Preschooler

While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child's left thigh is swollen. What should the nurse do next? Determine the circulatory status of the upper thigh. Obtain the child's vital signs. Assess the neurologic status of the toes. Notify the health care provider (HCP) immediately.

Assess the neurologic status of the toes. Because the nurse suspects a possible fracture based on the child's presentation, assessing the neurologic and circulatory status of the toes, the tissues distal to the fracture, is important. Soft tissue contusions, which accompany femur fractures, can result in severe hemorrhage into the tissue and subsequent circulatory and neurologic impairment. Once this information has been obtained, vital signs can be assessed, and the nurse can notify the HCP and report the findings. In fractures, circulation impairment will occur distal to the injury.

The nurse is caring for a young child on the oncology unit who has developed thrombocytopenia after cancer treatment. What is the priority action for the nurse to implement when caring for this client? Ensure a safe environment. Plan for extra nap times. Assess for signs of infection. Encourage high-protein foods.

Ensure a safe environment. Providing a safe environment protects the child from injury. This is important because the child is at risk for bleeding due to the thrombocytopenia. The other options are important for a child with cancer, but are not the priority in relation to thrombocytopenia.

The nurse is caring for a child with an acute exacerbation of asthma. Oral methylprednisolone has been ordered. Which of the following actions is most important for the nurse to take when administering this medication? Give the medication with food. Give the medication at bedtime. Give the medication 2 hours before meals. Do not give other medications with methylprednisolone.

Give the medication with food. Giving the medication with food helps reduce gastric irritation. Oral doses of corticosteroids should be given in the morning.

A 4-year-old has just returned from surgery. The child has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first? Encourage the parent to calm the child down. Immediately give the child an antiemetic I.V. Irrigate the NG tube to ensure patency. Notify the physician because the child has an NG tube.

Irrigate the NG tube to ensure patency. The nurse should first irrigate the NG tube because if the tube isn't draining properly or is kinked, the child will experience nausea. There's no reason to notify the physician immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn't really address the problem. Encouraging the parent to calm the child is always a good intervention but isn't the first thing to do in this case.

A 3-year-old client is admitted to the pediatric unit with pneumonia. The child has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the child has not been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should the nurse include in the care plan? Select all that apply. Maintain humidification with a cool mist humidifier. Keep the head of the bed flat. Limit fluid intake. Perform chest physiotherapy as ordered. Encourage coughing and deep breathing. Perform postural drainage.

Perform chest physiotherapy as ordered. Encourage coughing and deep breathing. Perform postural drainage. Maintain humidification with a cool mist humidifier. 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 limited. The child should be placed in semi-Fowler's to high Fowler's position to facilitate breathing and promote optimal lung expansion.

A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth? Up to 20 Up to 32 Up to 15 Up to 10

Up to 20 A child may have up to 20 deciduous teeth by age 5. The first tooth usually erupts by age 6 months; the last, by age 30 months. Deciduous teeth usually are shed between ages 6 and 13.

A child is receiving peritoneal dialysis to treat renal failure. To detect early signs of peritonitis, the nurse should stay alert for headache. abdominal tenderness. redness at the catheter site. abdominal fullness.

abdominal tenderness. The nurse should stay alert for abdominal tenderness because it's an early sign of peritonitis. Redness at the catheter site indicates a skin infection. Abdominal fullness is expected during dialysate infusion. Headache isn't associated with peritonitis.

When instilling ear drops on a 2-year-old child, the nurse should pull the pinna in which directions? up and forward down and back up and back down and slightly forward

down and back When instilling ear drops on child younger than age 3 years, the nurse should pull the pinna down and back. This helps open the ear canal to ensure drops reach the tympanic membrane. For an older child, the nurse should pull the pinna up and back.

A preschool child is admitted to the pediatric unit with acute nephritis. Which electrolyte replacement agent is used as an adjunct to treatment for this condition? calcium glubionate sodium lactate potassium chloride magnesium sulfate

magnesium sulfate Magnesium sulfate is an electrolyte that's used as an adjunct to treat acute nephritis. It also is used to treat seizures and severe toxemia. Calcium glubionate, potassium chloride, and sodium lactate are not therapeutic in acute nephritis and, in fact, may worsen the condition.

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is skin traction applied to an extended lower extremity. skeletal traction applied to a lower extremity. skin traction applied to a lower extremity, with the extremity suspended above the bed. skin traction applied bilaterally to the lower extremities.

skin traction applied to a lower extremity, with the extremity suspended above the bed. Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction.

A critically ill 4-year-old child is in the pediatric intensive care unit. Telemetry monitoring reveals junctional tachycardia. Identify where this arrhythmia originates.

In junctional tachycardia, the atrioventricular node fires rapidly. The atria are depolarized by retrograde conduction; however, conduction through the ventricles remains normal.

A nurse must administer an oral medication to a 3-year-old child. The best way for the nurse to proceed is by saying "It's time for you to take your medicine right now." "If you take your medicine now, you'll go home sooner." "Here is your medicine. Would you like apple juice or grape drink after?" "See how Jimmy took his medicine? He's a good boy. Now it's your turn."

"Here is your medicine. Would you like apple juice or grape drink after?" Asking the child if he would like apple juice or grape drink is the best approach because involving the child promotes cooperation, and permitting the child to make choices provides a sense of control. Telling a child to take the medicine "right now" could provoke a negative response. Promising that the child will go home sooner could decrease the child's trust in nurses and physicians. Telling the child to "see how Jimmy took his medicine" is inappropriate because it compares one child with another and doesn't encourage cooperation.

The parents of a preschooler are refusing a blood transfusion to treat severe hypovolemia because they are Jehovah's Witnesses. The parents are aware of the potential consequences of refusing the treatment. What is the priority nursing intervention at this time? Ask the parents to explain the reason for the refusal of the treatment. Provide additional teaching regarding the safety of blood transfusions. Ask the healthcare provider about alternative treatments to blood transfusion. Notify the hospital ethics committee to overrule the parents' decision.

Ask the healthcare provider about alternative treatments to blood transfusion. Jehovah's Witnesses believe that a blood transfusion is the same as oral intake of blood, which they regard as a sin. The nurse caring for the child should seek alternative therapies. Jehovah's Witnesses will accept fluid replacement, biomedical hemostats, and medications or surgical interventions to stop the bleeding causing the hypovolemia. The reason for the refusal is not related to the safety of the therapy, therefore it is inappropriate to provide teaching in this regard. It is not appropriate for the nurse to call the ethics committee, because the parents are acting in what they consider to be their child's best interest, and their religious decisions are supported by law. Nurses should be aware of the religious beliefs of a Jehovah's Witness and should not require an explanation of the refusal of treatment.

The nurse teaches appropriate care measures to the parents of a 5-year-old child who has been given trimethoprim/sulfamethoxazole for a urinary tract infection. What directives should be included in the teaching plan? Select all that apply. Administer medication with milk or food. Keep medication out of the sunlight. Report any rash. Use a sunscreen. Keep the child well hydrated.

Use a sunscreen. Report any rash. Keep medication out of the sunlight. Keep the child well hydrated. The child receiving trimethoprim/sulfamethoxazole should wear sunscreen daily while on the medication, and the medication must be kept out of direct sunlight. (It comes in a dark bottle.) Children with a urinary tract infection should drink lots of fluids to help flush the organisms from the bladder. The medication does need to be taken with milk or food. Trimethoprim/sulfamethoxazole has been associated with Steven-Johnson syndrome, so any rash requires prompt attention.

When assessing a child for impetigo, the nurse expects which assessment findings? linear, threadlike burrows honey-colored, crusted lesions circular lesions that clear centrally small, brown, benign lesions

honey-colored, crusted lesions In impetigo, honey-colored, crusted lesions develop once the pustules rupture. Small, brown, benign lesions are common in children with warts. Linear, threadlike burrows are typical in a child with scabies. Circular lesions that clear centrally characterize tinea corporis.

The nurse is caring for a child with a new diagnosis of diabetes. The nurse teaches blood glucose monitoring by allowing the child to practice checking the blood sugar of a toy bear dressed in a hospital gown. The nurse recognizes this approach to be appropriate for what age level? toddler (1 to 3 years) adolescence (10 to 19 years) preschool age (3 to 5 years) school age (5 to 10 years)

preschool age (3 to 5 years) Children in the preschool age-group have a rich fantasy life. Combined with their strong concept of self, fantasy play, and participation in care can minimize the trauma of being hospitalized. Adolescents should be allowed choices and control. School-age children are modest and need to have their privacy respected. Procedures should be explained to them. Toddlers should be examined in the presence of their parents because they fear separation. Allow choices when possible.

The mother asks the nurse why peanuts are one of the worst things a child can aspirate. What should the nurse include in the explanation as the main reason for the problem associated with aspirating peanuts? They swell when wet. They decompose when wet. They contain a fixed oil. They contain sodium.

They swell when wet. Peanuts swell and become soft when moistened with bronchial secretions, making them difficult to remove. Although peanuts contain a fixed oil that can cause lipoid pneumonia, begin to decompose when wet, and contain sodium, these factors do not make them particularly dangerous when aspirated.

Which finding is expected when the nurse is assessing a child who has sustained full-thickness burns? blanching to the touch excessive bleeding minimal pain blistering and a moist appearance

minimal pain Full-thickness burns are serious injuries in which all the skin layers are destroyed. Lack of pain is characteristic of full-thickness burns.With full-thickness burns, blanching and bleeding are absent because blood supply is destroyed.Blisters and a moist appearance characterize partial-thickness burns.

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the health care provider immediately? foul odor from the mouth moderate intercostal retractions irregular respirations while awake mouth breathing

moderate intercostal retractions Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician. Mouth breathing and a foul odor from the mouth aren't cause for concern. Irregular respirations while awake are not an unusual finding in a young child.

A hospitalized 5-year-old is pulseless, and after verifying the child is not breathing, the nurse begins chest compressions. Where should the nurse apply pressure? over the apex of the heart with the heel of one hand midway on the sternum with the tips of two fingers on the lower sternum with the heel of one hand on the upper sternum with the heels of both hands

on the lower sternum with the heel of one hand The chest is compressed with the heel of one hand positioned on the lower sternum, two fingerbreadths above the sternal notch (at the nipple line). Fingertips are used to compress the sternum in infants, and the heels of both hands are used in adult cardiopulmonary resuscitation.

A nurse is obtaining the history of a child, age 4. Which question best evaluates the child's developmental status? "Do you like your brother?" "What's your mommy's first name?" "Can you ride a tricycle?" "Can you draw your school?"

"Can you ride a tricycle?" Asking the child if he can ride a tricycle best helps evaluate the child's developmental status because a 4-year-old child should be able to perform such an action. A child may draw stick-like figures, but wouldn't be able to draw complicated pictures such as a school. A 4-year-old child may not be aware of his feelings, so asking whether he likes his brother wouldn't be appropriate. A 4-year-old child may not know his mother's first name, so asking it wouldn't evaluate developmental status.

A 3-year-old child of Vietnamese descent with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On examination, the nurse discovers red, round, welt-like lesions on the child's upper back and chest. Which question should the nurse ask next? "Are you aware of any child abuse?" "Has your child been exposed to shingles?" "Does your child have any allergies?" "Can you tell me about any cultural practices in your family?"

"Can you tell me about any cultural practices in your family?" The nurse should consider that the lesions may be caused by cultural practice. Many Vietnamese people perform coining, a cultural practice in which a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of a disease. Coining can produce welt-like lesions on the child's back or chest, and children subjected to the practice are commonly thought to have been abused. Interviewing the family and assessing its cultural background can help distinguish between abuse and culture practice. Shingles, a form of herpes zoster, is a communicable disease usually affecting immunocompromised individuals and older adults. The disease produces small crusty pustules on the lower back and trunk. The description of the lesions doesn't fit those produced by an allergic reaction.

A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. What would be the nurse's best response? "I can imagine how hard this is for you, but it's not what is best for the child." "I can't let you do this without calling your health care provider (HCP) first." "Can you tell me why you want to take your child home now?" "I know how you feel, but the medication will make your child feel better."

"Can you tell me why you want to take your child home now?" With a parent who is visibly upset, it is best to try to determine the cause. Therefore, asking the mother about why she wants to take the child home can provide insight into the problem. The nurse cannot stop the mother from taking her child home. However, the HCP should be notified about the mother's decision and efforts are needed to explain the ramifications of taking the child home. It is inappropriate for the nurse to say "I know how you feel" or "I can imagine how hard this is" unless the nurse has had the same experience.

A nurse is planning care with a family of a 4-year-old in preschool who is often disruptive in class, is difficult to engage, and rarely speaks. The child flaps his arms and screeches when he is upset. What would be the most appropriate responses for the nurse to make to the parents? Select all that apply. "Has your child been evaluated by a pediatrician? He seems to have some behaviors that are abnormal for a child of his age." "Has your child received all his childhood immunizations? You know there is evidence that childhood immunizations play a role in the development of autism." "Have you considered private school? This environment does not seem right for your child." "How do you respond if he disobeys or acts out at home? If your techniques help, stop, or prevent negative behavior, perhaps the teachers can try similar measures at school." "How does your child behave at home? If you do not see acting out behavior at home, part of his problem may be dealing with new situations such as school."

"Has your child been evaluated by a pediatrician? He seems to have some behaviors that are abnormal for a child of his age." "How does your child behave at home? If you do not see acting out behavior at home, part of his problem may be dealing with new situations such as school." "How do you respond if he disobeys or acts out at home? If your techniques help, stop, or prevent negative behavior, perhaps the teachers can try similar measures at school." The child's behavior appears to fit the criteria for autism, but suggesting the child's immunizations are causative is inaccurate according to recent research and dangerous regarding possibly convincing the mother to forego future immunizations. A better approach would be to suggest a full evaluation by a primary care provider, especially since symptoms could result from other illnesses or conditions. Inquiring about the child's behavior at home and the mother's discipline techniques would give the nurse a better idea of the home environment and could help determine whether this is a problem confined to the school setting or one that also occurs at home. Asking for the mother's input regarding discipline demonstrates a desire to involve her in problem solving. Suggesting a different school without a full evaluation does not address the problem.

The nurse is informing the parents of a 5-year-old with a congenital heart defect what actions are necessary if the child experiences cardiopulmonary arrest. Which statements by the parents indicate that the teaching has been understood? Select all that apply. "I'll give two breaths for every 30 compressions." "I'll check for responsiveness before starting CPR." "It's uncommon for a 5-year-old to need CPR." "I have to use compressions to circulate the blood." "I'll call 911 before I start resuscitation efforts."

"I have to use compressions to circulate the blood." "I'll give two breaths for every 30 compressions." "I'll check for responsiveness before starting CPR." Performing CPR for the child who is experiencing cardiac arrest includes checking responsiveness before beginning CPR, giving 2 breaths for every 30 compressions, and performing compressions to circulate blood. For children, CPR is initiated before calling 911. While cardiac arrest may be uncommon in most 5-year-olds, children with any kind of heart disease are at high risk for cardiopulmonary arrest, and the parents should be prepared for this possibility.

A 5-year-old child asks the nurse if it will hurt to have his tonsils and adenoids taken out. Which response by the nurse would be best? "It won't hurt because we put you to sleep." "It will hurt because of the incisions made in the throat." "It won't hurt because you are such a big boy." "It will hurt, but we have medicine to help you feel better."

"It will hurt, but we have medicine to help you feel better." Preschool-aged children are fearful of physical injury. Truthful but simple explanations will minimize distorted fears and reduce anxiety.Telling the child that it will not hurt is inappropriate, not truthful, and can possibly lead to mistrust.Additionally, stating that the child is a "big boy" may deter the child from reporting pain for fear of being labeled a "baby."A detailed explanation may be beyond the child's understanding and add to his fears. Using the term incision is inappropriate because the child probably will not understand what this term means.

A nurse suspects that a child, age 4, is being neglected. Which question should the nurse ask the parents to best assess the child's nutritional status? "Do you think your child eats enough?" "What did your child eat for breakfast?" "Has your child always been so thin?" "Is your child a picky eater?"

"What did your child eat for breakfast?" The nurse should ask what the child ate for breakfast in order to obtain objective information about the child's nutritional intake. Asking if the child has always been so thin, is a picky eater, or eats enough would elicit subjective replies that would be open to interpretation.

The parent of a preschool-age child tells the nurse that the child is hyperactive and something needs to be done. Which response by the nurse would be most appropriate initially? "What makes you think your child is hyperactive?" "What do you think needs to be done?" "How does your child behave normally?" "Does the preschool teacher think your child is hyperactive?"

"What makes you think your child is hyperactive?" The best approach by the nurse is to determine why the parent thinks the child is hyperactive. Some children are very active but do not have the necessary defining characteristics of hyperactivity. Asking what the parent thinks needs to be done, how the child behaves normally, and if the preschool teacher thinks the child is hyperactive would be an appropriate follow-up question once more information is gathered from the parent to determine whether the child indeed is hyperactive.

A 5-year-old child has been placed on phenytoin for tonic-clonic seizures. The child weighs 42 lb (19.1 kg), and the maintenance dose prescribed for this child is 7.5 mg/kg/day. How many milligrams should the child receive each day? Record your answer using a whole number.

143 Determine the dose by multiplying the child's weight by the dose ordered:19.1 kg x 7.5 mg = 143 mg/day.

A 44-lb (20-kg) preschooler is being treated for inflammation. The physician orders 0.2 mg/kg/day of dexamethasone by mouth to be administered every 6 hours. The elixir comes in a strength of 0.5 mg/5 ml. How many teaspoons of dexamethasone should the nurse give this client per dose? Record your answer using a whole number.

2 To perform this dosage calculation, the nurse should calculate the total daily dose for the child:20 kg × 0.2 mg/kg/day = 4 mgNext, the nurse should calculate the amount to be given at each dose:4 mg ÷ 4 doses = 1 mg/doseThe available elixir contains 0.5 mg of drug per 5 ml (which is equal to 1 teaspoon). Therefore, to give 1 mg of the drug, the nurse should administer 2 teaspoons (10 ml) to the child for each dose.

A 4-year-old child is ordered to receive 25 mL/hour of intravenous solution. The nurse is using a pediatric microdrip (60 gtt/mL) chamber to administer the medication. For how many drops per minute would the microdrip chamber be set? Record your answer using a whole number.

25 When using a pediatric microdrip chamber (60 gtt/mL), the number of milliliters per hour equals the number of drops per minute. If 25 mL/hour is ordered, the solution should infuse at 25 drops/minute. Thus, if the drip factor on a microdrip tubing is 60 and the infusion time is 60 minutes, these cancel and the answer is the volume (ml).

A 5-year-old child who weighs 44 lb (20 kg) is given penicillin V suspension for a throat culture positive for streptococcus. The dose is 40 mg/kg/day, divided into two doses. The pharmacy supplies penicillin V in a concentration of 250 mg/5 mL. The nurse should administer how many milliliters for each dose? Record your answer using a whole number.

8 Determine the dosage for 1 day:40 mg/kg/day x 20 kg = 800 mg/day or 400 mg/dose.Determine the volume for the dose:250 mg/5 mL = 400 mg/x.Cross multiply and solve for x:250x = 2000 mL.x = 8 mL.

A nurse is caring preoperatively for a preschooler scheduled for a Wilms' tumor removal. When explaining the location of the tumor to the parents, identify the area of the urinary system impacted.

A Wilms' tumor, also known as a nephroblastoma, is a tumor located on the kidney. The most common intra-abdominal tumor in children, Wilms' tumor usually affects children ages 6 months to 4 years and favors the left kidney.

A school nurse is conducting a seminar for parents of preschool children on the prevention of head injuries. What is the most appropriate information for the nurse to give the parents? Safety gates should be installed at staircases at home. Children should always be supervised by an adult when playing. Children should be accompanied by an adult when crossing the street. Children should always wear helmets when riding bicycles.

Children should always wear helmets when riding bicycles. The most significant way to prevent a head injury in young children is to have them wear a helmet while riding a bike. Safety gates at staircases are most important for preventing head injuries in infants. Although it is important to supervise preschool children when playing, supervision does not prevent a head injury. Accompanying children when crossing the street is important, but it would be more important to teach a child to look both ways before crossing. Most head injuries can be prevented through the use of helmets, therefore this is the most important information to teach.

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome (see exhibit). What action should the nurse take? Discontinue the prednisolone 40 mg, and give the 30-mg dose today. Contact the prescriber for clarification. Start the 30-mg dose tomorrow. Check the medication record first to see when the last dose of prednisolone was given.

Contact the prescriber for clarification. There are many problems with this medication prescription. The abbreviation QOD is ambiguous and open to various interpretations. The abbreviation D/C may be interpreted as "discontinue" or "discharge." The prescriber should have specifically stated when to start the lower dose because the nurse could reason beginning the medication that day, the next, or even the day after that. The only safe thing to do is call for clarificatio

The nurse is interviewing a pediatric client and family in a clinic after the client had a fever at home. The parent said she gave the client one adult acetaminophen earlier in the day because she ran out of children's acetaminophen. What is the nurse's next action? Select all that apply. Inform the healthcare provider of the acetaminophen dose. Continue to complete the physical assessment of the client. Document that the parent administered adult acetaminophen. Teach the parent not to use adult medications with children. Report the parent to the state welfare agency.

Continue to complete the physical assessment of the client. Inform the healthcare provider of the acetaminophen dose. Teach the parent not to use adult medications with children. Document that the parent administered adult acetaminophen. Children respond differently than adults to medications so adult medications should not be given to children. The nurse must communicate the use of adult acetaminophen to the healthcare providers and document the findings. The nurse should continue to complete the assessment for more data. The action of the administering acetaminophen is not abuse and does not need to be reported.

A child with hemophilia is brought to the clinic with spontaneous soft tissue bleeding of the right knee. Immediately on the child's arrival, what should the nurse do? Obtain a type and cross-match for platelets. Elevate the right knee. Administer aspirin for discomfort. Immobilize the knee in a dependent position.

Elevate the right knee. The goal is to decrease the bleeding. This can be aided by decreasing circulation to the area. Elevating the part and applying cold decreases circulation to the area. The child will also receive cryoprecipitate.Aspirin is contraindicated for a child with a bleeding disorder because it increases capillary fragility.The dependent position will increase bleeding and swelling, and the goal is to decrease bleeding.Lack of clotting factors, not lack of platelets, is the problem in children with hemophilia.

Which nursing action would be most successful in gaining a preschooler's cooperation in preparing for surgery? Have the child remove their own underwear. Encourage the child to use the hospital blanket as a transition object to make the child feel more secure. Let the child choose which parent can accompany the child to the preoperative waiting area. Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.

Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon. Giving the child a choice would promote cooperation, and children commonly prefer a nonthreatening method of travel such as a wagon. Having the child take off their own underwear isn't appropriate, because preschoolers commonly have a fear of genital mutilation; the child would likely resist removing underwear. Children usually won't transfer feelings of security from personal objects to another object such as a hospital blanket. Both parents are encouraged to accompany the child to the preoperative area, so having the child choose one parent isn't appropriate.

The mother of a 4-year-old child is concerned about her child's masturbating. What should the nurse tell the mother? The child needs counseling for the abnormal behavior. Masturbation is normal in children of this age. The child is expressing some unmet needs. Masturbation at this age provides sexual release.

Masturbation is normal in children of this age. Most boys and girls masturbate, most commonly at about 4 years of age and then again during adolescence.Masturbation is not abnormal behavior. Masturbation at this age is part of sensual exploration and curiosity about the body. A 4-year-old's masturbation does not express unmet needs or release sexual tension. Parents need to ensure privacy for the child.

A preschool child immobilized in a hip spica cast has trouble breathing after meals. Which action would be best? Give the child a laxative after meals. Teach the child pursed-lip breathing. Encourage the child to drink more between meals. Offer the child small feedings several times a day.

Offer the child small feedings several times a day. A hip spica cast extends up over the abdomen. Because the abdomen is in a fixed space, abdominal distention secondary to eating pushes the abdominal contents against the diaphragm, resulting in decreased chest expansion and subsequent possible respiratory distress. The child's problems are associated with meals, so offering small, frequent meals provides nutritional support while minimizing distention.Encouraging increased drinking would increase abdominal distention, thus increasing the child's respiratory distress.Pursed-lip breathing would prevent air trapping, not decreased chest expansion..Administering a laxative with meals would not relieve the decreased chest expansion.

While assessing a child experiencing respiratory distress, the nurse notes subcostal retractions. Which graphic highlights the area where subcostal retractions are seen?

Subcostal retractions are retractions seen below the lower costal margin of the rib cage. Option B highlights the area where subcostal retractions are seen. Option A shows the areas where intercostal retractions would be seen. Option C shows the area for suprasternal retraction. Option D shows the areas for clavicular retractions.

The mother of a toddler tells the nurse her child is "fussy" and not as "easygoing" as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. What instructions should the nurse should give the mother? Give the child finger foods and let him eat when he wants. Allow the child to determine when feeding should occur. Do not to feed the child if he cries. Provide structured feeding times and routines.

Provide structured feeding times and routines. Each child has unique temperaments and energy levels, and parents must adapt parenting strategies for each child. Children who are easily upset do better in structured environments where they can learn what to expect. Easy-going children can manage flexible feeding times. Not feeding the child when he cries will not promote nutrition and does not provide the structure that will help the child learn appropriate eating behaviors. Children who are very active and always "on the go" respond well to eating food that can be carried in their hand, and eating more frequently.

A nurse is completing a screening tool on a 4½-year-old child. To be consistent with others at this age, what behaviors would the nurse expect the child to demonstrate? Select all that apply. The child balances on each foot for at least 6 seconds. The child is able to follow one basic instruction through completion. The child draws a person with at least three body parts. The child copies a circle that is closed or very nearly closed. The child speaks clearly.

The child copies a circle that is closed or very nearly closed. The child speaks clearly. The child draws a person with at least three body parts. The child is able to follow one basic instruction through completion. By age 4½, a child would be able to copy a circle, speak clearly, and draw a person with at least three body parts. If given an appropriate task, the child is able to follow an instruction through completion. The majority of children do not achieve balancing on each foot for 6 seconds until about age 5½.

For a 3-year-old child with tracheobronchitis, the nurse formulates a nursing diagnosis of ineffective airway clearance related to stasis of secretions. After implementing interventions, what does the nurse indicate as the most desired outcome? The child exhibits decreased anxiety. The child exhibits an arterial oxygen saturation of 92%. The child exhibits clear breath sounds. The child exhibits a respiratory rate of 36 breaths per minute.

The child exhibits clear breath sounds. The nurse should expect clear breath sounds because this outcome indicates an improved respiratory status and airway clearance. A respiratory rate of 36 breaths per minute supports a nursing diagnosis of ineffective breathing pattern. An arterial oxygen saturation of 92% supports a nursing diagnosis of impaired gas exchange, and a decrease in anxiety supports the nursing diagnosis of anxiety.

A nurse realizes she is 1 hour and 30 minutes late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next? No further action is necessary. The nurse should notify the physician of the error. The nurse should follow facility procedures for reporting an error. The nurse should document a medication error in the client's chart.

The nurse should follow facility procedures for reporting an error. Although no harm came to the child, this scenario is an example of a medication error. The nurse should follow the facility's procedure for reporting the error because it allows the facility to adequately assess the causes of medication errors, and isn't meant to place blame on any one person. The nurse in this instance doesn't need to notify the physician because there was no harm to the child. Also, the nurse shouldn't document that an error took place in the child's chart; doing so may place the nurse at risk in the event of a lawsuit.

The nurse is observing the parents of a 4-year-old child who has been admitted to the hospital. Which of the following actions indicate that the parents understand how to best minimize anxiety during their child's hospitalization? Select all that apply. The parents bring the child's favorite toy to the hospital. The parents punish the child if the child is not cooperative. The parents explain all procedures to the child in great detail. The parents remain at the child's side during the hospitalization. The parents bring the child's siblings for a brief visit. The parents leave the room when the child undergoes a painful procedure.

The parents bring the child's favorite toy to the hospital. The parents remain at the child's side during the hospitalization. The parents bring the child's siblings for a brief visit. The most effective means of minimizing the child's anxiety during hospitalization is to have the parents stay. Having a familiar toy helps the child to deal with the anxiety of unfamiliar surroundings. Sibling visitation can also help to ease the child's anxiety. Explaining a procedure to a young child in great detail only maximizes fear. Parents can be effective in calming and comforting a child during painful procedures, so they should remain in the room. Rewards, not punishment, should be offered to a preschooler.

Parents of a preschool-age child ask the nurse about nutrition. Which statement about a preschooler's nutritional requirements is accurate? Caloric requirements per kilogram of body weight increase slightly during the preschool-age period. The quality of food that a preschooler consumes is more important than the quantity. Protein should account for 25% of the preschooler's total caloric intake. The preschooler's nutritional requirements differ greatly from those of a toddler.

The quality of food that a preschooler consumes is more important than the quantity. Stating that food quality is more important than quantity is most accurate because a high caloric intake may include many empty calories. The preschooler's caloric requirement is slightly lower than the toddler's. Overall, however, the preschooler's nutritional requirements are similar to a toddler's. The preschooler requires 1.5 g/kg of protein daily, satisfied by two meat servings, three milk servings, four bread servings, and four fruit and vegetable servings.

The nurse is instructing a 4-year-old child about an upcoming procedure. What approach should the nurse employ during teaching? Use simple terms. Include colorful details. Offer a toy to keep the child happy. Speak gently and use a high-pitched voice.

Use simple terms. When explaining a procedure to a 4-year-old child, the nurse must use simple terms that the child can understand. Speaking gently may ease the child, but this is not most important. Distracting the child with a toy is more appropriate during the procedure than before it. Because preschoolers have a limited attention span, the nurse should provide only the necessary, basic facts — not colorful details — to prevent anxiety.

A client with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the client's history, the nurse considers which information to be most important? lack of interest in food a recent episode of pharyngitis vomiting for 2 days a fever that started 3 days ago

a recent episode of pharyngitis A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the client may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.

A child is diagnosed with Wilms' tumor. During assessment, the nurse expects to detect an abdominal mass. gross hematuria. nausea and vomiting. dysuria.

an abdominal mass. The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Gross hematuria is uncommon, although microscopic hematuria may be present. Dysuria isn't associated with Wilms' tumor. Nausea and vomiting are rare in children with Wilms' tumor.

A 4-year-old, 40-lb (18.1-kg) child is brought to the pediatrician's office. The child has upper respiratory symptoms and has had a fever for 2 days. The health care provider diagnoses a viral illness, and the parent is instructed to treat the child with rest, fluids, and antipyretics. The nurse is reviewing the orders and questions which of the following instructions? acetaminophen 181 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 181 mg (10 mg/kg/dose) q6h for temperature higher than 102.5° F (39.2° C) aspirin 294 mg (65 mg/kg/24 hours) q6h with intermittent doses of acetaminophen 217 mg q4h acetaminophen 235 mg (10 to 15 mg/kg/dose) q4h for a temperature lower than 102.5° F (39.2° C) acetaminophen 253 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 181 mg (10 mg/kg/dose) q6h for a temperature higher than 102.5° F (39.2° C)

aspirin 294 mg (65 mg/kg/24 hours) q6h with intermittent doses of acetaminophen 217 mg q4h The correct dosage schedule for acetaminophen is 10 to 15 mg/kg/dose every 4 hours, and for ibuprofen it's 10 mg/kg/dose every 6 hours for a temperature higher than 102.5°F (39.2°C). Aspirin shouldn't be given to children because of the association between aspirin use in children with influenza virus or chickenpox and Reye's syndrome (a life-threatening condition characterized by vomiting and lethargy that may progress to delirium and coma).

A preschool-aged child with suspected epiglottitis is emitting no sounds during inhalation attempts and begins drooling. What is the nurse's priority action? administering oxygen by face mask administering parenteral antibiotics assisting with tracheotomy monitoring the electrocardiogram for arrhythmias

assisting with tracheotomy The child is showing signs of total airway obstruction, so the nurse should immediately prepare to assist with emergency tracheotomy. Supplemental oxygen is required with epiglottitis, but administration by mask or other external device will not be successful once obstruction progresses to this point. The child does need parenteral antibiotics; however, the priority is airway management. The most common rhythm in this client is sinus tachycardia related to compensation. However, monitoring for arrhythmias isn't a priority over airway management.

When assessing a child's cultural background, the nurse should keep in mind that heritage dictates a group's shared values. cultural background usually has little bearing on a family's health practices. physical characteristics mark the child as part of a particular culture. behavioral patterns are passed from one generation to the next.

behavioral patterns are passed from one generation to the next. The nurse should keep in mind that a family's behavioral patterns and values are passed from one generation to the next. Cultural background commonly plays a major role in determining a family's health practices. Physical characteristics don't indicate a child's culture. Although heritage plays a role in culture, it doesn't dictate a group's shared values, and its effect on culture is weaker than that of behavioral patterns.

The nurse teaches a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot. Which teaching and learning principles should the nurse address first? arranging to use actual equipment for demonstrations building the teaching on the child's current level of knowledge presenting the information in order from simplest to most complex organizing information to be taught in a logical sequence

building the teaching on the child's current level of knowledge Before developing any teaching program for a child, the nurse's first step is to assess the child to determine what is already known. Most older preschool children have some understanding of a condition present since birth. However, the child's interest will soon be lost if familiar material is repeated too often. The nurse can then organize the information in a sequence because there are several steps to be demonstrated. These exercises do not require the use of equipment. The nurse should judge the amount and complexity of the information to be provided based on the child's current knowledge and response to teaching.

A nurse is preparing immunizations for a child being treated for leukemia. Which immunization will the nurse hold at this time? chickenpox hepatitis A Haemophilus influenzae B (Hib) tetanus

chickenpox A child being treated for leukemia is at risk for having a weakened immune system and should not receive attenuated (weakened) live virus vaccines such as chickenpox, rotavirus, influenza nasal mist, or measles, mumps, and rubella. Administering these vaccines in a person with a weakened immune system may result in illness. Tetanus vaccine is a detoxified toxoid and cannot cause disease. Hepatitis A vaccine is an inactivated (killed) virus and cannot cause disease. Haemophilus influenzae B is a conjugate vaccine consisting of proteins, not virus, and cannot cause disease.

A client is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the client has coarctation of the aorta. truncus arteriosus. a ventricular septal defect. patent ductus arteriosus.

coarctation of the aorta. The nurse should suspect coarctation of the aorta because it causes signs of peripheral hypoperfusion, such as a weak femoral pulse and a bounding radial pulse. These signs are rare in patent ductus arteriosus, ventricular septal defect, and truncus arteriosus.

A nurse is finishing a shift on the pediatric unit. Because the shift is ending, which intervention takes priority? checking to see that client orders have been transcribed checking client pain levels for report to the next shift nurse completing input and output recording for the shift documenting the care provided during the shift

documenting the care provided during the shift Documentation should take top priority as this is the only way the nurse can legally claim that client interventions were performed. Checking client pain levels should be done throughout the shift and clients should be medicated so that they are not in need during busy change of shift times. Waiting until the end of the shift to review that client orders have been transcribed may lead to a delay in treatment and should be completed in a timely manner throughout the shift. Completing input and output recording can be assigned to a nurse assistant and should be delegated.

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated? droplet precautions standard precautions airborne precautions contact precautions

droplet precautions Meningococcal infections are spread through close mucous membrane or respiratory contact with large respiratory droplets. Meningococcal infections are not spread by small airborne organisms or contact with a person's skin or contaminated items. Standard precautions, used when touching body fluids, are not sufficient to prevent the spread of meningitis.

A parent tells the nurse that the parent's preschool-aged child with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently the child had an allergic reaction after eating kiwi fruit and bananas. Based on the parent's report, the nurse suspects that the child may have an allergy to color dyes. kiwi fruit. latex. bananas.

latex. If a child is sensitive to bananas, kiwi fruit, and chestnuts, she's likely to be allergic to latex. Children with spina bifida commonly develop an allergy to latex and shouldn't be exposed to it. Some children are allergic to dyes in foods and other products, but dyes aren't a factor in a latex allergy.

A mother tells the nurse that her 4 1/2-year-old child "does not seem to know the difference between right and wrong." This behavior is typical of which levels as described by Kohlberg's theory of levels of moral development? autonomous conventional principled preconventional

preconventional The preconventional level of Kohlberg's stages of moral development is typical of the preschool-aged child. Stage 1 behaviors of this preconventional level have a punishment-obedience orientation. Children at this stage avoid punishment and avoid those who have power.Autonomous, or postconventional, is the third stage of moral development as described by Kohlberg. These children are concerned with defining values and principles.The conventional level of morality development pertains to children aged 7 to 12 years who are concerned with loyalty and conformity.Principled is another name for the autonomous or postconventional stage, the third stage of moral development as described by Kohlberg. These children are concerned with defining values and principles.

A child, age 4, is hospitalized because of alleged sexual abuse. Which nursing intervention promotes healing for this child? providing play situations that allow disclosure avoiding touching the child preventing the suspected abuser from visiting the child asking the child to talk about what happened

providing play situations that allow disclosure The nursing intervention that promotes healing is to provide play situations. Through certain play situations, sexually abused child can disclose information without actually talking about themselves. Avoiding touch would be inappropriate because an abused child needs to be touched and cared for like any other hospitalized child. The nurse cannot restrict visitation unless the threat of repeated abuse exists while the child is hospitalized. A sexually abused child may not want to talk about what happened, so the nurse should provide a play situation and allow for the child to initiate conversation about the incident.

A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate? mixing the medication in milk so the child isn't aware that it's there explaining the medication's effects in detail to ensure cooperation showing trust in the child's ability to cooperate even with an unpleasant procedure making the child feel ashamed for not cooperating

showing trust in the child's ability to cooperate even with an unpleasant procedure To gain a preschooler's cooperation, the most appropriate strategy is for the nurse to show trust and express faith in the child's ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.

A 4-year-old child is admitted for a cardiac catheterization. Which is most important to include as the nurse teaches this child about the cardiac catheterization? a plastic model of the heart the parents a catheter that will be inserted into the artery other children undergoing a catheterization

the parents The most important aspect of teaching a preschooler is to have the family members there for support. Preschoolers are able to understand information that is individualized to their level. Including a plastic model of the heart and a catheter as part of the preoperative preparation may be helpful. The other family members will understand the heart model and catheter better than the preschooler will.

Before performing an otoscopic examination on a child, where should the nurse palpate for tenderness? tragus, mastoid process, and helix mastoid process, incus, and malleus tragus, cochlea, and lobule helix, umbo, and tragus

tragus, mastoid process, and helix Before inserting the otoscope, the nurse should palpate the child's external ear, especially the tragus and mastoid process, and should pull the helix backward to determine the presence of pain or tenderness. The umbo, incus, and malleus (parts of the middle ear) and the cochlea (part of the inner ear) are not palpable.

A client fell and broke an arm and had a cast applied. Which of these statements by the client indicates an immediate risk for compartment syndrome? "I can't wiggle my fingers." "Don't touch me." "My arm hurts." "I need to go home."

"I can't wiggle my fingers." Signs and symptoms of compartment syndrome, such as motor weakness, reflect a deficit or deterioration of neuromuscular status in the involved area. Inability to wiggle fingers indicates an immediate risk for compartment syndrome because it could suggest neurovascular pressure or damage caused by edema following the injury. The other statements don't indicate risk for compartment syndrome.

A nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is most appropriate? "The special medicine will feel warm when it's put in the tubing." "Your mom will be able to be in the room with you." "You must sleep the whole time that the test is being done." "The test usually takes an hour to complete."

"The special medicine will feel warm when it's put in the tubing." To prepare a 4-year-old child without increasing anxiety, the nurse should provide concrete information in small amounts about nonthreatening aspects of the procedure. Therefore, saying the special medicine will feel warm is most appropriate. Allowing parents to be in the room during a procedure depends on facility policy, therefore may not be true. This also does not provide information about the procedure. Explaining the time needed for the procedure wouldn't provide sufficient information. Stating that the child will need to sleep isn't true and could provoke anxiety.

How should a nurse prepare a suspension before administration? by diluting it with 5% dextrose solution by diluting it with normal saline solution by crushing remaining particles with a mortar and pestle by shaking it so that all the drug particles are dispersed uniformly

by shaking it so that all the drug particles are dispersed uniformly The nurse should shake a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't recommended for this drug form.

The nurse is calculating drug dosages for a child. What is the most important measurement for the nurse to consider? body surface area body mass index height weight in kilograms

weight in kilograms To calculate drug dosages for a child, most formulas involve the child's weight in kilograms. Therefore, this measurement is most important for the nurse to consider. A second recommended method involves the child's body surface area, but this would be calculated by the health care provider. Body mass index and height are not typically considered when calculating drug dosages.

A child, age 5, takes amoxicillin trihydrate orally three times per day to treat otitis media. For the most accurate calculation of a safe dosage, the nurse should use the child's body surface area. Young's rule based on the child's age. the child's weight in kilograms. Clark's rule based on the child's weight in pounds.

the child's body surface area. Using a child's body surface area may be the most accurate method for calculating safe drug dosages because body surface area is thought to parallel the child's organ growth and maturation and metabolic rate. Using the child's weight in kilograms, Young's rule based on the child's age, or Clark's rule based on the child's weight in pounds is likely to yield less accurate dosages.

A child experiences nausea and vomiting after receiving cancer chemotherapy drugs. What is most important for the nurse to include in the plan of care? Administer an antiemetic upon completion of chemotherapy treatment. Administer an antiemetic 30 to 60 minutes before the next chemotherapy session. Eliminate perfumes and other odors during the chemotherapy session. Encourage the child to eat a bland diet after chemotherapy treatment.

Administer an antiemetic 30 to 60 minutes before the next chemotherapy session. The nurse should administer an antiemetic 30 to 60 minutes before the chemotherapy session because antiemetics counteract nausea most effectively when given before administration of an agent that causes nausea. Antiemetics also work better when given continuously rather than as needed. A bland diet, eliminating odors, and an antiemetic after chemotherapy may all help to decrease nausea and vomiting, but the most important intervention is preventing the nausea and vomiting by administering an antiemetic before the chemotherapy session.

The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first? Start an intravenous (IV) infusion. Administer oxygen. Institute rewarming. Prepare for intubation.

Administer oxygen. Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.

A mother tells the nurse that her 4-year-old boy has developed some strange eating habits, including not finishing meals and eating the same food for several days in a row. She would like to develop a plan to correct this situation. When developing such a plan, what should the nurse and mother do? Do not allow him to leave the table until he has eaten the food. Decide on a good reward for finishing the meal. Restrict the availability of foods to those served at meal times. Allow him to make some decisions about the foods he eats.

Allow him to make some decisions about the foods he eats. Allowing a child to make some decisions about the foods he eats and not insisting that he finish meals can avoid power struggles. Refusing to finish meals and to eat certain foods is normal behavior for a preschool-aged child. It is important to avoid tension at mealtime and to avoid confrontation about food, which should not be used as a bribe or a reward.Rewarding a child for what is eaten can lead to power struggles between the parent and child over food.Restricting foods should be avoided; restriction can provoke power struggles and confrontation, thereby increasing tension.Not allowing the child to leave the table until finished can provoke power struggles and confrontation, thereby increasing tension.

A child has just ingested about 10 adult-strength acetaminophen tablets an hour ago. The mother brings the child to the emergency department. What should the nurse do? Place the interventions in the order of priority from first to last. All options must be used.

Assess the airway. Administer activated charcoal. Check serum acetaminophen levels. Administer acetylcysteine. Care of children with an acetaminophen overdose is based on time of ingestion. Immediate care of the child is to ensure airway, breathing, and circulation. If it has been less than 4 hours since ingestion, activated charcoal should be given. Acetaminophen levels should be drawn at 4 hours post-ingestion. Depending on the findings, acetylcysteine may also be used as an antidote.

A child is brought to the emergency department and is diagnosed with status asthmaticus. The child's respiratory rate is 40 breaths/min, and there are decreased breath sounds bilaterally throughout the lung fields. The nurse administers an aerosol bronchodilator and reassesses the lung sounds. Which finding is the best indicator that the bronchodilator has been effective? Breath sounds are louder bilaterally. The respiratory rate is 36 breaths/min. There is no audible wheezing. The child is coughing up sputum.

Breath sounds are louder bilaterally. Louder breath sounds mean that more air is moving throughout the lung fields.

A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions? with two fingertips with the heel of one hand with the fingers of one hand with the palm of one hand

with the heel of one hand When performing CPR on a child between ages 1 and 8, the nurse should use the heel of one hand to compress the chest one-third to one-half the depth of the chest. Using only the fingers of one hand isn't appropriate for CPR. The use of two fingertips is appropriate for infant CPR but this method can't compress the chest sufficiently on an older child. The palm is never used for chest compressions in CPR.

A school-age child with burns on the trunk and arms has no appetite. The nurse and the parent develop a plan of care to stimulate the child's appetite. Which suggestion made by the parent would indicate the need for additional teaching? deciding that the parent will feed the child withholding dessert and treats unless meals are eaten serving smaller and more frequent meals offering the child finger foods that the child likes

withholding dessert and treats unless meals are eaten Withholding certain foods until the child complies is punitive and rarely successful. Allowing the parent to feed the child, serving smaller and more frequent meals, and offering finger foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill.

A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals a temperature of 102° F (38.9° C). nausea and vomiting. worsening dyspnea. gastric distention.

worsening dyspnea. Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess.

A nurse is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should use the heel of one hand for sternal compressions. perform only two-person CPR. compress the sternum with both hands at a depth of 1½″ to 2″ (4 to 5 cm). deliver 12 breaths/minute.

use the heel of one hand for sternal compressions. The nurse should use the heel of one hand and compress one-third to one-half the depth of the chest. The nurse should use the heels of both hands clasped together and compress the sternum 1½″ to 2″ (at least 5 cm) for an adult. For a small child, two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of 12 breaths/minute.

The nurse is providing teaching regarding treatment to the parents of a young child with a urinary tract infection. Which statement by the parents indicates that the teaching has been successful? "We need to come to the emergency department for IV fluids." "We need to encourage cranberry juice to treat the infection." "We can treat the infection by increasing oral fluid intake." "We need to administer the oral antibiotics as prescribed."

"We need to administer the oral antibiotics as prescribed." Oral administration of antibiotics specific to the pathogen is the best course of treatment for a child with a urinary tract infection. Increasing oral fluid or giving cranberry juice may be preventative measures to protect against getting a urinary infection, but they would not treat the infection. Going to the emergency department for IV fluids is not a recommended course of action.

The nurse has been caring for a 4-year-old child with a severe traumatic brain injury. Which statement made by the parents prompts the nurse to discuss the possibility of organ donation? "We can't imagine what we'll do if our child dies." "We're hopeful that our child will make a complete recovery." "We're confident that the healthcare team is doing all they can." "We wonder if there is any good that can come from this tragedy."

"We wonder if there is any good that can come from this tragedy." Statements indicating that the family has accepted the grave condition of their child indicate the parents may be ready to discuss organ donation. Statements that represent a family's nonacceptance of the child's prognosis, a lack of understanding of treatments that are being given, or a misunderstanding of organ and tissue donation are indications that the family isn't ready to be approached or to make a decision.

A nurse is caring for a preschooler who sustained deep partial-thickness burns on the hands as a result of touching a hot pot on the stove. What is most important for the nurse to consider in discharge teaching? Delay the teaching until both parents are present. Ask the child to verbalize why the accident occurred. Provide teaching to the parents in the treatment room. Include the child in the teaching process.

Include the child in the teaching process. The nurse should include the preschooler in any discharge teaching performed. Preschoolers have developed reasoning skills and are beginning to understand the concepts of right and wrong and cause and effect, but verbalizing the reason for the accident is not the most important focus. It isn't necessary for both parents to be present during teaching, although it is desirable.

A charge nurse learns of another nurse who has had two unsuccessful attempts at starting a peripheral IV for a child. What is the most appropriate action by the charge nurse? Allow for a total of four IV attempts by the nurse, then contact the IV insertion team. Speak to the nurse about the situation and offer to start the child's IV. Allow the nurse another attempt under supervision before offering to start the IV. After a third unsuccessful attempt by the nurse, contact the supervisor to start the IV.

Speak to the nurse about the situation and offer to start the child's IV. When starting a peripheral IV for a child, no more than two attempts at insertion should be made by one nurse. Therefore, the charge nurse should interrupt the nurse and offer to start the IV. In children, total attempts at IV insertion should be limited to four because multiple unsuccessful attempts cause the child unnecessary pain, delay treatment, and increase the risk of complications.

The nurse assesses a preschooler with gastroenteritis. Which finding would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration? deep, rapid respirations decreased urine specific gravity diaphoresis absence of tear formation

absence of tear formation The absence of tears is typically found when moderate dehydration is observed as the body attempts to conserve fluids. Other typical findings associated with moderate dehydration include a dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with moderate dehydration. The specific gravity of urine increases with decreased output in the presence of dehydration.

The nurse is caring for a 5-year-old child who had a hernia repair 1 day ago. The child is vomiting, has a nasogastric (NG) tube to low intermittent suction, and has diarrhea. Which of the following laboratory results would be the immediate priority for the nurse to assess? chloride level potassium level calcium level magnesium level

potassium level Vomiting, diarrhea, and NG suction are all common causes of hypokalemia.

A pediatric nurse is caring for a child suspected of having been sexually abused. Which finding would best support the nurse's suspicions? fear of parents poor hygiene swelling of the genitals poor eye contact

swelling of the genitals The most likely finding for suspected sexual abuse would be difficulty walking or sitting; pain, swelling, or itching in the genitals; or bruises, bleeding, or lacerations of the genital area. Poor hygiene is a sign of physical neglect. Poor eye contact and fear of parents are common signs of physical, not sexual, abuse.

The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider? potassium level of 6.5 mEq/L (6.5 mmol/L) sodium 130 mEq/L (130 mmol/L) creatinine 2.5 mg/dL (221 umol/L) blood urea nitrogen (BUN) 40 mg/dL (urea 14.3 mmol/L)

potassium level of 6.5 mEq/L (6.5 mmol/L) A potassium level of 6.5 mEq/L requires immediate follow-up because it's considered critically high, making the child prone to cardiac arrhythmias. The creatinine, sodium, and BUN are all abnormal but to be expected in a client with acute renal failure. They do not require immediate follow-up, but the nurse's action will largely depend on the client's previous results and the degree of change.

After the nurse has taught the parents of a 5-year-old boy who has leukemia how to talk with their child about death and dying, which statement would indicate that the parents have age-appropriate expectations about their child's reaction to his impending death? "He might think he's caused his death because he's misbehaved." "He's too young to understand what is happening to him." "He'll accept his death as caused by his disease." "He'll understand how much his siblings will miss him."

"He might think he's caused his death because he's misbehaved." A 5-year-old child is in the preoperational stage of cognitive development and commonly thinks about behavior as magical; thus, the child may think that his behavior can cause death.Generally, children under 3 years of age are unable to differentiate death from temporary separation and are unable to understand what is happening, but by age 5 to 7 children understand that death means a body can no longer function.Logical thinking, evidenced by accepting death due to his disease, would occur during Piaget's stage of concrete operations, which occurs between ages 6 and 12 years.Although a 5-year-old child will be able to understand that he will be missed, he lacks the cognitive development to understand the extent of how much his siblings will miss him.

The nurse is caring for a 5-year-old child in pain. What is the best method to assess the child's pain? Observe the child for behaviors such as crying and restlessness. Ask the child to rate the pain intensity on a scale of 1 to 10. Ask the child to describe the way the pain feels. Ask the child to point to a face drawing that indicates pain intensity.

Ask the child to point to a face drawing that indicates pain intensity. In this age group, it would be most appropriate to use a nonverbal manner of pain assessment. The pain intensity rating scale consists of six faces with expressions ranging from happy and smiling to sad and tearful. It is highly reliable in children of this age-group. Observing the child for pain behaviors such as crying and restlessness is most appropriate for pain assessment in infants. Asking a child of this age to describe the way the pain feels may give inconsistent data. The numeric pain scale is most reliable in children older than age 8.

What actions should the nurse take for a 4-year-old girl who has just had a lumbar puncture? Administer a narcotic analgesic for insertion-site pain. Place a sandbag over the puncture site for 3 hours. Encourage the parents to hold the child. Ensure that the child lies flat for at least 8 hours.

Encourage the parents to hold the child. After a lumbar puncture, which is a traumatic procedure for a 4-year-old child, the child needs to be comforted by people she trusts. Thus, the nurse should encourage the parents to hold the child to provide the necessary support. The child should feel little pain at the insertion site after the lumbar puncture. Narcotics would not be the drugs of choice because they hinder assessment of neurologic status. A young child does not need to lay flat for any time after a lumbar puncture. Additionally, lying flat for 8 hours would be difficult, if not impossible, for a 4-year-old child. After a lumbar puncture, the application of a small bandage after applying pressure for a short time is usually sufficient to stop any leakage and prevent infection of the site. A sandbag is not needed.

A child is being discharged after being diagnosed with an asthma attack. What information regarding the rescue inhaler is most important for the nurse to include in discharge teaching? Monitor heart rate. Watch for hyperactivity. Record changes in taste. Report nausea and vomiting.

Monitor heart rate. Albuterol (salbutamol) is a beta-adrenergic blocker bronchodilator used to relieve bronchospasms associated with acute or chronic asthma or other obstructive airway diseases as a rescue inhaler. Signs and symptoms of albuterol toxicity that the nurse should instruct the parents to watch for include tachycardia, restlessness, nausea, vomiting, dizziness, and a bad taste in the mouth. While all of these are potential side effects, tachycardia and heart palpitations are the most serious, so monitoring the heart rate is most important to include in discharge teaching.

A nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which behavior should be brought to the attention of the nurse manager? The nurse works with the family members to find ways to accommodate their desire for prayer. The nurse has made accommodations for the family to stay in the room with the child. The nurse keeps communication channels open with the family and other healthcare providers. The nurse attempts to influence the family's decisions by presenting personal thoughts and opinions.

The nurse attempts to influence the family's decisions by presenting personal thoughts and opinions. When a nurse attempts to influence a family's decision with personal opinions and values, the situation becomes one of overinvolvement on the nurse's part, creating a nontherapeutic relationship. When a nurse keeps communication channels open or makes accommodations for prayer and staying with the child, the nurse is demonstrating an appropriate therapeutic relationship.

A young child is returning to the pediatric unit after having surgery to form a colostomy. When assessing the stoma, the nurse becomes most concerned when what is observed? a stoma that is edematous slight bleeding of the stoma a dark maroon stoma stomal tissue that is moist

a dark maroon stoma Ischemia may occur within 24 hours of the ostomy surgery and result in a dark, necrotic stoma that appears maroon to black. Causes of stomal necrosis include constricting sutures, mesenteric tension, disproportionate clipping of the mesentery, emboli, pressure associated with barrier wafer constriction, and abdominal edema or distension. A healthy stoma is dark pink and moist. Following surgery, a stoma may be edematous, and there may be bleeding when the stoma is touched.

A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing? caring for different children each shift to gain nursing experience taking vital signs for every child hospitalized on the unit assuming the charge nurse role instead of participating in direct child care caring for the same child from admission to discharge

caring for the same child from admission to discharge Primary care nursing requires that the primary nurse care for the same child (to whom the nurse is assigned) during a scheduled shift. The associate nurse is assigned to the child care assignment when the primary nurse has a day off or during the evening and night shifts. Caring for different children each shift doesn't promote continuity of care. Taking vital signs for every child on the floor is an example of team nursing, in which each member of the team is assigned one specific task for each child. The charge nurse may be directly involved in child care.

A parent brings a preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment does the nurse anticipate? administration of a dose of ipecac syrup gastric lavage and administration of activated charcoal I.V. infusion of normal saline solution insertion of a nasogastric tube and administration of an antacid

gastric lavage and administration of activated charcoal The healthcare provider will probably order gastric lavage or activated charcoal administration. Ipecac syrup is no longer recommended, and an antacid is not an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting, but in itself is not effective in eliminating the poisonous substance.

A girl has a urinary tract infection (UTI). Which statement by the parent demonstrates understanding of preventing future UTIs? "I should help my child learn to wipe her bottom from back to front." "I shouldn't let my daughter take bubble baths." "When she starts urinating frequently, I should call the provider to request antibiotics." "I will let her take a warm bath for 15 minutes each day."

"I shouldn't let my daughter take bubble baths." Saying that the child should not take bubble baths demonstrates effective teaching because oils in the bubble bath preparation may irritate the urethra, contributing to UTIs. Girls and women should wipe the perineum from front to back, not back to front, to avoid contaminating the urinary tract with fecal bacteria. Although antibiotics are used to treat UTIs, they are not given prophylactically. No evidence suggests that warm baths help prevent UTIs.

When assessing a child with muscular dystrophy, the nurse expects which finding? joint swelling waddling gait pain limited range of motion (ROM)

waddling gait A waddling, wide-based gait is a sign of muscular dystrophy. A nurse wouldn't expect pain, joint swelling, and limited ROM because they are rare with this disease.

A preschooler with a fractured femur of the left leg in traction tells the nurse that their leg hurts. It is too early for pain medication. What is the first action the nurse should take? Remove the weight from the left leg. Assess the feet for signs of neurovascular impairment. Place a pillow under the child's buttocks to provide support. Reposition the pulleys so the traction is looser.

Assess the feet for signs of neurovascular impairment. The nurse should assess the client frequently for signs of neurovascular impairment of the feet, such as pallor, coldness, numbness, or tingling. Pillows are not placed under the buttocks because the pillows would alter the alignment of the traction. Weights provide traction and should not be removed. Pulleys help maintain optimal alignment of the traction and therefore should be left alone.

The nurse is inspecting a child's throat (see figure). How should the nurse proceed with the throat examination? Remove the tongue blade from the child's hands after they have experienced what it feels like in their mouth. Ask the child to hold the tongue blade with both hands in their lap while the nurse uses another tongue blade. Have the parent hold the child with arms restrained. Guide the tongue blade while the child is holding it to depress the tongue to visualize the throat.

Guide the tongue blade while the child is holding it to depress the tongue to visualize the throat. If the child does not stick out their tongue so the nurse can visualize the throat, it is appropriate to use a tongue blade. Having the child participate by holding the tongue blade while the nurse guides it to facilitate visualization of the throat is the appropriate technique. It is not useful to remove the tongue blade or have the child hold it because the nurse will need to use the tongue blade to depress the tongue. It is preferable to engage the child's cooperation before asking the parent to restrain the child.

When developing a care plan for a hospitalized client, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds? preschool age adolescence school age infancy

preschool age Preschool-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 school-age children and adolescents. Adolescents also fear mutilation.

The mother of a 4-year-old child asks about dental care for her child. "I help brush her teeth every day, and her teeth look healthy," the mother states. "When should I take her to see a dentist?" Which response would be most appropriate? "Because you help brush her teeth, there is no need to see a dentist right now." "Ideally she should have seen a dentist already, but it's still not too late." "Your child doesn't need to see the dentist until she starts school." "A dental checkup is a good idea even if no problems are noticeable."

"A dental checkup is a good idea even if no problems are noticeable." Routine dental examinations should begin when a child is young, with newer recommendations suggesting visits begin before a child's first birthday, especially in at-risk children. Even though the mother helps the child brush her teeth every day, this does not replace the need for preventative dental visits, which can help reduce dental disease.The statement that the child should have been taken to a dentist already is likely to be interpreted as a reprimand. This tone is not therapeutic and may alienate the mother. There is nothing that can be done about decisions already in the past.Waiting until the child starts school may be too late because dental caries can occur before the age of 2 years.

The health care provider (HCP) has prescribed a sterile urine specimen for a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized, the procedure was very painful and traumatic. What is the nurse's best response? "I can apply a topical anesthetic 20 minutes before placing the catheter." "I'll request a prescription for a sedative to help them relax." "I can't do anything to reduce the pain, but you can hold your child during the procedure." "I'll get a prescription for a numbing lubricant to make the procedure more comfortable."

"I'll get a prescription for a numbing lubricant to make the procedure more comfortable." Two percent lidocaine lubricants have been found to significantly reduce the pain of urinary catheter insertion in children. If the unit does not have a standing protocol to use the lubricant, the nurse should request a prescription. A sedative would carry with it additional risks that could be avoided with the use of other methods to reduce pain. The parents should be encouraged to hold the child in addition to other pain relief methods. Frequent urination would make the use of topical anesthetics that must be left in place for a period of time impractical.

The nurse is caring for a 5-year-old child who is cognitively challenged. The parents ask the nurse how best to teach the child skills in order to foster independence. Which of the following teaching points should the nurse emphasize? Select all that apply. "Limit principles and abstract concepts in the teaching." "Teach one step at a time to facilitate short-term memory." "Use generous praise as a reward for learning." "Use repetition to reinforce learning." "Teach your child with a group of other children."

"Teach one step at a time to facilitate short-term memory." "Use generous praise as a reward for learning." "Limit principles and abstract concepts in the teaching." "Use repetition to reinforce learning." Pedagogy for a child who is cognitively challenged should incorporate teaching one step at a time, using praise, repeating information and practice, and limiting abstract concepts. These techniques provide a supportive learning environment for the child. Having a group of other children around may be distracting; children with cognitive challenges need to be in an environment with few extra stimuli so they can focus on learning.

The public health nurse is teaching the parents of a 5-year-old client diagnosed with sickle cell disease. What education will the nurse include? Select all that apply. Schedule regular appointments with a hematologist. Keep the client's immunizations up to date. Avoid giving the client pain medication. Wait 24 hours to call the healthcare provider if the client has a fever. Monitor for abnormal skin color.

Keep the client's immunizations up to date. Schedule regular appointments with a hematologist. Monitor for abnormal skin color. Sickle cell disease occurs when red blood cells (RBCs) morph into sickle cell shape and plug up the blood vessels causing extreme pain. To prevent sickle crisis, the client should have scheduled immunizations, regular appointments with a hematologist, and be monitored for abnormal skin color. The client will have pain due to the sickling of the cells and will need pain medication as needed. When a fever presents, the parents should call the healthcare provider immediately to prevent a sickle cell crisis.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first? Notify the nursing coordinator on duty. Firmly tell the father he must leave. Notify the nurse-manager. Notify hospital security or the local authorities.

Notify hospital security or the local authorities. The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

A nurse is caring for a 5-year-old child with end-stage acquired immunodeficiency syndrome (AIDS). The child confides that the child is ready to go to heaven and see Grandpa. The nurse knows that the child's parents aren't comfortable with the idea of discontinuing treatment. What should the nurse do? Tell the child that the nurse will talk with the parents and change the parents minds. Listen to the child but recognize that the child too young to make these decisions. Tell the physician that the family would like to discontinue treatment. Talk with the parents about the dying process and make the parents aware of what the child has confided.

Talk with the parents about the dying process and make the parents aware of what the child has confided. Chronically ill children commonly recognize their fate, whereas the parents continue to believe the child will become well again. The nurse should talk with the parents about the child's concerns. It's possible that the parents don't know what the child is feeling. Chronically ill children tend to have a good understanding of death, and should have input into decisions about the child's care. The nurse shouldn't tell the child that the nurse will try to change the parents' minds; the nurse might not be able to keep that promise. It would be unethical for the nurse to call the physician and misrepresent the parents' wishes.

The nurse includes recreational therapy in the plan of care for a 3-year-old child hospitalized with pneumonia and cystic fibrosis. What toy is the best choice for the child? fuzzy stuffed animal scissors, paper, and paste child's favorite doll 100-piece jigsaw puzzle

child's favorite doll The child's favorite doll would be a good choice of toy. The doll provides support and is familiar to the child. Although a 3-year-old may enjoy puzzles, a 100-piece jigsaw puzzle is too complicated for an ill 3-year-old child. In view of the child's lung pathology, a fuzzy stuffed animal would not be advised because of its potential as a reservoir for dust and bacteria, possibly predisposing the child to additional respiratory problems. Scissors, paper, and paste are not appropriate for a 3-year-old unless the child is supervised closely.

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention would be most appropriate to institute? allowing the child to play in the bathtub performing treatments quickly limiting conversation with the child keeping extraneous noise to a minimum

keeping extraneous noise to a minimum A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, they should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

The nurse assesses a family's ability to cope with their child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease? requesting teaching about cerebral palsy in general limiting interaction with extended family and friends seeking advice on coping on social media learning measures to meet the child's physical needs

limiting interaction with extended family and friends Limited interaction or lack of interaction with friends and family may lead the nurse to suspect a possible problem with the family's ability to cope with others' reactions and responses to a child with cerebral palsy. Learning measures to meet the child's physical needs demonstrates some understanding and acceptance of the disease. Requesting teaching about the disease suggests curiosity or a desire for understanding, thus demonstrating that the family is dealing with the situation. Participating in social media may serve as a form of support and can be a healthy coping mechanism.

A child with sickle cell anemia is admitted to the healthcare facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child? maintaining protective isolation applying cool compresses to affected joints administering antipyretics as ordered providing fluids

providing fluids During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Therefore, the highest priority is providing I.V. and oral fluids, which promotes hemodilution and aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn't require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis.

After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of parental role conflict related to child's hospitalization. Which defining characteristic suggests this diagnosis? The parents are expressing desire for more information. Parents make negative statements about health care provider. The parents are questioning the nursing plan of care. Parents express feelings of inadequacy in caring for child.

Parents express feelings of inadequacy in caring for child. Expression of feelings of inadequacy in providing for their child's needs is a defining characteristic of parental role conflict related to the child's hospitalization. Parents seeking more information or questioning the plan of care would support a diagnosis of readiness for enhanced parenting. Expressing negative feelings toward the health care provider would support a diagnosis of impaired coping.

A child who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond? "Make sure the child uses disposable plates and utensils." "Don't let the child share toys with other children." "Wear gloves when you're likely to come into contact with the child's blood or body fluids." "Use isopropyl alcohol to clean surfaces contaminated with the child's blood or body fluids."

"Wear gloves when you're likely to come into contact with the child's blood or body fluids." HIV is transmitted by blood and body fluids. Therefore, the nurse should respond by telling family members to wear gloves when anticipating contact with the child's blood or body fluids. Standard household methods for cleaning dishes and utensils are adequate, so the child needn't use disposable plates and utensils. To disinfect HIV-contaminated surfaces, the nurse should instruct the foster parents to use a solution of 1 part bleach to 10 parts water. The child may share toys; any toys that become soiled with the child's blood or body fluids should be disinfected with the bleach solution.

A nurse is assessing a 4-year-old child's peripheral IV line, observing that it is not infusing. What is the first action the nurse should take to correct this situation? Reposition the child's extremity. Adjust the height of the IV bag. Check the power source of the pump. Change the IV bag.

Reposition the child's extremity. The most likely reason for difficulty running an IV in this age group is a positional issue of the child or extremity because of the child's activity level.

The nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the health care provider as an indication that the client has low cardiac output? extremities warm to the touch and pale skin altered level of consciousness and thready pulse capillary refill of 2 seconds and blood pressure of 96/67 mm Hg bounding pulses and mottled skin

altered level of consciousness and thready pulse With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms would include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary refill; and a decrease in the level of consciousness.

A child is being seen in the emergency department for reports of severe sore throat, trouble swallowing, and fever. The child has swollen cervical lymph nodes and a fiery red pharynx on examination. Which assessment findings below should be reported immediately to the healthcare provider? sudden onset of ear pain loud snoring and noisy respirations drooling and not swallowing coughing and sneezing

drooling and not swallowing Drooling and refusal to open mouth indicate a potentially life-threatening situation as the child may be unable to swallow and have a severely narrowed throat. Coughing or sneezing does not indicate a priority problem. Noisy respirations could be indicative of a pending problem; however, the drooling is a higher priority. Sudden onset of ear pain is not as high a priority problem as the drooling and the inability to swallow.

A child underwent a tonsillectomy 4 hours ago. Which assessment finding should make the nurse suspect postoperative hemorrhage? refusal to drink clear fluids decreased heart rate frequent swallowing vomiting of dark brown emesis

frequent swallowing 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.

A parent of a child with hemophilia states that she worries whenever the child has a bump or cut. The nurse should explain that after the area is cleansed, the wound should be treated by applying which measure? gentle pressure a tourniquet above the injured area warm, moist compresses a wet-to-dry dressing

gentle pressure In children with hemophilia (an inherited bleeding disorder), a bump or cut can cause serious bleeding. After the injured area is cleansed, gentle pressure should be applied to allow clot formation, which will help stop the bleeding. In addition, the area should be immobilized and elevated.Cold applications, instead of warm moist compresses, are commonly used to promote vasoconstriction and help control the bleeding.A tourniquet should not be used because of the high risk of tissue hypoxia and resulting necrosis.Wet-to-dry dressings should be avoided because they could be irritating to the area.

A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to administer folic acid supplements. place ice packs on the client's painful joints. provide oral and I.V. fluids. administer antibiotics.

provide oral and I.V. fluids. Initial nursing interventions for the child in a sickle cell crisis include providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial but only after hydration and oxygenation have been addressed. Daily supplements of folic acid will help counteract anemia but aren't a priority during sickle cell crisis.

A healthcare provider diagnoses leukemia in a 4-year-old child who complains of being tired and sleeps most of the day. Which nursing diagnosis should the nurse use to best reflect this physiologic effect of leukemia? activity intolerance related to lack of normal blood cell production ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells ineffective airway clearance related to inability to have an effective cough imbalanced nutrition: less than body requirements related to decreased appetite

activity intolerance related to lack of normal blood cell production A nursing diagnosis of activity intolerance related to abnormal blood cell production reflects the nurse's understanding of leukemia's physiologic effects; a child with leukemia may experience weakness and hypoxia as a result of the anemia commonly associated with the disease. The nurse's findings don't support the other diagnoses of ineffective airway clearance related to the inability to have an effective cough, imbalanced nutrition: less than body requirements related to decreased appetite, or ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells.

While assessing the penis of a child who has had surgery to repair hypospadias, the nurse observes the appearance of the penis. The nurse should report which aspect to the surgeon? dusky blue at the tip pink somewhat misshapen swollen

dusky blue at the tip A dusky blue color at the tip of the penis may indicate a problem with circulation, and the nurse should notify the surgeon. Following surgery, it is normal for the penis to be swollen and pink. The penis may be misshapen and is unlikely to look normal even after reconstruction.

For a child with hemophilia, what is the most important nursing goal? Enhancing tissue perfusion Promoting tissue oxygenation Controlling pain Preventing bleeding episodes

Preventing bleeding episodes A child with hemophilia is prone to bleeding episodes stemming from coagulation problems. Therefore, the primary nursing goal is to prevent bleeding episodes and possible hemorrhage. A secondary effect of preventing bleeding episodes is maintenance of tissue perfusion and oxygenation. Hemophilia rarely causes pain.

The nurse meets with the family of a 3-year-old child who is seriously ill. What is the most important role of the nurse as collaborator? Collaborates with facility clergy to provide spiritual care. Coordinates the multidisciplinary services and provides information about them. Addresses financial concerns and coordinates resources. Orders consults with other specialties to help in treating the child's diagnosis.

Coordinates the multidisciplinary services and provides information about them. Coordinating the multidisciplinary services and providing information about them demonstrate collaboration because the nurse will be explaining the functions of social service, case management, and so forth. Providing parents with information about financial assistance programs is the responsibility of social services, not a nursing role. It is the healthcare provider's responsibility to order consults with other specialties. Collaborating with facility clergy to provide spiritual care is part of the nurse's role, but it is not the most important.

A child with hemophilia is hospitalized after falling. Now the child complains of severe pain in the left wrist. What should the nurse do first? Perform passive range-of-motion (ROM) exercises on the wrist. Notify the health care provider. Massage the wrist and apply a warm compress. Elevate the affected arm and apply ice to the injury site.

Elevate the affected arm and apply ice to the injury site. Severe joint pain in a child with hemophilia indicates bleeding; therefore, the nurse should first elevate the affected extremity and apply ice to the injury site to promote vasoconstriction. ROM exercises may worsen discomfort and bleeding. Massage and warm compresses also may increase bleeding. The nurse should notify the health care provider only after taking measures to stop the bleeding.

The nurse is teaching the parent of a preschool-age child with celiac disease about a gluten-free diet. The nurse determines that teaching has been successful when the parent tells the nurse they will prepare which breakfast for the child? wheat toast and grape jelly eggs and orange juice oatmeal and skim milk rye toast and peanut butter

eggs and orange juice Children with celiac disease cannot digest the protein in common grains such as wheat, rye, and oats. Eggs and orange juice would be appropriate foods.

A child age 4, begins to use curse words. Concerned about this behavior, the parents ask the nurse how to discourage it. Which advice should the nurse offer? "Tell the child it isn't acceptable and they will be disciplined if it continues." "Tell the child that the behavior makes you angry." "Tell the child that good little children don't use curse words." "Just ignore it. Children grow out of it."

"Tell the child it isn't acceptable and they will be disciplined if it continues." The nurse should advise the parents to tell the child it isn't acceptable because by explaining their objections and expectations, the parents teach the child why the behavior is unacceptable and help the child understand that it must stop. Telling the parents to ignore the behavior, or telling the child the behavior makes the parent angry, wouldn't teach the child that the behavior is inappropriate. Advising the parents to tell the child that good little children don't use curse works would reinforce the impression that the child is "bad," diminishing the child's self-image while doing little to change the objectionable behavior.

A 4-year-old child is admitted to the hospital for surgery. The nurse applies interventions to address what major stressor for a child of this age? fear of pain loss of control separation from family fear of bodily injury

separation from family For infants through preschoolers, separation from the family is the major stressor posed by hospitalization. To minimize the effects of separation, the nurse may suggest that a family member stay with the child as much as possible. Reducing this stressor may help a young child withstand other possible stressors of hospitalization, such as fear of bodily injury, loss of control, and fear of pain.

The nurse discovers that a young client has been given a dose of morphine four times the dose prescribed. What is the priority action of the nurse? Follow the facility policy for reporting of the error. Obtain naloxone and assess the need for administration. Monitor the client's respiratory rate for 5 minutes. Bring emergency resuscitation equipment to the child's room.

Obtain naloxone and assess the need for administration. Naloxone is an opioid antagonist that is given as an antidote for morphine. An antidote is an agent that neutralizes a poison or counteracts its effects. This would be an immediate priority for the nurse. Respiratory depression is a common side effect of opioids, and with a dosage error of this magnitude, it would be the priority to have naloxone ready to administer. Documentation of the error would happen after the client is treated and deemed stable. Emergency resuscitation equipment should be obtained after treating the client if indicated.

The nurse must administer a unit of packed red blood cells to a 4-year-old child. The child's blood type is Type B Rh factor positive. When the unit of blood arrives, it is labeled as Type O Rh factor negative. What is the appropriate action for the nurse to take? Document the error with an incident report. Have the child's blood retested for blood type. Return the blood and order a new unit of Type B. Begin the administration of the blood as ordered.

Begin the administration of the blood as ordered. Type O Rh negative blood is the universal donor and can be administered to a child who is Type B. As long as the crossmatch report confirms "OK to transfuse," there would be no need to return this unit to the blood bank. This should not be considered an error and would not be documented as such. There is no indication for retesting the child's blood type.

The parent of a preschool child with juvenile idiopathic arthritis (JIA) is worried that their child will have to stop attending preschool because of the illness. Which response by the nurse would be most appropriate? "Your child should be encouraged to attend school, but they will need extra time to work out early morning stiffness." "Your child will probably need to wear splints and braces so that their joints will be supported properly." "It may be difficult for your child to attend school because of the side effects of the medications they will be prescribed." "You should keep your child at home from school whenever they experience discomfort or pain in their joints."

"Your child should be encouraged to attend school, but they will need extra time to work out early morning stiffness." Socialization is important for this preschool-age child, and activity is important to maintain function. Because children with JIA commonly experience most problems in the early morning after arising, they need more time to "warm up." Adverse effects may or may not occur. The child's normal routine needs to be maintained as much as possible. Although splints and braces may be needed, they are worn during periods of rest, not activity, to maintain function.

Which concept should the nurse incorporate into the plan of care for a 4-year-old child to psychologically prepare the child for cardiac catheterization? Anxiety decreases when a preschooler is protected from learning about unpleasant events. Preschoolers are unable to understand the procedure. Preparation is a joint responsibility of the primary care provider, parents, and nurse. Little psychological preparation can be given to preschoolers.

Preparation is a joint responsibility of the primary care provider, parents, and nurse. For a preschooler, psychological preparation for events is the joint responsibility of the primary care provider, parents, and nurse, each playing a major role in caring for the child and meeting specific needs.Overprotecting a preschooler from unpleasant events can increase anxiety rather than decrease it because the child needs to learn how to cope with stress.Preschoolers are ready to understand information that is individualized to their level.Little psychological preparation can be given to infants and toddlers.

A preschool-age child presents to the emergency department. The client's parent tearfully reports that the child was on their shoulders in the driveway playing when the child began to fall. The parent grabbed the client by the leg, swinging them toward the grass to avoid landing on the pavement. As the parent swung the client, the client hit their head on the driveway and twisted their right leg. After a complete examination, it is determined that the client has a skull fracture and a spiral fracture of the femur. Which action should the nurse take? Restrict the parent's visitation. Refer the parent for parenting classes. Notify the police immediately. Record the parent's story in the medical record.

Record the parent's story in the medical record. The parent's story is consistent with the injuries incurred by the child; therefore, the nurse should document the cause of injury. There is no need to restrict the parent's visitation because the injuries sustained by the child are consistent with the explanation given. The police only need to be notified if there is suspicion of child abuse. The injuries incurred by this child appear to be accidental. There is no need to refer the parent for parenting classes. The parent appears to be upset about the accident and will not likely repeat such reckless behavior. However, the nurse should educate the parent regarding child safety.

A child with lead poisoning is admitted to the facility for chelation therapy. The nurse must stay alert for which adverse effect of chelation therapy? chills anaphylaxis heart failure seizures

seizures Chelation therapy removes lead by combining it with another substance to form a soluble compound that the kidneys can excrete. The nurse should stay alert for seizures because as lead is mobilized from bone and other tissues, the serum lead level rises rapidly, increasing the client's risk of seizures. Chelation therapy doesn't cause anaphylaxis, chills, or heart failure.

A parent of a child with a urinary tract infection calls the clinic and explains, "I'm concerned because my child refuses to obey me concerning the preventions you told me about. My child refuses to take the medication unless I buy them a present. I don't want to use discipline because of the illness, but I'm worried about the behavior." Which response by the nurse is best? "I sympathize with your difficulties, but just ignore the behavior for now." "I understand that things are difficult for you right now, but your child is ill and deserves special treatment." "I understand your concern, but this type of behavior happens all the time; your child will get over it when feeling better." "I understand it's hard to discipline a child who is ill, but things need to be kept as normal as possible."

"I understand it's hard to discipline a child who is ill, but things need to be kept as normal as possible." To ensure appropriate psychosocial development, a child needs to have normal patterns maintained as much as possible during illness. It is tempting to give ill children special treatment and to relax discipline. However, family routines and discipline should be kept as normal as possible. The child needs to know the limits to ensure feelings of security. When they are ill, children commonly attempt to stretch the rules and limits. If this occurs, returning to the previous well-behavior patterns will take time.

Parents of a 5-year-old child call the clinic to tell the nurse that they think their child has been abused by the daycare provider. What should the nurse advise them to do first? Talk to their attorney to file charges against the accused. Call Child Protective Services to file a complaint. Make an appointment to speak with the daycare provider. Schedule an immediate appointment with their healthcare provider.

Schedule an immediate appointment with their healthcare provider. Because more information needs to be obtained from the child and family, making an immediate appointment is most appropriate. A healthcare provider can also document chief complaints, document recollections, gather physical evidence, and take photographs. It's unclear what type of abuse the parents are concerned about. Calling Child Protective Services is appropriate but isn't the first action to take; the appointment with a healthcare provider should be scheduled before CPS is contacted. Talking to an attorney or the daycare provider are not the first priorities.

The nurse in an outpatient clinic is conducting a follow-up assessment on a child who had a severe streptococcal infection 1 week ago. The client is doing better, and the nurse is providing teaching to the parents about continuing to monitor the client for possible complications of the infection. Which information is most important for the nurse to discuss with the parents? "Return immediately if acute flank or mid-abdominal pain occurs." "Expect the child's weight to decrease over the next 2 weeks." "The infection may cause the child to have some burning with urination." "Fevers may continue to occur as the body recovers from the infection."

"Return immediately if acute flank or mid-abdominal pain occurs." Acute glomerulonephritis is a major complication of streptococcal infections in children. The onset is often marked by a sudden occurrence of acute flank or mid-abdominal pain. The child may show signs of fluid retention, such as weight gain and edema. Hypertension also commonly occurs.

The nurse begins cardiopulmonary resuscitation (CPR) on a 5-year-old unresponsive client. When the emergency response team arrives, the child continues to have no respiratory effort but has a heart rate of 50 bpm with cyanotic legs. What should the team do next? Continue administering breaths with a bag-mask device without compressions. Begin two-person CPR at a ratio of two breaths to 30 compressions. Suspend CPR briefly to apply defibrillation patches. Begin two-person CPR at a ratio of two breaths to 15 compressions.

Begin two-person CPR at a ratio of two breaths to 15 compressions. CPR is done on children with a heart rate of less than 60 bpm and signs of poor perfusion. Rescuers should use a 15:2 compression-to-ventilation ratio for two-rescuer CPR for a child. Breaths without compressions are indicated only for respiratory arrests where the heart rate remains above 60 bpm. The automated external defibrillator (AED) should be used as soon as it is ready, but rescuers should not discontinue compressions until the device is ready for use. The ratio for two-person CPR in adults is 30:2.

The nurse is assessing a 5-year-old client and wants to gain the client's cooperation. Which actions are appropriate for the nurse? Tell the child not to be afraid because it will not hurt. Save the more intimidating or intrusive parts of the assessment, such as eyes, ears, and genitalia, until the end of the assessment. Perform a head to toe assessment, just as for an adult. Tell the child that prizes are given for good behavior.

Save the more intimidating or intrusive parts of the assessment, such as eyes, ears, and genitalia, until the end of the assessment. It will be of no benefit to tell the child not to be afraid. Instead work to develop trust. Begin the assessment with growth and developmental assessments such as building with blocks or drawing. Save the more intrusive and frightening parts of the assessment until the end, after trust and rapport has been developed. Prizes may be given, but should be given no matter the behavior of the child.

The nurse is caring for a 3-year-old client being treated for severe status asthmaticus. After comparing clinical manifestations with laboratory results (reported below), a nurse determines evidence that this client has progressed to which condition? respiratory alkalosis metabolic acidosis respiratory acidosis metabolic alkalosis

respiratory acidosis A pH less than 7.35 and a PaCO2 greater than 45 mm Hg (6.0 kPa) indicate respiratory acidosis. Status asthmaticus is a medical emergency that's characterized by respiratory distress. At first, the client hyperventilates; then respiratory alkalosis occurs, followed by metabolic acidosis. If treatment is ineffective or has not begun, symptoms can progress to hypoventilation and respiratory acidosis, both of which are life-threatening. A client with respiratory alkalosis would have a pH greater than 7.45 and a PaCO2 less than 35 mm Hg (4.7 kPa). Metabolic acidosis is characterized by a pH less than 7.35 and a bicarbonate (HCO3-) level less than 22 mEq/L (22 mmol/L). Metabolic alkalosis is characterized by a pH greater than 7.45 and HCO3- above 26 mEq/L (26 mmol/L).

After being hospitalized for status asthmaticus, a child is discharged with prednisone and other oral medications. Two weeks later, when the child comes to the clinic for a checkup, the nurse instructs the parent to gradually decrease the dosage of prednisone, which will be discontinued. The parent asks why prednisone must be discontinued. How should the nurse respond? "Long-term steroid therapy may interfere with a child's growth." "The child may develop a hypersensitivity to steroids with continued use." "Prolonged steroid use may cause depression." "Steroids increase the appetite, leading to obesity with prolonged use."

"Long-term steroid therapy may interfere with a child's growth." Steroids suppress release of adrenocorticotropic hormone from the pituitary gland, stopping production of endogenous hormones by the adrenal cortex. Because prolonged adrenal suppression may cause growth restriction in a child, the duration and dosage of steroid therapy must be kept to a minimum. Steroids also may cause central nervous system effects, such as euphoria, insomnia, and mood swings. Although steroids increase the appetite, this effect isn't the reason for limiting their use in children. Steroids are present in the body, so hypersensitivity isn't a problem, and they're likely to cause euphoria, not depression.

Which nursing interventions are appropriate when creating a plan of care to promote the development of a preschooler? Select all that apply. Help the parents understand their child's behavior. Provide anticipatory guidance for parents. Identify deviations from normal growth and development patterns. Determine the child's future development. Send the child to a day care center.

Provide anticipatory guidance for parents. Help the parents understand their child's behavior. Identify deviations from normal growth and development patterns. Goals for promoting healthy development in preschoolers include anticipatory guidance, helping parents understand their child's behavior, identifying deviations from the norm, and assessing parent-child interaction. No one can assess or determine the child's future development, and trying to do so can limit the potential the child may achieve. Although learning to interact with others is important, sending the child to a day care center is not essential to promote healthy development. The nurse can encourage the parents to provide opportunities for the child to play with others.

The emergency department nurse is obtaining a history from the parents of a 4-year-old child. Multiple bruises and abrasions are noted. The nurse highly suspects child abuse based on which finding? The stories about the accident or injury from the parents conflict. The history is consistent with the child's injuries. The parents appear unkempt and have low socioeconomic status. The parents have a flat affect and appear emotionally detached from the child.

The stories about the accident or injury from the parents conflict. Conflicting stories about the accident or injury from the parents is a warning sign of abuse. A history consistent with the child's injuries, an unkempt appearance, and low socioeconomic status are not indicators of expected or potential abuse. While the emotional response of the parents may be concerning, it is not a warning sign of abuse.

A nurse is caring for a child who was involved in a bus accident on the way home from preschool. Several people were killed in the accident. When talking with the child's parents about normal reactions to a traumatic event, the nurse should tell them that they should immediately seek psychiatric care for the child. they should allow their child to watch television programs about the accident. they should allow the child to eat and sleep when the child wants. it is normal for the child to want to sleep with them at night.

it is normal for the child to want to sleep with them at night. It is normal for children involved in traumatic events to experience regression in growth and development or the ability to perform physical tasks. For example, a child who has been in an accident may wish to sleep with the parents. Children recovering from traumatic events should have a routine for school, play, meals, and sleep. The parents should not let the child watch television or other media programs about the accident. Children are very resilient; there is no reason to assume this child needs immediate psychiatric counseling.

A 3-year-old with dehydration has vomited 3 times in the last hour and continues to have frequent diarrhea stools. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 48.5 lb (22 kg), has a normal saline lock in their right hand, and has had 30 mL of urine output in the last 4 hours. Using the situation-background-assessment-recommendation (SBAR) technique for communication, the nurse calls the health care provider with the recommendation for which prescription? beginning an intravenous (IV) antibiotic starting a fluid bolus of normal saline giving a dose of loperamide establishing an indwelling catheter

starting a fluid bolus of normal saline The child is dehydrated, is not able to retain oral fluids, and continues to have diarrhea. A normal saline bolus should be given followed by maintenance of IV fluids. Antidiarrheal medications are not recommended for children and will prolong the illness. The child has gastroenteritis caused by a viral illness. IV antibiotics are not indicated for viral illnesses. Maintaining strict intake and output is important in all children with gastroenteritis.