Peds Exam 1 (testbank), transgender healthcare, BBCS 24 (test bank) 5, BBCS 12 (test bank) 5, BBCS 30 (test bank) 5, Peds exam 3 (testbank), Peds Exam 3 pretest/ch q'z/ati q's, Peds exam 2 (testbank)
(pretest 6) The father asks the nurse about the oxygen being administered to his 8 month old daughter for bronchitis. The oxygen delivery system is a nasal cannula. The father asks how much oxygen the child is receiving via this delivery method. You respond with: 1. 22-40% FiO2 2. 100% FiO2 3. 60-95% FiO2 4. 35-55% FiO2
1. 22-40% FiO2
A child is diagnosed with thrombocytopenia secondary to chemotherapy treatments. Which action by the nurse is the most appropriate? 1. Administer intramuscular injections (IM). 2. Perform oral hygiene. 3. Monitor intake and output. 4. Use palpation as a component of assessment.
1. Administer intramuscular injections (IM).
Which of these aspects of developmental health supervision should be included in each healthcare visit of young children? Select all that apply. 1. Assessment 2. Discipline 3. Education 4. Intervention 5. Toilet training
1. Assessment 3. Education 4. Intervention
The nurse working with a family has observed that the older children have a large number of dental caries and plans to provide the mother with information to prevent the development of dental caries in her new infant. Which interventions will prevent the development of dental caries in the infant? Select all that apply. 1. Avoiding nursing or giving the infant a bottle at bedtime 2. Giving foods high in sugar only at breakfast time 3. Using a soft moist gauze for cleaning 4. Using a topical anesthetic daily beginning as soon as the first tooth begins to erupt
1. Avoiding nursing or giving the infant a bottle at bedtime 3. Using a soft moist gauze for cleaning
The nurse is teaching a new mother developmental expectations. Which activity should the nurse expect a newborn to do within the first month of life? 1. Bring hands to eyes and mouth. 2. Push up with hands, moving chest up. 3. Keep hands in a relaxed position. 4. Roll over from back to abdomen.
1. Bring hands to eyes and mouth.
The school health nurse recognizes that children who display certain characteristics are at risk for poor school performance. The nurse will, therefore, observe each school-age child for which characteristics? Select all that apply. 1. Decreased ability to perform visual tracking. 2. Decreased auditory stimulation. 3. Decreased muscle tone. 4. Multiple dental caries. 5. Chronic tonsillitis.
1. Decreased ability to perform visual tracking. 2. Decreased auditory stimulation. 3. Decreased muscle tone.
Which of these measures used by a nurse will help relieve parental anxiety related to the changing appetite in the toddler who is gaining weight along the 50th percentile? 1. Discussing the growth of the toddler as compared to the growth chart 2. Suggesting ways to have the toddler eat higher calorie foods 3. Instructing the mother to feed the toddler alone without any distractions such as TV or music 4. Teaching the mother to avoid disciplining the toddler within one-half hour of eating
1. Discussing the growth of the toddler as compared to the growth chart
A young school-age client is hospitalized with a fractured femur. Which assessment tools are appropriate for this client? Select all that apply. 1. FACES pain scale 2. Oucher scale 3. Visual Analog Scale 4. CRIES Scale 5. Poker-chip tool
1. FACES pain scale 2. Oucher scale 5. Poker-chip tool
The nurse in the newborn nursery is admitting a neonate. To determine the health and development of the newborn, what will the nurse include in the assessment? Select all that apply. 1. Head circumference 2. Body length 3. Weight 4. Length of pregnancy 5. Hearing screens
1. Head circumference 2. Body length 3. Weight 4. Length of pregnancy
The nurse is providing education to a group of student nurses regarding disorders of the endocrine system that can cause short stature. Which disorders will the nurse include in the educational session? Standard Text: Select all that apply. 1. Hypothyroidism 2. Turner syndrome 3. Type 1 diabetes mellitus 4. Diabetes insipidus 5. Cushing syndrome
1. Hypothyroidism 2. Turner syndrome 5. Cushing syndrome
The nurse is providing education to a pediatric client diagnosed with diabetes. The client will be playing soccer over the summer. Which change in the clients management will the nurse explore during this education session? 1. Increased food intake 2. Decreased food intake 3. Increased need for insulin 4. Decreased risk of insulin reaction
1. Increased food intake
The nurse is working with a preschool-age client in Bryant traction for a fractured femur. Why is the Oucher Scale useful to the nurse caring for this child? 1. It provides continuity and consistency in assessing and monitoring the child's pain. 2. It decreases anxiety in the child. 3. It increases the child's comfort level. 4. It reduces the child's fear of painful procedures.
1. It provides continuity and consistency in assessing and monitoring the child's pain.
The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the child's abdomen where the tape measure should be placed for an accurate abdominal girth. 1. Just above the umbilicus, around the largest circumference of the abdomen 2. Below the umbilicus 3. Just below the sternum 4. Just above the pubic bone
1. Just above the umbilicus, around the largest circumference of the abdomen
Which teaching tips should be included when instructing parents on hydrocortisone administration? Standard Text: Select all that apply. 1. Maintain prescribed administration times. 2. Never discontinue medication abruptly. 3. Injections might be necessary when unable to take by mouth. 4. Lower doses are needed during illness. 5. Keep an emergency kit with the child at all times.
1. Maintain prescribed administration times. 2. Never discontinue medication abruptly. 3. Injections might be necessary when unable to take by mouth. 5. Keep an emergency kit with the child at all times.
The nurse is working with a hospitalized preschool-age child. The nurse is planning activities to reduce anxiety in this child. Which action by the nurse is the most appropriate? 1. Provide the child with a doll and safe medical equipment. 2. Read a story to the child. 3. Use an anatomically correct doll to teach the child about the illness. 4. Talk to the child about the hospitalization.
1. Provide the child with a doll and safe medical equipment.
The nurse is planning care for pediatric clients who have diagnoses that impact the endocrine system. Which changes occurring during the school-age and adolescence have a direct impact on the endocrine system? Standard Text: Select all that apply. 1. Puberty 2. Adrenarche 3. Menarche 4. Sexual exploration 5. Risk-taking behavior
1. Puberty 2. Adrenarche 3. Menarche
The nurse is conducting a health surveillance visit with a 6-month-old infant. Which methods are appropriate to monitor the infants growth pattern since birth? Select all that apply. 1. Weigh the infant twice and average together 2. Measure the infants height 3. Measure the infant's head circumference 4. Determine the infant's body mass index 5. Plot the infants growth on appropriate chart
1. Weigh the infant twice and average together 3. Measure the infant's head circumference 5. Plot the infants growth on appropriate chart
(pretest 5) A child with nephrotic syndrome has been prescribed prednisone. The nurse should monitor the child for which of the following medication side effects? 1. Gastric distress 2. bradycardia 3. hypoglycemia 4. weight loss
1. gastric distress
(Chapter 20) A child is admitted to the hospital with pneumonia. The childs oximetry reading is 88 percent upon admission to the pediatric floor. Which is the priority nursing intervention for this child? 1. Obtain a blood sample to send to the lab for electrolyte analysis. 2. Begin oxygen per nasal cannula. 3. Medicate for pain. 4. Begin administration of intravenous fluids.
2
(Chapter 26) A child diagnosed with acute glomerulonephritis is in the playroom and experiences blurred vision and headache. Which action by the nurse is the most appropriate? 1. Check the urine to see if hematuria has increased. 2. Obtain a blood pressure on the child; notify the healthcare provider. 3. Reassure the child, and encourage bed rest until the headache improves. 4. Obtain serum electrolytes, and send a urinalysis to the lab.
2 Blurred vision and headache may be signs of encephalopathy, a complication of acute glomerulonephritis. A blood pressure (BP) should be obtained and the healthcare provider notified. The healthcare provider may decide to order an antihypertensive to bring down the BP. This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, the other options (checking urine for hematuria, encouraging bed rest, and obtaining serum electrolytes) do not directly address the potential problem of encephalopathy.
An infant weighs 9 pounds, 3 ounces at birth. The nurse plans to make a home visit to the mother and infant when the infant is 7 days old. What is the lowest acceptable weight the infant should be at this age? 1. 7 pounds, 12 ounces 2. 8 pounds, 2 ounces 3. 8 pounds, 12 ounces 4. 9 pounds
2. 8 pounds, 2 ounces
A 24-hour urine collection for vanillylmandelic acid (VMA) has been ordered on a child suspected of having neuroblastoma. When is the most appropriate time for the nurse to begin the collection? 1. At 0700 2. After the next time the child voids 3. At bedtime 4. When the order is noted
2. After the next time the child voids
The nurse is preparing to assessment a toddler client. Which activities would gain cooperation from the toddler? Select all that apply. 1. Asking the parents to wait outside 2. Allowing the client to sit in the parents lap 3. Administering vaccinations prior to the assessment 4. Handing the client a stethoscope while taking the health history 5. Making a game out of the assessment process
2. Allowing the client to sit in the parents lap 4. Handing the client a stethoscope while taking the health history
Pediatric nurses have foundational knowledge obtained in nursing school and add specific competencies related to the pediatric client. Which would be considered an additional specific expected competency of the pediatric nurse? 1. Physical assessment 2. Anatomical and developmental differences 3. Nursing process 4. Management of healthcare conditions
2. Anatomical and developmental differences
The nurse is planning care for an adolescent client who will be hospitalized for several weeks following a traumatic brain injury. Which interventions will enhance family-centered care for this client and family? Select all that apply. 1. Making all ADL decisions for the adolescent and family 2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescents friends to visit during visiting hours 5. Leaving all questions for the healthcare provider
2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescents friends to visit during visiting hours
The nurse is planning care for clients seen in a newborn clinic. Which is the priority for a newborn client during the first clinic visit? 1. Providing pamphlets to reinforce information provided at the visit 2. Assessing the newborn-and-family interactions 3. Modeling infant-nurturing behaviors 4. Informing the parents of the infants gains in height and weight
2. Assessing the newborn-and-family interactions
The nurse is working on parenting skills with a group of mothers. Which mother would need the fewest discipline-related suggestions? 1. Authoritarian one 2. Authoritative one 3. Indifferent one 4. Permissive one
2. Authoritative one
A school-age client tells you that Grandpa, Mommy, Daddy, and my brother live at my house. Which type of family will the nurse identify in the medical record based on this description? 1. Binuclear family 2. Extended family 3. Gay or lesbian family 4. Traditional nuclear family
2. Extended family
A school-age client diagnosed with diabetes insipidus (DI) is admitted to the pediatric unit. Which laboratory value does the nurse anticipate for this client based on the diagnosis? 1. Hyperglycemia 2. Hypernatremia 3. Hypercalcemia 4. Hypoglycemia
2. Hypernatremia
(pretest 5) a 2-year-old child with nephrotic syndrome is admitted to the pediatric unit. The following orders have been written in the child's medical record. Which of the actions is the highest priority for the nurse to perform? 1. place the child on alternating pressure mattress 2. administer intravenous albumin 3. weigh all wet diapers 4. administer oral antibiotics
2. administer intravenous albumin
The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to: 1. hear a quiet but easily heard murmur. 2. hear a moderately loud murmur without a palpable thrill. 3. hear a very loud murmur with easily palpable thrill. 4. listen without a stethoscope and hear a murmur at chest wall.
2. hear a moderately loud murmur without a palpable thrill.
(pretest 6) A nurse is to administer ear drops to the right ear of a 6-year-old child. Which of the following actions by the nurse is appropriate? 1. Nurse warms the medication in the microwave 2. nurse pulls the pinna of the ear up and back 3. nurse rubs the area behind the ear after administering the medication 4. nurse has the child lie supine for one-half hour after administering the medication
2. nurse pulls the pinna of the ear up and back
(Chapter 20) Parents of a child admitted with respiratory distress are concerned because the child wont lie down and wants to sit in a chair leaning forward. Which response by the nurse is the most appropriate? 1. This helps the child feel in control of his situation. 2. The child needs to be encouraged to lie flat in bed. 3. This position helps keep the airway open. 4. This confirms the child has asthma.
3
A new mother is worried about a soft spot on the top of her newborn infants head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close? 1. 2 to 3 months of age 2. 6 to 9 months of age 3. 12 to 18 months of age 4. Approximately 2 years of age
3. 12 to 18 months of age
The child is admitted to the hospital after being diagnosed with retinoblastoma. Which assessment finding does the nurse anticipate for this child? 1. A red reflex 2. Yellow sclera 3. A white pupil 4. Blue-tinged sclera
3. A white pupil
A mother asks which developmental milestones she can expect when her baby is 6 months old. Which response by the nurse is the most appropriate? 1. Lifts head momentarily when prone 2. Has well-developed pincer grasp 3. Transfers objects from one hand to the other 4. Rolls from front to back
3. Transfers objects from one hand to the other
The nurse is caring for a child who has a long leg cast. The child complains of increasing pain in the toes of the casted foot. Which initial action by the nurse is the most appropriate? 1. Call the healthcare provider to report increasing pain. 2. Administer pain medication. 3. Reposition the child in bed. 4. Check to see if the cast is too tight.
4. Check to see if the cast is too tight.
(pretest 5) A baby is admitted with a diagnosis of intussusception. Which of the following s/s would the nurse expect to see? 1. Projective vomiting 2. acute constipation 3. explosive flatus 4. Currant jelly stools
4. Currant jelly stools
The nurse is monitoring the urine specific gravity and pH on a child receiving chemotherapy. Which urinalysis result is the goal for this child? 1. Spec gravity 1.030; pH 6 2. Spec gravity 1.030; pH 7.5 3. Spec gravity 1.005; pH 6 4. Spec gravity 1.005; pH 7.5
4. Spec gravity 1.005; pH 7.5
Lab monitoring for FTM: testosterone level cisgender:
500-600 ng/dL cisgender: 320-1000ng/dL
ATI 23: 2. A nurse is caring for a child who has Hirschsprung disease. Which of the following is an appropriate action for the nurse to take? A. Encourage a high-fiber, low-protein, low-calorie diet. B. Prepare the family for surgery. C. Place an NG for decompression. D. Initiate bedrest.
B B. A client who has Hirschsprung disease requires surgery to remove the affected segment of the intestine. Preparing the family for surgery is an appropriate action for the nurse to take.
ATI 24: 5. A nurse is caring for a child with enuresis. Which of the following is a complication of enuresis? A. Urinary tract infections B. Emotional problems C. Urosepsis D. Progressive kidney disease
B B. Emotional problems are a complication of enuresis.
ATI 25: 1. A nurse is caring for an infant who has a hydrocele. Which of the following is an appropriate action for the nurse to take? A. Prepare for immediate surgery. B. Explain to the parents that this will self-resolve. C. Retract foreskin and cleanse properly. D. Refer the family for counseling.
B B. Hydrocele is fluid in the scrotum and resolves spontaneously in the majority of cases.
ATI 23: 3. A nursing is caring for an infant who is postoperative following cleft lip and palate repair. Which of the following is an appropriate action for the nurse to take? A. Remove the packing in the mouth. B. Place the infant in an upright position. C. Offer a pacifier with sucrose. D. Assess mouth with a tongue blade.
B B. Placing the infant in an upright position will facilitate drainage and prevent aspiration. This is an appropriate action for the nurse to take.
ATI 18: A nurse is planning care for a child who has asthma. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Perform chest percussion B. Place the child in a upright position C. Monitor oxygen saturation D. Administer bronchodilators E. Administer dornase alfa daily
B C D
ATI 16: A nurse is caring for a child who is recieving a bronchodilator medication by nebulized aerosol therapy.. Which of the following actions should the nurse take? (Select all that apply) A. Instruct the child that the treatment will last 30 minutes B. Obtain VS prior to the procedure C. Tell the child to take slow deep breaths D. determine if the child should use a mask E. Attach the device to an air source
B,C,D,E
ATI 15: 2. A nurse is teaching the parent of a child who has strabismus. Which of the following should be included in the teaching? A. "Your child should be fitted for contact lenses." B. "Wearing glasses with convex lenses will correct this problem." C. "Placing a patch over the strong eye is needed." D. "Special lenses can correct the vision."
C C. Placing a patch over the strong eye to increase visual stimulation to the affected eye is used when treating strabismus.
ATI 37: 2. A nurse is caring for a 2-year-old child who has had three ear infections in the past 5 months. The nurse should know that the child is at risk for developing which of the following as a long-term complication? A. Balance difficulties B. Prolonged hearing loss C. Speech delays D. Mastoiditis
C C. Speech delay is a common complication of otitis media.
ATI 17: A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? (Select all that apply) A. Administer oral prednisone B. Initiate chest percussion and postural drainage C. Administer humidified oxygen D. Suction the nasopharynx E. Administer oral penicillin
C, D
ATI 18: A nurse is teaching an adolescent about the appropriate use of his asthma medications. Which of the following medications should the nurse instruct the client to use as needed before exercise? A. Fluticasone/salmeterol B. Montelukast C. Prednisone D. Albuterol
D
testosterone therapy (FTM): testosterone cypionate or enanthate
IM/SC - SC: less discomfort, may avoid scarring or fibrosis from long term IM weekly/biweekly regimen
reversible effects of testosterone therapy (FTM)
acne fat redistribution increased muscle mass irritable depression increased libido
testosterone therapy (FTM): transdermal
androderm patch: 2mg/24 hr, 4mg/24 hr preferable during the night
sex determinants: biology
brain's perceptional framework of gender in relation to one's physical anatomy chromosomal; XX XY gonadal: testes vs ovaries phenotypical observable physical properties
measuring testosterone: weekly injection
check peak mid week 3-4 days after injection no more then 800-1000 ng/dl
irreversible effects of testosterone therapy (FTM)
fertility androgenic alopecia clitoral growth
Effects of Estrogen Therapy (MTF) irreversible
fertility testicular volume loss breast growth
Gender Pronouns: objective
her, him, them, hir/Zir
Gender Pronouns: possessive
hers, his, theirs, hirs, zirs
Gender Pronouns: reflective
herself, himself, themself, hirself/ zirself
gender identity data
includes: -chosen name -chosen pronouns -gender identity -sex assigned at birth
terminology to be familiar with: MTF tucking
involves moving the testicals if present into the ingunial canal and moving hte penis and scrotom [psteriorly in the perianal region tight undergarments, a gaffe, adhesive or duct tape urinary trauma/infection local skin irritation testicular pain
transgender woman
male to female
measuring testosterone: Bi-weekly injection
peak 3-4 days after injection check trough level 3-4 days before next injection: low end of normal: 300-400
Gender Pronouns: subjective
she, he, they, Ze
waiting areas
should include: - trans friendly themed posters/brochures to demonstrate the support
Hgb and HCT values natal pop vs trans pop
similar to natal
sex determinants: geder
social construct: western: dichotomous other places: not a simple dichotomy
fluency of terminology
staff should be aware of basic terminology within this population
secondary sexual characteristics and effects of early intervention: female to male
suppression of menses stimulate growth spurt slow breast development
mons resection (FTM)
surgical procedure where fat is removed from the pubic mons
ovariectomy: (FTM)
surgical removal of one or both ovaries
bilateral mastectomy/male contouring (FTM)
surgical removal of the breasts
hysterectomy (FTM)
surgical removal of the uterus
Gatekeeper Model
therapist: After 3 months of therapy with me, I do find you meet the criteria for Gender Dysphoria.. I will refer you to a specialist, who will start you on hormones. A model of HMO and PPO organizations that uses the insured's primary care physician (the gatekeeper) as the initial contact for the patient for medical care and for referrals.
lab monitoring fot MTF
total and free teststerone (<55), estradiol (~200) q 3 months
staff training
training on transgender health issues should be provided to all clinical staff
tras unemployment rate: gen pop unemployment rate:
trans: 15% gen: 5% 3x more likely to be unemployed
FTM terminology: binders
"involved the use of tight fitting sports bras, shirts ace bandages, pr a specially made binder to ptovide a flat chest contour" - breast / back pain - local skin irritation - fungal infections
(pretest 5) A one-month-old baby, 8 lb, is in the hospital with a diagnosis of pyloric stenosis. The nurse is carefully assessing the chid's intake and output. Please calculate the maximum urinary output the baby should excrete per hour.
(3.6Kg x 2) = 7.2
(Chapter 20) Following parental teaching, the nurse is evaluating the parents understanding of environmental control for their childs asthma management. Which statement by the parents indicates appropriate understanding of the teaching? 1. We will replace the carpet in our childs bedroom with tile. 2. Were glad the dog can continue to sleep in our childs room. 3. Well be sure to use the fireplace often to keep the house warm in the winter. 4. Well keep the plants in our childs room dusted.
1
(Chapter 20) Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Decreased Cardiac Output 3. Pain, Acute 4. Tissue Perfusion, Ineffective (peripheral)
1
(31) The nurse is caring for a pediatric client diagnosed with eczema. Which topical medication order does the nurse anticipate for this client? 1. Corticosteroids 2. Retinoids 3. Antifungals 4. Antibacterials
1 Topical corticosteroids are used to reduce inflammation when the child has eczema. Topical retinoids are used for acne. Topical antifungals are used for dermatophytoses. Topical antibacterials would be used for problems such as burns.
(Chapter 19) A nurse is caring for a visually impaired 20-month-old who has not begun to walk. Which nursing diagnosis is the most appropriate for this client? 1. Delayed growth and development 2. Impaired physical mobility 3. Self-care deficit 4. Impaired home maintenance
1 A 20-month-old child who is not walking is delayed in growth and development. The childs mobility is not due to a physiological problem, so impaired mobility is not appropriate. Self-care deficit does not apply to this age of child. There is not enough data to determine if home maintenance is impaired.
A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a new RN on the pediatric unit, cautions the new nurse to be especially alert for which condition in the child? 1. Seizures 2. Bradycardia 3. Respiratory distress 4. Hyperthermia
1 A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.
(Chapter 26) A school-age client diagnosed with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention is a priority for this client? 1. Reposition the child every two hours. 2. Monitor BP every 30 minutes. 3. Encourage fluids. 4. Limit visitors
1 A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every two hours. Vital signs are taken every four hours, fluids need to be monitored and should not be encouraged, and the child needs social interaction, so visitors should not be limited.
(Chapter 25) A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment does the nurse ensure is prepared at the bedside? 1. Intubation setup 2. Appropriate bag and mask 3. Sterile gauze and saline 4. Soft arm restraints
1 A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so the newborns respiratory status can be stabilized. A bag and mask will not be adequate to ventilate a newborn with this condition. The defect is not external, so sterile gauze and saline are not needed. Soft arm restraints are not immediately necessary.
(28) A nurse is planning preoperative teaching for a school-age client scheduled to have a tonsillectomy. The client has a history of attention deficit hyperactivity disorder (ADHD). Which intervention will the nurse include in the plan of care? 1. Give instructions verbally and use a picture pamphlet, repeating points more than once. 2. Ask other children who have had this procedure to talk to the child. 3. Allow the child to lead the session to gain a sense of control. 4. Play a television show in the background.
1 A teaching session for a child with ADHD should foster attention. Giving instructions verbally and in written form, repeating points, will improve learning for a child with ADHD. The environment needs to be quiet, with minimal distractions. A child who has difficulty concentrating should not lead the session even though the child needs to feel in control. Talking to other children who have had this procedure may not foster understanding, because this child has ADHD. Distractions such as noise from a television should be minimized.
(Chapter 11) The nurse is working with an adolescent client who will be admitted to the hospital in two days. Which nursing approach is most appropriate to prepare this client for hospitalization? 1. Have teens who have had similar experiences talk to the adolescent about hospitalization. 2. Provide an opportunity for the child to talk with an adult who has had a similar experience. 3. Teach parents what to expect so the information can be shared with the adolescent. 4. Provide an opportunity for the teen to try on surgical attire.
1 Adolescents benefit from a different approach than younger children when being prepared for hospitalization. Written materials, anatomically correct dolls, and talking to peers who have had similar experiences are all appropriate for the adolescent. The adolescent should be taught first-hand what to expect during the hospitalization. Dressing up in surgical attire is appropriate for the younger child
(Chapter 11) The nurse is working with a school-age child who is hospitalized. Which action by the nurse will promote a sense of industry in this child? 1. Allow the child to assist with her care. 2. Encourage parents to participate in the childs care. 3. Give the child a detailed scientific explanation of the illness. 4. Speak to the child in a high-pitched voice.
1 Allowing the child to participate in her care will decrease the sense of loss of control and increase a sense of industry. While parents can certainly participate in their childs care, it does not increase the childs sense of control. School-age children in general will not understand detailed scientific explanations. Change in voice tone is appropriate when talking to very young children.
(Chapter 26) A child, in renal failure, is diagnosed with hyperkalemia. Which food choices will the nurse teach the parents and child to avoid? 1. Carrots and green, leafy vegetables 2. Chips, cold cuts, and canned foods 3. Spaghetti and meat sauce, breadsticks 4. Hamburger on a bun, cherry gelatin
1 Carrots and green, leafy vegetables are high in potassium. Chips, cold cuts, and canned foods are high in sodium but not necessarily potassium. Spaghetti and meat sauce with breadsticks and a hamburger on a bun with cherry gelatin would be acceptable choices for a low-potassium diet.
(20) Following parental teaching, the nurse is evaluating the parents understanding of environmental control for their childs asthma management. Which statement by the parents indicates appropriate understanding of the teaching? 1. We will replace the carpet in our childs bedroom with tile. 2. Were glad the dog can continue to sleep in our childs room. 3. Well be sure to use the fireplace often to keep the house warm in the winter. 4. Well keep the plants in our childs room dusted.
1 Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.
(Chapter 26) The nurse is providing care to a male infant who is diagnosed with hypospadias. Which clinical manifestation does the nurse anticipate when assessing this infant? 1. A urethral meatus that is located on the ventral surface of the penis 2. The presence of foreskin 3. A small opening or a fissure that extends the entire length of the penis 4. An opening on the dorsal surface of the penis
1 For an infant diagnosed with hypospadias, the nurse would anticipate a urethral meatus that is located on the ventral surface of the penis. Infants diagnosed with hypospadias may also have a partial absence of the foreskin. A small opening or a fissure that extends the entire length of the penis or an opening on the dorsal side of the penis would be expected for an infant diagnosed with epispadias.
(14) While teaching the parents of a newborn about infant care and feeding, which instruction by the nurse is the most appropriate? 1. Delay supplemental foods until the infant is 4 to 6 months old. 2. Delay supplemental foods until the infant reaches 15 pounds or greater. 3. Begin diluted fruit juice at 2 months of age, but wait three to five days before trying a new food. 4. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after
1 Four to six months is the optimal age to begin supplemental feedings because earlier feeding of nonformula foods is not needed by the infant and does not promote sleep. Earlier feeding of nonformula foods, regardless of the infants weight, is more likely to cause the development of food allergies. Also, early feeding is not well tolerated by infants because the necessary tongue control is not well developed and they lack the digestive enzymes to take in and metabolize many food products.
(18) A preschool-aged client, diagnosed with croup, has an increased pCO2, a decreased pH, and a normal HCO3 blood-gas value. Which documentation in the medical record is the most appropriate? 1. Uncompensated respiratory acidosis 2. Uncompensated respiratory alkalosis 3. Uncompensated metabolic acidosis 4. Uncompensated metabolic alkalosis
1 If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.
(14) The nurse is teaching the parents of a 4-month-old infant about good feeding habits. The nurse emphasizes the importance of holding the baby during feeding and not letting the infant go to sleep with the bottle. Which disorder is associated with propped feedings and going to sleep with the bottle? 1. Otitis media 2. Aspiration 3. Malocclusion problems 4. Sleeping disorders
1 It has been shown in numerous studies that allowing an infant to fall asleep with a bottle in his or her mouth causes pooling of the formula in the mouth, which increases the risk of both dental caries and otitis media. There has been limited data to date showing a positive correlation between bottle propping and increased risk of aspiration, malocclusions, and sleeping disorders.
(Chapter 19) A child is diagnosed with group A beta-hemolytic streptococcus (GABHS) infection of the throat. Which item will the nurse include in the teaching plan for the parents? 1. Complete the entire course of antibiotics. 2. Keep the child NPO (nothing by mouth). 3. Continue normal activities. 4. Do not allow the child to gargle with saltwater.
1 It is important for parents to complete the entire course of antibiotics for GABHS infections. Nothing-by-mouth, or NPO, status is not recommended because the child needs to stay hydrated. The child should rest, and use of warm saltwater gargles is recommended.
(Chapter 26) A child is scheduled for a kidney transplant. The nurse completes the preoperative teaching to prepare the child and parents for the surgery and postoperative considerations. Which statement by the parents indicates understanding of the teaching session? 1. We know its important to see that our child takes prescribed medications after the transplant. 2. Well be glad we wont have to bring our child in to see the doctor again. 3. Were happy our child wont have to take any more medicine after the transplant. 4. We understand our child wont be at risk anymore for catching colds from other children at school.
1 It is important that the nurse emphasize compliance with treatments that will need to be followed after the transplant. Follow-up appointments will be necessary, as well as medications and general health promotion.
(Chapter 20) A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). Which nursing intervention is the priority for this child? 1. Administer nebulized epinephrine and oral or IM dexamethasone. 2. Administer antibiotics and assist with possible intubation. 3. Swab the throat for a throat culture. 4. Obtain a sputum specimen.
1 Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.
(Chapter 25) The nurse is administering several medications to an infant with neurologic impairment and delay. Which medication is a proton pump inhibitor that is administered for gastroesophageal reflux? 1. Omeprazole 2. Ranitidine 3. Phenytoin 4. Glycopyrrolate
1 Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.
(Chapter 25) An infant born with an omphalocele defect is admitted to the intensive-care nursery. Which instruction from the nurse manager to the unlicensed assistive personnel is most appropriate? 1. Prepare a warmer. 2. Prepare a crib. 3. Prepare a feeding of formula. 4. Prepare the bilirubin light.
1 Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant many lose heat through the viscera; a warmer is indicated to prevent hypothermia. The crib would not provide adequate maintenance of temperature control. The infant is NPO (nothing by mouth) preoperatively and may or may not need a bilirubin light before surgery.
(Chapter 26) A preschool-age client diagnosed with with nephrotic syndrome is placed on prednisone for several weeks. Which teaching point is appropriate for the nurse to include in the teaching plan for this client? 1. Never stop the medication suddenly. 2. This drug is taken once a week on Sunday. 3. The child should always take the medication at night before bed. 4. This drug should be taken with meals.
1 Prednisone, a corticosteroid with anti-inflammatory action, is frequently used to treat nephrotic syndrome. It should never be stopped suddenly. The drug is taken more than once a week and can be taken any time during the day, but should remain on a constant schedule. Taking with food is always appropriate for most medications, but it does not have to be with a meal.
(Chapter 25) A 3-day-old preterm infant is diagnosed with necrotizing enterocolitis. The nurse plans care around the frequent radiographs. How frequently should the nurse anticipate that the radiology staff will bring the portable machine to the nursery? 1. Every 6 hours 2. Every 12 hours 3. Every 24 hours 4. Every 48 hours
1 Radiographs are done every 6 hours to evaluate for perforation.
(15) During the nurses initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which action by the nurse is most appropriate? 1. Administer prescribed analgesic. 2. Ask the childs parents if they think the child is hurting. 3. Reassess the child in 15 minutes to see if the pain rating has changed. 4. Do nothing, since the child appears to be resting.
1 Rationale 1: School-age children are old enough to accurately report their pain level. A pain score of 6 is an indication for prompt administration of pain medication. The child may be trying to be brave or may be lying still because movement is painful.
(Chapter 25) A neonate is fed 20 mL of formula every three hours by orogastric lavage. At the beginning of this feeding, the nurse aspirates 15 mL of gastric residual. Which action by the nurse is the most appropriate? 1. Withhold the feeding and notify the healthcare provider. 2. Replace the residual and continue with the full feeding. 3. Replace the residual but only give 5 mL of the feeding. 4. Withhold the feeding and check the residual in three hours.
1 Residual of more than half the amount of feeding indicates a feeding intolerance and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the healthcare provider should be notified of this finding. The amount of residual is too much to replace and continue with the feeding, and waiting for three hours to recheck the residual could delay treatment of a serious condition.
(14) During a 4-month-olds well-child check, the nurse discusses introduction of solid foods into the infants diet and concerns for foods commonly associated with food allergies. Due to allergies, which foods will the nurse instruction the parents to avoid until after 1 year of age? 1. Strawberries, eggs, and wheat 2. Peas, tomatoes, and spinach 3. Carrots, beets, and spinach 4. Squash, pork, and tomatoes
1 Strawberries, eggs, and wheat, along with corn, fish, and nut products, are all foods that have commonly been associated with food allergies. Carrots, beets, and spinach contain nitrates and should not be given before the age of 4 months. Squash, peas, and tomatoes are acceptable to try after an infant is 4 to 6 months old but should be given one at a time and three to five days after starting a new food. Pork can be tried after the infant is 8 to 10 months old, as meats are harder to digest and have a high protein load.
(Chapter 19) A school-age child has epistaxis. Which intervention by the school nurse is the most appropriate? 1. Tilting the childs head forward, squeezing the nares below the nasal bone, and applying ice to the nose 2. Tilting the childs head back, squeezing the bridge of the nose, and applying a warm, moist pack to the nose 3. Lying the child down and applying no pressure, ice, or warm pack 4. Immediately packing the nares with a cotton ball soaked with Neo-Synephrine
1 The correct initial treatment for a nosebleed is to tilt the head forward, squeeze the nares below the nasal bone for 10 to 15 minutes, and apply ice to the nose or back of the head. Tilting the childs head back may cause the blood to trickle down the throat. Warmth can cause an increase in bleeding because of vasodilation. Lying the child down without application of pressure to the nares may not stop the bleeding. A cotton ball soaked with Neo-Synephrine would only be used if the bleeding does not stop with pressure and ice.
(Chapter 19) The nurse suspects that an infant has a visual disorder caused by abnormal musculature. Which test will the nurse perform to detect this disorder? 1. A cover/uncover test 2. An ophthalmologic exam 3. A vision-acuity exam 4. A pupil-reaction-to-light test
1 The cover/uncover test can detect abnormal musculature of the eye that can lead to asymmetric eye movement. An ophthalmologic eye exam allows the practitioner to view the internal structures of the eye, not abnormal musculature. A vision acuity test is used to test for myopia. A pupil-reaction-to-light test evaluates neurological status.
(Chapter 25) A child experienced a lacerated spleen in a motor vehicle accident. Which is the highest-priority nursing intervention on admission to the pediatric intensive care unit (PICU) following surgery? 1. Observing for signs of hypovolemic shock 2. Maintaining IV fluids 3. Implementing strict bedrest 4. Administering blood products as ordered
1 The priority nursing intervention is observing for signs of hypovolemic shock due to bleeding from the lacerated spleen. The other interventions are appropriate but not the highest priority.
(Chapter 11) The nurse is working with a hospitalized preschool-age child. The nurse is planning activities to reduce anxiety in this child. Which action by the nurse is the most appropriate? 1. Provide the child with a doll and safe medical equipment. 2. Read a story to the child. 3. Use an anatomically correct doll to teach the child about the illness. 4. Talk to the child about the hospitalization.
1 Therapeutic play is a means of anxiety reduction in the hospitalized child. Allowing the child to play with safe medical equipment is an age-appropriate method through which the child can express her feelings, thereby reducing anxiety. Anatomically correct dolls are not age appropriate. Reading a story to the child does not allow for expression of feelings. Talking to the child may be beneficial, but it does not allow for active release of frustration and anxiety as active play does.
(Chapter 20) A child is showing signs of acute respiratory distress. Which position will the nurse place this child? 1. Upright 2. Side-lying 3. Flat 4. In semi-Fowlers
1 Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.
(Chapter 25) An infant is born with an esophageal atresia and tracheoesophageal fistula. Which preoperative nursing diagnosis is the priority for this infant? 1. Risk for Aspiration Related to Regurgitation 2. Acute Pain Related to Esophageal Defect 3. Ineffective Infant Feeding Pattern Related to Uncoordinated Suck and Swallow 4. Ineffective Tissue Perfusion: Gastrointestinal, Related to Decreased Circulation
1 With the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Pain is not usually experienced preoperatively with this condition. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. Tissue perfusion is not a problem with this condition.
(15) A toddler is hospitalized with a fractured femur. In addition to pain medication, which will best provide pain relief for this child? 1. Parents presence at the bedside 2. Age-appropriate toys 3. Deep-breathing exercises 4. Videos for the child to watch
1 arents presence at the bedside reduces anxiety and subsequently reduces pain. Although play and other methods of distraction might be somewhat effective, they do not equal the comfort that parents presence provides, especially in a 2-year-old, who is also at high risk for separation anxiety.
(Chapter 20) The nurse educator is teaching a group of nursing students how to perform a respiratory assessment for a newborn in the newborn intensive care unit (NICU) diagnosed with respiratory distress syndrome (RDS). Which normal characteristics of the newborns respiratory system increase the risk for obstruction? Standard Text: Select all that apply. 1. Shorter and narrower airway 2. Higher trachea 3. Bronchial branching at different angles 4. Inadequate smooth muscle bundles 5. Diaphragmatic breather
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(Chapter 20) The nurse is providing care to an infant who is diagnosed with bronchiolitis. Which breath sounds indicate the infant is experiencing respiratory distress? Standard Text: Select all that apply. 1. Tachypnea 2. Wheezing 3. Grunting 4. Retractions 5. Eupnea
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(Chapter 20) The nurse is assessing a school-age client who experienced blunt force trauma to the chest when an airbag deployed following a motor vehicle crash. Which areas of assessment are essential for this client? Standard Text: Select all that apply. 1. Monitor responsiveness and behavior. 2. Monitor SpO2. 3. Auscultate the lungs for crackles, wheezes, decreased breath sounds. 4. Document input and output. 5. Note changes in voice quality or coughing.
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(Chapter 26) The nurse is preparing an educational session for sexually active adolescents. Which statements are appropriate for the nurse to include when educating about sexually transmitted infections (STIs)? Standard Text: Select all that apply. 1. Frequently diagnosed STIs include chlamydia, genital herpes, gonorrhea, human papillomavirus, trichomoniasis, and syphilis. 2. Your risk for contracting an STI can be decreased by using a condom when having sex. 3. Birth control pills are useful in decreasing your risk of contracting an STI. 4. Risk factors for pelvic inflammatory disease (PID) include multiple sexual partners, lack of barrier protection during intercourse, and history of an STI. 5. Pelvic inflammatory disease (PID) is an infection of the lower genital tract.
1 2 4 It is appropriate for the nurse to include the frequently diagnosed STIs, the fact that the risk is decreased by using a condom, and the risk factors for pelvic inflammatory disease. Birth control pills are useful in decreasing the risk of pregnancy but are not useful for decreasing the risk of contracting an STI. PID is an infection of the upper genital tract, not the lower genital tract.
(Chapter 20) A school nurse is planning care for a school-age child recently diagnosed with asthma. Which items will the school nurse include in the plan of care at the school? Standard Text: Select all that apply. 1. Maintain a log of quick-relief medication administration. 2. Call the parents if quick-relief medications work appropriately. 3. Assess for symptoms of exercise-induced bronchospasm. 4. Coordinate education of the childs teachers. 5. Conduct a support group for all children with asthma.
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(Chapter 26) The nurse educator is teaching a group of nursing students the pathophysiologic reasons related to genitourinary (GU) disorders in the pediatric population. Which statements are appropriate for the nurse educator to include in the teaching session? Standard Text: Select all that apply. 1. Incomplete organ development during fetal development is the cause of many GU disorders. 2. Improper placement of the urethra in vagina is one cause of GU disorders. 3. GU disorders in the pediatric population can be caused by hydronephrosis. 4. GU disorders in the pediatric population are not caused by infections. 5. Anatomic obstruction or incomplete nerve innervation can cause GU disorders.
1 3 5 Pathophysiologic causes of GU disorders in the pediatric population include incomplete organ development during fetal development; hydronephrosis; and anatomic obstruction or incomplete nerve innervations. Improper placement of the urethra in the penis, not the vagina, is another pathophysiologic cause of GU disorders. GU disorders can also be caused by infection
(Chapter 19) The nurse teaches parents how to care for their child who has tympanostomy tubes inserted. Which actions by the parents indicate appropriate understanding of the teaching session? Standard Text: Select all that apply. 1. Encouraging the child to drink generous amounts of fluids 2. Administering a decongestant for one to two weeks following surgery 3. Restricting the child to quiet activities after surgery 4. Limiting diet to soft, bland foods 5. Avoiding getting water in ears during bath time
1 3 5 The correct responses include encouraging the child to drink generous amount of water, restricting the child to quiet activities after surgery, and avoiding water in the childs ears at bath time. Incorrect responses include administering a decongestant for one to two weeks following surgery and limiting diet to soft, bland foodsdecongestants are not needed after surgery, and a regular diet should be resumed.
(Chapter 26) A child is prescribed hemodialysis for the treatment of kidney failure. When providing care for this child, what will the nurse monitor for during the assessment? Standard Text: Select all that apply. 1. Shock 2. Hypotension 3. Infections 4. Migraines 5. Fluid overload
1, 2, 3 Rapid changes in fluid and electrolyte balance during hemodialysis may lead to shock and hypotension. Other complications to watch for are thromboses and infection. Migraines and fluid overload are not clinical manifestations associated with hemodialysis
(15) A young school-age client is hospitalized with a fractured femur. Which assessment tools are appropriate for this client? Standard Text: Select all that apply. 1. FACES pain scale 2. Oucher scale 3. Visual Analog Scale 4. CRIES Scale 5. Poker-chip tool
1, 2, 5 Rationale 1: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale. Rationale 2: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale. Rationale 5: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.
(31) The nurse is providing care to a pediatric client who is diagnosed with psoriasis. Which clinical manifestations does the nurse anticipate upon assessment of this client? Standard Text: Select all that apply. 1. Thick, silvery, scaly erythematous plaque 2. Pruritus 3. Dry skin, likely to crack and fissure 4. Fragile skin and blisters 5. Irregular border surrounded by normal skin
1, 2, 5 Rationale 1: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin. Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa. Rationale 2: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin. Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa. Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin. Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.
(31) The nurse is teaching a group of students about wound healing. Which items will the nurse include as occurring during the hemostasis and inflammation stage of wound healing? Standard Text: Select all that apply. 1. Clot formation to seal the wound 2. Production of collagen and granulation tissue 3. Scar formation and strengthening 4. Release of inflammatory mediators by platelets 5. Swelling as a result of increased capillary permeability
1, 2, 5 Rationale 1: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation. Rationale 2: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation. Rationale 5: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.
(15) The nurse is admitting a school-age Vietnamese client who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. The child is stoic and denies pain. Which nursing actions are most appropriate in this situation? Standard Text: Select all that apply. 1. Use the FLACC scale to determine the childs pain level. 2. Tell the child to ring the call bell if the leg starts hurting. 3. Administer pain medication now and continue on a regular basis. 4. Ask the childs parents to notify the nurse if the child complains of pain. 5. Use the NIPS scale to determine the childs pain level. Correct Answer: 1,3,4
1, 3, 4 RATIONALE 1:Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client. Rationale 3: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client. Rationale 4: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.
(Chapter 25) The nurse educator is preparing an in-service on the basic functions of the gastrointestinal (GI) system. Which statements will the nurse educator include in the in-service? Standard Text: Select all that apply. 1. The GI system is responsible for the ingestion of fluids and nutrients. 2. The GI system is responsible for the excretion of fluids and nutrients. 3. The GI system is responsible for the metabolism of nutrients. 4. As infants grow, their stomach capacity increases, decreasing the frequency with which they need to be fed. 5. By the second year of life, digestive processes are still developing.
1, 3, 4 The GI system is responsible for the ingestion of fluids and nutrients as well as the metabolism of nutrients. As infants grow, their stomach capacity increases, which does decrease the frequency with which they need to be fed. The GI system is responsible for the excretion of waste products. By the second year of life, digestive processes are fairly complete.
(Chapter 25) The nurse is caring for a school-age client who had an appendectomy after a ruptured appendix. Which orders does the nurse anticipate for this client? Standard Text: Select all that apply. 1. Antibiotics 2. A clear liquid diet 3. NG tube 4. Vital signs every 4 hours 5. Frequent monitoring of bowel sounds
1, 3, 4, 5 Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return
(Chapter 11) The nurse is providing care to a preschool-age client who was admitted to the medicalsurgical unit after an acute asthma attack. Which interventions foster a family-centered focus to client care? Standard Text: Select all that apply. 1. Discussing rooming in with the parents of the client 2. Allowing the client to cry it out after the parents leave for the evening 3. Providing comfort items from home, such as a blanket 4. Maintaining strict visitation for the family 5. Discussing what to expect during the hospital stay
1, 3, 5 Family-centered care principles that are used in the hospital setting include rooming in, providing comfort items from home, and discussing what to expect. Allowing the child to cry it out and maintaining strict visitation for the family are not family-centered principles
(14) The parents of a toddler are concerned about their childs finicky eating habits. While counseling the parents, which statements by the nurse are the most appropriate? Standard Text: Select all that apply. 1. The child is experiencing physiologic anorexia, which is normal for this age group. 2. A general guideline for food quantity at a meal is one-quarter cup of each food per year of age. 3. It is more appropriate to assess a toddlers nutritional demands over a 1-week period rather than a 24-hour one. 4. Nutritious foods should be made available at all times of the day so that she is able to graze whenever she is hungry. 5. The toddler should drink 16 to 24 ounces of milk daily.
1, 3, 5 Rationale 1: Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and it is a very normal finding at this age. It is not unusual for toddlers to have food jags during which they only want one or two food items for that day. So it is more helpful to look at what their intake has been over a week instead of a day. Two to three cups of milk per day are sufficient for a toddler, and more than that can decrease the childs desire for other foods and lead to dietary deficiencies. The correct general guideline for food quantity is one tablespoon of each food per year of age. Food should only be offered at meal and snack times, and children should sit at the table while eating to encourage their socialization skills. Rationale 3: Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and it is a very normal finding at this age. It is not unusual for toddlers to have food jags during which they only want one or two food items for that day. So it is more helpful to look at what their intake has been over a week instead of a day. Two to three cups of milk per day are sufficient for a toddler, and more than that can decrease the childs desire for other foods and lead to dietary deficiencies. The correct general guideline for food quantity is one tablespoon of each food per year of age. Food should only be offered at meal and snack times, and children should sit at the table while eating to encourage their socialization skills. Rationale 5: Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and it is a very normal finding at this age. It is not unusual for toddlers to have food jags during which they only want one or two food items for that day. So it is more helpful to look at what their intake has been over a week instead of a day. Two to three cups of milk per day are sufficient for a toddler, and more than that can decrease the childs desire for other foods and lead to dietary deficiencies. The correct general guideline for food quantity is one tablespoon of each food per year of age. Food should only be offered at meal and snack times, and children should sit at the table while eating to encourage their socialization skills.
required criteria for hysterectomy/ovariectomy or metoidioplasty, phalloplasty, or Vaginoplasty
1. 12 months of continuous hormone therapy required 2. 12 months living in gender role consistent with gender identity required
A supervisor is reviewing the documentation of the nurses in the unit. Which client documentation is the most accurate and contains all the required part for a narrative entry? 1. 2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mothers arms following catheter removal. M. May RN 2. 1/9/05 2 pm NG tube placement confirmed and irrigated with 30 ml sterile water. Suction set at low, intermittent. Oxygen via nasal canal at 2 L/min. Nares patent, pink, and nonirritated. K. Earnst RN 3. 4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. Respirations regular and even throughout the procedure. F. Luck RN 4. Feb. 05 Port-A-Cath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gamma globins hung and infusing at 30cc/hr. Child smiling and playful throughout the procedure. P. Potter, RN
1. 2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mothers arms following catheter removal. M. May RN
The telephone triage nurse at a pediatric clinic knows each call is important. Which call would require extra attentiveness from the registered nurse because of an increased risk of mortality? 1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis 2. A term 2-week-old infant of American Indian descent with an upper respiratory infection 3. A post term 4-week-old infant non-Hispanic black descent with moderate emesis after feeding 4. A 1-week-old infant born at 40 weeks gestation with symptoms of colic
1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis
Which legal or ethical offense would be committed if a nurse tells family members the condition of a newborn baby without first consulting the parents? 1. A breach of privacy 2. Negligence 3. Malpractice 4. A breach of ethics
1. A breach of privacy
During the nurses initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which action by the nurse is most appropriate? 1. Administer prescribed analgesic. 2. Ask the child's parents if they think the child is hurting. 3. Reassess the child in 15 minutes to see if the pain rating has changed. 4. Do nothing, since the child appears to be resting.
1. Administer prescribed analgesic.
When examining a 7-year-old, which action by the nurse would be most appropriate? 1. Allow the child to participate in the exam. 2. Ask the parent what kind of food the child likes to eat. 3. Ask the child whether he plays outside for at least 30 minutes a day. 4. Allow the child to decide whether he is ready for his next immunization.
1. Allow the child to participate in the exam.
A nurse is assessing an 11-month-old infant and notes that the infants height and weight are at the 5th percentile on the growth chart. Family history reveals that the infants two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority? 1. Alteration in Growth Pattern Related to Parental Anxiety 2. Alteration in Growth Pattern Secondary to Familial Short Stature 3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns 4. At Risk for Constitutional Growth Delay Related to Decreased Appetite
1. Alteration in Growth Pattern Related to Parental Anxiety
A neonatal nurse who encourages parents to hold their baby and provides opportunities for Kangaroo Care most likely is demonstrating concern for which aspect of the infants psychosocial development? 1. Attachment 2. Assimilation 3. Centration 4. Resilience
1. Attachment
It is important that parents of adolescents with special needs transition care of the adolescent so they can learn to make good decisions on their own. Which items are considered transitional needs? Standard Text: Select all that apply. 1. Attending school 2. Discussing sexual matters 3. Letting most friends know of the medical condition 4. Socialization beyond the family 5. To write his or her own individualized healthcare plan
1. Attending school 2. Discussing sexual matters 4. Socialization beyond the family
The pediatric nurse educator is conducting an in-service for novice nurses who will begin working on the pediatric oncology unit. The educator wants to include the common clinical manifestations of cancer. Which manifestation will the educator include in the presentation? Standard Text: Select all that apply. 1. Cachexia 2. Anemia 3. Gene abnormalities 4. Palpable mass 5. Chromosomal abnormalities
1. Cachexia 2. Anemia 4. Palpable mass
A child is diagnosed with a Wilms tumor. Which nursing action is most appropriate prior to surgery? 1. Careful bathing and handling 2. Monitoring of behavioral status 3. Maintenance of strict isolation 4. Administration of packed red-blood cells
1. Careful bathing and handling
The nurse is working with a child with a chronic condition. The nurse observes that over time, the parents have experienced a pattern of periodic grieving alternating with denial. What are the parents currently experiencing based on this assessment finding? 1. Chronic sorrow 2. Compassion fatigue 3. Dysfunctional parenting 4. Pathological grieving
1. Chronic sorrow
The nurse is preparing to complete a health surveillance appointment with a school-age client and parents. Which observations would necessitate the need for further assessment by the nurse? Select all that apply. 1. Client who does not make eye contact 2. Client with visible bruises in various stages of healing 3. Client holding a video game talking with parent 4. Client playing a card game with sibling 5. Client who appears red in the face while walking to exam room
1. Client who does not make eye contact 2. Client with visible bruises in various stages of healing 5. Client who appears red in the face while walking to exam room
The nurse is assigned to a child in a spica cast for a fractured femur suffered in an automobile accident. The childs teenage brother was driving the car, which was totaled. The nurse learns that the father lost his job three weeks ago and the mother has just accepted a temporary waitress job. Which nursing diagnosis will the nurse use when planning care for this child and family? 1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors 2. Impaired Social Interaction (Parent and Child) Related to the Lack of Family or Respite Support 3. Interrupted Family Processes Related to Child with Significant Disability Requiring Alteration in Family Functioning 4. Risk for Caregiver Role Strain Related to Child with a Newly Acquired Disability and the Associated Financial Burden
1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors
The school nurse completes an assessment of a school-age client to determine the services this child will need in the classroom. The client is a newly diagnosed with type I diabetes mellitus. Based on this information, which special healthcare need category is the most appropriate? 1. Dependent on medication or special diet 2. Dependent on medical technology 3. Increase use of healthcare services 4. Functional limitations
1. Dependent on medication or special diet
A seasoned nurse is precepting a novice nurse on a pediatric oncology unit. The seasoned nurse would like to review the ongoing physiologic and psychosocial care of the children who survive cancer. Which topics will the seasoned nurse include in the discussion with the novice nurse? Standard Text: Select all that apply. 1. Developing other cancers 2. Recommending regular office visits 3. Encouraging school-age clients to manage their own care 4. Needing weekly laboratory tests 5. Providing educational and psychosocial support
1. Developing other cancers 2. Recommending regular office visits 5. Providing educational and psychosocial support
The nurse in a pediatric acute-care unit is assigned the following tasks. Which task is not appropriate for the registered to nurse complete? 1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic. 2. Listen to the concerns of an adolescent about being out of school for a lengthy surgical recovery. 3. Provide information to a mother of a newly diagnosed 4-year-old diabetic about local support-group options. 4. Diagnose a 6-year-old with Diversional Activity Deficit related to placement in isolation.
1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic.
The nurse is planning care for a preschool-age child and family. In order to assess the family, what should the nurse plan to do during each health supervision visit? Select all that apply. 1. Discuss of the child's developmental status 2. Observe interactions among the family members 3. Discuss concerns with the parents 4. Administer age appropriate vaccinations 5. Record height and weight
1. Discuss of the child's developmental status 2. Observe interactions among the family members 3. Discuss concerns with the parents
The nurse is providing care to a preschool-age client who was admitted to the medicalsurgical unit after an acute asthma attack. Which interventions foster a family-centered focus to client care? Select all that apply. 1. Discussing rooming in with the parents of the client 2. Allowing the client to cry it out after the parents leave for the evening 3. Providing comfort items from home, such as a blanket 4. Maintaining strict visitation for the family 5. Discussing what to expect during the hospital stay
1. Discussing rooming in with the parents of the client 3. Providing comfort items from home, such as a blanket 5. Discussing what to expect during the hospital stay
(pretest 6) which of the following signs and symptoms of asthma would the nurse expect to see in an acute flare? Select all that apply: 1. Dyspnea 2. Stridor 3. Coughing 4. Wheezing 5. Emesis
1. Dyspnea 3. Coughing 5. Emesis
Which health promotion activities can the nurse recommend to the parents of a preschool-age child in order to enhance the childs self-concept? Select all that apply. 1. Encourage a play date with a school-age child. 2. Praise the child for staying dry at night. 3. Tell the child there will be a punishment for bathroom accidents. 4. Set aside time for the child each day. 5. Discuss appropriate activities to engage in with the daycare provider.
1. Encourage a play date with a school-age child. 2. Praise the child for staying dry at night. 4. Set aside time for the child each day.
A nurse is working with the family of a pediatric client. When planning to obtain an accurate family assessment, which initial step is the most appropriate? 1. Establish a trusting relationship with the family. 2. Select the most relevant family-assessment tool. 3. Focus primarily upon the mother, while learning her greatest concern. 4. Observe the family in the home setting, since this step always proves indispensable.
1. Establish a trusting relationship with the family.
The nurse is caring for a toddler client in the postoperative period. Which pain assessment tool is most appropriate for this client? 1. FLACC Behavioral Pain Assessment Scale 2. FACES pain scale 3. Oucher scale 4. Poker-chip tool
1. FLACC Behavioral Pain Assessment Scale
The nurse is assessing a family's effective coping strategies and ineffective defensive strategies. Which family-social-system theory is the nurse using in this assessment of the family? 1. Family-stress theory 2. Family-development theory 3. Family-systems theory 4. Family life-cycle theory
1. Family-stress theory
A follow-up visit for a newborn client is scheduled with the pediatric nurse practitioner 3 days after discharge. What will the nurse include in the assessment during the scheduled visit for this newborn? Select all that apply. 1. Feeding pattern 2. Jaundice 3. Length 4. Vision screen 5. Sleep pattern
1. Feeding pattern 2. Jaundice 5. Sleep pattern
A child diagnosed with cancer is prescribed chemotherapy. The latest lab value indicates the white-blood-cell count is very low. Which medication order does the nurse anticipate? 1. Filgrastim (Neupogen) 2. Ondansetron (Zofran) 3. Oprelvekin (Neumega) 4. Epoetin alfa (human recombinant erythropoietin)
1. Filgrastim (Neupogen)
The nurse educator is teaching a group of nursing students about the endocrine system. Which statements are appropriate for the educator to include in the teaching session? Standard Text: Select all that apply. 1. Gonadotropin-releasing hormone stimulates the anterior pituitary to produce LH and FSH. 2. Growth hormone regulates linear bone growth and growth of all tissues. 3. Antidiuretic hormone regulates urine concentration by the kidneys. 4. Thyroid hormone regulates serum calcium levels and phosphorus excretion. 5. Parathyroid hormone regulates metabolism of cells and body heat production.
1. Gonadotropin-releasing hormone stimulates the anterior pituitary to produce LH and FSH. 2. Growth hormone regulates linear bone growth and growth of all tissues. 3. Antidiuretic hormone regulates urine concentration by the kidneys.
The nurse is working with an adolescent client who will be admitted to the hospital in two days. Which nursing approach is most appropriate to prepare this client for hospitalization? 1. Have teens who have had similar experiences talk to the adolescent about hospitalization. 2. Provide an opportunity for the child to talk with an adult who has had a similar experience. 3. Teach parents what to expect so the information can be shared with the adolescent. 4. Provide an opportunity for the teen to try on surgical attire.
1. Have teens who have had similar experiences talk to the adolescent about hospitalization.
The school nurse performs screenings on all students in the middle school. In addition, the nurse will perform selected screenings on individual school-age children. When planning the screenings for the year, which screenings will the nurse include for all school-age children? Select all that apply. 1. Hearing 2. Height and weight 3. Blood-pressure measurement 4. Hepatitis B profile serology 5. Chest x-ray
1. Hearing 2. Height and weight 3. Blood-pressure measurement
An adolescent reports the following: I get up at 6 am, I attend early-morning band classes three times each week, I play sports for two hours each day after school, and homework takes me three hours each night. I always feel tired. Which question by the nurse is most appropriate based on this information? 1. How many hours of sleep do you get each night? 2. Do you consume foods high in iron? 3. Do you think you are doing too much? 4. Have you considered talking with your teachers about decreasing your homework, since you have so many extracurricular activities?
1. How many hours of sleep do you get each night?
There are many healthcare needs of children with chronic conditions. What nursing strategy would best help parents with continuity of care? 1. Include the family and older child in decision making. 2. Assist the family in gaining transportation to healthcare appointments. 3. Provide the family with resources such as social services. 4. Recognize and respect the cultural needs of the family.
1. Include the family and older child in decision making.
A 5-year-old sibling of a 9-year-old child with cystic fibrosis tells the nurse, I wish I had a breathing disease, too. The nurse knows the parents strive to spend quality time with each child and with both children together. What is the sibling currently experiencing? 1. Jealousy 2. Isolation 3. Loneliness 4. Anger
1. Jealousy
The pediatric nurse is providing care to a school-age child receiving chemotherapy to treat cancer. Which interventions are appropriate to include in the plan of care in order to monitor for oncologic emergencies? Standard Text: Select all that apply. 1. Monitor complete blood count (CBC). 2. Document intake and output. 3. Observe for behavioral changes. 4. Refer for psychosocial support. 5. Implement neutropenic precautions.
1. Monitor complete blood count (CBC). 2. Document intake and output. 3. Observe for behavioral changes.
A nursery nurse is planning care for the newborns currently in the newborn nursery. Which activities does the nurse plan for the first 48 hours of life? Select all that apply. 1. Monitor feeding behaviors. 2. Perform a hearing screening. 3. Perform a heel stick to obtain blood for the newborn screen. 4. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids. 5. Administer folic-acid injection to the infant to prevent bleeding.
1. Monitor feeding behaviors. 2. Perform a hearing screening. 3. Perform a heel stick to obtain blood for the newborn screen.
The nurse in the long-termcare clinic is reviewing the charts of a group of children with chronic physical, psychological, functional, and/or social limitations. Which conditions are most likely to lead to chronic limitations? Standard Text: Select all that apply. 1. Near drowning 2. Congenital heart defect 3. Sinusitis 4. Fetal insult when the mother contracted rubella in the first trimester of pregnancy 5. Sepsis contracted as a neonate
1. Near drowning 2. Congenital heart defect 4. Fetal insult when the mother contracted rubella in the first trimester of pregnancy 5. Sepsis contracted as a neonate
While assessing the development of a 9-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which developmental task is the nurse assessing this infant for? 1. Object permanence 2. Centration 3. Transductive reasoning 4. Conservation
1. Object permanence
The nurse is planning activities for a toddler with a birth injury of a torn brachial plexus that resulted in muscle atrophy and weakness of his right arm. Which nursing intervention is most appropriate for this client? 1. Offering the toddler a choice of clothing 2. Asking the toddler if he would like to take his medicine 3. Dressing the toddler 4. Feeding the toddler
1. Offering the toddler a choice of clothing
The nurse is performing an assessment of the ecological systems of childhood. What will the nurse include when assessing mesosystems? Select all that apply. 1. Parental involvement in school 2. Local political influences 3. Libraries in the community 4. Influences of the religious community 5. Age of each family member
1. Parental involvement in school 4. Influences of the religious community
A toddler is hospitalized with a fractured femur. In addition to pain medication, which will best provide pain relief for this child? 1. Parents presence at the bedside 2. Age-appropriate toys 3. Deep-breathing exercises 4. Videos for the child to watch
1. Parents presence at the bedside
A child is diagnosed with rhabdomyosarcoma. Which nursing intervention is most appropriate for this child? 1. Position the child with the head elevated. 2. Monitor for hematuria. 3. Demonstrate the use of a conformer. 4. Administer oxygen.
1. Position the child with the head elevated.
The nurse working in the clinic includes an adolescent history in every client intake interview. Which issue should the nurse address when the parents are not present? 1. Possible domestic violence 2. Teen job responsibilities 3. Activities that are done as a family 4. The adolescents role in the family
1. Possible domestic violence
The nurse is planning care for a preschool-age client who has cerebral palsy (CP). Which interventions are appropriate for this client? Standard Text: Select all that apply. 1. Providing heath supervision 2. Collaborating with physical therapy 3. Assisting with planning educational services 4. Prescribing medication for spasticity 5. Promoting growth and development
1. Providing heath supervision 2. Collaborating with physical therapy 3. Assisting with planning educational services 5. Promoting growth and development
A nurse is planning care for a pediatric client diagnosed with adrenal insufficiency (Addison disease). Which nursing diagnosis is the priority for this client? 1. Risk for Deficient Fluid Volume 2. Risk for Injury Secondary to Hypertension 3. Acute Pain 4. Imbalanced Nutrition: More than Body Requirements
1. Risk for Deficient Fluid Volume
(pretest 5) The nurse is educating the parents of a 2 month old regarding the immunizations that a child will receive that day. The nurse should educate the parents that which of the following immunizations will protect the child from a serious GI infection? 1. Rotavirus vaccine (RV) 2. Diptheria, tetanus, and acellular pertussis (TDaP) 3. Haemophilus influenzae type B (Hib) 4. Pneumococcal conjugative (PCV13)
1. Rotavirus vaccine (RV)
An adolescent is accompanied by the mother for an annual physical examination. The nurse is aware of privacy issues related to the adolescent. While the mother is in the room, the nurse should avoid which questions? Select all that apply. 1. Sexual activity 2. Cigarette smoking 3. School performance 4. Use of alcohol 5. Car seatbelt use
1. Sexual activity 2. Cigarette smoking 4. Use of alcohol
The school nurse is teaching a class about safety. The nurse will teach the children that they should wear protective athletic gear when participating in selected activities. Which of these activities require protective athletic gear? Select all that apply. 1. Skateboarding 2. Playing football 3. Swimming 4. Playing lacrosse 5. Performing acrobatic tricks
1. Skateboarding 2. Playing football 4. Playing lacrosse
While in the pediatricians office for their childs 12-month well-child exam, the parents ask the nurse for advice on age-appropriate toys for their child. Based on the child's developmental level, which types of toys would the nurse suggest? Select all that apply. 1. Soft toys that can be manipulated 2. Small toys that can pop apart and go back together 3. Jack-in-the-box toys 4. Toys with black and white patterns 5. Push-and-pull toys
1. Soft toys that can be manipulated 3. Jack-in-the-box toys 5. Push-and-pull toys
The nurse is counseling the parents of a 6-1/2-month-old infant. Which age-appropriate toy is most appropriate for the nurse to suggest to these parents? 1. Soft, fluid-filled ring that can be chilled in the refrigerator 2. Colorful rattle 3. Jack-in-the-box toy 4. Push-and-pull toy
1. Soft, fluid-filled ring that can be chilled in the refrigerator
The nurse is asked to teach injury prevention measures to a classroom of 4-year-old preschoolers. Which teaching points are most appropriate at this age? Select all that apply. 1. Stop, drop and roll if clothes catch fire 2. Never go into the road alone. 3. Acceptable places for climbing 4. Safe meeting place outside the house in case of fire 5. Car seat safety
1. Stop, drop and roll if clothes catch fire 2. Never go into the road alone. 4. Safe meeting place outside the house in case of fire 5. Car seat safety
The nurse is assessing an infant client during a health supervision visit. Which assessment findings are considered normal variations for this client? Select all that apply. 1. Sucking pads in the mouth 2. A rounded chest 3. Hearing breath sounds over the entire chest 4. Pubertal development 5. Knock-knees
1. Sucking pads in the mouth 2. A rounded chest 3. Hearing breath sounds over the entire chest
A pediatric client diagnosed with Turner syndrome tells the nurse, I feel different from my peers. Which response by the nurse is the most appropriate? 1. Tell me more about the feelings you are experiencing. 2. These feelings are not unusual and should pass soon. 3. Youll start to grow soon, so dont worry. 4. You seem to be upset about your disease.
1. Tell me more about the feelings you are experiencing.
While inspecting a 5-year-old childs ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority? 1. Temperature 2. Heart rate 3. Respirations 4. Blood pressure
1. Temperature
Several children arrived at the emergency department accompanied only by their fathers. Which father may legally sign emergency medical consent for treatment? 1. The divorced one from the binuclear family 2. The stepfather from the blended or reconstituted family 3. The divorced one when the single-parent mother has custody 4. The nonbiologic one from the heterosexual cohabitating family
1. The divorced one from the binuclear family
A parent of a newborn asks the nurse why a heel stick is being done on the baby to test for phenylketonuria (PKU). Which response by the nurse is the most appropriate? 1. This screening is required and detection can be done before symptoms develop. 2. The infant has high-risk characteristics. 3. Because the infant was born by cesarean, this test is necessary. 4. Because the infant was born by vaginal delivery, this test is recommended.
1. This screening is required and detection can be done before symptoms develop.
A parent questions how her toddler plays with other toddlers. Which response by the nurse displays the best description of the differences in play between the toddler and the preschooler? 1. Toddlers play side by side, while preschoolers play cooperatively. 2. Toddlers play house and imitate adult roles, while preschoolers become the Mom or Dad while playing house. 3. Toddlers play cooperatively, while preschoolers play interactive games. 4. There are no differences between toddlers and preschoolers since both groups play cooperatively.
1. Toddlers play side by side, while preschoolers play cooperatively.
The nurse is admitting a school-age Vietnamese client who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. The child is stoic and denies pain. Which nursing actions are most appropriate in this situation? Standard Text: Select all that apply. 1. Use the FLACC scale to determine the child's pain level. 2. Tell the child to ring the call bell if the leg starts hurting. 3. Administer pain medication now and continue on a regular basis. 4. Ask the child's parents to notify the nurse if the child complains of pain. 5. Use the NIPS scale to determine the child's pain level.
1. Use the FLACC scale to determine the child's pain level. 3. Administer pain medication now and continue on a regular basis. 4. Ask the child's parents to notify the nurse if the child complains of pain.
A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings? Select all that apply. 1. Wheezing 2. Increased tactile fremitus 3. Decreased vocal resonance 4. Decreased tactile fremitus 5. Bronchophony
1. Wheezing 3. Decreased vocal resonance 4. Decreased tactile fremitus
A mother who is bottle feeding her newborn asks to be discharged 24 hours post delivery, because she also has twin 2-year-old children at home. When should the nurse schedule the first office visit for this newborn? 1. Within 48 hours of discharge 2. Within one week of discharge 3. Within two weeks of discharge 4. When the infant is 1 month old
1. Within 48 hours of discharge
required criteria for breast/chest surgery
1. hormones recommended, but not required. 2. living as preferred gender not required
(pretest 6) Which of the following manifestations of celiac disease would the nurse expect to hear in a child's history? Select all that apply: 1. irritability 2. failure to thrive 3. abdominal pain 4. excessive hunger 5. recurring diarrhea
1. irritability 2. failure to thrive 3. abdominal pain 5. recurring diarrhea
required criteria for gender affirming hormone therapy (4)
1. persistent, well-documented DYSPHORIA 2. CAPACITY to make a fully informed decision and to consent for treatment 3. AGE of majority in the given country 4. if significant medical or mental health concerns are present, they must be reasonably well-CONTROLLED
(pretest 5) A child has been diagnosed with Hirchsprung's disease. Which of the following findings would the nurse expect the parents to report in the child's history? Select all that apply: 1. Ribbon-like stools 2. Chronic constipation 3. black tarry stools 4. distended abdomen 5. delayed meconium passage
1. ribbon-like stools 2. chronic constipation 4. distended abdomen 5. delayed meconium passage
(Chapter 20) The nurse is providing care to an infant in the emergency department. Upon assessment, the infant is noted to have to be experiencing tachypnea, wheezing, retractions, and nasal flaring. The infant is irritability and the parents state the infant has had poor fluid intake for two days. Pulse ox reading is currently at 85% on room air. The infants blood gas is pending. Which diagnosis does the nurse anticipate for this infant? 1. Bronchitis 2. Bronchiolitis 3. Pneumonia 4. Active pulmonary tuberculosis
2
(Chapter 20) The nurse is teaching the parents of a newly diagnosed cystic fibrosis patient how to administer the pancreatic enzymes. How often will the nurse teach the parents to administer the enzymes? 1. Two times per day 2. With meals and snacks 3. Every 6 hours around the clock 4. Four times per day
2
The nurse is teaching the parent of a type 1 diabetic preschool-age client about management of the disease. Which teaching point is appropriate for the nurse to include in this session? 1. Allowing the client to administer all the insulin injections 2. Allowing the client to choose which finger to stick for glucose testing 3. Allowing the client to draw up the insulin dose 4. Allowing the client to test blood glucose
2
(Chapter 19) The nurse completes postoperative discharge teaching to the parents of a child who had a tonsillectomy. Which statement by the parents indicates correct understanding of the teaching session? 1. We will call the physician for any indication of ear pain. 2. We will plan on administering acetaminophen (Tylenol) for pain. 3. We will be sure to give our child adequate amounts of citrus juices. 4. We will keep our child on bed rest for 10 days after the surgery.
2 Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy. Citrus juices should be avoided for the first week because highly acidic foods and beverages can cause irritation. Ear pain 4 to 8 days after a tonsillectomy may be experienced and does not indicate an ear infection. Children do not need to be confined to bed. They can return to school in 10 days.
ATI 10: 1. A nurse is caring for a preschooler. Which of the following is an expected behavior of a pre-school aged child? 1. describing manifestations of an illness 2. relating fears to magical thinking 3. understanding cause of illness 4. awareness of body functioning
2 2. Preschool-age children are egocentric and relate fears to magical thinking.
(18) A nurse is planning care for a child with hyperkalemia. Which clinical manifestation will the nurse plan to assessment this child for based on the diagnosis? 1. Seizures 2. Bradycardia 3. Respiratory distress 4. Hyperthermia
2 A child with hyperkalemia is at risk for cardiac issues. Seizures, respiratory distress, and hyperthermia are not risks of hyperkalemia.
(18) In the morning, a nurse receives a report on four pediatric clients who have some form of fluid-volume excess. Which client should the nurse assess first? 1. A client with periorbital edema, normal respiratory rate 2. A client with tachypnea and pulmonary congestion 3. A client with dependent and sacral edema, regular pulse 4. A client with hepatomegaly, normal respiratory rate
2 A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.
(18) A nurse is taking care of four different pediatric clients. Which client poses the great risk for dehydration? 1. 15-year-old working out in a weight room for an hour before football practice 2. 10-year-old playing baseball outdoors in 85 degree heat 3. 5-year-old refusing to eat because of a virus 4. A newborn under a radiant warmer for an hour after the first bath
2 A condition that increases the risk of insensible fluid loss places the child at risk for dehydration. Any of these situations can place the child at risk for dehydration but the child at greatest risk is the child playing baseball in direct heat, which will increase utilization of extracellular fluids more rapidly than the other situations.
(Chapter 19) During an admission assessment, the nurse notes that the child has impaired oral mucous membranes. Which intervention is most appropriate for the nurse to implement for this child? 1. Administering topical analgesics 2. Promoting an adequate intake of nutrients 3. Administering antibiotics as ordered 4. Using lemon and glycerin for oral hygiene
2 Adequate intake of fluids and nutrients promotes the intactness of the oral mucosal membrane tissue, which is the desired outcome for an impaired oral mucous membrane problem. Lemon and glycerin may dry the oral mucous membrane, which is not desirable. Administration of antibiotics or topical analgesics are medical interventions that might be performed but do not ensure that impaired tissue will be resolved.
(Chapter 19) A nurse is assessing infants for visually related developmental milestones. Which infant is showing a delay in meeting an expected milestone? 1. 4-month-old who has a social smile 2. 8-month-old who has just begun to inspect her own hand 3. 12-month-old who stacks blocks 4. 7-month-old who picks up a raisin by raking
2 An 8-month-old who has just begun to inspect her own hand is delayed. The infant usually inspects her own hand beginning at 3 months. A 4-month-old with a social smile, a 12-month-old who stacks blocks, and a 7-month-old who picks up a raisin by raking are all showing appropriate visually related milestones.
(Chapter 19) An infant is diagnosed with acute otitis media. Which intervention is most appropriate for the nurse to teach the infants parents? 1. Keep the baby in a flat lying position during sleep. 2. Administer acetaminophen (Tylenol) to relieve discomfort. 3. Administer a decongestant. 4. Place baby to sleep with a pacifier.
2 An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media. A flat lying position may exacerbate the discomfort. Elevating the head slightly is recommended. Decongestants are not recommended for treatment of acute otitis media. Placing infants to sleep with a pacifier may increase the incidence of otitis media.
(15) A hospitalized toddler-age client needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate? 1. Ineffective Individual Coping Related to an Invasive Procedure 2. Anxiety Related to Anticipated Painful Procedure 3. Fear Related to the Unfamiliar Environment 4. Knowledge Deficit of the Procedure
2 At this age, the child is not old enough to understand the need for an IV infusion. The stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for a child of this age.
(31) The nurse is examining a 12-month-old who is brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with bright red scaly plaques and small papules. Satellite lesions are also present. What is the most likely cause of this clients diaper rash? 1. Impetigo (staph) 2. Candida albicans (yeast) 3. Urine and feces 4. Infrequent diapering
2 Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red scaly plaques with sharp margins. Small papules and pustules may be seen, along with satellite lesions. Even though diaper dermatitis can be caused by impetigo, urine and feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.
(Chapter 26) A child recently had a kidney transplant and is prescribed cyclosporine. The parents ask the nurse about the reason for the cyclosporine. Which reason will the nurse include in the response for why this medication is prescribed? 1. To boost immunity 2. To suppress rejection 3. To decrease pain 4. To improve circulation
2 Cyclosporine is given to suppress rejection. It doesnt boost immunity, decrease pain, or improve circulation.
(Chapter 25) A newborn is diagnosed with Hirschsprung disease. Which clinical manifestations found on assessment support this newborns diagnosis? 1. Acute diarrhea; dehydration 2. Failure to pass meconium; abdominal distension 3. Currant jelly; gelatinous stools; pain 4. Projectile vomiting; altered electrolytes
2 Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.
(14) While teaching a health promotion class to a group of parents of children in a Head Start class, which information should the nurse include to help decrease the risk of dental caries? 1. Delay introducing cows milk until at least 1 year of age. 2. Offer drinking cups only at meal and snack times. 3. Encourage use of homemade baby food without preservatives. 4. Offer juices diluted 50% with water.
2 Offering drinking cups only at meal and snack times encourages drinking when thirsty rather than carrying a cup around. This reduces the risk of dental caries. Delaying the introduction of cows milk, making homemade baby food, or diluting juice does not decrease dental caries.
(Chapter 26) The nurse teaches parents that the anticholinergic drug oxybutynin is used to treat enuresis. The parents ask the nurse why the medication is being prescribed. Which response by the nurse is the most appropriate? 1. Its an antidepressant that is used to help the child relax. 2. It will help decrease the spasms sometimes associated with enuresis. 3. It has an antidiuretic effect, so your child can attend sleepovers. 4. It will slow the production of urine, so your child does not have to urinate as frequently.
2 Oxybutynin (Ditropan) is an anticholinergic that relaxes the smooth muscle of the bladder and decreases spasms. Oxybutynin is not an antidepressant or an antidiuretic, and does not slow urine production.
(Chapter 11) The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is the most appropriate? 1. Escort the parents to the waiting room and assure them that they can see their child soon. 2. Allow the parents to stay with the child. 3. Ask the physician if the parents can stay with the child. 4. Tell the parents that they do not need to stay with the child.
2 Parents should be allowed to stay with their child if they wish to do so. This position is supported by the Emergency Nurses Association and is a key aspect of family-centered care
(31) A pediatric client sustains a minor burn. When teaching the family the treatment for this burn, the nurse would teach that the clients diet should be high in which substance? 1. Fats 2. Protein 3. Minerals 4. Carbohydrates
2 Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.
(18) A school-age client is hypokalemic. The nurse is helping the client complete her menu. Which food selection will the nurse encourage for this client? 1. A hamburger with French fries 2. Pizza with a fruit plate 3. Chicken strips with chips 4. A fajita with rice
2 Pizza with the fruit plate should be encouraged because fruits (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination.
(28) A nurse is caring for four pediatric clients in the hospital. Which client should the nurse refer for play therapy? 1. An adolescent with asthma 2. A preschool-age child with a fractured femur 3. A school-age child having an appendectomy 4. An infant with sepsis
2 Play therapy is often used with preschool and school-age children who are experiencing anxiety, stress, and other specific nonpsychotic mental disorders. In this case, the child who experiences a condition that requires longer hospitalization and recovery, such as a fracture of the femur, should be referred for play therapy. The adolescent with asthma, the school-age child having an appendectomy, and the infant with sepsis do not have as high a need for play therapy as the preschool child with a broken bone.
(15)A parent asks the nurse if there is anything that can be done to reduce the pain that his 3-year-old experiences each morning when blood is drawn for lab studies. Which intervention would the nurse implement based on the parents concern? 1. Intravenous sedation 15 minutes prior to the procedure 2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure 3. Use of guided imagery during the procedure 4. Use of muscle-relaxation techniques
2 Sedation is not generally used with quick minor procedures such as venipuncture. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.
(15) The nurse is preparing to perform a heel stick on a neonate. Which complementary therapy is appropriate for the nurse to use decrease pain during this quick but painful procedure? 1. Swaddling 2. Sucrose pacifier 3. Massage 4. Holding the infant
2 Sucrose provides short-term natural pain relief and is most appropriate for use in neonates to decrease pain associated with a quick procedure. The other measures are more appropriate following the procedure or as an adjunct to pain medication for ongoing pain or distress.
(Chapter 20) The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis? 1. Measles, mumps, and rubella (MMR) 2. Haemophilus influenzae type B (HIB) 3. Hepatitis B 4. Polio
2 The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.
(Chapter 26) A nurse is preparing to admit a child with possible obstructive uropathy. Which laboratory test should the nurse expect to draw on this child? 1. Platelet count 2. Blood urea nitrogen (BUN) and creatinine 3. Partial thromboplastin time (PTT) 4. Blood culture
2 The blood urea nitrogen (BUN) and creatinine are serum lab tests for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the BUN and creatinine will be elevated. Platelet count and partial thromboplastin time (PTT) are drawn when a bleeding disorder is suspected. A blood culture is done when an infectious process is suspected.
(Chapter 26) A preschool-age client is diagnosed with acute glomerulonephritis and is admitted to the hospital. Which nursing diagnosis is most appropriate for this client? 1. Risk for Injury Related to Loss of Blood in Urine 2. Fluid-Volume Excess Related to Decreased Plasma Filtration 3. Risk for Infection Related to Hypertension 4. Altered Growth and Development Related to a Chronic Disease
2 The fluid is excessive, and fluid and electrolyte balance should be monitored. There is no risk for injury because the blood loss in the urine is not such that it causes anemia. While a risk for infection may be present, it is not related to the hypertension. Growth and development is not normally affected because this is an acute process, not a chronic one.
(20) The nurse is providing care to an infant in the emergency department. Upon assessment, the infant is noted to have to be experiencing tachypnea, wheezing, retractions, and nasal flaring. The infant is irritability and the parents state the infant has had poor fluid intake for two days. Pulse ox reading is currently at 85% on room air. The infants blood gas is pending. Which diagnosis does the nurse anticipate for this infant? 1. Bronchitis 2. Bronchiolitis 3. Pneumonia 4. Active pulmonary tuberculosis
2 The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes.
(Chapter 19) A nurse is caring for a visually impaired school-age child. Which nursing intervention is the highest priority for this child during the admission process? 1. Explaining playroom policies 2. Orienting the child to where furniture is placed in the room 3. Letting the child touch equipment that will be used during the hospitalization 4. Taking the child on a tour of the unit
2 The priority intervention is to orient the child to furniture placement in the room. This is priority because it addresses basic safety for a visually impaired client. Policies, handling equipment, and tours can be done at a later time.
(31) A nurse is caring for a toddler client who is diagnosed with scabies and prescribed a 5 percent permethrin lotion. How will the nurse apply this lotion when administering it to the toddler? 1. To the scalp only 2. Over the entire body from the chin down, as well as on the scalp and forehead 3. Only on the areas with evidence of scabies activity 4. Only on the hands
2 Treatment of scabies involves application of a scabicide, such as 5 percent permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.
The nurse is providing care for a pediatric client who has a third-degree circumferential burn of the right arm. Which nursing diagnosis is the priority for this client? 1. Risk for Infection 2. Risk for Altered Tissue Perfusion 3. Risk for Altered Nutrition: Less than Body Requirements 4. Impaired Physical Mobility
2 When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is Risk for Altered Tissue Perfusion to the Extremity. Infection, Nutrition, and Mobility would have second priority in this case.
(Chapter 11) The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that which hospitalized child at highest risk to experience separation anxiety when parents cannot stay? 1. 6-month-old 2. 18-month-old 3. 3-year-old 4. 4-year-old
2 While all of these children can experience separation anxiety, the young toddler is at highest risk. Toddlers are the group most at risk for a stressful experience when hospitalized. Separation from parents increases this risk greatly.
ATI 10: 2. A nurse on a pediatric unit is caring for a toddler. Which of the following toddler behaviors is an effect of hospitalization? (Select all that apply.) 1. Believes the experience is a punishment 2. Experiences separation anxiety 3. Displays intense emotions 4. Exhibits regressive behaviors 5. Manifests disturbance in body image
2, 3, 4 2. Separation anxiety is a potential effect of hospitalization in a toddler. 3. Intense emotions are a potential impact of hospitalization in a toddler. 4. Behavior regression is a potential impact of hospitalization in a toddler.
The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that which hospitalized child at highest risk to experience separation anxiety when parents cannot stay? 1. 6-month-old 2. 18-month-old 3. 3-year-old 4. 4-year-old
2. 18-month-old
A mother of an 18-month old asks the nurse whether she can begin to introduce low-fat milk like the rest of the family drinks. The nurse answers the mother based on the knowledge that low-fat milk can safely be introduced at what age? 1. 18 months 2. 24 months 3. 3 years 4. 4 years
2. 24 months
A nurse who is the manager of an ambulatory pediatric healthcare center is planning protocols for the routine healthcare visits of the children. Children at this care center have a high incidence of obesity. At which age should the nurses at this clinic calculate the body mass index (BMI) for all pediatric clients? 1. 12 months 2. 24 months 3. 36 months 4. 4 years
2. 24 months
The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first? 1. A child with a temperature of 101 degrees F 2. A child who has stridor 3. A child who has absent Babinski sign 4. A child who has a pot belly appearance
2. A child who has stridor
The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is the most appropriate? 1. Escort the parents to the waiting room and assure them that they can see their child soon. 2. Allow the parents to stay with the child. 3. Ask the physician if the parents can stay with the child. 4. Tell the parents that they do not need to stay with the child.
2. Allow the parents to stay with the child.
A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse takes priority? 1. Instruct the father to hold the toddler down tightly to complete the examination. 2. Allow the toddler to sit on the parents lap and begin the assessment. 3. Allow the toddler to stand on the floor until he stops crying. 4. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddlers behavior.
2. Allow the toddler to sit on the parents lap and begin the assessment.
A hospitalized toddler-age client needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate? 1. Ineffective Individual Coping Related to an Invasive Procedure 2. Anxiety Related to Anticipated Painful Procedure 3. Fear Related to the Unfamiliar Environment 4. Knowledge Deficit of the Procedure
2. Anxiety Related to Anticipated Painful Procedure
When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old? 1. Say the name of an object and after 5 minutes ask the child to tell you what you said the object was. 2. Ask the child to repeat his address. 3. Ask the child to say a poem and listen to the child's speech articulation. 4. Have the child point to various parts of the body as you name them.
2. Ask the child to repeat his address.
The nurse, talking with the parents of a toddler who is struggling with toilet training, reassures them that their child is demonstrating a typical developmental stage. According to Erikson, which developmental stage will the nurse document in the medical record for this toddler? 1. Trust versus mistrust 2. Autonomy versus shame and doubt 3. Initiative versus guilt 4. Industry versus inferiority
2. Autonomy versus shame and doubt
A 7-year-old child is admitted for acute appendicitis. The parents are questioning the nurse about expectations during the childs recovery. Which information tool would be most useful in answering a parents questions about the timing of key events? 1. Healthy People 2020 2. Clinical pathways 3. Child mortality statistics 4. National clinical practice guidelines
2. Clinical pathways
As an advocate for the child undergoing bone-marrow aspiration, which intervention would the nurse suggest to decrease the pain experienced due to the procedure? 1. General anesthesia 2. Conscious sedation 3. Intravenous narcotics ten minutes before the procedure 4. Oral pain medication for discomfort after the procedure
2. Conscious sedation
(pretest 5) A baby was just born with gastroschosis. Which of the following actions by a nurse is the priority? 1. Inform the parents regarding the etiology of the defect 2. Cover the defect with a moist, sterile dressing 3. Administer intravenous antibiotics, as ordered 4. educate the parents regarding the surgical repair
2. Cover the defect with a moist, sterile dressing
A parent asks the nurse if there is anything that can be done to reduce the pain that his 3-year-old experiences each morning when blood is drawn for lab studies. Which intervention would the nurse implement based on the parents concern? 1. Intravenous sedation 15 minutes prior to the procedure 2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure 3. Use of guided imagery during the procedure 4. Use of muscle-relaxation techniques
2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure
The nurse is planning care for a school-age client and family who have expressed wanting to use complementary and alternative modalities (CAM) in the treatment plan. Which interventions can the nurse safely implement into the plan of care? Select all that apply. 1. Substituting an herbal remedy for a prescribed medication 2. Encouraging the parents to share which modalities they would like to implement 3. Educating on the benefits and risks for each modality 4. Using essential oils to decrease nausea 5. Discouraging the use of faith-based therapies
2. Encouraging the parents to share which modalities they would like to implement 3. Educating on the benefits and risks for each modality 4. Using essential oils to decrease nausea
In working with parents of children with chronic diseases, the nurse is concerned with helping the parents to protect themselves from compassion fatigue. Which activities are appropriate for the nurse to encourage? Standard Text: Select all that apply. 1. Sleeping more than 9 hours per 24-hour period 2. Exercising 3. Fostering social relationships 4. Developing a hobby 5. Moving away
2. Exercising 3. Fostering social relationships 4. Developing a hobby
The nurse recognizes that the pediatric client is from a cultural background different from that of the hospital staff. Which goal is most appropriate for this client when planning nursing care? 1. Overlook or minimize the differences that exist. 2. Facilitate the family's ability to comply with the care needed. 3. Avoid inadvertently offending the family by imposing the nurses perspective. 4. Encourage complementary beneficial cultural practices as primary therapies.
2. Facilitate the family's ability to comply with the care needed.
A nurse is preparing to perform a physical assessment on a toddler. Which action is most appropriate for the nurse to take? 1. Perform the assessment from head to toe. 2. Leave intrusive procedures such as ear and eye examinations until the end. 3. Explain each part of the examination to the child before performing it. 4. Ask the mother to tell the child not to be afraid.
2. Leave intrusive procedures such as ear and eye examinations until the end.
Parents of a preschool child report that they find it necessary to spank the child at least once a day. Which response should the nurse make to the parents? 1. Spanking is one form of discipline; however, you want to be certain that you do not leave any marks on the child. 2. Lets talk about other forms of discipline that have a more positive effect on the child. 3. Can you try only spanking the child every other day for one week and see how that affects the child's behavior? 4. I think you are not parenting your child properly, so let's talk about ways to improve your parenting skills.
2. Lets talk about other forms of discipline that have a more positive effect on the child.
A preschool-age child is brought to the clinic by the mother, who says the child has been lethargic and anorexic lately and complains of bone pain. On exam, the nurse notes petechiae, joint pain, and an enlarged liver. Which diagnosis does the nurse anticipate for this child? 1. Hodgkin disease 2. Leukemia 3. Rhabdomyosarcoma 4. Ewing sarcoma
2. Leukemia
What is the pediatric nurses best defense against an accusation of malpractice or negligence? 1. Following the physicians written orders 2. Meeting the scope and standards of practice for pediatric nursing 3. Being a nurse practitioner or clinical nurse specialist 4. Acting on the advice of the nurse manager
2. Meeting the scope and standards of practice for pediatric nursing
A pediatric client is admitted to the hospital unconscious. The client has a history of type 1 diabetes, and according to the clients mother, has been to two birthday parties in the last few days and has resisted taking the prescribed insulin. At school the client had two more pieces of birthday cake and some ice cream at a class birthday party. What is the likely reason for this clients unconscious state? 1. Metabolic alkalosis 2. Metabolic ketoacidosis 3. Insulin shock 4. Insulin reaction
2. Metabolic ketoacidosis
There are several tools that help with obtaining a cultural assessment of a client and his family. Which tool would be appropriate to gather 12 major concepts of cultural assessment? 1. Sunrise enabler 2. Model for cultural competence 3. Transcultural assessment model 4. Health traditions model
2. Model for cultural competence
A family actively participates in school functions. One of the children is paraplegic and requires a wheelchair for mobility. Which process does the nurse determine the family is working on based on these assessment findings? 1. Stagnation 2. Normalization 3. Isolation 4. Interaction
2. Normalization
A nurse is conducting a daily weight on a pediatric client diagnosed with diabetes insipidus and notes the child has lost two pounds in 24 hours. Which action by the nurse is the most appropriate? 1. Continue to monitor the child. 2. Notify the healthcare provider regarding the weight loss. 3. Chart the weight and report the loss to the next shift. 4. Do nothing more than chart the weight, as this would be a normal finding.
2. Notify the healthcare provider regarding the weight loss.
(pretest 5)A baby, 12 hours old, in the neonatal ICU, has been diagnosed with esophageal atresia with trachoesophageal fistula. Which of the following assessments is the highest priority for the nurse to make? 1. Quantity of nasogastric secretions 2. oxygen saturation levels 3. Apical heart rate 4. weight of wet diapers
2. O2 saturation
A 12-year-old pediatric client is in need of surgery. Which member of the health care team is legally responsible for obtaining informed consent for an invasive procedure? 1. Nurse 2. Physician 3. Unit secretary 4. Social worker
2. Physician
An school-age client who recently moved to a new school in a different town presents to an ambulatory care center and describes the following: I have no friends in my new school, and I no longer want to go to play soccer. I know I will be lonely there, too. Which of these takes priority when speaking with the school-age client? 1. Helping the school-age client realize the value of soccer 2. Promoting healthy mental-health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school 4. Stressing the importance of remaining in a close parent-child relationship during these stressful times
2. Promoting healthy mental-health outcomes
Which of these developmental milestones should the nurse expect to find in children who are between 2 and 3 years old? Select all that apply. 1. Always feeds self 2. Scribbles and draws on paper 3. Kicks a ball 4. Throws ball overhand 5. Goes up and down stairs
2. Scribbles and draws on paper 3. Kicks a ball 5. Goes up and down stairs
A child with a brain tumor is admitted to the pediatric intensive care unit (PICU)after brain surgery to remove the tumor. Which postoperative order would the nurse question? 1. Antibiotics 2. Sodium levels every 24 hours 3. Anticonvulsants 4. Hourly intake and output
2. Sodium levels every 24 hours
The nurse is caring for a pediatric client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) disorder. Which interventions should the nurse implement for this child? Standard Text: Select all that apply. 1. Encouragement of fluids 2. Strict intake and output 3. Administration of ordered diuretics 4. Specific gravity of urine 5. Weight only on admission but not daily
2. Strict intake and output 3. Administration of ordered diuretics 4. Specific gravity of urine
The nurse is preparing to perform a heel stick on a neonate. Which complementary therapy is appropriate for the nurse to use decrease pain during this quick but painful procedure? 1. Swaddling 2. Sucrose pacifier 3. Massage 4. Holding the infant
2. Sucrose pacifier
During a clinic visit, the parents of a 15-month-old ask what disease and injury prevention topics would be appropriate to discuss at this age. Which response by the nurse is the most appropriate? 1. It's never too early to teach a child to wear a helmet when riding a bicycle. 2. Teaching simple handwashing is a good topic at this age. 3. Tell the child over and over to stay away from water unless you are with him. 4. Tell him firmly no when he tries to cross the street.
2. Teaching simple handwashing is a good topic at this age.
A nurse is working with pediatric clients in a research facility. The nurse recognizes that federal guidelines are in place that delineate which pediatrics clients must give assent for participation in research trials. Based upon the clients age, the nurse would seek assent from which children? Select all that apply. 1. The precocious 4-year-old starting as a cystic fibrosis research-study participant. 2. The 7-year-old leukemia client electing to receive a newly developed medication, now being researched. 3. The 10-year-old starting in an investigative study for clients with precocious puberty. 4. The 13-year-old client beginning participation in a research program for ADHD treatments.
2. The 7-year-old leukemia client electing to receive a newly developed medication, now being researched. 3. The 10-year-old starting in an investigative study for clients with precocious puberty. 4. The 13-year-old client beginning participation in a research program for ADHD treatments.
An adolescent reports participating in an exercise program at school each Wednesday throughout the school year. Further history reveals that the adolescent does not participate in any other physical activities. Which outcome is most appropriate for this adolescent? 1. The adolescent is reporting information consistent with what 60 percent of adolescents report as participation in physical activities. 2. The adolescent is not meeting the recommendations of the Healthy People 2020 initiative. 3. The adolescent should be encouraged to continue this program of exercise, since something is better than nothing. 4. The adolescent should be encouraged to vigorously exercise for at least five minutes each day.
2. The adolescent is not meeting the recommendations of the Healthy People 2020 initiative.
A 9-year-old child who has been followed in the same pediatric home since birth is at the healthcare center for a well-child visit. A nurse who measures the height and weight of the child documents 35th percentile for height and 90th percentile for weight. How should the nurse interpret these data? 1. The child is beginning a growth spurt. 2. The child is obese and needs dietary counseling. 3. The parents are most likely below the 50th percentile for height and weight. 4. As soon as the child begins the adolescent growth spurt, the height and weight measurements will normalize.
2. The child is obese and needs dietary counseling.
A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the previous measurements two months ago were at the 25th percentile. Which interpretation by the nurse is the most accurate? 1. The infant is not gaining enough weight. 2. The infant has gained a significant amount of weight. 3. The previous measurements were most likely inaccurate. 4. These measurements are most likely inaccurate.
2. The infant has gained a significant amount of weight.
A preschool child is seen in the clinic, and the nurse anticipates a diagnosis of leukemia. Which reaction does the nurse anticipate this child will exhibit upon diagnosis? 1. Acceptance, especially if able to discuss the disease with children their own age 2. Thoughts that they caused their illness and are being punished 3. Understanding of what cancer is and how it is treated 4. Unawareness of the illness and its severity
2. Thoughts that they caused their illness and are being punished
The nurse is performing a well-child exam on a child who turned 4 years old 3 months ago. What can the nurse ask the child to do to assess appropriate milestones for this age? 1. Jump up and down 2. Throw a ball 3. Stack three or more blocks 4. Draw lines on paper
2. Throw a ball
A nurse caring for a school-age client notices some swelling in the childs ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate? 1. Skin integrity, especially in the lower extremities 2. Urine output 3. Level of consciousness 4. Range of motion and ankle mobility
2. Urine output
The nurse has set up a group discussion for several families with chronically ill children. The nurse informs these parents that they may face which ethical issue? 1. Normalization 2. Withholding and refusal of treatment 3. Repeated hospital admissions 4. Lack of proper dietary needs
2. Withholding and refusal of treatment
A mother reports that her adolescent is always late. The mother states, She was born late and has been late every day of her life. Which response should the nurse make to this mother? 1. You need to establish specific time frames for your adolescent and be certain she adheres to them. 2. You should not expect your adolescent to be an on-time individual unless you set specific alarms and then reinforce the value of being on-time. 3. You should not expect your adolescent to be on time. Teenagers are always late. 4. You have a major problem. There must be a lot of screaming in your home.
2. You should not expect your adolescent to be an on-time individual unless you set specific alarms and then reinforce the value of being on-time.
The parents of a 1-year-old infant are concerned that this baby seems more shy and scared of new situations than their other child and ask the nurse if this is normal. The nurse knows that the infant is exhibiting a characteristic of the slow-to-warm-up. Which statement to the parents is most appropriate by the nurse? 1. Your infant is showing a regularity in patterns of eating. 2. Your infant displays a predominantly negative mood. 3. Your infant initially reacts to new situations by withdrawing. 4. Your infant has intense reactions to the environment.
2. Your infant displays a predominantly negative mood.
(pretest 6) A nurse is to administer 2 ophthalmic medications- an ointment and drops. Which of the following actions by the nurse is appropriate? 1. Rest the medication containers on the lower lid of the eye 2. administer the eye drop medication before administering the medicated ointment 3. administer both medications into the lateral sclera of each eye 4. squeeze the ointment into the sac created by the upper eyelid of the eye
2. administer the eye drop medication before administering the medicated ointment
(pretest 5) A child is admitted to the pediatric unit with nephrotic syndrome. Which of the following lab results would the nurse expect to see? 1. Thrombocytopenia 2. hypoalbuminemia 3. neutropenia 4. hypermagnesemia
2. hypoalbuminemia
(pretest 6) The medications used to assist a newborn with respiratory distress syndrome are which of the following? 1. Antibiotics and steroids 2. steroids and synthetic surfactant 3. Synagis and steroids 4. antibiotics and synthetic surfactant
2. steroids and synthetic surfactant
(pretest 5)A primary health crare provider has ordered a medication for n infant 250mg PO every 4 hours. The solution is avilable on the unit in the following concentration: 500mg/5mL. How many mL should the nurse prepare to administer per dose? If rounding is needed, please round to the nearest tenth.
2.5
testosterone therapy (FTM): topical ideal goal: __ - __ g of testosterone per day
2.5-10g
_____% of trans people living in poverty ___% of gen pop living in poverty
29% (almost 1 in 3) 14% almost 2x more likely to live in poverty
(Chapter 20) A child is prescribed rifampicin for treatment of tuberculosis. For which length of time will the nurse tell the parents that this child must remain on the medication? 1. 2 months 2. 4 months 3. 6 months 4. 8 months
3
(Chapter 20) A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse which symptoms made the practitioner suspect cystic fibrosis. Which response by the nurse is the most appropriate? 1. Steatorrheic stools 2. Constipation 3. Meconium ileus 4. Rectal prolapse
3
(Chapter 11) A preschool-age client is seen in the clinic for a sore throat. In this childs mind, what is the most likely causative agent for the sore throat? 1. Was exposed to someone else with a sore throat. 2. Did not eat the right foods. 3. Yelled at his brother. 4. Did not take his vitamins.
3 Preschoolers understand some concepts of being sick but not the cause of illness. They are likely to think that they are sick as a result of something that they have done. They will frequently view illness as punishment. A child of this age does not yet understand that he can become sick from exposure to someone else who is sick. The other two answers, while not causes of sore throat, can be factors in some illnesses but are beyond the thinking of a 4-year-old.
(Chapter 11) The nurse needs to administer a medication to a preschool-age child. The medication is only available in tablet form. Which action by the nurse is the most appropriate? 1. Place the tablet on the childs tongue and give the child a drink of water. 2. Break the tablet in small pieces and ask the child to swallow the pieces one by one. 3. Crush the tablet and mix it in a teaspoon of applesauce. 4. Crush the table and mix it in a cup of juice.
3 A 4-year-old is not mature enough to swallow a pill or pieces of a pill. The medication should be crushed and mixed with a very small amount of food, not juice.
(Chapter 25) The nurse is preparing to ambulate a school-age client who had an appendectomy. In addition to pharmacological pain management, the nurse can use which nonpharmacological pain-management strategy for this client? 1. A heating pad 2. A warm, moist pack 3. A pillow on the abdomen 4. An ice pack
3 A pillow placed on the abdomen can be a nonpharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incisional area as they can impair the healing process of the wound.
(28) A school-age client diagnosed with autism is admitted to the hospital because of recent vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission? 1. Take the child on a quick tour of the whole unit. 2. Take the child to the playroom immediately for arts and crafts. 3. Orient the child to the hospital room with minimal distractions. 4. Admit the child to a four-bed unit with small children
3 Autistic children interpret and respond to the environment differently from other individuals. The child needs to be oriented to new settings and adjusts best to a quiet, controlled environment. A hospital room with only one other child is best.
(28) The nurse is conducting a health history for a school-age client. The parents of the client tell the nurse that their child has the following behaviors: excessive handwashing, counting objects, and hoarding substances. Based on these assessment findings, which diagnosis does the nurse anticipate for this client? 1. Depression 2. Separation anxiety disorder 3. Obsessive-compulsive disorder 4. Bipolar disorder
3 Common behaviors of obsessive-compulsive disorder (OCD) are excessive handwashing, counting objects, and hoarding substances. These practices may take up one or more hours each day.
(18) A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give? 1. Hydrochlorothiazide (Aquazide) 2. Spironolactone (Aldactone) 3. Furosemide (Lasix) 4. Mannitol (Osmitrol)
3 Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. Thiazide diuretics (hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium. Spironolactone (Aldactone) is a potassium-sparing diuretic and would not be effective for excretion of calcium.
(Chapter 25) A child with severe gastroenteritis is admitted to a semiprivate room on the pediatric unit. The charge nurse should place this client with which roommate? 1. An infant with meningitis 2. A child with fever and neutropenia 3. Another child with gastroenteritis 4. A child recovering from an appendectomy
3 Gastroenteritis may be viral or bacterial and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be placed with another child with an infectious process.
(Chapter 11) The nurse is caring for a client in the pediatric intensive-care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing intervention is most appropriate based on the situation? 1. Ask the physician to talk with the family. 2. Explain to the parents that their anger is affecting their child so they will not be allowed to visit the child until they calm down. 3. Acknowledge the parents concerns and collaborate with them regarding the care of their child. 4. Call the chaplain to sit with the family.
3 Hospitalization of the child in a pediatric intensive-care unit is a great stressor for parents. If the parents feel that they are not informed or involved in the care of their child, they may become angry and upset. Calling the physician or chaplain may be appropriate at some point, but the nurse must assume the role of supporter in this situation to promote a sense of trust. Telling the parents that they cannot visit their child will only increase their anger.
(Chapter 25) The nurse is planning postoperative care for an infant after a cleft-lip repair. Which nursing intervention is most appropriate for this infant? 1. Prone positioning 2. Suctioning with a Yankauer device 3. Supine or side-lying positioning 4. Avoidance of soft elbow restraints
3 Integrity of the suture line is essential for postoperative care of cleft-lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding. The prone position should be avoided. A Yankauer suction device is made of hard plastic and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft suction catheter. Soft elbow restraints may be used to prevent the infant from touching the incisional area
(Chapter 26) A child is admitted to the hospital unit with a diagnosis of minimal-change nephrotic syndrome (MCNS). Which clinical manifestations does the nurse anticipate when conducting the admission assessment? 1. Hematuria, bacteriuria, weight gain 2. Gross hematuria, albuminuria, fever 3. Massive proteinuria, hypoalbuminemia, edema 4. Hypertension, weight loss, proteinuria
3 Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema. While hematuria and hypertension may be present, they are not pronounced. Gross hematuria and hypertension are associated with glomerulonephritis. Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen.
(20) A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse which symptoms made the practitioner suspect cystic fibrosis. Which response by the nurse is the most appropriate? 1. Steatorrheic stools 2. Constipation 3. Meconium ileus 4. Rectal prolapse
3 Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.
(31) The nurse is planning care for a 3-month-old infant diagnosed with eczema. Which should be the focus of the nurses care for this infant? 1. Maintaining adequate nutrition 2. Keeping the baby content 3. Preventing infection of lesions 4. Applying antibiotics to lesions
3 Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.
(Chapter 26) The nurse is preparing to discharge a toddler-age client who just had an orchiopexy. Which discharge instruction is appropriate for this client? 1. Information to the parents about the childs resuming normal vigorous activities 2. Discussion with the parents about the low incidence of testicular malignancy and no further need for any follow-up 3. Explanation to the parents about the need for loose, nonrestrictive clothing 4. Reassurance to the parents that infertility is not a future risk
3 Orchiopexy is the surgical correction of cryptorchidism (failure of the testes to descend into the scrotal sac). Discharge instructions should include information about the need for loose, nonrestrictive clothing to avoid pressure on the postoperative site. The risk of testicular cancer is 35 to 50 times greater in men with a history of cryptorchidism. Long-term planning includes teaching the child to perform monthly testicular examinations once puberty has been reached. Vigorous activities such as straddling toys, riding bicycles, or rough play should be avoided for up to two weeks following surgery to promote healing and prevent injury. A discussion of fertility and the possible need for fertility testing is important, since cryptorchidism increases the risk of infertility.
(Chapter 19) A nurse is planning to teach school-age children about the common cold. Which information should the nurse include in the teaching session? 1. Vaccinations can prevent contraction of a nasopharyngitis virus. 2. Antibiotics will eliminate the nasopharyngitis virus. 3. Proper handwashing can prevent the spread of the infection. 4. Aspirin should be taken for alleviation of fever if the common cold is contracted.
3 Proper handwashing should be taught to school-age children to reduce the spread of the common cold virus. No vaccine can prevent the common cold. Antibiotics are not used to treat viral infections. Aspirin should not be taken for fever because of its association with Reye syndrome.
(28) An adolescent client diagnosed with panic disorder is prescribed paroxetine (Paxil), a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse she often takes diet pills because she is trying to lose weight. Which response by the nurse is the most appropriate? 1. You can continue with the paroxetine (Paxil) and the diet pills. 2. It is important to stop both the paroxetine (Paxil) and the diet pills. 3. Discontinue using the diet pills while taking the paroxetine (Paxil). 4. You should discuss the safety of these two medications pills with a pharmacist.
3 Serotonin syndrome, the serious and life-threatening side effect of SSRIs, can develop when the drug is taken with diet pills, St. Johns wort, other antidepressants, alcohol, or LSD. In this case, the diet pills should be discontinued in order to avoid serotonin syndrome. The Paxil should not be discontinued, and waiting to discuss the use of diet pills with a pharmacist would not be an appropriate option.
(Chapter 25) The nurse is providing instruction to the parents of an infant with a colostomy. Which statement by the parents indicates appropriate understanding of the teaching session? 1. We will change the colostomy bag with each wet diaper. 2. We will use adhesive enhancers when we change the bag. 3. We will watch for skin irritation around the stoma. 4. We will expect a moderate amount of bleeding after cleansing the area around the stoma.
3 Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning
(Chapter 19) The nurse is caring for four clients. Which client has the highest risk of developing retinopathy of prematurity? 1. 30-week-gestation infant who was in an Oxy-Hood for 12 hours and weighed 1800 grams. 2. 32-week-gestation infant who needed no oxygen and weighed 1850 grams. 3. 28-week-gestation infant who has been on long-term oxygen and weighed 1400 grams. 4. 28-week-gestation infant who was on short-term oxygen and weighed 1420 grams.
3 The 28-week-gestation infant on oxygen weighing 1400 grams has the highest risk of retinopathy of prematurity because of gestational age (28 weeks or less), weight (less than 1500 g), and oxygen therapy. The other neonates have fewer risk factors.
(14) During a well-child physical, an adolescent female has a normal history and physical except for an excessive amount of tooth enamel erosion, a greater-than-normal number of filled cavities, and calluses on the back of her hand. Her body mass index is in the 50th to 75th percentile for her age. Which disorder is the nurse concerned about based on the assessment findings? 1. Anorexia nervosa 2. Kwashiorkor 3. Bulimia nervosa 4. Marasmus.
3 The erosion of tooth enamel, dental caries, and calluses on the back of her hand all most likely are due to frequent vomiting of gastric acids, which is common with bulimia nervosa as part of a bingepurge cycle. Anorexia nervosa is an eating disorder where adolescents literally starve themselves to prevent weight gain; they also exercise excessively and use laxatives and diuretics to lose weight. Anorexia usually manifests as extreme weight loss and an obsession with food. Kwashiorkor is a protein deficiency, usually from malnutrition, that manifests as generalized edema. Marasmus is a lack of energy-producing calories that can be seen in anorexia, and this causes emaciation, decreased energy levels, and retarded development.
(28) The nurse is planning care for a school-age client, who is diagnosed with bipolar disorder and is having suicidal ideations. Which nursing diagnosis is the priority for this client? 1. Powerlessness Related to Mood Instability 2. Social Isolation Related to Disorder 3. Risk for Injury Related to Suicidal Ideas 4. Impaired Social Interaction
3 The priority for a child with bipolar disorder and suicidal ideas is safety. Risk for Injury would be the nursing diagnosis that would address safety for the child. The other diagnoses have a lower priority.
(18) A 1-month-old client is admitted to the emergency room with severe diarrhea. Which assessment suggests the client is severely dehydrated? 1. Skin moist and flushed; mucous membranes dry 2. Low specific gravity of urine; skin color pale 3. Fontanels depressed; capillary refill greater than three seconds 4. High specific gravity of urine; moist mucous membranes
3 Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.
(Chapter 11) A toddler recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant. Which action by the mother best demonstrates understanding of how to give the medication? 1. Verbalizing how to give the medication 2. Acknowledging understanding of written instructions 3. Drawing up the medication correctly in an oral syringe and administering it to the child 4. Observing the nurse draw up the medication and administering it to the child.
3 Verbalization of how to give the medication and acknowledging understanding of written instructions are methods that might be used, but they do not actually demonstrate understanding. Observing the nurse draw up and administer the medication may be used in the teaching process. The best way for the mother to demonstrate understanding is to actually draw up and give the medication.
(15) The nurse is caring for a child who has been sedated for a painful procedure. Which nursing activity is the priority for this child? 1. Allow parents to stay with the child. 2. Monitor pulse oximetry. 3. Assess the childs respiratory effort. 4. Place the child on a cardiac monitor
3 When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.
(Chapter 11) A child is being discharged from the hospital after a 3-week stay following a motor vehicle accident. The mother expresses concern about caring for the childs wounds at home. She has demonstrated appropriate technique with medication administration and wound care. Which nursing diagnosis is the priority in this situation? 1. Knowledge Deficit of Home Care 2. Altered Family Processes Related to Hospitalization 3. Parental Anxiety Related to Care of the Child at Home 4. Risk for Infection Related to Presence of Healing Wounds
3 While all of the diagnoses might have been appropriate at some point, the current focus is the mothers anxiety about caring for the child at home. The priority of the nurse is relieving this anxiety.
(Chapter 11) The nurse is providing care to a school-age client who is admitted to the hospital after a motor vehicle accident. Which interventions are appropriate to prepare this client and family for their hospital stay? Standard Text: Select all that apply. 1. A hospital tour 2. A health fair brochure 3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation
3, 4, 5 Interventions that are appropriate for this client and family are those that occur as the result of an unplanned hospital admission. The nurse would orient the client and family to the unit and provide age-appropriate explanation for all procedures. It is also appropriate for the nurse to consult with the child life program. A hospital tour and a health fair brochure are appropriate interventions for a planned hospitalization
A pediatric client is seen in the clinic with a possible diagnosis of type 2 diabetes. The mother asks what the healthcare provider uses to make the diagnosis. The nurse explains that type 2 diabetes is suspected if the child has obesity, acanthosis nigricans, and two non-fasting blood-glucose levels above which level? 1. 120 2. 80 3. 200 4. 50
3. 200
A nurse is assessing language development in all the infants presenting at the doctors office for well-child visits. At which age range would the nurse expect a child to verbalize the words dada and mama? 1. 3 and 5 months 2. 6 and 8 months 3. 9 and 12 months 4. 13 and 18 months
3. 9 and 12 months
The nurse is evaluating the car seat of a 3-year-old who weighs 42 pounds. Which recommendation should the nurse make about the car seat to the parents? 1. Convertible, rear-facing seat 2. Belt-positioning booster seat 3. A car seat with a harness approved for higher weights and heights 4. A regular seat with lap and shoulder strap
3. A car seat with a harness approved for higher weights and heights
An adolescent female presents at a nurse practitioners office and requests a signature for working papers. The nurse reviews her chart and notes that the last physical examination was two years ago. In addition to providing the signature for the working papers, what else should the nurse use this visit? 1. An opportunity to discuss birth-control measures 2. A time to discuss exercise and sports participation 3. A health-supervision opportunity 4. A chance to discuss the importance of pursuing post secondary education
3. A health-supervision opportunity
A child diagnosed with a Wilms tumor is prescribed chemotherapy. Which laboratory test will the nurse monitor prior to administering the chemotherapy to determine the childs infection-fighting capability? 1. Hemoglobin 2. Red-blood-cell count 3. Absolute neutrophil count (ANC) 4. Platelets
3. Absolute neutrophil count (ANC)
The nurse is caring for a client in the pediatric intensive-care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing intervention is most appropriate based on the situation? 1. Ask the physician to talk with the family. 2. Explain to the parents that their anger is affecting their child so they will not be allowed to visit the child until they calm down. 3. Acknowledge the parents concerns and collaborate with them regarding the care of their child. 4. Call the chaplain to sit with the family.
3. Acknowledge the parents concerns and collaborate with them regarding the care of their child.
The nurse is working in an adolescent medical clinic. What can the nurse anticipate when comparing adolescents in the clinic with chronic conditions to their peers? 1. A high level self-esteem 2. A concern for their parents 3. An altered body image 4. A decreased concern about their appearance
3. An altered body image
The nurse is providing care to a school-age client who is admitted to the hospital after a motor vehicle accident. Which interventions are appropriate to prepare this client and family for their hospital stay? Select all that apply. 1. A hospital tour 2. A health fair brochure 3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation
3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation
The nurse is caring for a child who has been sedated for a painful procedure. Which nursing activity is the priority for this child? 1. Allow parents to stay with the child. 2. Monitor pulse oximetry. 3. Assess the child's respiratory effort. 4. Place the child on a cardiac monitor.
3. Assess the child's respiratory effort.
The antiemetic drug ondansetron (Zofran) is administered to a child receiving chemotherapy. When should the nurse administer this medication? 1. Only if the child experiences nausea 2. After the chemotherapy has been administered 3. Before chemotherapy administration as a prophylactic measure 4. Never; this antiemetic is not effective for controlling nausea and vomiting associated with chemotherapy.
3. Before chemotherapy administration as a prophylactic measure
The nurse is working on parenting skills with a mother of three children. The nurse demonstrates a strategy that uses reward to increase positive behavior. Which strategy will the nurse document in the medical record based on this description? 1. Time out 2. Reasoning 3. Behavior modification 4. Experiencing consequences of misbehavior
3. Behavior modification
The camp nurse is assessing a group of children attending summer camp. The nurse will expect which children to most likely have problems perceiving a sense of belonging? 1. Children whose parents divorced recently 2. Children who gained a stepparent recently 3. Children recently placed into foster care 4. Children adopted as infants
3. Children recently placed into foster care
Cultures have many different childrearing practices. Which culture is known to value the male child more than the female child, and often teaches children to avoid displaying emotion? 1. Mexican 2. Amish 3. Chinese 4. Navajo
3. Chinese
The nurse is caring for a newly-admitted infant diagnosed with failure to thrive. The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order? 1. Tetralogy of Fallot 2. Pulmonary atresia 3. Coarctation of the aorta 4. Ventricular septal defect
3. Coarctation of the aorta
The nurse needs to administer a medication to a preschool-age child. The medication is only available in tablet form. Which action by the nurse is the most appropriate? 1. Place the tablet on the child's tongue and give the child a drink of water. 2. Break the tablet in small pieces and ask the child to swallow the pieces one by one. 3. Crush the tablet and mix it in a teaspoon of applesauce. 4. Crush the table and mix it in a cup of juice.
3. Crush the tablet and mix it in a teaspoon of applesauce.
A toddler recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant. Which action by the mother best demonstrates understanding of how to give the medication? 1. Verbalizing how to give the medication 2. Acknowledging understanding of written instructions 3. Drawing up the medication correctly in an oral syringe and administering it to the child 4. Observing the nurse draw up the medication and administering it to the child.
3. Drawing up the medication correctly in an oral syringe and administering it to the child
While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process? 1. Cardiac 2. Respiratory 3. Gastrointestinal 4. Genitourinary
3. Gastrointestinal
A nurse obtains a nutritional health history from a 10-year-old child. Which of these food selections, if consumed on a regular basis, should lead the nurse to become concerned about the need for improving oral hygiene? 1. Peanuts and crackers 2. Sorbet and yogurt 3. Gummy bears and licorice 4. Fluoridated water
3. Gummy bears and licorice
At the conclusion of teaching parents about cerebral palsy, the nurse asks, What is your hope for your toddler with cerebral palsy? Which reply from a parent best indicates an understanding of a realistic achievement for the child? 1. I hope my child qualifies for the Winter Olympics like I did. 2. I hope my child just enjoys life. 3. I hope my child will attend our neighborhood school. 4. I hope my child is liked and accepted by other children.
3. I hope my child will attend our neighborhood school.
An adolescent is receiving methotrexate chemotherapy after undergoing limb-salvage surgery for osteogenic sarcoma. Which statement by the adolescent indicates understanding of the purpose of leucovorin therapy after the methotrexate? 1. Im glad I only need one dose of the leucovorin. 2. I dont have any pain so I wont need to take the leucovorin this time. 3. I know I will be taking the leucovorin every 6 hours for about the next 3 days. 4. I dont have any nausea so I wont need the leucovorin.
3. I know I will be taking the leucovorin every 6 hours for about the next 3 days.
A nurse asks the mother of a 4-month-old infant to undress the infant. The nurse observes the mother taking off several layers of clothing and knows that the outdoor temperature is 70 degrees Fahrenheit. Which statement by the nurse is most appropriate in this situation? 1. My, you are dressing your infant warmly today. 2. Did you think it was cold when you left your home this morning? 3. I see that you have many layers of clothing on your baby. This may cause your baby's temperature to rise. 4. When you leave the office, only put one layer of clothing on your baby.
3. I see that you have many layers of clothing on your baby. This may cause your baby's temperature to rise.
The nurse in the pediatric clinic observes a parental lack of warmth and interest toward the child. Which family style will the nurse most likely document in this situation? 1. Authoritarian 2. Authoritative 3. Indifferent 4. Permissive
3. Indifferent
The parents of an 8-year-old state that their son seems very interested in trying new activities. When the parents ask for suggested activities for this age child, the nurse recommends scouts as an activity that will foster growth and development. In which stage of Eriksons psychosocial stages of development is this child? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Identity versus role confusion
3. Industry versus inferiority
Which statement by the nurse is most appropriate prior to giving an intramuscular injection to a 2-1/2-year-old child? 1. We will give you your shot when your mommy comes back. 2. This is medicine that will make you better. First we will hold your leg, then I will wipe it off with this magic cloth that kills the germs on your leg right here, then I will hold the needle like this and say one, two, three . . . go and give you your shot. Are you ready? 3. It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker. 4. This is a magic sword that will give you your medicine and make you all better.
3. It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker.
An obese adolescent who adamantly denies sexual activity has a positive pregnancy test, which was performed in the adolescent clinic. Which statement by the nurse is the most appropriate in this situation? 1. Tell me how you feel about your body image. 2. When was your last menstrual period (LMP)? 3. Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy.
3. Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy.
A nurse observes the parent/child interaction during the 4-year-old well-child checkup and notes that the parent speaks harshly to the child and uses negative remarks when speaking with the nurse. Which statement by the nurse would be most beneficial? 1. Perhaps you should leave the room so that I can speak with your child privately. 2. I am going to refer you for counseling since your interactions with your child seem so negative. 3. Let's talk privately. Let's discuss the way you speak with your child and possible ways to be more positive. 4. Addressing the child, the nurse says, Are you unhappy when Mommy talks to you like this?
3. Let's talk privately. Let's discuss the way you speak with your child and possible ways to be more positive.
Two 3-year-olds are playing in a hospital playroom together. One is working on a puzzle while the other is stacking blocks. Which type of play are these children exhibiting? 1. Cooperative play 2. Associative play 3. Parallel play 4. Solitary play
3. Parallel play
A child is being discharged from the hospital after a 3-week stay following a motor vehicle accident. The mother expresses concern about caring for the child's wounds at home. She has demonstrated appropriate technique with medication administration and wound care. Which nursing diagnosis is the priority in this situation? 1. Knowledge Deficit of Home Care 2. Altered Family Processes Related to Hospitalization 3. Parental Anxiety Related to Care of the Child at Home 4. Risk for Infection Related to Presence of Healing Wounds
3. Parental Anxiety Related to Care of the Child at Home
Injury prevention is an important aspect of parent teaching. Which injury prevention strategy would reduce the risk of suffocation? 1. Measure crib slat spacing at 2-3/8 inches or less. 2. Never leave an infant alone in a bath. 3. Position the infant on her back to sleep. 4. Use only approved restraint systems.
3. Position the infant on her back to sleep.
The nurse educator is presenting a lecture about risks to developmental progression. Which items will the educator include in the lecture? Select all that apply. 1. Family support 2. Access to the Internet 3. Recent loss of employment 4. Terminal illness of a family member 5. Hazards within the home environment
3. Recent loss of employment 4. Terminal illness of a family member 5. Hazards within the home environment
A mother of a school-age client who recently had surgery for the removal of tonsils and adenoids complains that the child has begun sucking his thumb again. Which coping mechanisms is the child using to cope with the surgery and hospitalization? 1. Repression 2. Rationalization 3. Regression 4. Fantasy
3. Regression
During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action? 1. Recent memory 2. Language development 3. Remote memory 4. Social-skill development
3. Remote memory
The nurse can instruct parents to expect children in which age group to begin to assume more independent responsibility for their own management of a chronic condition, such as blood-glucose monitoring, insulin administration, intermittent self-catheterization, and appropriate inhaler use? 1. Toddlers 2. Preschoolers 3. School-age 4. Adolescents
3. School-age
An adolescent client with cystic fibrosis suddenly becomes non-compliant with the medication regime. Which intervention by the nurse will most likely improve compliance for this client? 1. Give the child a computer-animated game that presents information on the management of cystic fibrosis. 2. Arrange for the physician to sit down and talk to the child about the risks related to non-compliance with medications. 3. Set up a meeting with some older teens with cystic fibrosis who have been managing their disease effectively. 4. Discuss with the child's parents the privileges that can be taken away, such as cell phone, if compliance fails to improve.
3. Set up a meeting with some older teens with cystic fibrosis who have been managing their disease effectively.
A school-age client is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching? 1. I can expect my child to have some pain for the next few days. 2. I will plan to give my child pain medicine around the clock for the next day or so. 3. Since my child just had surgery today, I can expect the pain level to be higher tomorrow. 4. I will call the office tomorrow if the pain medicine is not relieving the pain.
3. Since my child just had surgery today, I can expect the pain level to be higher tomorrow.
An adolescent client diagnosed with Graves disease is admitted to the hospital. Which clinical manifestations would the nurse expect on assessment? 1. Weight gain, hirsutism, and muscle weakness 2. Dehydration, metabolic acidosis, and hypertension 3. Tachycardia, fatigue, and heat intolerance 4. Hyperglycemia, ketonuria, and glucosuria
3. Tachycardia, fatigue, and heat intolerance
The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport and elicit an accurate response from the family? 1. Does any member of your family have a history of asthma, heart disease, or diabetes? 2. Hello, I would like to talk with you and get some information on you and your child. 3. Tell me about the concerns that brought you to the clinic today. 4. You will need to fill out these forms; make sure that the information is as complete as possible.
3. Tell me about the concerns that brought you to the clinic today.
The nurse is assessing an infant client and parents during a routine health supervision visit at 2 months of age. Which items will the nurse assess to determine if the infants mental health needs are being addressed? Standard Text: Select all that apply. 1. Immunization record 2. Newborn screen results 3. Temperament during the visit 4. Feeding schedule 5. Sleep-wake patterns
3. Temperament during the visit 4. Feeding schedule 5. Sleep-wake patterns
A 12-year-old child is admitted to the unit for a surgical procedure. The child is accompanied by two parents and a younger sibling. What is the level of involvement in treatment decision making for this child? 1. That of an emancipated minor. 2. That of a mature minor. 3. That of assent. 4. None.
3. That of assent.
(pretest 6) A nurse is educating the parents of a child with an atrial spinal defect regarding the child's condition. Which of the following information would be appropriate for the nurse to provide? 1. The baby becomes cyanotic because the blood is flowing through a hole from the right side of the heart to the left side of the heart 2. The baby has a murmur because there is a hole between the aorta and the pulmonary artery 3. The baby's heart is working harder than a normal heart because some of its blood is reentering the pulmonary system 4. The baby's heart rate is slowed because of the high number of red blood cells in the blood
3. The baby's heart is working harder than a normal heart because some of its blood is reentering the pulmonary system
The school health nurse is evaluating the home environment of several children as it relates to child safety. The nurse visits the home of each child and gathers the following data. Which activity places a child at greatest risk for bodily harm? 1. The parents are in a methadone program. 2. The parents consume alcohol on a daily basis. 3. The child is permitted to target practice with a revolver, unsupervised. 4. The child is a latchkey child.
3. The child is permitted to target practice with a revolver, unsupervised.
A preschool-age client is hospitalized following surgery for a ruptured appendix. During assessment of the child, the nurse notes that the child is sleeping. Vital signs are as follows: temperature 97.8 degrees F axillary, pulse 90, respirations 12, and blood pressure 100/60. Which conclusion by the nurse is appropriate based on the assessment findings? 1. The client is comfortable and the pain is controlled. 2. The client is in shock secondary to blood loss during surgery. 3. The client is experiencing respiratory depression secondary to opioid administration for postoperative pain. 4. The client is sleeping to avoid pain associated with surgery.
3. The client is experiencing respiratory depression secondary to opioid administration for postoperative pain.
At a routine healthcare visit, a nurse measures a toddler and plots the height and weight on the growth charts. The nurse documents that the toddler is above the 95th percentile for weight and is at the 5th percentile for height. How should the nurse interpret these data? 1. The toddler is proportionate for the age. 2. The toddler needs to eat more at each feeding. 3. The height and weight are disproportionate, and the toddler needs further evaluation. 4. The family is most likely short.
3. The height and weight are disproportionate, and the toddler needs further evaluation.
The community-health nurse is assessing several families for various strengths and needs in regard to after-school and backup child-care arrangements. Which family type will benefit the most from this assessment and subsequent interventions? 1. The binuclear family 2. The extended family 3. The single-parent family 4. The traditional nuclear family
3. The single-parent family
A pediatric client is diagnosed with type 1 diabetes. The nurse teaches the client the difference between insulin shock and diabetic hyperglycemia. The nurse evaluates that the client understands the teaching when the client states which characteristics of diabetic hyperglycemia? 1. Tremors and lethargy 2. Hunger and hypertension 3. Thirst and flushed skin 4. Shakiness and pallor
3. Thirst and flushed skin
Despite the availability of Childrens Health Insurance Programs (CHIP), many eligible children are not enrolled. Which nursing intervention would be the most appropriate to help children become enrolled in CHIP? 1. Assessment of the details of the familys income and expenditures 2. Case management to limit costly, unnecessary duplication of services 3. To advocate for the child by encouraging the family to investigate its CHIP eligibility 4. To educate the family about the need for keeping regular well-childvisit appointments
3. To advocate for the child by encouraging the family to investigate its CHIP eligibility
Which nursing intervention is most appropriate when providing education to the pediatric client and family? 1. Giving primary care for high-risk children who are in hospital settings 2. Giving primary care for healthy children 3. Working toward the goal of informed choices with the family 4. Obtaining a physician consultation for any technical procedures at delivery
3. Working toward the goal of informed choices with the family
A preschool-age client is seen in the clinic for a sore throat. In this child's mind, what is the most likely causative agent for the sore throat? 1. Was exposed to someone else with a sore throat. 2. Did not eat the right foods. 3. Yelled at his brother. 4. Did not take his vitamins.
3. Yelled at his brother.
(Chapter 20) A nurse is assessing a neonate. Which assessment finding indicates that the neonates respiratory status is worsening? 1. Acrocyanosis 2. Arterial CO2 of 40 3. Periorbital edema 4. Grunting respirations with nasal flaring
4
(Chapter 20) The practitioner changes the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse explains that salmeterol (Serevent) is used to treat asthma because the drug produces which characteristic? 1. Decreases inflammation 2. Decreases mucous production 3. Controls allergic rhinitis 4. Dilates the bronchioles
4
(Chapter 11) A young school-age client is in the playroom when the respiratory therapist arrives on the pediatric unit to give the child a scheduled breathing treatment. Which action by the nurse is the most appropriate? 1. Reschedule the treatment for a later time. 2. Show the respiratory therapist to the playroom so the treatment may be performed. 3. Escort the child to his room and ask the child-life specialist to bring toys to the bedside. 4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed.
4 Procedures should not be performed in the playroom. Scheduled respiratory treatments should be performed on time; however, the child should be allowed to return to the playroom as soon as the procedure is completed.
ATI 10: 3. A nurse is teaching a parent about parallel play in children. Which of the following statements by the nurse should be included in the teaching? 1. "Children sit and observe others playing." 2. "Children exhibit organized play when in a group." 3. "The child plays alone." 4. "The child plays independently when in a group."
4 4. Parallel play is when the toddler plays independently but is among other children in a group.
ATI 10: 4. A nurse is teaching a group of parents about separation anxiety. Which of the following should be included in the teaching? 1. It is often observed in the school-age child. 2. Detachment is the stage exhibited in the hospital. 3. It results in prolonged issues of adaptability. 4. Kicking a stranger is an example.
4 4. Physical aggression toward strangers is a behavior seen in the protest stage of separation anxiety.
(Chapter 11) The nurse must perform a procedure on a toddler. Which technique is the most appropriate when performing the procedure? 1. Ask the mother to restrain the child during the procedure. 2. Ask the child if it is okay to start the procedure. 3. Perform the procedure in the childs hospital bed. 4. Allow the child to cry or scream.
4 4: While the toddler will need to be restrained, the parent should not be the one to do this. The nurse should avoid giving the child a choice if there is no choice. The treatment room should be utilized for the procedure so that the hospital bed remains a safe place. The child should be allowed to cry or scream during the procedure.
(14) The nurse is providing care to a pediatric client recently diagnosed with celiac disease. Which food choice indicates appropriate understanding of the material presented? 1. Pizza with milk 2. Spaghetti and meat sauce with juice 3. Hot dog on a bun with a shake 4. Fruit plate with Gatorade
4 A child with celiac disease needs a gluten-free diet. Included on the list are fruits, meats, rice, and vegetables, including corn. Excluded are bread, cake, doughnuts, cookies, crackers, and many processed foods that may contain hidden gluten. Therefore, the child would be allowed to have the fruit plate with Gatorade.
(Chapter 25) The nurse is evaluating an infants tolerance of feedings after a pyloromyotomy. Which finding indicates that the infant is not tolerating the feeding? 1. Need for frequent burping 2. Irritability during feeding 3. The passing of gas 4. Emesis after two feedings
4 An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.
The mother of an infant born prematurely at 32 weeks expresses the desire to breastfeed her child. The nurse correctly responds with which statement when the mother asks how long she should breastfeed her baby? 1. Until the child begins solid foods. 2. Many breastfeed for 2 years. 3. It is recommended that mothers of preterm infants breastfeed at least a month. 4. Breast milk should be the only food for the first 6 months.
4 Breast milk should be the only food for the first 6 months, and should continue until 12 months even after solid foods are introduced.
(Chapter 11) A group of children on one hospital unit are all suffering separation anxiety. Which child is experiencing the despair stage of separation anxiety? 1. Does not cry if parents return and leave again 2. Screams and cries when parents leave 3. Appears to be happy and content with staff 4. Lies quietly in bed
4 Children in the despair stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these. Screaming and crying are components of the protest stage. The young child who appears to be happy and content with everyone is in the denial stage, as is the child who does not cry if parents return and leave again.
(Chapter 26) Which symptoms are characteristic of a preschool-age client who is diagnosed with a urinary tract infection? 1. Foul-smelling urine, elevated blood pressure, and hematuria 2. Severe flank pain, nausea, headache 3. Headache, hematuria, vertigo 4. Urgency, dysuria, fever
4 Clinical manifestations of a urinary tract infection (UTI) in a preschool-age client include fever, urgency, and dysuria. While hematuria may be present, there is no elevated blood pressure, headache, or vertigo.
(31) A 2-month-old client has a candidal diaper rash. Which medication does the nurse anticipate will be prescribed for this client? 1. Bacitracin ointment 2. Hydrocortisone ointment 3. Desitin 4. Nystatin given topically and orally
4 Diaper candidiasis is treated with an antifungal cream (Nystatin). An oral antifungal agent may be given to clear the candidiasis from the intestines. Bacitracin is for an infection caused by staphylococcus. Mild diaper rash is treated with a barrier such as Desitin. Moderate diaper rash is treated with hydrocortisone ointment.
(31) The school nurse is conducting pediculosis capitis (head lice) checks. Which findings would indicate a positive head check? 1. White, flaky particles throughout the entire scalp region 2. Maculopapular lesions behind the ears 3. Lesions in the scalp that extend to the hairline or neck 4. White sacs attached to the hair shafts in the occipital area
4 Evidence of pediculosis capitis includes white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Lesions may be present from itching, but the positive sign is evidence of nits. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.
(Chapter 19) A neonate has been diagnosed with a herpes simplex viral infection of the eye. Which medication will the nurse prepare to administer? 1. Fluoroquinolone eye drops or ointment 2. Intravenous penicillin 3. Oral erythromycin 4. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment
4 Neonatal herpes simplex virus is treated vigorously with parenteral acyclovir for 14 days or longer and topical ophthalmic medication (trifluridine, iododeoxyuridine, or vidarabine). Fluoroquinolone eye drops are used to treat bacterial eye infections. Intravenous penicillin treats selected bacterial infections. Oral erythromycin is used to treat chlamydial eye infections.
(15) The nurse is working in a pediatric surgical unit. In discussing patient-controlled analgesia (PCA) in a preoperative parental meeting, which client would be a candidate for PCA? 1. Developmentally delayed 16-year-old, postoperative bone surgery 2. 5-year-old, postoperative tonsillectomy 3. 10-year-old who has a fractured femur and concussion from a bike accident 4. 12-year-old, postoperative spinal fusion for scoliosis
4 Patient-controlled analgesia (PCA) is most appropriate in children 5 years and over. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. PCA is generally prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed or have suffered head trauma are not candidates for PCA.
(Chapter 25) A child with inflammatory bowel disease is prescribed prednisone daily. At which time is it most appropriate for the family to administer the prednisone? 1. Between meals 2. One hour before meals 3. At bedtime 4. With meals
4 Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.
(Chapter 19) The child who had a tonsillectomy earlier today is now awake and tolerating fluids. The child asks for something to eat. Which food choice is most appropriate for this client? 1. Orange slices 2. Lemonade 3. Grapefruit juice 4. Applesauce
4 Soft foods such as applesauce can be added as tolerated to a diet following a tonsillectomy. Citric juices or citric fruits should be avoided because they may cause a burning sensation in the throat.
(Chapter 20) A nurse delegates the task of neonatal vital-sign assessment to a nurse technician. Which instruction will the nurse give to the technician prior to assign care? 1. Report any neonate using abdominal muscles to breathe. 2. Report any neonate with apnea for 10 seconds. 3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute. 4. Report any neonate with a breathing pause that lasts 20 seconds or longer.
4 The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.
(Chapter 25) A school-age client is recovering after abdominal surgery. The nurse is planning care for the return of bowel function. Which intervention should be included in the clients plan of care? 1. Fowlers position three times per day for 30 minutes each time 2. Assist the child in choosing a low-fat diet. 3. Commode at bedside 4. Ambulate 34 times a day.
4 The best data that indicate return of bowel sounds are flatus and passage of stool. Ambulation is the primary intervention to assist with both. A Fowlers position, bedside commode, and a low-fat diet will not assist with bowel function.
(Chapter 11) An infant has been NPO for surgery for 4 hours and does not have an intravenous line. The nurse receives a call from the operating room with the information that the surgery has been postponed due to an emergency. Which action by the nurse is the most appropriate? 1. Feed the infant 4 ounces of formula. 2. Reassure the parents that it will not be much longer before surgery. 3. Allow the parents to feed the infant an ounce of oral rehydration solution. 4. Call the physician to see if the infant needs to have an intravenous line started.
4 The infant who is NPO is at high risk for dehydration. The nurse does not know how much longer it will be before surgery. The nurse cannot independently make the decision to feed the infant. Feeding the infant could further postpone the surgery, should an operating room become available sooner than expected. It is best to keep the infant NPO and consult the physician to see if an intravenous line is needed
(Chapter 19) Which action by the nurse can assist a child who has a mild hearing loss and reads lips to adapt to hospitalization? 1. Speaking directly to the parents for communication 2. Speaking in a loud voice while facing the child 3. Using a picture board as the main means of communication 4. Touching the child lightly before speaking
4 The nurse can facilitate hospital adaptation of a child who has a hearing loss and can lip-read by obtaining the childs visual attention by lightly touching the child before communicating. Speaking to the parents only does not help the child with the hospitalization. Speaking in a loud voice may not promote hearing in the child, and a picture board, while useful, should not be the primary means of communication for a child who reads lips.
(15) The nurse is caring for a child who has a long leg cast. The child complains of increasing pain in the toes of the casted foot. Which initial action by the nurse is the most appropriate? 1. Call the healthcare provider to report increasing pain. 2. Administer pain medication. 3. Reposition the child in bed. 4. Check to see if the cast is too tight.
4 While all of the actions are appropriate, the nurses initial action is to assess for external factors that might be causing pain.
(Chapter 11) The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for the toddler-age client? 1. Assign the same nurse to the toddler as much as possible. 2. Let the child listen to an audiotape of the mothers voice. 3. Place a picture of the family at the bedside. 4. Encourage a parent to stay with the child.
4 While all of the interventions are appropriate for the hospitalized toddler, presence of a parent is most important. Separation from parents is the major stressor for the hospitalized toddler.
(28) A school-age client is prescribed Adderall (amphetamine mixed salts) for attention deficit hyperactivity disorder (ADHD). At which time is it most appropriate for the nurse to teach the parents to administer this medication? 1. At bedtime 2. Before lunch 3. With the evening meal 4. Early in the morning
4 A side effect of Adderall can be insomnia. Administering the medication early in the day can help alleviate the effect of insomnia.
The nurse is working in a pediatric surgical unit. In discussing patient-controlled analgesia (PCA) in a preoperative parental meeting, which client would be a candidate for PCA? 1. Developmentally delayed 16-year-old, postoperative bone surgery 2. 5-year-old, postoperative tonsillectomy 3. 10-year-old who has a fractured femur and concussion from a bike accident 4. 12-year-old, postoperative spinal fusion for scoliosis
4. 12-year-old, postoperative spinal fusion for scoliosis
A child is being prepared for an invasive procedure. The mother of the child has legal custody but is not present. After details of the procedure are explained, who can provide legal consent on behalf of a minor child for treatment? 1. The divorced parent without custody 2. A cohabitating unmarried boyfriend of the childs mother 3. A grandparent who lives in the home with the child 4. A babysitter with written proxy consent
4. A babysitter with written proxy consent
The nurse must perform a procedure on a toddler. Which technique is the most appropriate when performing the procedure? 1. Ask the mother to restrain the child during the procedure. 2. Ask the child if it is okay to start the procedure. 3. Perform the procedure in the child's hospital bed. 4. Allow the child to cry or scream.
4. Allow the child to cry or scream.
The nurse is administering a dose of rapid-acting insulin at 0800 to an insulin-dependent pediatric client. Based on when the insulin peaks, when will the client be at greatest risk for a hypoglycemic episode? 1. At about noon 2. Between bedtime and breakfast the next morning 3. Between lunch and dinner 4. Around 0930
4. Around 0930
A young school-age client is in the playroom when the respiratory therapist arrives on the pediatric unit to give the child a scheduled breathing treatment. Which action by the nurse is the most appropriate? 1. Reschedule the treatment for a later time. 2. Show the respiratory therapist to the playroom so the treatment may be performed. 3. Escort the child to his room and ask the child-life specialist to bring toys to the bedside. 4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed.
4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed.
A school-age client has been receiving morphine every two hours for postoperative pain as ordered. The medication relieves the pain for approximately 90 minutes, and then the pain returns. Which action by the nurse is the most appropriate? 1. Tell the child that pain medication cannot be administered more frequently than every two hours. 2. Reposition the child and quietly leave the room. 3. Inform the parents that the child is dependent on the medication. 4. Call the healthcare provider to see if the child's orders for pain medication can be changed.
4. Call the healthcare provider to see if the child's orders for pain medication can be changed.
An infant has been NPO for surgery for 4 hours and does not have an intravenous line. The nurse receives a call from the operating room with the information that the surgery has been postponed due to an emergency. Which action by the nurse is the most appropriate? 1. Feed the infant 4 ounces of formula. 2. Reassure the parents that it will not be much longer before surgery. 3. Allow the parents to feed the infant an ounce of oral rehydration solution. 4. Call the physician to see if the infant needs to have an intravenous line started.
4. Call the physician to see if the infant needs to have an intravenous line started.
The nurse is performing an assessment of a childs biologic family history. Which situation would necessitate the nurses asking the mother for information should use the term childs father instead of your husband? 1. Traditional nuclear family 2. Traditional extended family 3. Two-income nuclear family 4. Cohabitating informal stepfamily
4. Cohabitating informal stepfamily
A new pediatric hospital will open soon. While planning nursing care, the hospital administration is considering two models of providing health care: family-focused care and family-centered care. Which action best implements family-centered care? 1. Telling the family what must be done for the familys health 2. Assuming the role of an expert professional to direct the health care 3. Intervening for the child and family as a unit 4. Conferring with the family in deciding which healthcare option will be chosen
4. Conferring with the family in deciding which healthcare option will be chosen
Which assessment question would get the most accurate response when a nurse is assessing learning/reading skills in the early childhood years? 1. What rewards do you use when your child does something good? 2. What is your childs language like now? 3. Does your child get along well with others? 4. Do you keep books for your child readily available?
4. Do you keep books for your child readily available?
The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for the toddler-age client? 1. Assign the same nurse to the toddler as much as possible. 2. Let the child listen to an audiotape of the mother's voice. 3. Place a picture of the family at the bedside. 4. Encourage a parent to stay with the child.
4. Encourage a parent to stay with the child.
(pretest 6) A newborn baby is receiving digoxin (Lanoxin) and furosemide (Lasix) for CHF. Which of the following actions would be appropriate for the nurse to preform? 1. Hold digoxin if the apical heart rate is 170bpm 2. Hold digoxin for a digoxin level of 1 ng/mL 3. Hold both the digoxin and furosemide for a weight increase of 5% in one day 4. Hold both the digoxin and the furosemide for a potassium 3.2 mEq/L
4. Hold both the digoxin and the furosemide for a potassium 3.2 mEq/L
The nurse is working with a group of parents who have children with chronic conditions. Which statement by a parent would indicate a risk for a caregiver burden that could become overwhelming? 1. My mother moved in and helped us take our quadruplets home. 2. Our health insurance sent us a rejection letter for my childs brand-name medication, and we must fill out forms to get the generic. 3. I chose to quit my job to be home with my child, and my husband helps in the evening when he can. 4. I have to care for my child day and night, which leaves little time for me.
4. I have to care for my child day and night, which leaves little time for me.
A group of children on one hospital unit are all suffering separation anxiety. Which child is experiencing the despair stage of separation anxiety? 1. Does not cry if parents return and leave again 2. Screams and cries when parents leave 3. Appears to be happy and content with staff 4. Lies quietly in bed
4. Lies quietly in bed
A child who is diagnosed with leukemia has a sibling who is expressing feelings of anger and guilt. How would the nurse characterize this reaction by the sibling? 1. Abnormal; the sibling should be referred to a psychologist. 2. Normal; the illness doesnt affect the sibling. 3. Unexpected; the cancer is easily treated. 4. Normal; the sibling is affected too, and anger and guilt are expected feelings.
4. Normal; the sibling is affected too, and anger and guilt are expected feelings.
A school nurse is performing annual height and weight screening. The nurse notes that three females who are close friends each lost 15 pounds over the past year. What is the priority nursing action in this situation? 1. Call the respective parents to discuss the eating patterns of each adolescent. 2. Speak with the girls in a group to discuss the problems associated with anorexia nervosa. 3. Refer these adolescents to the school psychologist. 4. Obtain a nutritional history for each of these adolescents.
4. Obtain a nutritional history for each of these adolescents.
The nurse is reviewing the immunization record of an adolescent who will be seen later in the day. Which item in the client's history makes hepatitis B status a priority? 1. Chronic acne 2. Overuse injuries from playing varsity sports 3. Chronic asthma 4. Plans to get a tattoo
4. Plans to get a tattoo
The clinic nurse is working with a child with multiple disabilities. The parents have asked the nurse to help them in meeting with the school board to develop an Individualized Education Plan (IEP) and an Individualized Health Plan (IHP). Which nursing intervention is most appropriate? 1. Providing a written list of the childs medical diagnoses for the IEP meeting. 2. Offering to wait with the child while the parents attend the IEP meeting. 3. Listening to the parents concerns and complaints about the school district. 4. Presenting verbally the childs cognitive, physical, and social skills to school officials at the IEP meeting.
4. Presenting verbally the childs cognitive, physical, and social skills to school officials at the IEP meeting.
While being comforted in the emergency department, a young school-age sibling of a pediatric trauma victim blurts out to the nurse, Its all my fault! When we were fighting yesterday, I told him I wished he was dead! Which response is most appropriate by the nurse? 1. Asking the child if she would like to sit down and drink some water 2. Sitting the child down in an empty room with markers and paper so that she can draw a picture 3. Calmly discussing the catheters, tubes, and equipment that the patient requires and explaining to the sibling why the patient needs them 4. Reassuring the child that it is normal to get angry and say things that we do not mean but that we have no control over whether or not an accident happens
4. Reassuring the child that it is normal to get angry and say things that we do not mean but that we have no control over whether or not an accident happens
Which nursing role is not directly involved when providing family-centered approach to the pediatric population? 1. Advocacy 2. Case management 3. Patient education 4. Researcher
4. Researcher
The nurse is planning care for a pediatric client diagnosed with adrenal hyperplasia. Which nursing diagnosis is most appropriate for this client? 1. Impaired Social Interaction Related to Unnatural Facial Features 2. Nutrition: Less than Body Requirements due to Nausea and Vomiting 3. Depression Related to Inability to Take in Oral Fluids 4. Risk for Deficient Fluid Volume Related to Failure of Regulatory Mechanisms
4. Risk for Deficient Fluid Volume Related to Failure of Regulatory Mechanisms
The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which instruction should the nurse give as a strategy for illness/disease prevention? 1. Don't allow visitors for the first month. 2. Smoke outside only. 3. Take the newborn to weekly child-stimulation classes. 4. SIDS risk-reduction measures
4. SIDS risk-reduction measures
While teaching parents of a newborn about normal growth and development, which statement is most appropriate for the nurse to include in the session? 1. Weight should triple by 6 months of age. 2. Weight should double by 1 year of age. 3. Weight should double by 4 months of age. 4. Weight should triple by 1 year of age.
4. Weight should triple by 1 year of age.
While trying to inform a young school-age client about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy. Which response by the nurse is the most appropriate in this situation? 1. Please stop talking about your puppy. I need to tell you about your CT scan. 2. Ignore the child's responses and continue discussing the procedure. 3. I'll come back when you are ready to talk with me more about your CT scan. 4. You must be so excited to have a new puppy! They are so much fun. Now, let me tell you again about going downstairs in a wheelchair to a special room.
4. You must be so excited to have a new puppy! They are so much fun. Now, let me tell you again about going downstairs in a wheelchair to a special room.
During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be: 1. soles are flat with prominent fat pads. 2. positive Babinski reflex. 3. metatarsus varus. 4. asymmetric thigh and gluteal folds.
4. asymmetric thigh and gluteal folds.
trans individuals attempted suicide rate: ____% general pop attempted suicide rate: ____%
40% 4.6% almost 10x more likely
ATI 26: 5. A nurse is caring for a child who has a prescription for prednisone (Deltasone) 2 mg/kg/day. The child weighs 35 kg. How many mg should the nurse administer per day? (Round the answer to the nearest whole number.)
70mg
Lab monitoring for FTM: estradiol level
<50 pg/mL
ATI 19:A nurse is reviewing the diagnostic findings for a preschool age child who is suspected of having cystic fibrosis. Which of the following findings should the nurse identify as an indication of cystic fibrosis? A. Sweat chloride content 85mEq/L B. Increased serum levels of fat-soluble vitamins C. 72 hour stool analysis sample, indicating hard, packed stools D. Chest x-ray negative for atelectasis
A
ATI 26: 4. A nurse is caring for a 10-year-old child who has nephrotic syndrome. Which of the following findings should the nurse report to the provider? A. Serum protein 5.0 g/dL B. Hgb 14.5 g/dL C. Hct 40% D. Platelet 200,000 mm3
A A. Serum protein 5.0 g/dL is out of reference range for a 10-year-old child and should be reported to the provider.
ATI 19: A nurse is performing an admission assessment for a child who has cystic fibrosis. Which of the following findings should the nurse expect? (Select all that apply) A. Wheezing B. Clubbing of fingers and toes C. Barrel-shaped chest D. Thin, watery mucus E. Rapid growth spurts
A B C
ATI 24: 3. A nurse is teaching a parent of a child who has a urinary tract infection. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Wear nylon underpants. B. Avoid bubble baths. C. Empty bladder completely with each void. D. Provide information about clinical manifestations of infection. E. Wipe perineal area back to front.
A B C B. The nurse should discuss avoiding bubble baths. C. The nurse should discuss the need to completely empty the bladder with each void. D. The nurse should review the clinical manifestations of infection.
ATI 18: A nurse is discussing risk factors for asthma with a group of newly licensed nurses. Which of the following conditions should the nurse include in the teaching? (Select all that apply) A. Family history of asthma B. Family history of allergies C. Exposure to smoke D. Low birth weight E. Being underweight
A B C D
ATI 23: 4. A nurse is teaching a parent of an infant about gastrointestinal reflux disease (GERD). Which of the following should be included in the teaching? (Select all that apply.) A. Offer frequent feedings. B. Thicken formula with rice cereal. C. Use a bottle with a one-way valve. D. Position baby upright for 1 hr after feedings. E. Use a wide based nipple for feedings.
A B D A. Frequent feeding will assist in decreasing the amount of vomiting episodes. B. Thickened formula will assist in decreasing the amount of vomiting episodes. D. Positioning the infant in an upright position for 1 hr following feedings will assist in decreasing the amount of vomiting episodes.
ATI 25: 3. A nurse is caring for an infant who has ambiguous genitalia. Which of the following are appropriate actions for the nurse to take? (Select all that apply.) A. Prepare for surgery. B. Obtain a detailed family history. C. Plan for a circumcision. D. Refer to genetic counseling. E. Explain the need for a chromosomal analysis.
A B D E A. Infants who have ambiguous genitalia will need surgery. Preparing the family for surgery is an appropriate action for the nurse to take. B. A detailed family history is used for gender assignment, and is therefore an appropriate action for the nurse to take. D. Families with an infant who has ambiguous genitalia will need ongoing support. Referring to genetic counseling is an appropriate action for the nurse to take. E. Chromosomal analysis is used for gender assignment, and is therefore an appropriate action for the nurse to take.
ATI 23: 1. A nurse is assessing an infant. Which of the following are clinical manifestations of hypertrophic pyloric stenosis? (Select all that apply.) A. Projectile vomiting B. Dry mucus membranes C. Currant jelly stools D. Sausage-shaped abdominal mass E. Constant hunger
A B E A. A client who has a pyloric stricture has thickening of the pyloric sphincter, resulting in projectile vomiting. B. A client who has pyloric stricture is unable to consume adequate food and fluid, resulting in dehydration. Dry mucous membranes is a clinical manifestation of hypertrophic pyloric stenosis. E. A client who has pyloric stricture is unable to consume adequate food and fluid, resulting in constant hunger.
ATI 18: A nurse is teaching a child who has asthma how use a peak flow meter. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Zero the meter before each usage B. Record the average of the attempts C. Perform three attempts D. Deliver a long, slow breath into the meter E. Sit in a chair with feet on the floor
A C
ATI 23: 5. A nurse is caring for a child. Which of the following are clinical manifestations of Meckel's diverticulum? (Select all that apply.) A. Abdominal pain B. Fever C. Mucus, bloody stools D. Vomiting E. Rapid, shallow breathing
A C A. Abdominal pain is a clinical manifestation of Meckel's diverticulum. C. Mucus, bloody stools is a clinical manifestation of Meckel's diverticulum.
ATI 25: 2. A nurse is caring for a male infant. Which of the following are clinical manifestations of an epispadias? (Select all that apply.) A. Bladder exstrophy B. Inability to retract foreskin C. Widened pubic symphysis D. Broad, spade-like penis E. Pain
A C D A. Bladder exstrophy is a clinical manifestation of a male infant who has epispadias. C. Widened pubic symphysis is a clinical manifestation of a male infant who has epispadias. D. Broad, spade-like penis is a clinical manifestation of a male infant who has epispadias.
ATI 19:A nurse is admitting a child who has cystic fibrosis. Which of the following medications should the nurse anticipate including in the plan of care? (Select all that apply) A. Tobramycin B. Loperamide C. Fat-soluble vitamins D. Albuterol E. Dornase alfa (Pulmozyme)
A C D E
ATI 15: 3. A nurse is assessing a child. Which of the following are clinical manifestations of myopia? (Select all that apply.) A. Headaches B. Photophobia C. Difficult reading D. Difficulty focusing on close objects E. Poor school performance
A C E A. Headaches are a clinical manifestation of myopia. C. Difficulty reading is a clinical manifestation of myopia. E. Poor school performance is a clinical manifestation of myopia.
ATI 15: 5. A nurse is completing a physical assessment of a child with suspected glaucoma. Which of the following findings confirm this diagnosis? (Select all that apply.) A. Epiphora B. Absent red reflex C. Strabismus D. Blepharospasm E. Report of pain
A D E A. Epiphora is a clinical manifestation of glaucoma. D. Blepharospasm is a clinical manifestation of glaucoma. E. Report of pain is a clinical manifestation of glaucoma.
ATI 16: A nurse is teaching an adolescent to self-administer a corticosteroid medication using a metered-dose inhaler. Which of the following instructions should the nurse include? (Select all that apply) A. Shake the device prior to use B. Rinse and expectorate after administration C. Inhale slowly with medication administration D. Exhale quickly after medication administration E. Wait 30 seconds between puffs
A, B, C
ATI 17: A nurse is assessing a child who has epiglottis. Which of the following findings should the nurse expect? (Select all that apply) A. Hoarseness and difficulty speaking B. Difficulty swallowing C. Low-grade fever D. Drooling E. Dry, barking cough F Stridor
A,B,D,E
ATI 17: A nurse is caring for a child in the postoperative period following a tonsillectomy. Which of the actions should the nurse take first? A. Encourage the child to blow her nose gently B. Administer analgesics on a schedule C. Offer an orange juice D. Position the child supine
B
ATI 19: A nurse is providing discharge teaching for a child who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a low-calorie, low-protein diet B. Administer pancreatic enzymes with meals and snacks C. Implement a fluid restriction during times of infection D. Restrict physical activity
B
ATI 37: 4. A nurse is caring for a toddler who has rhinitis, cough, and diarrhea for 2 days. Upon assessment, it is noted that the tympanic membrane has a orange discoloration and decreased movement. Which of the following is an appropriate statement for the nurse to make? A. "Your child has an ear infection that requires antibiotics." B. "Your child could experience transient hearing loss." C. "Your child will need to be on a decongestant until this clears." D. "Your child will need to have a myringotomy."
B B. Rhinitis, cough, diarrhea, and an orange discoloration of the tympanic membrane are clinical findings of OME. Transient hearing loss is a complication of OME.
ATI 26: 3. A nurse is caring for a 10-year-old child who has acute glomerulonephritis (AGN). Which of the following findings should the nurse report to the provider? A. Serum BUN 8 mg/dL B. Serum creatinine 1.3 mg/dL C. Blood pressure 100/74 mm Hg D. Urine output 550 mL over 24 hr
B B. Serum creatinine 1.3 mg/dL is out of reference range for a 10-year-old child, therefore should be reported to the provider.
ATI 18: A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply) A. Oxygen saturation 95% B. Wheezing C. Retraction of sternal muscles D. Warm extremities E. Nasal flaring
B C E
ATI 26: 2. A nurse is caring for a child. Which of the following are clinical manifestations of poststreptococcal glomerulonephritis (APSGN)? (Select all that apply.) A. Frothy urine B. Periorbital edema C. Ill appearance D. Decreased creatinine E. Hypertension
B C E B. A client who has APSGN will exhibit periorbital edema due to decrease in plasma filtration. C. A client who has APSGN will exhibit an ill appearance due to the manifestations experienced from the inadequate functioning of the kidneys. E. A client who has APSGN will exhibit hypertension due to inadequate function of the kidneys and possibly edema.
ATI 26: 1. A nurse is caring for a child. Which of the following are clinical manifestations of nephrotic syndrome? (Select all that apply.) A. Dipstick protein of 1+ B. Edema in the ankles C. Hyperlipidemia D. Weight loss E. Anorexia
B C E B. A client who has nephrotic syndrome will exhibit edema in the ankles due to the decreasing colloidal osmotic pressure in the capillaries. C. A client who has nephrotic syndrome will exhibit hyperlipidemia due to the increased hepatic synthesis of proteins and lipids. E. A client who has nephrotic syndrome will exhibit anorexia due to the edema of the intestinal mucosa.
ATI 37: 5. A nurse is assessing an infant. Which of the following findings are clinical manifestations of acute otitis media? (Select all that apply.) A. Decreased pain in the supine position B. Rolling head side to side C. Loss of appetite D. Increased sensitivity to sound E. Crying
B C E B. Infants who have acute otitis media will roll their head side to side because of the pain and pressure in the ear. C. Infants who have acute otits media will exhibit a loss of appetite due to the pain and pressure in the ear. E. Infants who have acute otitis media will exhibit crying and irritability from the pain.
ATI 24: 2. A nurse is assessing a child who has a urinary tract infection. Which of the following are clinical manifestations of a urinary tract infection? (Select all that apply.) A. Night sweats B. Swelling of the face C. Pallor D. Pale colored urine E. Fatigue
B C E B. Swelling of the face is a clinical manifestation in children with a urinary tract infection. C. Pallor is a clinical manifestation in children with a urinary tract infection. E. Fatigue is a clinical manifestation in children with a urinary tract infection.
ATI 15: 4. A nurse is assessing a toddler for possible hearing loss. Which of the following are clinical manifestations of a hearing impairment? (Select all that apply.) A. Uses telegraphic speech B. Speaks loudly C. Repeats sentences D. Appears shy E. Is overly attentive to the surroundings
B D B. Speaking loudly is a clinical manifestation of a hearing impairment. D. Shyness or withdrawn behavior are clinical manifestations of a hearing impairment.
ATI 37: 3. An infant who has clinical manifestations of acute otitis media (AOM) is brought to an outpatient facility by his parent. The nurse should recognize that which of the following factors places the infant at risk for otitis media? (Select all that apply.) A. Breastfeeding without formula supplementation. B. Attends day care 4 days per week. C. Immunizations are up to date. D. History of a cleft palate repair. E. Parents smoke cigarettes outside
B D E B. Infants who attend day care have an increased risk of OM because of the exposure to multiple people. D. Infants born with cleft palate are more prone to AOM because micro-organisms can easily enter the eustachian tubes. E. Exposure to secondhand smoke increases an infant's risk for AOM.
ATI 24: 1. A nurse is assessing an infant who has a suspected urinary tract infection. Which of the following are anticipated findings? (Select all that apply.) A. Increase in hunger B. Irritability C. Decrease in urination D. Vomiting E. Fever
B D E B. Irritability is a clinical manifestation in an infant with a urinary tract infection. D. Vomiting is a clinical manifestation in an infant with a urinary tract infection. E. Fever is a clinical manifestation in an infant with a urinary tract infection.
ATI 25: 4. A nurse is caring for an infant. Which of the following are clinical manifestations of obstructive uropathy? (Select all that apply.) A. Decreased urine flow B. Urinary tract infection C. Metabolic alkalosis D. Concentrated urine E. Hydronephrosis
B E B. Urinary tract infection is a clinical manifestation of obstructive uropathy. E. Hydronephrosis is a clinical manifestation of obstructive uropathy.
ATI 16: A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first? A. Increase the oxygen flow rate B. Encourage the child to take deep breaths C. Ensure proper placement of the sensor probe D. Place the child in the Fowler's position
C
ATI 16: A nurse in the ED is assessing a newly-admitted infant. Which of the following findings is an early indication of hypoxemia? A. Nonproductive cough B. Hypoventilation C. Cyanosis D. Nasal stuffiness
C
ATI 17: A nurse if caring for a child who is in the postoperative period following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding? A. Hgb 11.6 and Hct 37% B. Inflammed and reddened throat C. Frequent swallowing and clearing of throat D. Blood-tinged mucus
C
Lab monitoring for FTM
CBC hepatic function panel total and free testosterone, estrafiol baseline q3 months for a year q6-12 months thereafter
A new parent group inquires about the stages through which their children will progress as they grow older. The nurse is discussing Piagets developmental stages. In what order would the nurse expect the child to progress through Piagets stages of development? List them in order. Choice 1. Sensorimotor Choice 2. Formal operational Choice 3. Preoperational Choice 4. Concrete operational
Choice 1. Sensorimotor Choice 3. Preoperational Choice 4. Concrete operational Choice 2. Formal operational
Place the nursing assessments of a toddler in the best order. Choice 1. Examination of eyes, ears, and throat Choice 2. Auscultation of chest Choice 3. Palpation of abdomen Choice 4. Developmental assessment
Choice 4. Developmental assessment Choice 2. Auscultation of chest Choice 3. Palpation of abdomen Choice 1. Examination of eyes, ears, and throat
(31) The nurse is teaching a group of adolescents about care for acne vulgaris. Which interventions will the nurse include in the teaching session? Standard Text: Select all that apply. 1. Wash skin with mild soap and water twice a day. 2. Use astringents and vigorous scrubbing. 3. Avoid picking or squeezing the lesions. 4. Apply tretinoin (Retin-A) liberally. 5. Avoid sun exposure if on tetracycline.
Correct Answer: 1,3,5 The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses). The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses). The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).
(Chapter 20) A child with asthma will be receiving an oral dose of prednisone. The order reads prednisone 2 mg/kg per day. The child weighs 50 lbs. The child will receive ____ milligrams daily. (Round the answer.) Standard Text: Round the answer to the nearest whole number.
Correct Answer: 45.5 = 46 Rationale: 22.7 2 = 45.5 (46)
ATI 16: A nurse is caring for a child who is receiving oxygen. Which of the following findings indicates oxygen toxicity? A. Increased BP B. Hyperventilation C. Decrease PaCO2 D. Unconciousness
D
ATI 17: A nurse is teaching a group of parents about influenza. Which of the following information should the nurse include in the teaching? A. Amantadine will prevent the illness B. Rimantadine is administered intramuscularly C. Zanamivir can be given to children 1 year or older D. Oseltamivir should be given within 48 hours of onset of symptoms
D
ATI 24: 4. A nurse is planning care of a child who has a urinary tract infection. Which of the following should the nurse include? A. Administer antidiuretic. B. Restrict fluids. C. Evaluate the child's self-esteem. D. Encourage frequent voiding.
D D. It's important to encourage frequent voiding. This assists in flushing the bacteria through the urinary system.
ATI 37: 1. A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? A. Provide emotional support to the family. B. Educate the family on care of the child. C. Prevent clinical complications. D. Administer analgesics.
D D. The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the toddler's physiological need first. Therefore, administering analgesics to alleviate or decrease physical pain is the priority action for the nurse to take.
ATI 15: 1. A nurse is planning to perform a peripheral vision test on a child. Which of the following is an appropriate action for the nurse to take? A. Place the child 10 feet away from the chart. B. Show a set of cards to the child one at a time. C. Cover the child's eye while performing the test on the other eye. D. Have the child focus on an object while performing the test.
D D. When performing a peripheral vision test, the nurse asks the child to focus on an object while bringing a pencil into the child's peripheral vision
A child undergoing chemotherapeutic treatment for cancer is being admitted to the hospital for fever of 102 degrees F and possible sepsis. Cultures, antibiotics, and acetaminophen (Tylenol) along with bed rest have been ordered for this child. Place the following steps in order from first to last. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Administer the antibiotics. Response 2. Administer the acetaminophen (Tylenol). Response 3. Obtain the cultures. Response 4. Ensure the child has bed rest.
Response 2. Administer the acetaminophen (Tylenol). Response 3. Obtain the cultures. Response 1. Administer the antibiotics. Response 4. Ensure the child has bed rest.
Effects of Estrogen Therapy (MTF) reversible
arrests progression of balding decreased spontaneous erections decreased muscle mass softening of skin
prevenlance of trans people in 2011 to 2014
doubed 700,000 --> 1.4 milion
cultural humility
each person should be approached as an individual with no preconceptions
gender expression
how do you express yourself? feminine - androgynous/others - masculine
gender identity
how you feel and see yourself woman - gender queer/others - male
chapter 14
http://testbankgo.eu/chapter-14-12/
Chapter 15
http://testbankgo.eu/chapter-15-11/
Chapter 18
http://testbankgo.eu/chapter-18-12/
Chapter 20
http://testbankgo.eu/chapter-20-11/
Chapter 28
http://testbankgo.eu/chapter-28-8/
Chapter 31
http://testbankgo.eu/chapter-31-7/
phalloplasty (FTM)
no erection unless implant constructs male genitalia using skin flaps
Estrogen therapy
oral / transdermal / IM estradiol androgen blockers progestagens
FTM terminology: packing
placement of a penile prothesis in one's underwear, giving both an outward appearance as well as reducing gender dysphoria
bathrooms
policies should either define all bathrooms as gender -neutral or specifically state patient may choose either men's or women's room based on own preference
informed consent model
provider: Before we start you on hormones, I want to make sure you understand the risks, benefits, as well as the most current information regarding transitioning and hormone replacement therapy in healthcare.
scrotoplasty (FTM)
reconstructive surgery procedure in which a scrotum is made; silicone implants may be placed in the scrotum
secondary sexual characteristics and effects of early intervention: male to female
reduction in growth spurt erectile response blocked prevention of facial hair growth, voice/skeletal/facial changes prevention of androgenic alopecia
transgender and healthcare discrimination
refusal of medical care based of their gender identity 1 in 3 have a negative experience with a healthcare providor about 1 in 4 do not seek the care they need for fear of being mustreated 3x more likely to traval >30 miles to receive trans-competent care
metoidioplasty (FTM)
sensory ligament of clit is released, a "free-up" may have spontaneous erections
seX
sex assigned at birth female - intersex - male
sexual orientation
who are you attracted to sexually and/or emotionally? woman-gender queer/others-male
