree, resulting in cholestasis. Abdominal distention is a clinical manifestation of biliary atresia due to hepatomegaly. Dark urine is a clinical manifestation of biliary atresia due to conjugated bilirubin escaping from the liver and being excreted in the urine. Incorrect answers: B. Infants who have biliary atresia have difficulty metabolizing fat, leading to poor weight gain. C. Acholic or gray stools are a clinical manifestation of biliary atresia. Pale, putty-colored stools are due to the lack of bilirubin in the intestinal tract.

A nurse is caring for an infant who has biliary atresia. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Yellow sclerae B. Rapid weight gain C. Tar-colored stools D. Abdominal distention E. Dark urine

Correct Answer: C. Longer intestinal tract ** Compared to adults or older children, infants have a longer intestinal tract. This results in greater fluid losses, especially through diarrhea. Incorrect Answers: A. Compared to adults or older children, infants have a larger amount of extracellular fluid. This results in a larger fluid volume and more rapid water loss in this age group. B. Compared to adults or older children, infants have a larger body surface area. This results in greater fluid losses through insensible means. D. Compared to adults or older children, infants have an increased rate of metabolism. This results in the production of more metabolic waste, which must be excreted by the kidneys.

A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client? A. Less extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism

Correct Answer: D. Maintain a cardiorespiratory monitor ** Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidified oxygen and suction equipment should be used as needed. Incorrect Answers: A. Pertussis causes paroxysms of coughing with frequent vomiting. Therefore, infants who have pertussis are at risk of fluid volume deficit. B. The nurse should take this action when caring for a child who has a mumps infection, which causes enlarged, painful parotid glands. C. The nurse should initiate standard and droplet precautions when providing care for a client who has pertussis.

A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? A. Assess for edema of the extremities B. Apply warm compresses to the neck area C. Initiate airborne precautions D. Maintain a cardiorespiratory monitor

Correct Answer: A. Measure the client's weight daily ** When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding most critical. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weight. Incorrect Answers: B. Checking for the absence of tears is part of a hydration assessment. However, the lack of tears does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another assessment that is the priority. C. Palpating the fontanel is part of a hydration assessment. However, unless the fontanel is extremely sunken, this assessment does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another assessment that is the priority.

A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A. Measure the client's weight daily B. Check for tears C. Palpate the fontanel D. Assess skin turgor

Correct Answer: B. Measure the infant's head circumference ** Increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements. Incorrect Answers: A. Measuring the infant's intake and output is an essential component of postoperative care. However, the greatest risk to this infant is neurological complications. Therefore, this action is not the nurse's priority. C. Checking the infant's lower-extremity function is an essential component of postoperative care. However, the greatest risk to this infant is neurological complications. Therefore, this action is not the nurse's priority. D. Monitoring the infant's blood pressure is an essential component of postoperative care. However, the greatest risk to this client is neurological complications. Therefore, this action is not the nurse's priority.

A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take? A. Measure the infant's intake and output B. Measure the infant's head circumference C. Check the infant's lower-extremity function D. Monitor the infant's blood pressure

Correct Answer: C. Prone ** When providing preoperative care for an infant who has a myelomeningocele, the nurse should maintain the infant in a prone position. This position reduces pressure and the risk of trauma to the sac. Incorrect Answers: A. When providing preoperative care for an infant who has a myelomeningocele, the nurse should avoid placing the infant in a side-lying position. This position places direct pressure on the sac and increases the infant's risk of trauma. B. When providing preoperative care for an infant who has a myelomeningocele, the nurse should avoid placing the infant in a supine position. This position places direct pressure on the sac and increases the infant's risk of trauma. D. When providing preoperative care for an infant who has a myelomeningocele, the nurse should avoid placing the infant in a semi-Fowler's position. This position places direct pressure on the sac and increases the infant's risk of trauma.

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-Fowler's

Correct Answer: A. People can come back to life after they die. ** A preschooler typically views death as temporary and interchangeable with life. Incorrect Answers: B. An understanding that death is inevitable is usually not achieved until age 9 to 10. C. School-age children might view death as a monster. D. Toddlers are typically unable to comprehend the meaning of death; however, a preschooler has usually moved beyond this level of egocentricity.

A nurse is caring for the family of a preschooler who has 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 Answers: B. Ability to build a tower of 6 blocks D. Slightly bowed or curved leg appearance ** The nurse should expect a 24-month-old toddler to be able to stack a short tower of 6 or 7 blocks. Additionally, a 24-month-old toddler will have a "pot-bellied" appearance; the legs should be slightly bowed to support the weight of the comparatively large trunk. Incorrect Answers: A. The nurse should expect a 24-month-old toddler to have 16 teeth. C. The nurse should expect a 24-month-old toddler to have a vocabulary of about 300 words and to be able to speak in 2- to 3-word phrases. E. The nurse should expect a 24-month-old toddler to have a head circumference that is equal to or less than the chest circumference.

A nurse is conducting a health assessment for a 24-month-old toddler at the local health department. The nurse should expect which of the following findings? (Select all that apply.) A. 8 deciduous teeth B. Ability to build a tower of 6 blocks C. Vocabulary of 10-20 words D. Slightly bowed or curved leg appearance E. Head circumference greater than chest circumference

Correct Answer: D. Cover the oximetry sensor with clothing ** The nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading. Incorrect Answers: A. The nurse should move the sensor to a new site every 4 to 8 hours. The pulse oximetry sensor should not remain in a single location for an extended period of time because of the risk of tissue necrosis. B. The pulse oximetry sensor should be placed around the infant's hand or foot to obtain an accurate reading. C. The pulse oximeter uses a sensor to measure oxygen in the infant's hemoglobin. Conduction gel would interfere with the reading because it would not allow the sensor to attach to the skin.

A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hr 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 Answer: A. Initiate protective-environment isolation for the child ** 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. Incorrect Answers: B. Aplastic anemia decreases the production of RBCS, WBCS, and platelets, which increases the child's risk for bleeding. The nurse should apply pressure to peripheral puncture sites for a minimum of 5 minutes to prevent bleeding following blood specimen collection. C. Ferrous sulfate is a required medication for a child who has iron-deficiency anemia, so it is not a necessary intervention for this client. The nurse should avoid mixing medications into liquids because if the child fails to drink the entire glass, the dosage received is not complete. D. Aplastic anemia does not affect the child's blood glucose level, so this is not a necessary intervention.

A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include? A. Initiate protective-environment isolation for the child B. Apply pressure for 1-2 min at the puncture site following blood specimen 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 4 hr

Correct Answer: A. Monitor the child's oxygen saturation level ** When using the airway, breathing, and circulation (ABC) approach to client care, the priority intervention is to monitor the child's oxygen saturation level. Promoting oxygen utilization prevents further sickling of the child's red blood cells and allows adequate oxygenation of the surrounding tissue. Incorrect Answers: B. The nurse should administer prescribed antibiotics to treat any existing infection. However, another intervention is the priority to include in the plan of care. C. The nurse should encourage fluid intake to prevent dehydration and clumping of red blood cells. However, another intervention is the priority to include in the plan of care. D. The nurse should apply a warm compress to the joints to reduce pain and inflammation. However, another intervention is the priority to

A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? A. Monitor the child's oxygen saturation level B. Administer prescribed antibiotics to the child C. Increase the child's fluid intake D. Apply warm compresses to the child's affected joints

Correct Answer: C. Use manual jaw control when feeding the toddler ** The nurse should encourage the parent to include the use of manual jaw control during feedings. Children diagnosed with cerebral palsy can lose jaw control, and more effective control can be achieved by providing stability to the jaws during feeding. Incorrect Answers: A. Due to the risk of injury for both healthy children and children diagnosed with cerebral palsy, the use of mobile infant walkers is discouraged. B. The nurse should encourage activities involving repetitive joint movement for children diagnosed with cerebral palsy. These activities will assist with fine and gross motor development. D. Wrist splints can assist in maintaining or increasing the mobility of children diagnosed with cerebral palsy. Therefore, the nurse should encourage the use of these devices.

A nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. Which of the following interventions should the nurse include? A. Use a mobile walker for the toddler B. Discourage activities involving repetitive joint movement C. Use manual jaw control when feeding the toddler D. Discourage the use of wrist splints

Correct Answer: A. Higher body fat content is associated with earlier onset of menarche ** The nurse should inform the parents that the onset of menarche is expected to occur around 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. Incorrect Answers: B. The nurse should inform the parents that breast development usually begins around 8 to 12 years of age, followed 2 to 6 months later the appearance of pubic hair. C. The nurse should inform the parents that ovulation is stimulated by the increasing amount of estrogen that develops after the onset of menarche. This increased level of estrogen promotes further sexual maturation. D. The nurse should inform the parents that menarche is an indication of late puberty. The onset of menstrual periods is preceded by an increase in height, breast development, and the appearance of pubic hair.

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 Answer: C. Check the bag for stool every 4 hours ** The nurse should check the bag for stool every 4 hours or less to prevent the bag from overfilling and leaking. Stool from an ileostomy is acidic and can cause excoriation of the skin. Incorrect Answers: A. The nurse should allow the infant to lie on his abdomen because the ostomy has no nerves. Therefore, laying on the ostomy will not cause pain. B. The nurse should tuck the ostomy appliance into the infant's diaper to prevent accidental removal. D. The nurse should plan to replace the appliance once a week. Frequently changing the appliance increases the risk of injury to the skin surrounding the stoma.

A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? A. Avoid laying the infant on his abdomen B. Avoid tucking the appliance into the infant's diaper C. Check the bag for stool every 4 hours D. Replace the appliance every 3 days

Correct Answer: B. The guardian places the child in time-out after misbehaving ** The nurse should encourage the guardian to continue to use time-out as a form of discipline. This technique is effective with a preschooler if carried out correctly. The nurse should review the process of using time-outs with the guardian (e.g. ensuring the time-out takes place in a safe and quiet location) and recommend that the length of the time-out is 1 minute for each year of the child's age. Incorrect Answers: A. The nurse should inform the guardian that a preschooler is in the preoperative stage of cognitive development. Therefore, the child is not yet able to understand fully why an action is wrong. C. The nurse should inform the guardian that a preschooler is in the preoperative stage of cognitive development. Therefore, the child is not yet able to understand how consequences match misbehaviors. The nurse should recommend the guardian decide ahead of time what the consequence should be and then consistently follow through with that consequence if misbehavior occurs. D. The nurse should inform the guardian that assigning an extra chore for misbehavior is an example of an unrelated consequence and should provide the guardian with information about natural and logical consequences. A natural consequence occurs without intervention from the guardian (e.g. getting burned after touching a heater even though the child knows it is dangerous). A logical consequence is directly related to an established rule (e.g. not being allowed to have dessert until the child has eaten vegetables at dinner).

A nurse is discussing disciplinary techniques with the guardian of a preschooler. Which of the following actions indicates to the nurse that the guardian is using an age-appropriate disciplinary technique? A. The guardian explains to the child why her behavior is unacceptable B. The guardian places the child in time-out after misbehaving C. The guardian allows the child to choose the consequence of her misbehavior D. The guardian assigns an extra chore for the child's misbehavior

Correct Answer: A. Celiac disease ** The nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. Other malabsorption conditions include short- bowel syndrome, lactose intolerance, and congenital enzyme deficiency. Incorrect Answers: B. Ulcerative colitis causes chronic diarrhea because it is an inflammatory bowel disease. C. Hirschsprung's disease causes chronic diarrhea because of motility disorders. D. Crohn's disease causes chronic diarrhea because it is an inflammatory bowel disease.

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hirschsprung's disease D. Crohn's disease

Correct Answer: B. Assign the child several small chores ** The nurse should recommend assigning the child several small chores. The completion of each chore in a short amount of time offers the child a sense of accomplishment and promotes the achievement of the developmental task of industry. Incorrect Answers: A. Providing consistent care that meets a physical need promotes trust; however, it doesn't promote industry. Trust is a developmental that should be achieved during infancy. C. Discussing career choices and plans for adulthood with an adolescent is a means of promoting the achievement of the developmental task of identity. D. Talking about the family's value system with an adolescent is a means of promoting the achievement of the developmental task of

A nurse is instructing a group of parents and guardians about child development. Which of the following recommendations should the nurse make to promote the developmental task of industry in the school-age child? A. Have an after-school snack ready for the child each day B. Assign the child 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 Answer: B. Engaging in play near other children ** The nurse should identify that toddler play happens in parallel to that of other children. As socialization begins, the child plays alongside other children, not with them. Incorrect Answers: A. Play becomes associative at about 5 years of age when the child attempts to follow rules but might cheat to avoid losing. C. The nurse should not expect a 2-year-old child to understand the concept of sharing until around 3 years of age. D. The nurse should not expect a child to have the gross motor ability to skip and hop on 1 foot until about 4 years of age.

A nurse is observing the behavior of a 2-year-old child. Which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers? A. Playing a simple game with another child B. Engaging in play near other children C. Sharing crayons with another toddler D. Jumping on 1 foot without help

Correct Answer: C. Wash and dry the genitalia, perineum, and surrounding skin ** The first action the nurse should take is to wash and dry the genitalia, perineum, and the skin in the area to which the urine collection bag will be secured. Incorrect Answers: A. The nurse should apply the collection bag to the skin at the area of the symphysis pubis third, after applying the bag to the perineum. B. The nurse should apply the collection bag to the skin at the area of the perineum after washing and drying the genitalia, perineum, and surrounding skin. D. After applying the urine collection bag, the nurse can initiate the Perez reflex, which results in urination, by stroking the muscles on either side of the infant's spine. The Perez reflex is present in infants who are 4 to 6 months of age.

A nurse is obtaining a urine sample from a 5-month-old infant by applying a urine collection bag. Which of the following actions should the nurse take first? A. Apply the collection bag to the skin at the area of the symphysis pubis B. Apply the collection bag to the skin at the area of the perineum C. Wash and dry the genitalia, perineum, and surrounding skin D. Stroke the muscles on either side of the infant's spine

Correct Answers: A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake *Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. A nutritional goal for this child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake. Incorrect Answers: C. A consistently structured routine of feeding the child at the same time and place is used to promote weight gain. A child who has failure to thrive might not offer feeding cues. D. Caregivers should sit directly in front of the child to maintain a face-to-face position during feeding and promote eye contact. The

A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake C. Follow the child's cues to time food and fluids D. Sit beside the child's high chair for feedings E. Play music videos during scheduled meal times

Correct Answer: A. Provide thorough skin care ** The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection. Incorrect Answers: B. This child is not likely to receive a blood transfusion, which would be indicated for significant blood loss. C. Fluid restriction might be necessary for a child who has nephrotic syndrome. D. The child's diet might require protein, sodium, and fat restrictions, but there is generally no indication for a low-carbohydrate diet.

A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse A. Provide thorough skin care B. Test for blood type and cross-match C. Allow ample hydrating fluids D. Maintain a low-carbohydrate diet

Correct Answer: D. Encourage quiet play ** A platelet count of 20,000/mm^3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk of injury, thereby reducing the chance of hemorrhage. Incorrect Answers: A. Iron is given to a child who has anemia. A platelet count of 20,000/mm^3 is not an indication of an anemic condition. B. Platelets are the blood component associated with clotting. C. RBCS are the blood component responsible for carrying oxygen to body tissues.

A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm^3. Based on this laboratory 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 Answer: B. Position the child on a cooling blanket and cover her with a sheet ** A cooling blanket will lower the temperature of the blood circulating at the skin's surface. This cooler blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated to the skin and dispensed to the cooler outside surface. Incorrect Answers: A. Hyperthermia is caused by external conditions that create more heat than the body can eliminate. The body temperature exceeds the point, which differs from the elevation of the body's actual set point associated with hyperpyrexia (fever). Because of this, antipyretics are not effective in treating hyperthermia. C. The child should be placed in a warm bath. The nurse should gradually add cool water until the water temperature is 1°C (2°F) lower than the child's body temperature. Placing the child in water that is too cool will result in vasoconstriction of the blood vessels on the surface, which will not allow the visceral heat to dissipate to the cooler outside air. D. The nurse should assess the child's temperature every 30 to 60 minutes or continually during the cooling process to prevent hypothermia.

A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hr 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° to 29.4°C (80° to 85°F) D. Assess the child's temperature every 2 hr during the cooling process

Correct Answer: A. Encourage the parents to bring the child's stuffed animal Encouraging parents to bring in a child's favorite stuffed animal may lessen the disruptiveness of hospitalization. Incorrect Answers: B. Children who have autism have difficulty organizing behaviors; therefore, it is best not to give choices. C. Phenytoin is taken by children who have seizure disorders. D. Children who have autism need decreased stimulation and avoidance of auditory or visual distraction. A private room is preferable.

A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring the child's stuffed animal B. Give the child choices when planning daily activities C. Administer phenytoin 3 times per day D. Provide a shared room with another child his age

Correct Answer: B. Lay the preschooler on the nonoperative side The preschooler should not be positioned on the shunt side postoperatively to avoid putting pressure on the shunt or surgical site. Incorrect Answers: A. The nurse should monitor the child's pupillary response every 15 to 30 minutes immediately following neurological surgery. Increased intracranial pressure can put pressure on the oculomotor nerve, causing unilateral pupil dilation. C. The nurse should maintain the preschooler in a flat position to avoid rapid draining of intracranial fluid through the shunt. D. The nurse should check the preschooler's bowel sounds frequently because peritonitis or an ileus can be postoperative complications.

A nurse is planning care for a preschooler who is immediately postoperative following the placement of a ventriculoperitoneal shunt. Which of the following interventions should the nurse include in the plan? A. Monitor the preschooler's pupils every 8 hours B. Lay the preschooler on the nonoperative side C. Keep the head of the bed elevated to 30° D. Check bowel sounds once per day

Correct Answer: C. Encourage the child to participate in physical activities ** The nurse should encourage the child to remain physically active to promote mobility and joint function. Incorrect Answers: A. The nurse should discourage the child from sleeping during the daytime. Children who have JIA have interrupted sleep patterns. Therefore, the nurse should encourage 30 to 60 minutes of quiet play instead of napping to improve nighttime sleep. B. The nurse should apply moist heat compresses to the child's affected joints or provide a long bath each morning to alleviate stiffness and pain. D. The nurse does not need to limit any specific foods for a child who has JIA. The child should maintain a healthy weight to decrease pressure on joints.

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 hour 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 Answer: C. Speak at the child's eye level ** The nurse should instruct the guardian to speak at the child's eye level and ensure there is adequate lighting on the speaker's face to facilitate lip-reading and communication. Incorrect Answers: A. The nurse should instruct the guardian to avoid exaggerating the pronounciation of words because this can decrease understanding. B. The nurse should instruct the guardian to use hand gestures to promote understanding. D. The nurse should instruct the guardian to use facial expressions when speaking to assist in conveying the message being spoken.

A nurse is providing teaching to the guardian of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend facilitate communication with the child? A. Exaggerate the pronunciation of each word B. Keep hands still when speaking c. Speak at the child's eye level D. Avoid using facial expressions when speaking

Correct Answer: C. Maintain the child on bed rest ** The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs. Incorrect Answers: A. Cold compresses are contraindicated because they enhance sickling and vasoconstriction. B. Meperidine is not recommended because this central nervous system stimulant can produce anxiety, tremors, and generalized seizures. D. A child who has sickle cell anemia and is in a vaso-occlusive crisis requires increased fluid intake to prevent sickling.

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities B. Administer meperidine every 4 hr until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for 8 hr

Correct Answers: B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min ** The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea.

A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (Select all that apply.) A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding c. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings U E. Provide gavage feeding if respiratory rate exceeds 80/min

Correct Answer: C. Palpate the abdomen for bladder distension ** A neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess bladder distension due to the possibility of incomplete emptying of the bladder. Incorrect Answers: A. The nurse should not place a diaper on the infant until after the defect has been repaired and healed due to the risk of tearing the sac. The nurse should place padding under the infant to absorb urine and stool and provide frequent skin care. B. Povidone-iodine is neurotoxic and should not come into contact with the spinal malformation. D. The nurse should keep the meningocele sac from drying by applying sterile nonadherent dressings moistened with 0.9% sodium chloride every 2 to 4 hours. A dry dressing might stick to the sac and cause tearing.

A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

Correct Answer: C. Use photographs to help explain the procedure ** The nurse should recognize the school-age child's increased language ability and desire for knowledge. The nurse should use photographs and simple diagrams to explain the procedure in an interesting and concrete way that the child can understand. Incorrect Answers: A. The nurse should limit teaching sessions to 10 to 15 minutes for a preschooler but can extend sessions for a school-age child to about 20 minutes. B. The nurse should use correct medical terminology when providing preoperative teaching for this child. D. The nurse should schedule preoperative teaching sessions for a school-age child no more than 1 day prior to the procedure.

A nurse is planning preoperative teaching for a school-age child who is scheduled for cardiac surgery. Which of the following actions should the nurse plan to take when teaching the child? A. Limit teaching sessions to 10 min B. Use simple, concrete terms when giving explanations c. Use photographs to help explain the procedure D. Conduct the teaching session 2 days before the procedure

Correct Answer: D. Rock the child using long, rhythmic movements ** 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 and forth in long, wide movements. Incorrect Answers: A. This is an example of a distraction strategy. B. This is an example of guided imagery. C. Evidence-based practice indicates that bouncing is not an appropriate action.

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 Answer: D. Encourage the child to focus on a recent pleasurable experience ** The nurse should encourage the child to focus on a recent pleasurable experience such as a trip to the zoo, when using the nonpharmacological technique of guided imagery. This technique encourages the child to focus on the pleasurable experience rather than the sensation of pain. The technique can also be combined with relaxation and breathing techniques. Incorrect Answers: A. The nurse should ask the child to find different designs in a kaleidoscope when using the nonpharmacological technique of distraction. B. The nurse should encourage the child to take a deep breath and let their body go limp during exhalation when using the nonpharmacological technique of relaxation. C. The nurse should encourage the child to think about a stop sign when beginning to feel pain when using the nonpharmacological technique of thought-stopping.

A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. Give the child a kaleidoscope and ask the child to find different designs B. Encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. Encourage the child to focus on a recent pleasurable experience

Correct Answer: A. Schedule the child for a preoperative visit to the facility ** A preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure. Incorrect Answers: B. After 9 years of age, a child understands concepts of death. The nurse should inform the child that he is taking a "special sleep" not that he is being "put to sleep." Children who have pets might regard being "put to sleep" as experiencing death. C. Reading a cartoon book is developmentally appropriate for a preschool-age child or toddler. Participating in therapeutic play has benefits for those age groups. D. Children need factual information and explanations about what will happen during hospitalizations.

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

Correct Answer: 7.5

A nurse is preparing to administer acetaminophen 240 mg PO daily to a child who has a temperature of 38.9°C (102°F). The amount available is acetaminophen oral solution 160 mg/5 mL. How many ml should the nurse administer dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: D. Hold the infant's buttocks together after administering the fluid Because the infant is incontinent, the nurse should hold the buttocks together for a short time to maintain retention of the enema, Incorrect Answers: A. Tap water is hypotonic and can cause a rapid fluid shift and fluid overload. An isotonic solution of 0.9% sodium chloride should be used. B. For an infant, the tubing should be inserted 2.5 cm (1 in) into the rectum for the administration of the enema. C. The infant should be placed in a supine position with the buttocks over a bedpan and the head and back supported by pillows.

A nurse is preparing to administer an enema to a 10-month-old infant. Which of the following actions should the nurse plan to take? A. Administer the enema using room-temperature tap water B. Insert the tubing 7.5 cm (3 in) into the rectum C. Position the infant sitting upright on a bedpan while administering the enema D. Hold the infant's buttocks together after administering the fluid

Correct Answer: 15

A nurse is preparing to administer diphenhydramine 5mg/kg/day PO divided equally every 8 hr to a school-age child who weighs 50 lb. Diphenhydramine oral solution 12.5 mg/5 mL is available. How many mL should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: A. Inactivated poliovirus vaccine (IPV) ** The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The first 3 doses are administered between 2 and 18 months of age. Incorrect Answers: B. The nurse should verify that the child received the Hib vaccine at age 2, 4, and 6 months as well as at age 12 to 15 months. This immunization is not routinely administered at 6 years of age. C. The nurse should verify that the child received the pneumococcal conjugate vaccine at 2, 4, 6, and 12 to 15 months of age. This immunization is not routinely administered at 6 years of age. D. The nurse should verify that the child received the HBV vaccine within 12 hours after birth and received additional doses at 1 to 2 months and 6 to 18 months of age. This immunization is not routinely administered at 6 years of age.

A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTAP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer? A. Inactivated poliovirus vaccine (IPV) B. Haemophilus influenzae type B vaccine (Hib) C. Pneumococcal conjugate vaccine (PCV) D. Hepatitis B vaccine (HBV)

Correct Answer: A. The child prefers to sit on the parent's lap during the examination ** Toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the examination. Incorrect Answers: B. Preschool and school-aged children are typically interested in a demonstration of how the examination equipment works. Toddlers might want to inspect the equipment before use but are not usually interested in how it functions. C. School-aged children are typically interested in how the body works and are open to instructions. Toddlers can understand the names and basic actions that body parts can perform, but they do not usually ask specific questions about body functions. D. Adolescents are typically concerned about comparing their development to the development of peers. Toddlers are just beginning to understand their existence as a separate person from their mother and are not concerned with how their development compares to other toddlers.

A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age

Correct Answer: A. The infant looks at his hands ** Infants usually start to look at their hands while lying down or sitting between 12 to 20 weeks of age. Convergence on near objects is usually well established by 3 months of age. Incorrect Answers: B. By 3 months of age, infants' hands should be mostly open, and they usually hold onto objects placed into their hands. Voluntary grasping of objects does not usually occur until 5 months of age. A crude pincer grasp usually develops by 8 to 9 months of age. C. Infants usually have a partial to slight head lag when pulled to a sitting position at 3 months. By 4 to 6 months, infants gain full head control. D. While some infants might independently roll from their back to their abdomen earlier than expected, a nurse would not expect an infant to be able to do this until 6 months of age.

A nurse is preparing to assess a 3-month-old infant during a well-child visit. Which of the following observations should the nurse expect? A. The infant looks at his hands B. The infant has a pincer grasp C. The infant has no head lag when pulled to a sitting position D. The infant can independently roll from his back to his abdomen

Correct Answer: C. Examine the infant's throat at the end of the examination ** The nurse should perform noninvasive assessments first to avoid causing the infant to cry, which can make the remainder of the examination difficult. Incorrect Answers: A. The nurse should pull the infant's pinna downward and toward the back of the head when examining the ears. The ear canal is curved upward until approximately 3 years of age. Pulling the pinna down and back straightens the ear canal and allows easier visualization of the tympanic membrane. B. The nurse should assess the infant's heart rate by auscultating the apical pulse for 1 min. D. The nurse should not measure the blood pressure in an 11-month-old infant. Blood pressure is routinely measured starting at 3 years of age.

A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? A. Pull the infant's pinna up and back when examining the ears B. Palpate and count the infant's radial pulse for 15 seconds C. Examine the infant's throat at the end of the examination D. Check the infant's blood pressure in both arms

Correct Answer: A. Burp the infant at least 2 to 3 times during the feeding ** Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed. Incorrect Answers: B. Infants who have a cleft lip and palate are typically "noisy" feeders due to the increased amount of air that is swallowed during a feeding. The nurse should watch the infant carefully for signs of distress during a feeding such as a wrinkled brow, elevated eyebrows, or watering eyes. If these distress signs are noted, the nurse should remove the nipple and allow time for the infant to swallow the formula. C. Formula is expected to appear in the nose of an infant who has a cleft lip and palate due to a lack of separation between the oral and nasal cavities. D. Parents and caregivers should be encouraged to begin feeding the infant as soon as possible. This opportunity enables the caregivers to gain experience and confidence in their ability to feed the infant prior to discharge, which typically occurs before the surgical repair.

A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A. Burp the infant at least 2 to 3 times during the feeding B. Remove the nipple from the infant's mouth if swallowing becomes audible C. Stop the feeding if formula appears in the nasal cavity of the infant D. Discourage the parents from participating in the feeding prior to a surgical repair

Correct Answer: D. "The test shows us if your child had a recent strep infection." ** 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. Incorrect Answers: A. A therapeutic blood level indicates a medication (e.g. an antibiotic) is effective. B. A rubella titer indicates the presence of measles. C. A serum albumin level is monitored in a child who has nephrotic syndrome.

A nurse is preparing to obtain an antistreptolysin O (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 your 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 Answer: C. Prepare concentrated sucrose for oral administration ** The nurse should provide the newborn with oral sucrose 2 minutes prior to performing the heel puncture. This practice, along with non- nutritive sucking, has been shown to decrease the pain the newborn experiences during the heel puncture. Incorrect Answers: A. Tolmetin is an oral analgesic medication for clients 2 years of age and older. Therefore, the nurse should not administer this medication to the newborn. B. The nurse should apply EMLA cream to the puncture site about 1 hour prior to the procedure. This allows time for the EMLA cream to decrease the pain the newborn experiences during the heel puncture. D. If skin-to-skin contact with a parent is not possible, the nurse should swaddle and rock or hold the infant to decrease the pain that the newborn experiences during the heel puncture. Swaddling the newborn can reduce pain associated with procedures because it mimics the feeling of being in the womb, whereas being placed in an extended position would be uncomfortable for the newborn and would likely

A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take? A. Administer tolmetin prior to the procedure B. Apply a eutectic mixture of local anesthetics (EMLA) cream to the newborn's heel after the procedure C. Prepare concentrated sucrose for oral administration D. Place the newborn in an extended position

Correct Answer: C. Call the poison control center. ** According to evidence-based practice, the nurse should instruct the parents to call the poison control center, which will then identify what further actions the parents should take. Incorrect Answers: A. Giving the toddler milk to drink will depend on the poison that has been ingested. Evidence-based practice indicates that the nurse should take a different action first. B. The parents may need to take the toddler to the emergency department, but this will depend on the poison and amount that has been ingested. Evidence-based practice indicates that the nurse should take a different action first. D. Inducing vomiting will depend on the poison that has been ingested. Evidence-based practice indicates that the nurse should take a different action first. For many poisons, such as corrosives, inducing vomiting can cause additional harm by prompting burns.

A nurse is providing anticipatory guidance about the accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk. B. Go to an emergency department. c. Call the poison control center. D. Induce vomiting.

Correct Answer: A. Provide a high-fat diet for the toddler ** Children who have cystic fibrosis have impaired intestinal absorption of fat. Therefore, the toddler will require an increased intake of fat. Incorrect Answers: B. The parent does not need to restrict the toddler's intake of sodium. C. The parent should increase the toddler's daily caloric intake. An increase in foods high in folic acid is not required for children who have cystic fibrosis. D. The parent should increase the toddler's daily caloric intake by 110% to 200% to meet increased nutritional needs. Therefore, the toddler should not skip meals.

A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry

Correct Answer: C. "I should lightly massage my baby underneath the straps once a day." **The parent should lightly massage the skin under the harness daily to promote circulation. Incorrect Answers: A. The parent should avoid using powders and lotions because they can accumulate in the skin folds and cause irritation. B. The parent should never adjust the length of the straps on the harness. The straps should only be adjusted by the health care provider to ensure prevention of hip extension and adduction. D. The diaper should be placed under the harness to maintain cleanliness.

A nurse is providing discharge teaching for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? A. "I should apply powder to the folds of skin on my baby's knees and thighs." B. "I should adjust the straps on the harness once a week as my baby grows." C. "I should lightly massage my baby underneath the straps once a day." D. "I should place my baby's diaper over the straps of the harness."

Correct Answer: C. Apply antibacterial ointment to the infant's penis once per day ** The nurse should instruct the guardian to apply an antibacterial ointment to the infant's penis once daily to decrease the risk of infection. Incorrect Answers: A. The nurse should instruct the guardian to avoid clamping the catheter at any time. B. The nurse should instruct the guardian to avoid giving the infant tub baths until the catheter and stent are removed and bathing is approved by the provider. D. The nurse should instruct the guardian to increase the infant's fluid intake.

A nurse is providing discharge teaching to the guardian of an infant following a hypospadias repair. Which of the following instructions should the nurse include? A. Clamp the infant's catheter for 30 minutes each day B. Give the infant a tub bath once per day C. Apply antibacterial ointment to the infant's penis once per day D. Decrease the infant's fluid intake for 3 days

Correct Answer: C. "I will inspect my child's mouth every day for sores." ** A child who has leukemia is at an increased risk of mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations. Incorrect Answers: A. The parent should avoid taking rectal temperatures to prevent trauma to the child. B. A child who has leukemia will have a compromised immune system and should not receive the MMR vaccine. D. The nurse should advise the parents to avoid any activities that could cause injury or bleeding, such as riding bicycles or climbing playground equipment.

A nurse is providing discharge teaching to the parent of a school-aged child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will take my child's rectal temperature daily." B. "I will make sure my child gets his MMR vaccine this week." C. "I will inspect my child's mouth every day for sores." D. "I will allow my child to ride his bicycle tomorrow."

Correct Answer: D. Keep the child away from people who have an infection ** Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections. Incorrect Answers: A. The nurse should instruct the parents to restrict the child's sodium intake and, in severe cases, restrict fluids. A child who has acute glomerulonephritis should have a restricted potassium intake. B. Corticosteroids are the first-line treatment for children who have nephrotic syndrome. C. A child who has nephrotic syndrome should be weighed at home daily to determine the effectiveness of the therapy.

A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A. Restrict the child's potassium intake B. Administer acetaminophen to the child twice daily C. Weigh the child once each week D. Keep the child away from people who have an infection

Correct Answer: B. Vocabulary of 10 or more words ** At 18 months, children typically have a vocabulary of 10 or more words. Incorrect Answers: A. A 2-year-old child can state his/her name and typically refers to self by name as opposed to using the correct pronoun. C. A 2-year-old child is typically able to follow and complete simple commands. D. Toddlers typically cannot name a color until they have reached 30 months of age.

A nurse is providing education for a group of parents about toddler language development during a well-child visit. Which of the following findings should the parent expect in an 18-month-old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Following simple directional commands D. Naming a single color

Correct Answer: C. Scrambled eggs ** A client who has celiac disease should be on a gluten-free diet and should avoid foods containing barley, oat, rye, and wheat; therefore, scrambled eggs are an appropriate breakfast item for the nurse to recommend to the client. Incorrect Answers: A. Gluten is found primarily in wheat and rye, but it is also found in smaller quantities in barley and oats; therefore, plain flour pastries are an inappropriate breakfast item for the nurse to recommend to the client. B. Wheat cereal is an inappropriate breakfast item for the nurse to recommend to this client. D. Rye toast is an inappropriate breakfast item for the nurse to recommend to this client.

A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? A. Plain flour pastry B. Wheat cereal C. Scrambled eggs D. Rye toast

Correct Answer: B. Muscle weakness ** Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea. Incorrect Answers: A. Bradycardia is not an adverse effect of baclofen. This medication can cause hypotension. C. Diarrhea is not an adverse effect of baclofen. This medication can cause constipation. D. Dry skin is not an adverse effect of baclofen. This medication can cause increased sweating.

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 Answer: D. Metabolic acidosis ** Metabolic acidosis is an expected finding for clients who have acute renal failure. Incorrect Answers: A. Hyperkalemia is an expected finding for clients who have acute renal failure. B. Hypocalcemia is an expected finding for clients who have acute renal failure. C. An elevated plasma creatinine level is an expected finding for clients who have acute renal failure.

A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis

Correct Answer: D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes ** Zinc oxide can be applied as a barrier ointment to areas that are reddened or open and moist. While removing the waste material, zinc oxide should be left in place as much as possible during a diaper change. More ointment can be applied as needed. The ointment can be removed, if necessary, by applying mineral oil to the area and gently wiping. Incorrect Answers: A. Healthy and slightly irritated skin can be exposed to air to maximize drying and to prevent dermatitis. However, hair dryers and heat lamps have been shown to cause burns and should not be used. B. Superabsorbent disposable diapers should be used to reduce wetness on the skin when diaper dermatitis is present. These diapers prevent the mixing of urine and stool, which increases the occurrence of dermatitis. C. Over-washing of the skin, especially with perfumed soaps or wipes, can be irritating and increase the risk for the development of

A nurse is providing teaching about home care to the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? A. Dry the affected area with a hair dryer on the low setting twice per day B. Use cloth diapers washed in a low-residue detergent C. Wash the genital area vigorously with each diaper change D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes

Correct Answer: A. Remove bibs before the infant goes to sleep ** The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation. Incorrect Answers: B. The nurse should instruct the parent to dress the infant in a 1-piece sleep sack and avoid using blankets to decrease the risk of suffocation. C. The nurse should instruct the parent to avoid placing the infant in direct sunlight for more than 2 to 3 minutes at a time. If the infant will be exposed to sunlight for a longer period, the parent should cover any exposed areas of skin. D. The nurse should instruct the parent to set the hot water heater to no more than 49°C (120°F) to prevent burn injuries.

A nurse is providing teaching about home safety to the parent of a 2-month-old infant. Which of the following information should the nurse include? A. Remove bibs before the infant goes to sleep B. Cover the infant with a lightweight blanket at bedtime C. Place the infant in direct sunlight for at least 10 minutes each day D. Set the hot water heater to 60°C (140°F)

Correct Answer: A. "Initial vaccines should be administered between birth and 2 weeks of age." ** The first dose of the hepatitis B vaccine should be administered within the first 2 weeks after birth. The dose should be given before discharge from the hospital if the mother is hepatitis B surface antigen (HBSAg) negative. Incorrect Answers: B. If a client receives an initial dose in a series but misses a subsequent dose, the client will not need to begin the series again. The client should receive the missed dose as soon as possible. C. Allergic reactions to vaccines are most often caused by the inactive parts of the vaccine, which are used to enhance the effectiveness of the vaccine. Examples of inactive ingredients that might cause an allergic reaction include purified culture medium proteins such as egg and antibiotics such as neomycin. D. A vaccination does not need to be postponed for minor illnesses such as a common cold. A rectal temperature of 37.5°C (99.5 F) is

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 begin the vaccination series over again if subsequent doses 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 a rectal temperature of 99.5°F and head congestion."

Correct Answer: B. "Keep hair off your forehead." ** Hair and scalp care can provide relief from the manifestation of acne. Frequent shampooing and keeping hair away from the face can improve acne. Incorrect Answers: A. Abrasive skin agents such as exfoliating cleansers can worsen acne and cause trauma to the skin. Only gentle skin cleansers should be used. C. Tetracycline should be taken on an empty stomach to improve the absorption of the medication. D. The nurse should instruct the client not to squeeze or pick acne lesions. Squeezing acne lesions ruptures glands and causes sebum to spread into the skin, which increases inflammation.

A nurse is providing teaching for a 14-year old client who has acne. Which of the following instruction should the nurse include? A. "Use an exfoliating cleanser." B. "Keep hair off your forehead." C. "Take tetracycline after meals." D. "Squeeze acne lesions as they appear."

Correct Answer: D. "You will be able to participate in physical exercises." ** Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided. Incorrect Answers: A. Passive range-of-motion exercises are not done after a bleeding episode because rebleeding can occur. Active motion is best to allow activity to be tailored to the child's pain level. B. A manifestation of hemophilia A is hemarthrosis (bleeding into a joint capsule). This can result in numbness, tingling, or pain, along with discoloration, warmth, and swelling of the affected joint. The nurse should instruct the child to rest the joint, elevate it above the level of the heart, and apply ice to decrease the rate of bleeding into the joint capsule. C. Intracranial hemorrhage is a leading cause of death in clients who have hemophilia A. The nurse should instruct the child to avoid the use of aspirin because it has antiplatelet properties that can increase bleeding.

A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A. "Have your parent stretch and move your legs for you." B. "Apply heat to joints that become painful, stiff, and swollen." C. "Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."

Correct Answer: C. Barking cough ** Infants who have tracheomalacia have a weakened trachea, which can lead to collapse. Clinical manifestations of tracheomalacia include a barking cough, stridor, wheezing, cyanosis, and apnea. Incorrect Answers: A. Tracheoesophageal fistula is an upper gastrointestinal disorder; therefore, bowel sounds would not be absent in this condition. B. Neck contortions are an expected finding in an infant who has a hiatal hernia. D. Projectile vomiting is an expected finding in an infant who has hypertrophic pyloric stenosis.

A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortions C. Barking cough D. Projectile vomiting

Correct Answer: C. "I will wash my child's clothes in hot water." ** 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. Incorrect Answers: A. Impetigo is a bacterial infection of the skin caused by staphylococci or streptococci bacteria. B. Impetigo is spread via direct contact and is contagious from the time of initial appearance of lesions until all lesions have healed. D. Impetigo does not cause the formation of antibodies that prevent reinfection. Therefore, the child can get impetigo again in the future.

A nurse is providing teaching to a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding 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 now has immunity against impetigo."

Correct Answer: D. Leave the medicated shampoo on the scalp for 5 to 10 minutes ** The nurse should instruct the parent to use a shampoo made of 2% ketoconazole or 1% selenium sulfide for the treatment of tinea capitis. For the shampoo to be effective, the parent should leave it on the child's scalp for 5 to 10 minutes prior to rinsing. Incorrect Answers: A. The nurse should instruct the parent to use aluminum acetate solution compresses for the treatment of lesions caused by herpes simplex virus type 1 or for tinea pedis. B. The nurse should instruct the parent that tinea infections are caused by fungi and require antifungal treatments and medications. C. The nurse should instruct the parent to seal non-washable toys in a plastic bag for 2 weeks for the treatment of pediculosis.

A nurse is providing teaching to a parent of a preschooler who has tinea capitis. Which of the following instructions should the nurse include in the teaching? A. Apply aluminum acetate solution compresses to the lesions B. Apply hydrocortisone cream to the lesions twice daily C. Seal nonwashable toys in a plastic bag for 2 weeks D. Leave the medicated shampoo on the scalp for 5 to 10 minutes

Correct Answer: C. "Attend school regularly." **The nurse should encourage this adolescent with idiopathic arthritis to attend school. The adolescent should attend school even on days when joint pain or stiffness occurs. Incorrect Answers: A. The client should apply moist heat to relieve joint pain and stiffness. B. Opioid pain medications are not routinely prescribed for pain associated with juvenile idiopathic arthritis. The nurse should instruct the client to take NSAIDS on a routine schedule to maintain adequate therapeutic levels. D. There is no "arthritis diet" or certain foods for the adolescent to avoid to decrease symptoms of arthritis. However, to avoid excessive weight gain, the client should monitor and match the caloric intake to individual energy needs.

A nurse is providing teaching to an adolescent client who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? A. "Apply cold compresses to relieve your joint pain." B. "Take opioids routinely." C. "Attend school regularly." D. "Adhere to an arthritis diet."

Correct Answer: A. Hip Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. ** When participating in vigorous exercise that involves both the arms and legs, the client should use a hip as the insulin injection site. Incorrect Answers: B. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the upper arms during basketball competitions. C. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the thighs during basketball competitions. D. The lower leg is not a recommended injection site for insulin. Insulin is administered subcutaneously into adipose or fat tissue over a muscle. Recommended injection sites for insulin are the abdomen, hips, buttocks, upper arms and thighs. When participating in vigorous

A nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions? A. Hip B. Upper arm C. Thigh D. Lower leg

Correct Answer: C. "We can help our child by structuring our daily routine." ** Children who have autism spectrum disorder benefit from a structured routine. This environment can minimize the anxiety the child might have with sudden schedule changes and socialization requirements and satisfy a preference for ritualistic behavior. Incorrect Answers: A. Donepezil might slow the progression of early onset Alzheimer's disease but is not indicated for autism spectrum disorder. B. Children with autism spectrum disorder have a limited interest in others and struggle with interpersonal interaction; therefore, individual therapy with a consistent caregiver is often preferred. D. There is no evidence that prematurity causes autism spectrum disorder.

A nurse is providing teaching to the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the teaching? A. "Donepezil might slow the progression of the disorder." B. "My child will prefer group therapy with other children." c. "We can help our child by structuring our daily routine." D. "Our child probably has this condition as a result of prematurity."

Correct Answers: A. "My child will likely be irritable for the next few weeks." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." ** A child who is diagnosed with Kawasaki disease will likely be irritable for up to 2 months. A child who has Kawasaki disease receives high doses of gamma globulin during the initial phase, which might result in the inability to produce adequate antibodies in response to a live vaccine; therefore, these vaccines should be delayed for 11 months. Also, the temperature of this child who has Kawasaki disease should be recorded until she has been afebrile for several days. Incorrect Answers: B. Peeling of the skin of the hands and feet is expected for a child who has Kawasaki disease. The peeling does not cause any pain and

A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? (Select all that apply.) A. "My child will likely be irritable for the next few weeks." B. "I will notify my child's doctor if the skin on her hands or feet begins to peel." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." O E. "My child will have joint stiffness primarily at the end of the day."

Correct Answer: D. Allow the infant to splash in the bathtub ** The nurse should suggest allowing this 4-month-old infant to splash in the bathtub as a play activity. Splashing is appropriate for the developmental age of the infant and provides tactile stimulation. However, the nurse should emphasize and teach bath safety to prevent injury. Incorrect Answers: A. The nurse should suggest showing a board book with large pictures as a play activity to provide visual stimulation for a 9- to 12-month-old infant. An example of an activity that provides visual stimulation for a 4-month-old infant would be placing a toy that has bright colors in the infant's hand. B. The nurse should suggest imitating animal sounds as a play activity to provide auditory stimulation for a 9- to 12-month-old infant. activity that provides auditory stimulation for a 4-month-old infant is placing rattle in the infant's hand.

A nurse is providing teaching to the guardians of a 4-month-old infant on how to play with the infant. Which of the following play activities should the nurse suggest for this infant? A. Show the infant a board book with large pictures B. Imitate the sounds of different farm animals for the infant C. Give the infant a large push-pull toy D. Allow the infant to splash in the bathtub

Correct Answer: A. "My child should consume 1,000 calories per day." ** Toddlers who are 2 years old should consume 1,000 calories daily. Incorrect Answers: B. Toddlers who are 2 years old should have 2 oz of protein daily. C. Toddlers who are 2 years old should have no more than 24 oz (3 cups) of milk per day. D. Toddlers who are 2 years old should consume 8 oz (1 cup) of vegetables per day.

A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should consume 1,000 calories per day." B. "My child should have 4 oz of protein per day." c. "I should give my child 32 oz (4 cups) of milk per day." D. "I should feed my child 4 oz (1/2 cup) of vegetables per day."

Correct Answer: A. Bulky stools ** The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools. Incorrect Answers: B. The nurse should identify that a weakened rectal sphincter is not a manifestation of cystic fibrosis. C. The nurse should identify that a prolapsed rectum is associated with insufficient pancreatic enzymes. D. The nurse should identify that a prolapsed rectum is associated with increased intra-abdominal pressure.

A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure

Correct Answer: B. Dry clothing in a hot dryer for at least 20 min ** The nurse should instruct the parent to dry the child's clothing in a hot dryer for at least 20 minutes. Incorrect Answers: A. The nurse should instruct the parent to machine-wash the child's clothing and bed linens in hot water. C. The nurse should instruct the parent to soak the child's combs and brushes for 10 minutes in boiling water. D. The nurse should instruct the parent to seal the child's nonwashable items in a bag for 14 days.

A nurse is providing teaching to the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include? A. Machine-wash clothing in cold water B. Dry clothing in a hot dryer for at least 20 min c. Soak combs and brushes for 5 min in boiling water D. Seal nonwashable items in a bag for 7 days

Correct Answer: C. Notify the provider immediately if the sclera becomes inflamed ** Although the conjunctiva becomes inflamed during this infection, the sclera should remain clear and white. If the sclera becomes inflamed, it can indicate the presence of a serious conjunctival infection, and the child should be assessed immediately by an ophthalmologist. Incorrect Answers: A. The parent should clean secretions from the eye by wiping from the inner canthus towards the outer canthus and downward. B. Warm compresses can be applied to assist in removing dried secretions. However, the compress should not be left on the eye because can enhance bacterial growth. D. Applying pressure to the inner canthus of the eye after medication administration will block the lacrimal punctum. This will prevent the medication from flowing into the nasopharynx and causing an unpleasant taste.

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 from the outer canthus toward the inner canthus and upward B. Keep the infected eye covered with warm compresses for the first 24 to 48 hr C. Notify the provider immediately if the sclera becomes inflamed D. Apply pressure to the outer canthus of the eye for1 min after administering the eye drops

Correct Answer: A. "I will apply the harness over a t-shirt and knee socks." ** Applying the harness over a t-shirt and knee socks indicates that the parent understands the instructions. This step will prevent the harness straps from rubbing against and causing irritation to the infant's skin. Incorrect Answers: B. Putting the infant's diaper over the harness will cause soiling of the harness and allow direct contact of the harness with the skin, which can lead to skin irritation and breakdown. C. The parent should return to the clinic for harness adjustments. Parents should not make any adjustments to the harness without the supervision of a health care professional. D. Lotions and powders should not be applied due to the possibility of causing irritation to the skin around the buckles.

A nurse is providing teaching to the parent of an infant who has developmental hip dysplasia and a new prescription for a Pavlik harness. Which of the following parent statements indicates an understanding of the teaching? A. "I will apply the harness over a t-shirt and knee socks." B. "I will put my baby's diaper over the harness." C. "I will make the required harness adjustments as my baby grows." D. "I will apply powder around the harness buckles each day."

Correct Answer: A. Copying a circle ** The nurse should explain that copying a circle is a skill achieved by the age of 4 years. Incorrect Answers: B. Cutting food using a table knife is a fine motor skill expected of 7-year-old children. C. The initial use of cursive writing is an expected skill for an 8- to 9-year-old child. D. Children will print their first name around the age of 5 years.

A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include as expected finding for this age group? A. Copying a circle B. Cutting foods using a table knife C. Beginning to write in cursive D. Printing the first and last name clearly

Correct Answer: B. "Your baby can start the pneumococcal vaccine now." ** The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age. Incorrect Answers: A. The nurse should instruct the guardian that the infant should not receive the varicella vaccine until 1 year of age. C. The nurse should instruct the guardian that the infant can receive an annual influenza vaccine beginning at 6 months of age. D. The nurse should instruct the guardian that the infant can receive the first dose of the measles, mumps, and rubella vaccine beginning at 12 months of age.

A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella vaccine at 6 months of age." B. "Your baby can start the pneumococcal vaccine now." C. "Your baby should receive the flu vaccine before 6 months of age." D. "You baby can start the measles, mumps, and rubella vaccine now."

Correct Answer: C. Sodium 125 mEq/L ** The nurse should expect an infant with acute renal failure to have hyponatremia. A sodium level of 125 mEg/L is below the expected reference range for an infant. Incorrect Answers: A. The nurse should expect an infant with acute renal failure to have an elevated BUN level. A BUN level of 5 mg/dL is within the expected reference range for an infant. B. The nurse should expect an infant with acute renal failure to have an elevated creatinine level. A creatinine level of 0.2 mg/dL is within the expected reference range for an infant. D. The nurse should expect an infant with acute renal failure to have hyperkalemia. A potassium level of 4.2 mEq/L is within the expected reference range for an infant.

A nurse is reviewing the laboratory values for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect? A. BUN 5 mg/dL B. Creatinine 0.2 mg/dL C. Sodium 125 mEq/L D. Potassium 4.2 mEg/L

Correct Answer: A. "The infant might be dehydrated." ** An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration. Incorrect Answers: B. This infant's hemoglobin value is within the expected reference range. Clients who have anemia have a decreased hemoglobin level. C. Overhydration would result in a decreased hematocrit level. A hematocrit level of 51% is an increased value. D. Leukemia presents with a high WBC count and a low RBC count. These hemoglobin and hematocrit levels do not indicate the impaired bone marrow production seen in leukemia.

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

Correct Answer: A. "Use a stable, relaxing routine like a bath and story time before bed." ** Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime and allow parental-child interaction prior to bed. Incorrect Answers: B. Completely darkened rooms can elicit fear in preschoolers, including fear of the dark and of "monsters" that hide in the dark. C. Allowing the child to fall asleep routinely in a parent's lap might make him unable to fall asleep alone. The child should learn to sleep in his own bed with a transitional object, such as a blanket or toy. D. The parent should avoid responding to attention-seeking behavior, which the child learns will delay and disrupt bedtime.

A nurse is talking with a parent of a preschooler. The parent reports that she struggles to get her child to go to bed at a consistent time. She explains that the child gets out of bed, enters his parents' room, and cries when they tell him to stay in his own bed. Which of the following instructions should the nurse give the parent? A. "Use a stable, relaxing routine like a bath and story time before bed." B. "Make sure the room is completely dark when placing your child in bed." C. "Let your child go to sleep in your lap and then put him in his bed." D. "Respond consistently if your child cries out for you after putting him to bed."

Correct Answer: C. "My baby loves to play with the pillows in her crib." ** Parents should never place pillows in their infant's crib since they pose a suffocation hazard. Incorrect Answers: A. This comment indicates that the client has appropriate information about the fine motor development of 4-month-old infants. At this age, the infant is beginning to reach for and grasp objects and place them in her mouth. It is appropriate anticipatory guidance to start reminding older children at this time to keep small objects away from the infant's reach to keep her safe from a potential choking hazard. B. This comment indicates that the client has appropriate information about the gross motor development of 4-month-old infants. Parents should encourage infants to learn to explore their environment by crawling and rolling over. D. This comment indicates that the client has the appropriate information about using a car seat for a 4-month-old infant. Until the child is 2 years old, she should be in a rear-facing car seat in the back seat of the car.

A nurse is talking with the parent of a 4-month-old infant about growth and development. Which of the following statements indicates that the parent needs further teaching? A. "I need to remind my older kids to keep small objects out of the baby's reach." B. "I let my baby play on her stomach when she is awake and I am watching." C. "My baby loves to play with the pillows in her crib." D. "I put my baby in a rear-facing car seat in the back seat of the car."

Correct Answer: D. "I will place a pressure dressing over the area following the procedure." ** Applying a pressure dressing over the area following the procedure helps prevent bleeding from the site. Incorrect Answers: A. The child should not receive an antibiotic prior to a bone marrow biopsy because the use of an antibiotic might skew the test results. B. The child should be in the prone position because the provider will obtain the specimen from the iliac crest. C. Bone marrow aspiration will not affect the brain or its fluids. Lumbar punctures are likely to cause headaches.

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

Correct Answer: C. "Keep a diary of the foods your child eats each day." ** The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. Incorrect Answers: A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from." Answer

Correct Answer: A. Regression ** The nurse should identify that the 6-year-old sibling's behavior is an indication of regression. With this defense mechanism, the individual reverts to a prior stage of development as a means of coping with stress. Incorrect Answers: B. Repression is a defense mechanism in which the individual involuntarily blocks awareness of a stressor. The 6-year-old sibling's behavior is not an indication of repression. C. Rationalization is a defense mechanism in which the individual attempts to explain unacceptable behavior or feelings with logical reasoning. The 6-year-old sibling's behavior is not an indication of rationalization. D. Identification is a defense mechanism in which individuals attempt to boost self-esteem by behaving like or portraying qualities of someone who is held in high regard. The 6-year-old sibling's behavior is not an indication of identification.

A nurse is talking with the parent of an infant during a well-child visit. The parent states, "My 6-year-old child started wetting the bed after we brought her sister home. She hasn't done that in over a year." This behavior by the sibling is an indication of which of the following defense mechanisms? A. Regression B. Repression C. Rationalization D. Identification

Correct Answers: A. Hot dogs B. Grapes C. Bagels D. Marshmallows ** Foods that are shaped like a tube, such as hot dogs and grapes, place toddlers at risk for choking because they can completely block the throat when swallowed whole due to their shape and solidity. Foods that are hard to chew, such as bagels and marshmallows, place toddlers at risk for choking; if swallowed before they are adequately chewed, they can block the airway. Incorrect Answer: E. All foods and fluids can potentially cause choking. However, graham crackers become soft quickly when mixed with saliva. Their

A nurse is teaching a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods increase the risk of choking in toddlers? (Select all that apply.) A. Hot dogs B. Grapes C. Bagels D. Marshmallows E. Graham crackers Answer

Correct Answer: A. Hydrocephalus ** In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered. Therefore, the infant is at risk of hydrocephalus, and the nurse should monitor the infant for this condition. Incorrect Answers: B. Congenital hypotonia is a paralytic form of spinal muscular atrophy that is characterized by progressive weakness and wasting of skeletal muscles; therefore, the infant should not be monitored for this complication. C. Otitis media results from blocked eustachian tubes and is not related to neural tube defects; therefore, the infant should not be monitored for this condition. D. Osteomyelitis results from an organism gaining access to the bone; therefore, the infant should not be monitored for this condition.

A nurse is teaching 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. Otitis media D. Osteomyelitis

Correct Answer: C. "I need to apply paste to the back of the wafer on my child's appliance." ** The parent should apply stoma paste to the back of the wafer on the appliance and around the stoma. This paste will act as a sealant to prevent skin breakdown. Incorrect Answers: A. The parent should dress the infant in 1-piece outfits to restrict the infant's hands from reaching the pouch. B. The parent should use diapers that are larger than the ones the child usually wears to go over the stoma and facilitate drainage. D. A child who has a colostomy will need bladder training when developmentally ready because the urinary system is still intact.

A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in 1-piece outfits." B. "I need to buy diapers that are tighter than those my infant usually wears." C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet train my child."

Correct Answer: D. Demonstrate the injection technique on an orange ** The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. Demonstrating the injection technique on an orange poses no risk to the client and is the first action the nurse should take. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Incorrect Answers: A. The nurse should allow the parent to give the nurse an injection while the child observes; however, there is another action the nurse should take first. B. The nurse should have the child teach the injection technique to the parents; however, there is another action the nurse should take first. C. The nurse should have the parent give the insulin injection to the child; however, there is another action the nurse should take first.

A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first? A. Allow a parent to administer an injection to the nurse B. Have the child teach the injection technique to the parents C. Have a parent administer the insulin injection to the child D. Demonstrate the injection technique on an orange

Correct Answer: B. "I will continue to take my medication when my peak flow rate is in the green zone." ** This statement by the adolescent indicates an understanding of the teaching. A peak flow rate in the green zone indicates the current treatment has been effective; therefore, the adolescent should continue with their current medication regimen. Incorrect Answers: A. The nurse should instruct the adolescent to use a quick-relief (i.e. rescue) medication when they feel short of breath because this is a manifestation of an acute attack. C. The nurse should instruct the adolescent to obtain 3 readings and to write down the highest of the 3 readings rather than the average. D. The nurse should inform the adolescent that a flow rate in the yellow zone indicates inadequate control of asthma.

A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will use my peak flow meter whenever I feel short of breath." B. "I will continue to take my medication when my peak flow rate is in the green zone." C. "I need to use the average of 3 readings when I measure my flow rate." D. "My asthma is being controlled if my flow rate is in the yellow zone."

Correct Answer: D. Repeat memorized facts about the painful event ** Having the adolescent repeat memorized facts about the painful event is an example of the nonpharmacological pain management strategy of thought-stopping. Thoughts such as "the pain will be gone soon" or "I'll be home by this time tomorrow" can help the adolescent control the pain. After listing the facts, the nurse should then have the adolescent condense and memorize the facts to repeat them whenever pain occurs. Incorrect Answers: A. Having the adolescent put together a puzzle is an example of the nonpharmacological pain management strategy of distraction. B. Having the adolescent discuss a recent pleasurable event is an example of the nonpharmacological pain management strategy of guided imagery. C. Having the adolescent tighten and then relax each body part is an example of the nonpharmacological pain management strategy of

A nurse is teaching an adolescent about various strategies for chronic pain management. Which of the following activities should the nurse use as an example of the nonpharmacological strategy of thought-stopping? A. Assemble a puzzle B. Discuss a recent pleasurable event C. Tighten and then relax each body part D. Repeat memorized facts about the painful event

Correct Answer: C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." ** The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions. Incorrect Answers: A. Imaginary playmates are common during the preschool years due to the high level of imagination among this age group. B. Imaginary playmates are common during the preschool years and are not a cause for concern as long as the preschooler also socializes with other children. D. The nurse should instruct the guardian that this behavior is expected and that pretending with the preschooler is okay.

A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A. "Children commonly begin having imaginary friends when they reach school age." B. "Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." D. "Set limits by not allowing your child to have the imaginary friend present during family meals."

Correct Answer: A. "I will give my child a dose of albendazole today and again in 2 weeks." ** The nurse should instruct the parent to repeat the dose of albendazole in 2 weeks to eradicate the parasite and prevent reinfection. Incorrect Answers: B. Pinworm specimens are collected in the morning as soon as the child wakes up and before the child bathes or has a bowel movement. C. To prevent reinfection, the child should be given a shower rather than a tub bath. D. The child's bed linens and clothing should be washed in hot water because pinworms can survive on surfaces for an extended period of time.

A nurse is teaching the parent of a preschool-aged child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will give my child a dose of albendazole today and again in 2 weeks." B. "I will collect specimens immediately after my child has a bowel movement." C. "I will give my child a tub bath twice each day." D. "I will place my child's bed linens in a sealed plastic bag for 7 days."

Correct Answers: C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49°C (120°F). ** Infants and children should remain in the rear-facing position in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines. As the infant begins to crawl and becomes more mobile, the risk of falls increases. To prevent a burn injury, the temperature of the water heater should not exceed 49°C (120°F). Incorrect Answers: A. A stationary infant walker is recommended. Wheeled infant walkers can quickly move across uneven surfaces and result in injury. B. Soft pillows and cushions should not be used in cribs due to the increased risk of suffocation.

A nurse is teaching the parent of an infant about home safety. Which of the following pieces of information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker. B. Place soft pillows around the edge of the infant's crib. C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49°C (120 F).

Correct Answer: C. "I should make sure my baby's clothing does not have buttons." ** The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration. Incorrect Answers: A. The nurse should instruct the parent to avoid the use of talcum powder to reduce the risk of aspiration pneumonia if inhaled. B. The nurse should instruct the parent to avoid using a drop-side crib to reduce the risk of suffocation and falls. D. The nurse should instruct the parent to use a crib that has slats that are <6 cm (2.36 in) apart to reduce the risk of suffocation.

A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop-side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons." D. "I should ensure the crib slats are no more than 3 inches apart."

Correct Answer: B. "We should not smoke around our child." ** Preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inflammation of the respiratory tract. Incorrect Answers: A. A child who has an ear infection is not contagious; therefore, the child may play with other children who have ear infections. C.A child who has recurrent ear infections is able to swim; however, wearing earplugs may decrease the risk of infection. D. A child who has recurrent ear infections should not forcefully blow the nose during a cold, as this causes organisms to ascend through the eustachian tubes.

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

Correct Answer: A. "My child may take aspirin for his joint pain." ** Children who have rheumatic fever may take salicylates (aspirin) to control the inflammatory process that occurs in the joints. Incorrect Answers: B. A child who has rheumatic fever does not require blood transfusions since there is no blood loss from this disorder. C. A child who has rheumatic fever only needs standard isolation precautions. Rheumatic fever is an immune response that occurs after an infection with group A B- hemolytic streptococci. D. Kawasaki disease causes peeling hands, but rheumatic fever does not.

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

Correct Answer: A. They provide direct stimulation of auditory nerve fiber. ** Cochlear implants work by directly stimulating nerve fibers in the cochlea. Incorrect Answers: B. Bone conduction hearing aids, not cochlear implants, conduct sound waves through the skull to the inner ear. C. Some hearing aids use digital sound processing to help clients who have high-frequency hearing loss, but cochlear implants do not. D. An implantable piezoelectric device converts vibrations in the eardrum and ossicles to signals that are amplified by a sound processor. A driver transmits them to the inner ear for sound perception.

A nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants? A. They provide direct stimulation of auditory nerve fiber. B. They conduct sound waves through the mastoid bone to the cochlea. C. They process digital sound to amplify several sound frequencies. D. They convert vibrations in the ear's structures to electrical signals.

Correct Answer: B. Massage the anterior area of the infant's ear following administration ** The nurse should instruct the parents to massage the anterior area of the ear following the administration of eardrops to facilitate instillation of the medication. Incorrect Answers: A. Otic solution should be warm or room temperature before instilling it in the infant's ear. C. Hyperextending the neck is for nasal medication administration rather than otic medication administration. D. The nurse should instruct the parents to pull the auricle up and back for children older than 3 years of age and downward and straight back for children younger than 3 years of age.

A nurse is teaching the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include? A. Chill the medication prior to administration B. Massage the anterior area of the infant's ear following administration C. Hyperextend the infant's neck during administration D. Pull the auricle up and back during medication administration

Correct Answer: D. "Your child will need to take thyroid hormone replacement for her entire life." ** In congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require lifelong thyroid hormone replacement to support normal growth and development. Incorrect Answers: A. A child who has congenital hypothyroidism does not require estrogen replacement. B. A child who has congenital hypothyroidism does not have a blood coagulation disorder. C.A child who has congenital hypothyroidism has a thyroid gland that is absent, small, or malfunctioning; however, the child does not require surgical removal of the gland.

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

Correct Answer: C. "Would you like assistance in planning where your child will die?" ** The nurse should inform the parents that they can choose to keep the child in a hospital setting or take the child home to die. The nurse should be aware that active participation in planning for the location of the child's death promotes positive bereavement outcomes. The nurse should provide assistance to the parents in making and implementing this plan. Incorrect Answers: A. The nurse should ask the parents if they would like to participate in providing care for their child. Active participation in the child's care promotes positive bereavement outcomes. B. The nurse should support the parents' and child's decisions and should allow the parents to participate in activities of their choosing (e.g. having multiple visitors, playing games, and going on family outings). If the child and parents choose a low-stimulation the nurse should ensure it is provided.

A nurse on a pediatric oncology unit is helping the parents of a child who is terminally ill to prepare for the impending loss of their child. Which of the following statements should the nurse make? A. "The nursing staff will bathe your child and take care of his daily needs." B. "Your child will be most comfortable in a low-stimulation environment." C. "Would you like assistance in planning where your child will die?" D. "Would you like hospice to continue providing curative care in your home?"

Correct Answer: D. A child who has pertussis ** The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to others on the unit. Pertussis, or whooping cough, is a bacterial infection that is transmitted via exposure or direct contact with the respiratory secretions from an infected person. Manifestations of pertussis include fever, sneezing, and a severe productive cough that generally becomes worse before getting better. Incorrect Answers A. Rocky Mountain spotted fever is a bacterial infection that is most commonly transmitted via a tick bite. Manifestations include fever, myalgia, and a maculopapular rash that primarily appears on the wrists and ankles. The rash can spread to the palms of the hands and the soles of the feet. The nurse should plan to use standard precautions when caring for a child who has Rocky Mountain spotted fever. B. Roseola is a viral infection classified within the herpes virus family. Primary manifestations are a rash and high fever. Other manifestations include lymphadenopathy, a sore throat, and a severe cough. The nurse should plan to use standard precautions when caring for a child who has roseola. C. Molluscum contagiosum is an infection caused by the poxvirus. Clinical manifestations include flesh-colored papules on the face, trunk, and extremities. Molluscum contagiosum is transmitted via direct skin-to-skin contact. Therefore, the nurse should initiate contact precautions when caring for a child who has Molluscum contagiosum.

A nurse on a pediatric unit has just received reports for 4 newly admitted clients. For which of the following children should the nurse plan to initiate droplet precautions? A. A child who has Rocky Mountain spotted fever B. A child who has roseola C.A child who has Molluscum contagiosum D. A child who has pertussis

Correct Answer: D. Ensure that staff visits with the child are kept short ** Children who have autism spectrum disorders have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible. Incorrect Answers: A. Children who have autism spectrum disorders have difficulty adjusting to new situations. The nurse should assign this child to a private room with decreased auditory and visual stimulation to assist the child's adaptation. B. Children who have autism spectrum disorders prefer minimal physical contact. The nurse should refrain from holding or restraining the child and should reduce eye contact as much as possible to prevent outbursts. C. Children who have autism spectrum disorders have difficulty redirecting their focus and changing activities. The nurse should clearly state expectations and instructions at the appropriate developmental level and should not provide choices about scheduling planned care.

A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short

Correct Answer: B. Allow the child to manipulate toy medical equipment ** A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging the child to touch the equipment, the nurse is helping decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people. Incorrect Answers: A. A child who fears hospitalization and surgery is likely to have nighttime awakenings and possibly night terrors. While the nurse can take actions to diminish a child's fears at night, this intervention does not address that particular problem. C. Play therapy differs from therapeutic play and allows a specially trained therapist to interpret the emotions of children who have mental health issues. D. Therapeutic play is a 1-on-1 activity between the nurse and the child.

A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan to offer which of the following benefits? A. Decrease the child's fear of the dark B. Allow the child to manipulate toy medical equipment C. Provide an opportunity to analyze the child's emotions D. Encourage parents to engage with their child

Correct Answer: B. Frequent hospitalizations ** Children who experience multiple and frequent hospitalizations are at an increased risk for stress-related reactions to hospitalization. Incorrect Answers: A. Children between the ages of 6 months and 5 years are more vulnerable to the stress of hospitalization than a 10-year-old child. C. A child's stress and anxiety with hospitalization are reduced when parents are highly involved with their children and have close bonds. Children who are hospitalized are at risk for increased stress if there is a lack of cohesion between the parent and the child. D. Children who demonstrate irritable and difficult temperaments are at increased risk of stress-related reactions to hospitalization.

A nurse on a pediatric unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? A. Age 10 years B. Frequent hospitalizations C. Parent bonding with child D. Calm, quiet demeanor

Correct Answers: B. Nausea D. Urticaria E. Stridor ** A common gastrointestinal response to excessive histamine release is nausea. A common skin manifestation of excessive histamine release is hives, also known as urticaria. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor. Incorrect Answers: A. Histamine is a potent vasodilator; therefore, a client who is going into anaphylaxis will exhibit tachycardia. C. Histamine is a potent vasodilator, so the child will exhibit hypotension.

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

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

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

Correct Answer: D. Albuterol ** The nurse should plan to administer albuterol to a child who is experiencing an acute exacerbation of asthma. This is considered a rescue medication due to its rapid onset of action. Albuterol is a beta-adrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs. Incorrect Answers: A. Zafirlukast is not considered a rescue medication, It is a leukotriene modifier that is used for asthma prophylaxis and maintenance therapy and to prevent exercise-induced bronchospasm. B. Budesonide is not considered a rescue medication. It is a glucocorticoid that is used for long-term control and prophylaxis of chronic asthma. C. Montelukast is not considered a rescue medication. It is the most commonly prescribed leukotriene modifier used for prophylaxis

A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer to the child? A. Zafirlukast B. Budesonide C. Montelukast D. Albuterol

Correct Answers: B. Apply pressure to the child's nose using the thumb and forefinger E. Keep the child calm ** Applying pressure continuously for 10 minutes to the nose with the thumb and forefinger helps control the bleeding. Most bleeding comes from the front portion of the nasal septum, so pressure on this area is generally effective. If bleeding persists, placing ice or a cold cloth on the bridge of the nose and inserting cotton or tissue into the nostril might help. The nurse should keep the child calm to help slow the bleeding. Agitation can raise blood pressure, which will increase the bleeding. Incorrect Answers: A. C. A child who is experiencing a nosebleed should be placed in a seated position leaning forward to decrease the risk of aspiration. D. Applying a cold cloth to the bridge of the child's nose can help slow the bleeding.

A school nurse is providing care to a child who has a nosebleed. Which of the following actions should the nurse perform? (Select all that apply.) A. Place the child in a supine position B. Apply pressure to the child's nose using the thumb and forefinger C. Have the child tilt his head back D. Apply a warm cloth to the bridge of the child's nose E. Keep the child calm

Correct Answers: A. "I should eat extra food on busy days when I am more active." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." ** The nurse should instruct the adolescent to increase the intake of allowable foods when the level of activity is increased. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. Additionally, the nurse should instruct the adolescent to increase the intake of sugar-free fluids when sick because fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids such as water, broth, and tea. The adolescent should continue with the usual intake at mealtimes and follow the recommended meal plan as much as possible.

A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (Select all that apply.) A. "I should eat extra food on busy days when I am more active." B. "I should wait for 2 hr after eating before going swimming with my friends." c. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." E. "I should have a 16 oz sports drink if I start feeling weak or shaky."

Correct Answer: A. The infant's mother is likely HIV positive. ** Transmission of HIV from a woman to her infant can occur during pregnancy, in delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants. Incorrect Answers: B. The ELISA test is unreliable for HIV testing in infants under 18 months of age because of false-positive results due to maternal antibodies. The results are reliable, however, for clients 18 months of age and older. C. While antiretroviral medications cannot cure HIV, they do slow the progress of the infection for clients of all ages. D. Infants who are HIV positive should receive immunization against childhood illnesses, including measles, mumps, rubella, and influenza.

An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors? A. The infant's mother is likely HIV positive. B. The infant's ELISA test result is probably a false positive for HIV. C. Antiretroviral medications are inappropriate for infants and children who have HIV. D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations.

Correct Answer: B. Use an oral syringe to place the medication alongside the infant's tongue **The nurse should use an oral syringe to administer the medication slowly alongside the infant's tongue or at the side of the mouth. The nurse should give the child time to swallow between deposits. Incorrect Answers: A. Infants should not be given honey due to the risk of exposure to botulism spores. The nurse can use other foods like pudding or jam to alter the taste of the medication. C. The might refuse the formula due to an altered taste from the medication. Additionally, if the infant does not drink the entire bottle, incomplete dosing of the medication can occur. D. The nurse should administer the medication while holding the infant firmly in a semi-reclining position. Administering the medication with the infant in a supine position can result in aspiration.

The nurse is preparing to administer an oral medication to an 8-month-old infant. Which of the following actions should the nurse take? A. Mix the medication with 1 tsp of honey to sweeten the taste for the infant B. Use an oral syringe to place the medication alongside the infant's tongue C. Add the medication to the infant's bottle of formula D. Place the infant in a supine position to administer the medication

Correct Answer: A. "I should ignore the stuttering and not interrupt her." ** Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become prolonged.

The nurse is providing teaching to the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should ignore the stuttering and not interrupt her." B. "I should finish my child's sentence if she is stuck on a word." C. "I should reward my child when she doesn't stutter." D. "I should tell my child to slow down when she starts stuttering."