Quiz 2
he nurse is performing a gastrointestinal assessment on a 7-year-old boy. The parents are assisting with the history. Which assessment findings are indicative of constipation? Select all that apply.
"Our child reports he is in pain because his bowel movements are so hard." "Our child only has 3 to 4 bowel movements per week." "I can tell he holds his bowel movement much of the time because of the way he stands."
The nurse is developing a plan of care for an infant with heart failure who is receiving digoxin. The nurse would hold the dose of digoxin and notify the physician if the infant's apical pulse rate was:
80 beats per minute
The nurse is caring for infants with failure to thrive (FTT). Which infants would be at risk for this condition? A. A newborn baby with tetralogy of Fallot B. An infant with a cleft palate C. An infant born to a diabetic mother D. An infant born to an impoverished mother E. An infant with bronchopulmonary dysplasia F. An infant born to a teenage mother
A, B, D, E
The nurse reviews the record of a 3-week-old infant and notes that the physician has documented a diagnosis of Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing which symptom most likely led the mother to seek health care for the infant?
Foul smelling, ribbon like stool
A child is diagnosed with a food allergy to milk. When teaching the parents about this allergy, what would the nurse suggest as possible substitutions for milk? Select all that apply.
Fruit juice Rice milk Soy milk
The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy." Which intervention would be most helpful for the parents?
Having a wound ostomy and continence nurse meet with them
The nurse is participating in a poisoning prevention program. This activity is an example of which type of community-based nursing intervention?
Health education program
1. A potential complication of bone marrow suppression is __________
Infection
What is the best practice should the nurse teach parents about oral hygiene for a child receiving chemotherapy
Inspect the child's mouth daily for ulcers
Complications of ______ poisoning include behavioral issues and learning difficulties, and at high level, encephalopathy, seizures, and brain damage
Lead
the nurse is performing an admission assessment on 6-month-old infant with a diagnosis of hydrocephalus. The nurse assesses for the major sign associated with hydrocephalus when the nurse?
Palpate anterior fontanelles
the mother of a 4-year-old child brings the child to the clinic and tells the pediatric nurse specialist that the child's abdomen seems to be swollen. A nurse suspecting the possibility of Wilm's tumor would avoid which of the following during the physical assessment?
Palpating the abdomen for a mass
A nurse is caring for a child who has suspected meningitis and a decreased level of consciousness. which is an appropriate nursing intervention?
Place the child on universal precautions
The nurse is teaching the parents of an overweight 18-month-old girl about diet. Which intervention will be most effective for promoting proportionate growth?
Remove high-calorie, low-nutrient foods from the diet.
The mother of a 7-year-old girl tells the school nurse that her child is deathly afraid of going to school. What would be the best intervention the nurse could suggest in this situation?
Return the child to school and investigate the cause of the fear.
The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What would be the nurse's best intervention in this case?
Schedule a full evaluation since this may indicate a neurologic disorder.
The nurse is caring for a child who is taking corticosteroids for systemic lupus erythematosus. The nurse closely monitors the child based on the understanding that corticosteroids exert which major action?
They can mask signs of infection.
Prematurity, difficult delivery, and infection during pregnancy are risk factors associated with neurologic disorders.
True
The FLACC pain scale rating should be used in the young pre-verbal child.
True
A child with heart failure is receiving supplemental oxygen. The nurse understands that in addition to improving oxygen saturation, this intervention also has what effect?
cause vasodilation
An infant with bronchiolitis is hospitalized. The causative organism is the respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires the following isolation:
contact precautions
Which description of stool is characteristic of intussusception?
currant jelly-like stools
The parents of a child diagnosed with celiac disease ask the nurse what types of food they can offer their child. What recommendation would the nurse include in the teaching plan?
fruit juice
The nurse is conducting a physical examination of a 9-month-old baby with a flat, discolored area on the skin. The nurse documents this as a:
macule
The nurse is caring for a 5-year-old girl post tonsillectomy. The girl looks out the window and tells the nurse that it is raining and says, "The sky is crying because it is sad that my throat hurts." The nurse understands that the girl is demonstrating which mental process?
magical thinking
When examining the abdomen of a child, which technique would the nurse use last?
palpation
The nurse administers vitamin K intramuscularly to the newborn based on which rationale?
promote blood clotting
The nurse is administering a hepatitis B vaccine to a child. What is the classification of this type of vaccine?
recombinant vaccines
When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?
skeletal traction
Which instruction is most important when teaching home management of a child with hemophilia?
soft bristled toothbrushes should be used
When conducting a physical examination of a child with suspected Kawasaki disease, which finding would the nurse expect to assess?
strawberry tongue
The nurse is caring for the family of a 9-year-old child with cerebral palsy. Which intervention will best improve communication between the nurse and the family?
using reflective listening techniques
The nurse is providing a class for a group of childcare providers. When discussing allergic reactions, which statement by a participant indicates the need for further instruction?
"If a child has previously eaten a food and not had a reaction they are not 'truly' allergic to it.
The nurse is caring for a child with widespread itching and has recommended bathing as a relief measure. After teaching the mother about this, which statement from the mother indicates a need for further instruction?
"After bathing, I need to rub his skin everywhere to make sure he is completely dry."
The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which approach would be most appropriate to elicit the child's cooperation?
"Can you blow this cotton ball across the tray?"
After teaching a group of nursing students about family-centered care, which statement made by the students would best indicate that the teaching was successful?
"Family-centered care recognizes the concept of family as the constant."
The nurse is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching?
"I will set our water heater at 130 degrees."
After teaching a group of parents about language development in toddlers, what if stated by a member of the group indicates successful teaching?
"When my 3-year-old asks 'Why?' all the time, this is completely normal."
The school nurse is working with a 10-year-old girl with recurrent abdominal pain. The girl's teacher has been less than understanding about the frequent absences and trips to the nurse's office. How should the nurse respond?
"The pain she is having is real."
Vocabulary at three years old should constitute how many words?
1000
The number of hours of sleep required for growth and development decreases with age. Children between the ages of 6 and 8 years require approximately ____ hours of sleep per night
12
The nurse understands that passive immunity is effective for how long after birth?
3 months
After teaching the parents of a 6-year-old how to administer an enema, the nurse determines that the teaching was successful when they state that they will give how many solutions to their child?
500-1,000 ml
The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next?
Administer next dose as ordered in 12 hours
The nurse is developing a teaching plan for toddler safety to present at a parenting seminar. Which safety intervention should the nurse address?
Advise parents to use a forward-facing car seat with harness straps and a clip, placed in the backseat of the car.
A 5-year-old patient is admitted to the hospital with a broken arm. His arm is immobilized. What appropriate nursing intervention is age-appropriate for this child regarding his hospitalization?
Allow the child to help with bathing, feeding, and changing bandages
_________ accidents are the number one cause of death in adolescents.
Automobile
When assessing a child following a head injury. Which nursing action is appropriate?
Checking the nose and ears for drainage
A nurse working in a trauma center would facilitate referral to a burn center for which of the following children? Check all that apply
Chemical burn Electrical burn Burn in the perianal area
Decorticate posturing occurs with damage of the cerebral ______________
Cortex
The nurse is assessing a child with a possible fracture. What would the nurse identify as the most reliable indicator?
point tenderness
When preparing a teaching plan for the parents of a group of 4-6-year-old children about recommended immunizations for school entrance, the nurse would be sure to include which of the following?
DTaP, IPV, MMR, VZV
The following are inorganic causes of failure to thrive (FTT) (Select all that apply).
Dysfunctional Parental Interaction Neglect
Which respiratory alteration is considered to be a medical emergency?
Epiglottis
CT scans and MRIs are useful in the diagnosis of hemorrhages, infections, or obstructions.
False
G6PD is most common in males of Asian descent.
False
The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like it just bursts out of his mouth." A diagnosis of hypertrophic pyloric stenosis is suspected. When performing the physical examination, what would the nurse most likely find?
Hard, moveable, olive-shaped mass in the right upper quadrant
One of the complications of cerebral palsy is:
Hydrocephalus
Management of cerebral palsy includes promoting:
Mobility
Which assessment finding suggests that the neonate has spina bifida?
Noticeable dimpling above the separation of the buttocks
A child with a cast or in traction you want to assess? Select all that apply
Pain pallor
Which instructions about preventing SIDS should a nurse include when providing education to the parents of an infant?
Position the infant on his back to sleep
Kohlberg's theory states that adolescents are experiencing what stage of moral development?
Post-conventional
The nurse asks a 9-year-old child and mother about the child's best friend to assess which of the following about the child?
Social development
The nurse is helping a family plan for the discharge of their child, who will be going home in a spica cast. Which of the following points of information would be most important for the nurse to consider?
The child's bedroom is on the second floor
A nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux. To assist in reducing the episodes of emesis, the nurse tells the mother to do which of the following?
Thicken the feedings by adding rice cereal to formula
The following are common developmental concerns of toddlers. (Select all that apply).
Toilet training Sibling rivalry
All blood cells originate from a single type of cell called a multipotent stem cell
True
CT scans and MRIs are useful in the diagnosis of hemorrhages, infections, or obstructions.
True
Children with dark skin tend to have more pronounced cutaneous reactions compared to children with lighter skin.
True
Prematurity, difficult delivery, and infection during pregnancy are risk factors associated with neurologic disorders.
True
Tinea is a term used to refer to a fungal disease of the skin occurring on any part of the body.
True
A nurse is developing a plan of care for a child who is admitted to the hospital for surgery. The child is visually impaired. What would be most appropriate for the nurse to include in the child's plan of care? Select all that apply.
Using the child's body parts to refer to the area where he may have postoperative pain Allowing the child to explore the postoperative equipment with his hands
Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, which of the following would be most appropriate to determine?
he reasons they choose to use alcohol
The developmental task of the school-aged period, according to Erikson, is gaining a sense of:
industry versus inferiority
A child is brought to the emergency department by his parents because he suddenly developed a barking cough. Further assessment leads the nurse to suspect that the child is experiencing croup. What would the nurse have most likely assessed?
inspiratory stridor
A nurse is reviewing the medical record of a child with hearing loss and notes that the child's hearing loss is in the range 40 to 60 decibels (dB). The nurse interprets this as indicating what level of hearing loss?
moderate loss
The nurse is caring for a child of divorced parents on the postoperative unit. Both parents are with the child upon returning from surgery. The nurse hears the parents arguing just outside the child's room. What is the best response by the nurse?
"I know this is a stressful time, but your child can hear you arguing outside the room."
The nurse is caring for an infant with osteogenesis imperfecta and is providing instruction on how to reduce the risk of injury. Which response from the mother indicates a need for further teaching?
"I must carefully lift the baby from under the armpits."
The nurse is caring for a 2-month-old infant who has been diagnosed with acute heart failure. The nurse is providing teaching about nutrition. Which statement by the mother indicates a need for further teaching?
"I need to feed him every hour to make sure he eats enough."
The mother of a 5-year-old child with allergies to a variety of foods including eggs, milk, peanuts and shellfish, asks if her child will "always have these problems". What response by the nurse is most accurate?
"In most cases allergies to peanuts and shellfish persist into adulthood but the others may diminish and disappear."
The nurse is caring for an active 14-year-old boy who has recently been diagnosed with scoliosis. He is dismayed that a "jock" like himself could have this condition, and is afraid it will impact his spot on the water polo team. Which response by the nurse would best address the boy's concerns?
"Let's talk to another boy with scoliosis, who is winning trophies for his swim team."
The nurse is providing care for a 14-year-old girl with severe acne. The girl expresses sadness and distress about her appearance. Which response by the nurse would be most appropriate?
"Many people feel this way; I know someone who can help."
A nurse is providing instructions to the parents of a 3-month-old with developmental dysplasia of the hip who is being treated with a Pavlik harness. Which statements by the parents demonstrate understanding of the instructions? Select all that apply.
"We should change her diaper without taking her out of the harness." "We need to adjust the straps so that they are snug but not too tight." "We need to check the area behind her knees for redness and irritation."
The nurse is caring for a newborn diagnosed with an atrial septal defect (ASD). The parents voice concern and state, "I can't believe this is happening. Will our child be okay?" What is the nurse's best response?
"While each case is different, the majority of these defects correct on their own. Let's see what the tests show, then speak with the doctor."
The nurse is caring for a 2-year-old girl in a bilateral brace with tibia vara. Her parents are upset by their toddler's limited mobility. Which response by the nurse would be most appropriate?
"You are doing a great job. Let's put our heads together on how to keep her busy." Explanation: The nurse should support the parents by encouraging and praising their compliance with bracing. It is also important to work with the parents to help develop age-appropriate diversions to promote normal growth and development. Telling the parents that they must be compliant or their daughter could develop severe bowing does not teach, does not offer solutions, and does not address the parents' concerns. Telling the parents that they must simply accept this and that the treatment could take years is likely to upset them and does not teach. It also does not address their concerns.
A parent takes the 4-month-old infant to the health care provider. The parent asks what type of baby cereal to provide now that the infant is starting solid foods. How should the nurse respond?
"You should buy rice cereal."
Three children in a family, ages 7 months, 4 years, and 9 years have been tested for lead poisoning. The two younger children's tests reflect elevated lead levels and they will be undergoing treatment. The children's mother questions why her younger children were not "spared" as their older sibling was. What response by the nurse is most correct?
"Younger children are often impacted because of their play behaviors place them on the floors and they often put things into their mouths."
A 6-year-old child with cerebral palsy has been admitted to the hospital for some tests. The child's condition is stable. A parent remains with the child, but the parent is obviously exhausted and stressed. Which response by the nurse would be most appropriate?
"Your child is in good hands; consider going home to get some sleep."
The nurse caring for an infant prepares to perform a heel stick. The parents are at the bedside and ask the nurse if their infant will feel pain when stuck. Which is the best response for the nurse to make?
"Your infant will experience pain for a brief moment when the heel is stuck."
After teaching the parents of a 6-year-old how to administer an enema, the nurse determines that the teaching was successful when they state that they will give how much solution to their child?
500 to 1,000
The nurse is providing guidance after observing a mother interact with her negative 2-year-old boy. For which interaction will the nurse advise the mother that she is handling the negativism properly?
Telling the child firmly that we don't scream in the office
The school nurse providing school health screenings knows that the 7- to 11-year-old is in Piaget's stage of concrete operational thoughts. What should this age group accomplish when developing operations? Select all that apply.
Ability to use stored memories of past experiences to evaluate and interpret present situationspreparations autonomously. Ability to see things from another person's point of view and think through an action Ability to assimilate and coordinate information about the world from different dimensions Ability to understand the principle of conservation -that matter does not change when its form changes
The nurse is providing home care instructions for a 13-year-old girl recently diagnosed with systemic lupus erythematosus. Which response by the girl indicates a need for further teaching?
"I need to wear sunscreen in the summer to prevent rashes."
A nurse is working with an adolescent who is slightly overweight and was recently diagnosed with hypertension. They are discussing nutritional management. Which statement by the adolescent demonstrates understanding of the information?
"I should eat plenty of fresh fruits and vegetables."
The nurse is teaching the mother of a 5-year-old boy with a history of impaction how to administer enemas at home. Which response from the mother indicates a need for further teaching?
"I should position him on his abdomen with knees bent."
The nurse is caring for a 3-year-old girl with short bowel syndrome as a result of trauma to the small intestine. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. How should the nurse respond?
"I will help you become an expert on your daughter's care."
The mother of a 3-week-old infant old brings her daughter in for an evaluation. During the visit, the mother tells the nurse that her baby is spitting up after feedings. Which response by the nurse would be most appropriate?
"Infants this age commonly spit up."
The nurse is caring for a 13-year-old boy in traction prior to surgery for slipped capital femoral epiphysis. He has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. He is complaining that he feels isolated and is resisting further treatment. Which response by the nurse would be most appropriate?
"Let's come up with things to do like books, movies, games, and friends to visit."
The nurse is interviewing a 3-year-old girl who tells the nurse: "Want go potty." The parents tell the nurse that their daughter often speaks in this type of broken speech. What would be the nurse's appropriate response to this concern?
"This is a normal, common speech pattern in the 3-year-old and is called telegraphic speech."
A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information?
"This is a primitive reflex known as the palmar grasp."
The nurse is conducting a physical examination of a child with suspected developmental dysplasia of the hip. Which finding would help confirm this diagnosis?
A distinct "clunk" is heard with Barlow and Ortolani maneuvers.
Immune thrombocytopenic purpura ITP is thought to be an immune response following a viral infection that produces __________ antibodies
Antiplatelet
The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality?
Currant jelly-like
With a diagnosis of hemophilia, part of the teaching plan for the child's parent will include treatment measures to control minor bleeding episodes. these will include?
Bed rest, topical coagulants, and cold compress
A 5-year-old is admitted to the hospital with the tentative diagnosis of leukemia. The child's grandfather asks the nurse to explain how leukemia is diagnosed. Which diagnostic procedure should the nurse discuss?
Bone marrow aspiration
What activity would the nurse expect to find in an 18-month-old?
Climbing stairs with assistance
The school nurse is walking through the lunchroom when one of the children says she started to feel strange after trading lunches with a friend. Which assessment would be most important?
Determining if her throat itches
A 10-year-old girl is brought to the emergency department by her father after tripping over a rock while running in the yard. She tells the nurse, "I think I twisted my ankle." When assessing the child, what would the nurse most likely assess?
Edema
The parents of children with chronic neurological disorders will require large amounts of _______ and support throughout the child's lifetime
Education
A nurse is caring for a 14-year-old girl who received an electrical burn. The nurse would anticipate preparing the girl for which diagnostic tests as ordered?
Electrocardiographic monitoring
A 6-year-old boy has been admitted to the hospital with burns. The nurse notes carbonaceous sputum. What action would be the priority?
Ensuring a patent airway.
The nurse is assessing a 2-year-old boy who has missed some developmental milestones. Which finding will point to the cause of motor skill delays?
The child is homeless and has no toys.
A mother of three brings her children in for their vaccinations. The mother tells the nurse that her mother recently died and her husband just lost his job due to his company downsizing. Which parenting behaviors is the nurse likely to observe? Select all that apply?
The mother becomes very frustrated and tells the nurse she can't handle her toddler's temper tantrum. The mother rarely looks at her infant when the nurse is assessing the child.
A type of play seen in preschool children encourages children to act out troubling situations, such as one that might occur in the hospitalized child who must undergo an upsetting procedure. This type of play is referred to as:
Dramatic play
The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like it just bursts out of his mouth." A diagnosis of hypertrophic pyloric stenosis is suspected. When performing the physical examination, what would the nurse most likely find?
Hard, movable, olive shaped mass in the right upper quadrant
Which statement by a school-age girl indicates a need for further teaching about the prevention of urinary tract infections?
I really enjoy taking bubble bath
Which of the following is the only immunoglobulin capable of crossing the placenta and conferring passive immunity to a fetus?
IgG
A 2-week-old child responds to a bell during an initial health supervision examination. The child's records do not show that a newborn hearing screening was done. Which is the best action for the nurse to take?
Immediately schedule the infant for a newborn hearing screening.
The nurse is preparing a teaching plan for the parents of a child who has been diagnosed with a congenital heart defect. What would the nurse be least likely to include?
Maintenance of strict bed rest
The nurse should assess for hypoxia, fatigue, and ____ in the child with anemia
Pallor
The nurse is assessing an 11-year-old girl with scoliosis. What would the nurse expect to find? Select all that apply.
Pronounced one-sided hump on bending over Asymmetric shoulder elevation
The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?
Risk for impaired skin integrity due to cast and location
The nurse is developing a teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include?
Soaking the area in warm water every day
When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is some soft bedding material, and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because:
Soft bedding material should not be in areas where infants sleep.
9. A care plan for a child with neonatal seizures will include ensuring adequate ________ correcting any underlying metabolic disturbances, and administering anticonvulsant therapy
Ventilation
When reviewing the history of a child with suspected primary immunodeficiency, what would the nurse be least likely to find?
Weight appropriate for height
Why are younger children more prone to otitis media?
Wider, shorter horizontal eustachian tubes
The nurse is caring for an infant with candidal diaper rash. Which topical agent would the nurse expect the physician to order?
antifungals
The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as:
erythema toxicum
Which exercise would the nurse suggest as most helpful to maintain mobility in a child with juvenile idiopathic arthritis?
swimming
A nurse knows the importance of assessing a client's community because:
the health of a person is influenced by the health of the community.
A nurse is reviewing the health records of several 4-month-old infants who were seen in the pediatric office today. Which infant behavior will require referral for further evaluation of growth and development?
unable to support head