prep u sum 13

An adolescent is started on valproic acid to treat seizures. Which statement should be included when educating the adolescent?

"A common adverse effect is weight gain." Explanation: Weight gain is a common adverse effect of valproic acid. Drowsiness and irritability are adverse effects more commonly associated with phenobarbital. Felbamate (Felbatol) more commonly causes insomnia.

A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents:

"Has your child had strep throat recently?" Explanation: Group A beta-hemolytic streptococcal infection typically precedes rheumatic fever. An inflammatory disease, rheumatic fever affects the heart, joints, and central nervous system. It isn't infectious and can't be transmitted from one person to another. Congenital heart defects don't play a role in the development of rheumatic fever. H. influenzae vaccine doesn't prevent streptococcal infection or rheumatic fever.

The physician orders digoxin (Lanoxin) 0.1 mg orally every morning for a 6-month-old infant with heart failure. Digoxin is available in a 400 mcg/mL concentration. How many milliliters of digoxin should the nurse give? Record your answer using two decimal places.

0.25 Explanation: To convert mg to mcg: 1,000 mcg/1 mg = X mcg/0.1 mg; X = 100 mcg. To calculate drug dose: Dose on hand/Quantity on hand = Dose desired/X. 400 mcg/mL = 100 mcg/X; X = 0.25 mL.

Dowager's hump

Abnormal curvature in the upper thoracic spine.

The nurse is caring for a 10-year-old child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action would be most appropriate for the nurse to take?

Consulting with the social worker to help the family find appropriate resources Explanation: The nurse can help this family by assisting them with finding appropriate financial, psychological, and social support and by providing referrals to the local community agencies and the Cystic Fibrosis Foundation. The child should be treated as much like a normal child as possible, and he should be encouraged to make friends with other children regardless of their physical condition. The nurse shouldn't encourage the parents not to visit because the child might feel abandoned.

enteric precautions

Gowns and gloves required, masks not required, protection from feces and urine.

Bence Jones protein

Immunoglobulin (protein) fragment found in the urine of patients with multiple myeloma Presence of Bence Jones protein in the urine almost always confirms multiple myeloma, but absence doesn't rule it out.

A 12-year-old child diagnosed with muscular dystrophy is hospitalized secondary to a fall. Surgery is necessary as well as skeletal traction. Which complication would be of greatest concern to the nursing staff?

Respiratory infection Explanation: Respiratory infection can be fatal for children with muscular dystrophy due to poor chest expansion and decreased ability to mobilize secretions. Skin integrity, infection of pin sites, and nonunion healing are all causes for concern, but not as important as prevention of respiratory infection.

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation. Explanation: The pulse and respiratory rates normally increase during and for a short time after ambulation, especially if it's the first ambulation after 3 days of bed rest. A normal walking pace is 70 to 100 steps/minute; a much slower pace may indicate distress. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds the head erect, gazes straight ahead, and keeps the toes pointed forward; option 3 describes a client with activity intolerance.

The nurse should include which fact when teaching an adolescent group about the human immunodeficiency virus (HIV)?

The virus can be spread through many routes, including sexual contact Explanation: HIV can be spread through many routes, including sexual contact and contact with infected blood or other body fluids. The incidence of HIV in the adolescent population has increased since 1995, even though more information about the virus is targeted to reach the adolescent population. Only about 25% of all new HIV infections in the United States occurs in people younger than age 22.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

yellow sclerae. Explanation: Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools are signs of hypoxia and GI bleeding, respectively.

In the client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints Explanation: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

A nurse is teaching an adolescent with type 1 diabetes about the disease. Which instruction by the nurse about how to prevent hypoglycemia would be most appropriate for the adolescent?

"Carry crackers or fruit to eat before or during periods of increased activity." Explanation: Hypoglycemia can usually be prevented if an adolescent with diabetes eats more food before or during exercise. Because exercise with adolescents isn't commonly planned, carrying additional carbohydrate foods such as crackers or fruit is a good preventive measure.

An adolescent, age 16, is brought to the clinic for evaluation for a suspected eating disorder. To best evaluate the effects of role and relationship patterns on the child's nutritional intake, the nurse should ask:

"Do you like yourself physically?" Explanation: Role and relationship patterns focus on body image and the client's relationship with others, which commonly interrelate with food intake. Questions about activities and food preferences elicit information about health promotion and health protection behaviors. Questions about food allergies elicit information about health and illness patterns.

The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?

Administering I.V. fluids Explanation: I.V. infusions containing normal saline solution and potassium should be given first to maintain fluid and electrolyte balance. For the client's comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to aid in the diagnosis of bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication often is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.

For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority?

Avoiding abdominal palpation Explanation: Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a child with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious.

A 2-month-old infant arrives in the emergency department with a heart rate of 180 beats/minute and a temperature of 103.1° F (39.5° C) rectally. Which intervention is most appropriate?

Give acetaminophen (Tylenol). Explanation: Acetaminophen should be given first to decrease the infant's temperature. A heart rate of 180 beats/minute is normal in an infant with a fever. Fluid intake is encouraged after the acetaminophen is given to help replace insensible fluid losses. Carotid massage is an attempt to decrease the heart rate as a vagal maneuver; it won't work in this infant because the source of the increased heart rate is fever. A tepid sponge bath may be given to help decrease the temperature and calm the infant.

Several children at a daycare center have been infected with hepatitis A virus. Which instruction by the nurse would reduce the risk of hepatitis A to other children and staff members?

Hand washing after diaper changes Explanation: Children in daycare centers are at risk of hepatitis A infection which is transmitted via fecal-oral route due to poor hand hygiene practices and poor sanitation. Isolation of sick children, use of masks during contact, and sterilization of all eating utensils would not be useful in breaking the chain of infection.

Which of the following complications is most common after an abdominal aortic aneurysm resection?

Hemorrhage and shock Explanation: Hemorrhage and shock are the most common complications after abdominal aortic aneurysm resection. Renal failure can occur as a result of shock or from injury to the renal arteries during surgery. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair.

Which diet plan is recommended for an infant with heart failure?

Increase caloric content per ounce Explanation: Formulas with increased caloric content are given to meet the greater caloric requirements from the overworked heart and labored breathing. Fluid restriction and low-sodium formulas aren't recommended. An infant's nutritional needs depend on fluid. Daily weights at the same time of the day on the same scale before feedings are recommended to follow trends in nutritional stability and diuresis. Low-sodium formulas may cause hyponatremia.

A 4-year-old child had a subungual hemorrhage of the toe after a jar fell on his foot. Electrocautery is performed. Which teaching statement regarding the rationale for using electrocautery to treat the injury is most accurate?

It's used to relieve pain and reduce the risk of infection Explanation: The hematoma is treated with electrocautery to relieve pain and reduce the risk of infection. Electrocautery doesn't prevent the loss of the nail. The discoloration seen with subungual hemorrhage is from the collection of blood under the nail bed. It isn't permanent and doesn't affect nail growth.

The nurse is teaching parents about accident prevention for a toddler. Which of the following guidelines is most appropriate?

Make sure all medications are kept in containers with childproof safety caps. Explanation: All over-the-counter and prescription medications should have childproof safety caps. Poisoning accidents are common in toddlers, due to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat. Wearing a seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Toddlers should be in a rear-facing convertible car seat; those who weigh 20 to 40 lb can be placed facing forward.

A client is examined and found to have pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. Which term best describes these lesions?

Petechiae Explanation: Petechiae are small macular lesions 1 to 3 mm in diameter. Ecchymosis is a purple-to-brown bruise, macular or papular, that varies in size. A hematoma is a collection of blood from ruptured blood vessels that's more than 1 cm in diameter. Purpura are purple macular lesions larger than 1 cm.

A 2-year-old child is admitted to the pediatric unit with the diagnosis of bacterial meningitis. Which diagnostic measure would be appropriate for the nurse to perform first?

Place the toddler in respiratory isolation Explanation: Nurses should take necessary precautions to protect themselves and others from possible infection from the bacterial organism causing meningitis. The affected child should immediately be placed in respiratory isolation; then the parents can be informed about the treatment plan. This should be done before laboratory tests are performed.

When assisting in developing a plan of care for a hospitalized child, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds?

Preschool age Explanation: School-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older children and adolescents.

Intraosseously

fluid admin - good if cannot obtain IV access (small animals). Also can be given at a relatively fast speed. acceptable for dehydration and shock

herpes zoster infection

aka shingles-- a viral disease of spinal ganglia-- is a dermatomally distributed skin lesion. Virus invades a spinal ganglion and is transported along the axon to the skin, where it produces an infection that causes a sharp burning pain in the dermatome supplied by the involved nerve. A few days later, the skin of the dermatome becomes red and vesicular eruptions appear.

When counseling parents of a neonate with congenital hypothyroidism, the nurse understands that the severity of the intellectual deficit is related to which parameter?

Duration of the condition before treatment Explanation: The severity of the intellectual deficit is related to the degree of hypothyroidism and the duration of the condition before treatment. Cranial malformations don't affect the severity of the intellectual deficit, nor does the degree of hypothermia as it relates to hypothyroidism. It isn't the specific T4 level at diagnosis that affects the intellect but how long the child has been hospitalized.

A 13-month-old is admitted to the pediatric unit with a diagnosis of gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal that he's dehydrated. Which nursing interventions are correct to prevent further dehydration? Select all that apply:

• Give clear liquids in small amounts • Encourage the child to eat nonsalty soups and broths • Monitor the I.V. solution per the physician's order Explanation: A child experiencing nausea and vomiting won't be able to tolerate a regular diet. He should be given sips of clear liquids, and the diet should be advanced as tolerated. Unsalted soups and broths are appropriate clear liquids. I.V. fluids should be monitored to maintain the fluid status and help to rehydrate the child. Milk shouldn't be given because it can worsen the child's diarrhea. Solid foods may be withheld throughout the acute phase, but clear fluids should be encouraged in small amounts (3 to 4 tablespoons every half hour).

An 18-month-old male child is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this child?

A protuberant abdomen Explanation: A child with celiac disease has a protuberant abdomen, diarrhea, steatorrhea, and anorexia, which result in malnutrition. A concave abdomen, bulges in the groin area, and a palpable abdominal mass aren't associated with celiac disease.

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase (Pancrease). At a follow-up visit, which finding suggests the need for further teaching?

Fatty stools Explanation: Pancreatic enzymes normally aid in food digestion in the intestine. In a child with cystic fibrosis, however, these natural enzymes can't reach the intestine because mucus blocks the pancreatic duct. Without these enzymes, undigested fats and proteins produce fatty stools. Treatment with pancreatic enzymes should result in stools of normal consistency; noncompliance with the treatment produces fatty stools. Noncompliance doesn't cause bloody urine, bloody stools, or glucose in urine.

A 30-year-old client is admitted to the emergency department with a deep partial-thickness burn on his arm after a fire in his workplace. Which signs and symptoms should the nurse expect to see?

Necrotic tissue through most of the dermis Explanation: A deep partial-thickness burn causes necrosis of the epidermal and dermal layers. Redness and pain are characteristics of a superficial injury. Superficial burns cause slight epidermal damage. With deep burns, the nerve fibers are destroyed and the client doesn't feel pain in the affected area. Necrosis through all skin layers is seen with full-thickness injuries.

A recent abduction of a 2-month-old infant has raised awareness of the need for security plans for hospitals. Which security measure helps ensure the hospitalized infant's security?

Placing an identification bracelet on the infant and the parent immediately on admission Explanation: The safest way to ensure that the parents or legal guardians are who they say they are is to place a bracelet on both the infant and the parents or guardians at the time of admission. Limiting visitors isn't necessary. Locking the door and having visitors call the nurses' station for admission increases the workload of the nursing staff. It isn't feasible to place security guards at the entrances.

A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal?

Preventing infection Explanation: Preventing infection is the nurse's primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they're secondary to preventing infection.

Parents of a 6-year-old child tell a physician that the child has been having periods of unawareness with short periods of staring. Based on his history, the child is probably having which type of seizure?

Typical absence Explanation: A typical absence seizure has an onset between ages 4 and 8. It's exhibited by an abrupt loss of consciousness, amnesia, or unawareness characterized by staring and a 3-cycle/second spike and waveform on an EEG. The attack lasts from 10 to 30 seconds and may occur as frequently as 50 to 100 times a day. No postictal or confused state follows the attack. A complex partial seizure most commonly occurs in older children and adults, causing a brief impairment of consciousness. A myoclonic seizure occurs in older children and is exhibited by lightning jerks without loss of consciousness. An abrupt increase in muscle tone, loss of consciousness, and marked autonomic signs and symptoms characterize the tonic seizure.

A client understands what resources are available to help him perform wound care at home when he states the following:

"Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need." Explanation: The client's acknowledgement that he will need to speak to the home care nurse about supplies demonstrates that he is able to perform self-care, and is familiar with the resources available. The social worker can help with financial issues, not wound care issues. The home health care nurse is available for consultation, but she won't provide all of the client's health care needs. Dressing changes don't need to be performed in the physician's office.

The cardinal signs of diabetes insipidus are polyuria and polydipsia. Hypernatremia, not hyponatremia, occurs with diabetes insipidus. Jaundice occurs because of abnormal bilirubin metabolism, not diabetes insipidus. Hyperchloremia, not hypochloremia, occurs with diabetes insipidus.

"My infant's fluid intake will be restricted." Explanation: The simplest test used to diagnose diabetes insipidus is restriction of oral fluids and observation of consequent changes in urine volume and concentration. A weight loss of 3% to 5% indicates severe dehydration, and the test should be terminated at this point. This test is done in the hospital, and the infant is watched closely.

The nurse is assisting in developing a teaching plan for a child with acute poststreptococcal glomerulonephritis. What is the most important point to address in this plan?

Blood pressure monitoring Explanation: Because poststreptococcal glomerulonephritis may cause severe, life- threatening hypertension, the nurse must teach the parents how to monitor the child's blood pressure. Infection control, nutritional planning, and prevention of streptococcal pharyngitis are important but are secondary to blood pressure monitoring.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?

Bulb syringe with tubing Explanation: An infant with a surgically repaired cleft lip must be fed with a bulb syringe with tubing or Breck feeder to prevent sucking or suture line trauma. The other options wouldn't prevent these actions.

When preparing to feed an infant with pyloric stenosis, which intervention is important?

Burp the infant frequently Explanation: Infants with pyloric stenosis usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger (feedings aren't easily tolerated). Burping often lessens gastric distention and increases the likelihood the infant will retain the feeding. Feedings are given slowly with the infant lying in a semiupright position. Parental participation should be encouraged and allowed to the extent possible. Record the type, amount, and character of the vomit as well as its relation to the feeding. The amount of feeding volume lost is usually refed.

A client diagnosed with acute myelocytic leukemia (AML) has been receiving chemotherapy. During the last two cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia?

Closely observe the client's skin for petechiae and bruising. Explanation: The nurse should closely observe the client's skin for petechiae and bruising, early signs of thrombocytopenia. Daily platelet counts may not reflect the client's condition as quickly as subtle changes in the client's skin. Performing frequent cardiovascular assessments and checking the client's history won't help detect early signs and symptoms of thrombocytopenia.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

Contact isolation Explanation: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, used to prevent transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

Decreasing the rate of feedings and the concentration of the formula Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping, so this intervention should have already been performed. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Changing tube feeding administration sets every 24 hours prevents bacterial growth; it doesn't decrease the client's discomfort.

The nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent?

Fear related to disturbed body image Explanation: Fear related to disturbed body image is the most appropriate nursing diagnosis for a hospitalized adolescent because of the adolescent's developmental level and concern for physical appearance. An adolescent may fear disfigurement resulting from procedures and treatments. Separation is rarely a major stressor for the adolescent, eliminating a diagnosis of Anxiety related to separation from parents. Adolescents may have Fear related to the unknown but typically ask questions if they want information. A diagnosis of Ineffective coping related to activity restrictions may be appropriate for a toddler who has difficulty tolerating activity restrictions but is an unlikely nursing diagnosis for an adolescent.

An 8-year-old client has tested positive for West Nile virus infection. The nurse suspects the client has the severe form of the disease when she recognizes which signs and symptoms?

Fever, muscle weakness, and change in mental status Correct Explanation: Severe West Nile virus infection (also called West Nile encephalitis or West Nile meningitis) affects the central nervous system and may cause headache, neck stiffness, fever, muscle weakness or paralysis, changes in mental status, and seizures. Such signs and symptoms as fever, rash, malaise,anorexia, nausea and vomiting, and lymphadenopathy suggest the mild form of West Nile virus infection.

The mother of a 3-year-old with a myelomeningocele is thinking about having another baby. The nurse should inform the woman that she should increase her intake of which acid?

Folic acid to 4 mg/day Explanation: The American Academy of Pediatrics recommends that a woman who has had a child with a neural tube defect increase her intake of folic acid to 4 mg per day 1 month before becoming pregnant and continue this regimen through the first trimester. A woman who has no family history of neural tube defects should take 0.4 mg/day. All women of childbearing age should be encouraged to take a folic acid supplement because the majority of pregnancies in the United States are unplanned. Ascorbic acid hasn't been shown to have any effect on preventing neural tube defects.

A preschool-age child underwent a tonsillectomy 4 hours ago. Which data collection finding would make the nurse suspect postoperative hemorrhage?

Frequent swallowing Explanation: Frequent swallowing — an attempt to clear the throat of trickling blood — suggests postoperative hemorrhage. Emesis may be brown or blood-tinged after a tonsillectomy; only bright red emesis signals hemorrhage. The child may refuse fluids because of painful swallowing, not bleeding. Hemorrhage is associated with an increased, not decreased, heart rate.

When collecting data on a child with juvenile hypothyroidism, the nurse expects which finding?

Goiter Explanation: Juvenile hypothyroidism results in goiter, weight gain, sleepiness, and a slow heart rate. It doesn't cause weight loss, insomnia, or tachycardia.

mantoux test

Intradermal test to determine tuberculin sensitivity based on a positive reaction where the area around the test site becomes red and swollen

The mother of a preschooler recently diagnosed with type 1 diabetes mellitus makes an urgent call to the pediatrician's office. She says her child had an uncontrollable temper tantrum while playing and now is lethargic and hard to arouse. The nurse should instruct the mother to take which action first?

Measure the child's blood glucose level. Explanation: In a child with type 1 diabetes mellitus, behavioral changes may signal either hypoglycemia or hyperglycemia; measuring the blood glucose level is the only way to determine which condition is present. Urine glucose measurement doesn't accurately reflect the current blood glucose level. Forcing a lethargic child to drink fluids could cause aspiration. After measuring the child's blood glucose level, the mother may need to take additional emergency measures such as administering insulin or a simple glucose source. If the child doesn't respond to these measures, the mother may need to call for emergency help.

Which adverse effect can be expected by the parents of a 2-year-old child who has been started on rifampin after testing positive for tuberculosis?

Orange body secretions Explanation: Rifampin and its metabolites will turn urine, feces, sputum, tears, and sweat an orange color. This isn't a serious adverse effect. Rifampin may also cause GI upset, headache, drowsiness, dizziness, vision disturbances, and fever. Liver enzyme and bilirubin levels increase because of hepatic metabolism of the drug. Parents should be taught the signs and symptoms of hepatitis and hyperbilirubinemia such as jaundice of the sclera or skin.

Which nursing diagnosis is most relevant in the first 12 hours of life for a neonate born with a myelomeningocele?

Risk for infection Explanation: All of these nursing diagnoses are important for a child with a myelomeningocele. However, during the first 12 hours of life, the most life-threatening event would be an infection. The other diagnoses will be addressed as the child develops

The parents of a school-age child with asthma express concern about letting the child participate in sports. What should the nurse tell the parents about the relationship between exercise and asthma?

Taking prophylactic drugs before the activity can prevent asthma attacks and enable the child to engage in most sports. Explanation: Although exercise may trigger asthma attacks, taking prophylactic asthma drugs before beginning the activity can prevent attacks, enabling the child to engage in most sports. Asthma attacks may be triggered by various factors, including allergens, exercise, medications, upper respiratory infections, and psychological stress. Provided the asthma is under control, most children can participate in sports and other physical activities; in fact, they benefit from exercise. Activity restrictions hamper peer interaction, which is essential to the development of the school-age child. A child with asthma may tolerate intermittent activities better than continuous ones.

One day after an appendectomy, a 9-year-old client rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart?

The child rates pain at 4 out of 5. Pain medication administered as prescribed. Explanation: Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses a passive coping behavior (such as distraction) may rate pain as more intense than children who use active coping behavior (such as crying). Making judgments about pain based on behavior can result in children being inadequately medicated for pain.

When the parents of an infant diagnosed with hypothyroidism have been taught to count the pulse, which intervention should the nurse teach them in case they obtain a high pulse rate?

Withhold the medication and call the primary health care provider Explanation: If parents have been taught to count the pulse of an infant diagnosed with hypothyroidism, they should be instructed to withhold the dose and consult their primary health care provider if the pulse rate is above a certain value.

A teenager with heart failure prescribed digoxin (Lanoxin) asks the nurse, "What's the drug supposed to do?" The nurse responds to the teenager based on the understanding that this drug is classified as:

a cardiac glycoside Explanation: Digoxin is a cardiac glycoside. It decreases the workload of the heart and improves myocardial function. ACE inhibitors cause vasodilation and increase sodium excretion. Diuretics help remove excess fluid. Vasodilators enhance cardiac output by decreasing afterload.

When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:

a preoccupation with death. Explanation: An adolescent who demonstrates a preoccupation with death (such as by talking about death frequently) should be considered at high risk for suicide. Although depression, excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents, they also occur in adolescents who aren't suicidal.

For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in:

an arched, side-lying position, avoiding flexion of the neck onto the chest. Explanation: For a lumbar puncture, the nurse should place the infant in an arched, side- lying position to maximize the space between the third and fifth lumbar vertebrae. The nurse's hands should rest on the back of the infant's shoulders to prevent neck flexion, which could block the airway and cause respiratory arrest. The infant should be placed at the edge of the bed or table during the procedure, and the nurse should speak quietly to calm the child. A mummy restraint would limit access to the lumbar area because it involves wrapping the child's trunk and extremities snugly in a blanket or towel. A prone position wouldn't cause separation of the vertebral spaces.

rule of nines

method used to calculate the amount of fluid lost as the result of a burn; divides the body into 11 areas, each accounting for 9% of the total body area

The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply:

no because she isn't sexually active. Explanation: A 16-year-old client who isn't sexually active doesn't need a Pap test. When a client is sexually active or reaches age 18, a Pap test should be performed.

During the first few days of recovery from ostomy surgery for ulcerative colitis, which aspect should be the first priority of client care?

ostomy care

When talking with 10- and 11-year-old children about death, the nurse should incorporate which guides? Select all that apply:

• The children will be curious about the physical aspects of death • The children will know that death is inevitable and irreversible • The children will be influenced by the attitudes of the adults in their lives Explanation: School-age children are curious about the physical aspects of death and may wonder what happens to the body. By age 9 or 10, most children know that death is universal, inevitable, and irreversible. Their cognitive abilities are advanced and they respond well to logical explanations. They should be encouraged to ask questions. Because the adults in their environment influence their attitudes towards death, they should be encouraged to include children in the family rituals and be prepared to answer questions that may seem shocking. Teaching about death should begin early in childhood. Comparing death to sleep can be frightening for children and cause them to fear falling asleep.

A 10-year-old child has been experiencing insatiable thirst and urinating excessively; his serum glucose is normal. Which condition is the child probably experiencing?

Diabetes insipidus Explanation: Polydipsia and polyuria with normal serum glucose are indicative of diabetes insipidus. Interview and laboratory results can determine whether the origin is neurogenic or nephrogenic. Type 1 or 2 diabetes mellitus present with an elevated serum glucose. A child with hyperthyroidism may present as dehydrated from the excessive sweating and rapid respirations that accompany this hypermetabolic state.

A nurse should teach the client to watch for which complication of gastric resection?

Dumping syndrome Explanation: Dumping syndrome is a problem that occurs postprandially after gastric resection because ingested food rapidly enters the jejunum without proper mixing and without the normal duodenal digestive processing. Diarrhea, not constipation, may also be a symptom. Gastric or intestinal spasms don't occur, but antispasmodics may be given to slow gastric emptying.

The nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider?

Incompatibility between the history and the injury Explanation: Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. The other criteria also may suggest child abuse but are less reliable indicators.

Which factor will most likely decrease drug metabolism during infancy?

Inefficient liver function Explanation: Inefficient liver function will most likely decrease drug metabolism during infancy. As the liver matures during the 1st year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism; reduced protein-binding ability may affect drug distribution but not metabolism.

Which action should a nurse take first when admitting a client with herpes zoster infection?

Institute isolation precautions according to facility policy. Explanation: The nurse should first institute isolation precautions to prevent the spread of the herpes zoster infection. After isolation precautions are in effect, the nurse can instruct the client to wear light clothing and provide a tepid bath to promote client comfort. The nurse should also caution the client against scratching the lesions because that might cause infection and scarring.

Which finding is an early indicator of bladder cancer?

Painless, intermittent hematuria Explanation: As cancer cells destroy normal bladder tissue, bleeding occurs and causes painless, intermittent hematuria. (Pain is a late symptom of bladder cancer.) The other options aren't associated with bladder cancer. Occasional polyuria may occur with diabetes or increased alcohol or caffeine intake. Nocturia commonly accompanies benign prostatic hypertrophy. Dysuria may indicate a urinary tract infection (UTI).

A teenager is brought to the facility by friends after accidentally ingesting gasoline while siphoning it from a car. Based on the nurse's knowledge of petroleum distillates, which system would be most affected?

Respiratory system Explanation: The primary concern with petroleum distillate ingestion is its effect on the respiratory system. Aspiration or absorption of petroleum distillates can cause severe chemical pneumonitis and impaired gas exchange. The GI, neurologic, and cardiovascular systems may be affected if the petroleum contains additives such as pesticides.

A nurse is caring for a client with suspected upper GI bleeding. The nurse should monitor this client for:

black, tarry stools. Explanation: As blood from the GI tract passes through the intestines, bacterial action causes it to become black. Hemoptysis involves coughing up blood from the lungs. Hematuria is blood in the urine. Bright red blood in the stools indicates bleeding from the lower GI tract.

The nurse is caring for a teenage client involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with sterile petroleum gauze. Explanation: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress, as tension pneumothorax may develop. If so, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.

The charge nurse overhears a nurse complaining that she has been assigned to a toddler diagnosed with tetralogy of Fallot for the past 3 days and the mother is very demanding. Which response by the charge nurse is best?

"It's important for the child to have someone assigned to him who's familiar with his care." Explanation: A toddler with tetralogy of Fallot requires the care of someone who's familiar with the toddler's condition. Providing continuity of care enhances safety and promotes well- being for this toddler and his parents. Options 2 and 3 are condescending to the nurse and don't help enhance the nurse's understanding of the situation. Both responses would further increase the nurse's anger. Changing the assignment isn't in the best interest of the toddler.

Which method is most reliable for confirming a preschooler's identity before administering a medication?

Check the hospital identification bracelet. Explanation: The only safe method for identifying the child is to check the identification band for the client's name and medical record number and then compare that information with the medication record. Children sometimes exchange beds during play, so checking the name on the bed isn't reliable. Infants are unable to give their names, toddlers or preschoolers may admit to any name, and school-age children may deny their identities in an attempt to avoid the medication. Parents aren't always at the bedside, so they shouldn't be relied on for identification

A nurse is caring for a 17-year-old girl who's receiving parenteral nutrition in 25% dextrose solution. How should this solution be administered?

Directly into the superior vena cava Explanation: Solutions that contain more than 12.5% dextrose are administered through a central venous access device directly into the superior vena cava by way of the jugular or subclavian vein. Special tubing is used that contains an in-line filter to remove bacteria and particulate material. A superficial vein, gastrostomy tube, and the oral route are never used for this type of solution.

A 15-year-old client who sustained a spinal cord injury is on bedrest. Which intervention by the nurse might best help the adolescent cope with the prolonged bedrest?

Encouraging visitation by his friends Explanation: Encouraging visitation by friends might best help the adolescent cope with prolonged bedrest. Friends are much more important than family to this age-group. Providing reading material and video games might be somewhat helpful, but not as helpful as encouraging visits from friends.

A 2-year-old child is brought to the emergency department with suspected croup. Which data collection finding reflects increasing respiratory distress?

Intercostal retractions Explanation: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, and intercostal retractions. Fever is a sign of infection. Bradycardia is a late sign of impending respiratory arrest. Cyanosis, not pallor, is a sign of increasing respiratory distress.

A toddler is brought to the emergency department in cardiac arrest. The physician tries three times to insert an I.V. catheter but is unsuccessful. By which alternate route can the physician administer emergency medications?

Intraosseously Explanation: The physician can safely administer emergency medications, such as sodium bicarbonate, calcium, glucose, crystalloids, colloids, blood, dopamine, epinephrine, and dobutamine by the intraosseous route if the I.V. route is inaccessible. Emergency medications shouldn't be administered by the sublingual, topical, or subcutaneous routes.

During a senior citizen health screening, the nurse observes a 75-year-old female with a severely increased thoracic curve, or "humpback". What is this condition called?

Kyphosis Explanation: Kyphosis refers to an increased thoracic curvature of the spine, or "humpback." Lordosis is an increase in the lumbar curve or swayback. Scoliosis is a lateral deformity of the spine. Genus varum is a bow-legged appearance of the legs.

What's the best way for a nurse to position a 3-year-old child with right lower lobe pneumonia?

Left side-lying Explanation: The child with right lower lobe pneumonia should be placed on his left side. This places the unaffected left lung in a position that allows gravity to promote blood flow though the healthy lung tissue and improve gas exchange. Placing the child on his right side, back, or stomach doesn't promote circulation to the unaffected lung.

A client with cancer is being evaluated for possible metastasis. Which of the following is a common metastasis site for cancer cells?

Liver Explanation: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.

An infant, age 8 months, has a tentative diagnosis of congenital heart disease. During data collection, the nurse measures a heart rate of 170 beats/minute and a respiratory rate of 70 breaths/minute. How should the nurse position the infant?

Sitting in an infant seat Explanation: Because the infant's data collection findings suggest that respiratory distress is developing, the nurse should position the infant with the head elevated at a 45-degree angle to promote maximum chest expansion; an infant seat maintains this position. Placing an infant flat on his back or abdomen or in high Fowler's position could increase respiratory distress by preventing maximal chest expansion.

The nurse is caring for an infant with hypospadias. Which anomaly would the nurse assess the infant for that commonly accompanies this condition?

Undescended testes Explanation: Because undescended testes may also be present in hypospadias, the small penis may appear to be an enlarged clitoris. This shouldn't be mistaken for ambiguous genitalia. If there's any doubt, more tests should be performed. Hernias don't generally accompany hypospadias.

A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order:

a barium enema. Explanation: A barium enema commonly is used to confirm and correct intussusception. Performing a suprapubic aspiration or inserting an NG tube or an indwelling urinary catheter wouldn't help diagnose or treat this disorder.

A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

pain management. Explanation: With a superficial partial thickness burn such as a solar burn (sunburn), the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

For a client with cirrhosis, deterioration of hepatic function is best indicated by:

difficulty in arousal. Explanation: Hepatic encephalopathy, a major complication of advanced cirrhosis, occurs when the liver no longer can convert ammonia (a by-product of protein breakdown) into glutamine. This leads to an increased blood level of ammonia — a central nervous system toxin — which causes a decrease in the level of consciousness. Fatigue, muscle weakness, nausea, anorexia, and weight gain occur during the early stages of cirrhosis.

The nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:

pathologic bone fractures. Explanation: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver failure and heart failure aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma.

The nurse is preparing to administer chloramphenicol (Chloromycetin Otic) to a 2-year-old client with an infection of the external auditory canal. The order reads, "2 drops in the right ear three times per day." Which steps should the nurse take to administer this medication? Select all that apply:

• Wash her hands and arrange supplies at the bedside. • Warm the medication to body temperature. • Examine the ear canal for drainage. Explanation: The nurse should prepare to instill the eardrops by washing her hands, gathering the supplies, and arranging the supplies at the bedside. To avoid adverse effects resulting from eardrops that are too cold (such as vertigo, nausea, and pain), the medication should be warmed to body temperature in a bowl of warm water. Temperature of the drops should be tested by placing a drop on the wrist. Before instilling the drops, the ear canal should be examined for drainage that may reduce the medication's effectiveness. Because the dose is to be given in the right ear, the child should be placed on his left side with his right ear facing up. For an infant or a child younger than age 3, gently pull the auricle down and back because the ear canal is straighter in children of this age-group.

The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication of this condition?

Bone fracture Explanation: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause — not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

pleural friction rub

creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together, evident during inspiration, expiration, or both and no change with coughing; usually uncomfortable, especially on deep inspiration.

A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate?

"We've found that babies can't digest solid food properly until they're 4 months old." Explanation: Infants younger than 4 months lack the enzymes needed to digest complex carbohydrates. Option 1 doesn't address the grandmother's question directly. Option 2 is a cliché that may block further communication with the grandmother. Option 4 is incorrect because no evidence suggests that introducing solid food early causes eating disorders.

The nurse is teaching a group of adolescents about automobile safety. Which is the most effective teaching method for this age-group?

Coordinating a panel of peers who were involved in motor vehicle accidents Explanation: Coordinating a panel of peers to discuss motor vehicle accidents and their prevention is more effective for this age-group. Adolescents are more likely to listen to others their age who have experienced similar circumstances. Lecturing about the effects of drugs and alcohol on driving will most likely be ineffective for this age-group. Adolescents won't be motivated to read the written materials. Animated videos aren't age-appropriate and may minimize the importance of the material.

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate?

Providing small, frequent meals Explanation: Clients with ulcerative colitis, also known as inflammatory bowel syndrome, tolerate small, frequent meals better than a few large meals daily. Eating large amounts of food may exacerbate the abdominal distention, cramps, and nausea typically caused by ulcerative colitis. Frequent meals also provide the additional calories needed to restore nutritional balance. This client doesn't lack digestive enzymes and therefore doesn't need enzyme supplementation. Antibiotics are contraindicated because they may interfere with the actions of other prescribed drugs and because ulcerative colitis isn't caused by bacteria. High-fiber foods may irritate the bowel further.

Which nursing objective is most important when working with neonates who are suspected of having congenital hypothyroidism?

Early identification Explanation: The most important nursing objective is early identification of the disorder. Nurses caring for neonates must be certain that screening is performed, especially in neonates who are preterm, discharged early, or born at home. Promoting bonding, allowing rooming in, and encouraging fluid intake are all important but are less important than early identification.

The nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which of the following observations indicates that teaching has been effective?

The child eats finger foods by himself. Explanation: The child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to feed himself. Because spasticity affects coordinated chewing and swallowing as well as the ability to bring food to the mouth, it's difficult for the child with cerebral palsy to eat neatly. Independence in eating should take precedence over neatness. The child with cerebral palsy may require more time to bring food to the mouth; thus, chewing and swallowing shouldn't be rushed to finish a meal by a specified time. The child with cerebral palsy may vomit after eating due to a hyperactive gag reflex. Therefore, the child should remain in an upright position after eating to prevent aspiration and choking.

A mother reports that her 6-year-old girl recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A diagnosis of a urinary tract infection (UTI) is made, and the child is prescribed antibiotics. Which interven-tions are appropriate? Select all that apply:

• Assess the mother's understanding of UTI and its causes • Instruct the mother to administer the antibiotic as prescribed—even if the symptoms diminish • Discourage taking bubble baths Explanation: Assessing the mother's understanding of UTI and its causes provides the nurse with a baseline for teaching. The full course of antibiotics must be given to eradicate the organism and prevent recurrence, even if the child's signs and symptoms de-crease. Bubble baths can irritate the vulva and urethra and contribute to the development of a UTI. Fluids should be encouraged, not limited, in order to prevent urinary stasis and help flush the organism out of the urinary tract. Instructions should be given to the child at her level of understanding to help her better understand the treatment and promote compliance. The child should wipe from the front to the back, not back to front, to minimize the risk of contamination after elimination.

A 3-year-old client is admitted to the pediatric unit with pneumonia. He has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the toddler hasn't been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should be included by the nurse in the care plan? Select all that apply:

• Perform chest physiotherapy as ordered. • Encourage coughing and deep breathing. • Perform postural drainage. • Maintain humidification with a cool mist humidifier. Explanation: Chest physiotherapy and postural drainage work together to break up congestion and then drain secretions. Coughing and deep breathing are also effective to remove congestion. A cool mist humidifier helps loosen thick mucous and relax airway passages. Fluids should be encouraged, not restricted. The child should be placed in semi-Fowler's to high Fowler's position to facilitate breathing and promote optimal lung expansion.

The nurse is collecting data on whether the client has received all recommended immunizations for his age. Which immunizations should he have received between ages 4 and 6?

Diphtheria, tetanus, and acellular pertussis (DTaP), MMR, inactivated polio virus (IPV), and pneumococcal vaccine Explanation: Between ages 4 and 6 the child should receive DTaP, MMR, IPV, and Varicella vaccine. Hepatitis A is completed by age 2yrs. MMR alone is incomplete. H. influenzae, type B immunization is completed by age 15 months.

A 14-year-old female client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

Identity Explanation: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. When an adolescent is hospitalized, she is separated from her peer group and body image may be altered. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.