206- Exam 6
A child is admitted with a temperature, 101.2°F (38.4°C); pulse rate 100 beats/min; respirations 24 breaths/min. On admission the pain is localized in right lower quadrant. Legs are drawn up against the abdomen. Bowel sounds are sluggish. Rebound tenderness is present. White blood cell count of 17,000/mm3. Ultrasound confirms appendicitis. Which instruction would the nurse give to the child and the parent? a. Do not rub or put pressure on the abdomen. b. Drink cool fluids to reduce the temperature. c. Use a heating pad to decrease the abdominal discomfort. d. Place an ice pack over the place of the discomfort.
a
A child's mother asks the nurse how likely it is the child will develop asthma because the child's father has asthma. Which response by the nurse is most appropriate? a. "Immune responses can be genetic and run in the family." b. "We don't know why children develop immune disorders." c. "Asthma can be prevented by avoiding any family allergens." d. "Your child will develop asthma since the father has asthma."
a
A parent brings the 2-week-old newborn to the office because the infant has been experiencing gastroesophageal reflux over the past week. Which intervention(s) should the nurse recommend to the parent at this point? Select all that apply. a. Feed the infant a formula thickened with rice cereal. b. Feed the infant while holding the infant in an upright position. c. Keep the infant upright in an infant chair/car seat for 30 minutes after feeding. d. If breastfeeding, switch to feeding the infant formula. e. Consult the heath care provider regarding having botulinum toxin injected into the lower esophageal sphincter. f. Consult a pediatric surgeon regarding having a myotomy procedure performed.
a, b, c
A school-aged child is brought to the emergency room with severe abdominal pain. The nurse performs a physical assessment. Which assessment parameters indicate appendicitis? Select all that apply. a. Normal to hyperactive bowel sounds early b. Hypoactive bowel sounds with perforation c. Irritation and pain in the right lower quadrant d. Low-grade fever, nausea, anorexia, and vomiting e. Rebound tenderness present with palpation in the left upper quadrant f. Distended abdomen with unperforated appendicitis
a, b, c, d
A child allergic to insect stings presents to the school nurse stating, "A bee stung me on the playground." Which action by the nurse is priority? a. Notify the client's caregivers and primary health care provider b. Assess the client's airway and breathing rate c. Administer epinephrine subcutaneously to the client d. Locate the stinger and remove it with tweezers
b
A nurse is caring for a child who has had watery diarrhea for 3 days. Which of the following is an action for the nurse to take? a. offer chicken broth b. initiate oral rehydration therapy c. start IV with hypertonic solution d. keep child NPO until diarrhea subsides
b
A nurse is teaching a group of teens about HIV & AIDS. Which of the following statements should the nurse include in the teaching? a. you can contact HIV through casual kissing b. HIV is transmitted via IV substance use c. HIV is now curable if caught early d. meds inhibit transmission of the HIV virus
b
Which of the following is a complication of enuresis? a. UTI b. emotional problems c. urosepesis d. progressive kidney disease
b
A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child's care plan should be given priority? a. Beginning active range-of-motion exercises b. Seeing that the child ingests a protein-rich diet c. Maintaining fluids through an intravenous line d. Encouraging the child to take deep breaths hourly
c
After teaching a group of students about hemophilia, the instructor determines that the students have understood the information when they identify hemophilia A as involving a problem with: a. platelets. b. factor IX. c. plasmin. d. factor VIII.
d
What is the typical pain presentation of a pt with appendicitis? a. pain starts in the left side below the belly button b. pain is diffuse all over the abd c. pain starts in the LUQ radiating to the shoulder d. pain starts around the umbilicus and then moves to the RLQ
d
Which of the following findings would the nurse expect to see in a child with chronic renal failure? a. flushed face b. hyperactivity c. wt gain d. delayed growth
d
Which of the following isolation precautions should the nurse implement for a pt with AIDS? a. contact b. airborne c. droplet d. standard
d
A school-aged child, who is allergic to bee stings, states, "I think I was stung by a bee outside." Which intervention by the school nurse is most appropriate? a. Assess the client for signs of anaphylactic shock b. Administer epinephrine c. Determine if the client was stung d. Apply an ice compress to the site
a
A pt with appendicitis suddenly develops tachycardia & tachypnea with a high fever. Which intervention would have the highest priority? SATA a. call the surgeon as the appendix may have perforated b. apply a warm compress to the abd c. maintain NPO status d. apply pressure to abd e. initiate IV NS
a, c, e
During a routine assessment, the nurse determines that a school-age child has head lice. What did the nurse assess in this child? a. macular rash on the arms b. white flecks on hair shafts c. red raised rash on the neck d. pustule formation on the trunk
b
A nurse is planning care for a child that has a UTI. Which of the following interventions should the nurse include? a. admin an antidiuretic b. restrict fluids c. evaluate child' self esteem d. encourage child to void frequently
d
A nurse is caring for a child who has suspected Enterobius vermicularis. Which of the following actions should the nurse take? a. perform tape test b. collect stool specimen for culture c. test stool for occult blood d. initial IV fluids
a
A nurse is caring for a school age child dx with nephrotic syndrome. Which of the following findings should the nurse report to the HCP? a. blood protein 5.0 b. Hgb 14.5 c. Hct 40 d. platelet 200,000
a
A preschooler has celiac disease. The parent is preparing a gluten-free diet. The nurse knows that the parent understands the diet when the parent prepares which breakfast foods? a. Eggs and orange juice b. Wheat toast and grape jelly c. Cheerios (oat cereal) and skim milk d. Rye toast and peanut butter
a
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting? a. Only occurs with feeding b. Is projected 1 ft away from infant c. Is curdled and extremely sour smelling d. Continues until stomach is empty
a
A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child? a. pyloric stenosis b. peptic ulcer disease c. gastroesophageal reflux d. appendicitis
a
The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child? a. Effortless vomiting just after the child has eaten b. Forceful vomiting followed by the child being eager to eat again c. Severe constipation with occasional ribbon-like stools d. Bouts of diarrhea with failure to gain weight
a
While assessing a child, the nurse notes a runny nose, temperature 100.4°F (38°C), and a whoop sound when the child coughs. On which diagnosis will the nurse anticipate providing education for this family? a. pertussis b. tuberculosis c. influenza d. nasopharyngitis
a
The nurse teaches a parent to differentiate between regurgitation and vomiting in the infant. The parent correctly states which characteristic of regurgitation? Select all that apply. a. occurs with feeding b. no appearance of distress c. followed by dry retching d. forceful expulsion of stomach contents e. timing unrelated to feeding
a, b
A nurse is assessing a child pt that has a rotavirus infection. Which of the following is a suspected manifestation? SATA a. fever b. vomiting c. watery stools d. bloody stool e. confusion
a, b, c
A nurse is preparing a presentation for a group of new parents and is planning to discuss nutrition during the first year. As part of the presentation, the nurse is planning to address foods that should be avoided to reduce the risk of possible food allergies. Which foods would the nurse most likely include? Select all that apply. a. Eggs b. Shrimp c. Peanuts d. Carrots e. Potatoes f. Bananas
a, b, c
Which of the following findings would a nurse expect to find in a chid with nephrotic syndrome? SATA a. urine dipstick 2+ protein b. edema in the ankles c. hyperlipidemia d. polyuria e. anorexia
a, b, c, e
A nurse is teaching the caregiver of an infant about GERD. Which of the following should the nurse include in the teaching? SATA a. offer frequent feedings b. thicken formula with rice cereal c. use a bottle with a 1 way valve d. position the infant upright after feeding e. use a wide based nipple for feeding
a, b, d
A public health nurse is instructing on the short-term and long-term effects of sexually transmitted infections. Which effects would be included? Select all that apply. a. emotional stress b. implications for fertility c. risk for developing diabetes d. relationships with future partners e. risk for hypertension
a, b, d
Food allergies have become more and more common in the last few decades. What are some common food allergies of childhood? Select all that apply. a. Eggs b. Peanuts c. Cheerios d. Milk e. Apples
a, b, d
A nurse is assessing a baby with hypertrophic pyloric stenosis. Which of the following s/s should the nurse expect? SATA a. projectile vomiting b. dry mucus membranes c. currant jelly stools d. sausage-shaped abd mass e. constant hunger
a, b, e
A nurse is admitting a child with severely symptomatic HIV. Which of the following findings should the nurse expect? SATA a. kaposi's sarcoma b. hepatitis c. wasting syndrome d. pulmonary candidiasis e. cardiomyopathy
a, c, d
A nurse is teaching a caregiver of a child who has HIV. Which of the following should the nurse include in the info? SATA a. obtain flu vaccine yearly b. monitor fever 24 hrs before seeking medical care c. avoid people who have colds d. provide nutritional supplements e. admin ASA for pain
a, c, d
A nurse is teaching a group of parents about E.Coli. What info should the nurse include in the teaching? SATA a. severe abd cramping occurs b. watery diarrhea is present for 5 days or more c. it can lead to hemolytic uremic syndrome d. it is a food borne pathogens e. antibiotics are used for tx
a, c, d
Which instructions should a nurse give to a client who has a history of urinary tract infections to prevent recurrence? Select all that apply. a. Wipe from front to back. b. Use bubble bath to wash. c. Encourage fluids throughout the day. d. Finish all antibiotics prescribed. e. Limit bathing to once a week.
a, c, d
The nurse should identify which of the following findings as in indication that the child is in the middle symptomatic category of HIV? SATA a. herpes zoster b. anemia c. oral candidiasis d. hepatomegaly e. lymphadenopathy
c, d, e
A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant? a. Upper left b. Upper right c. Lower left d. Lower right
d
A 4-year-old boy with nephrotic syndrome has extensive edema. The best intervention to reduce periorbital edema would be to: a. apply cool, sterile soaks to his head. b. encourage him to eat low-protein foods. c. apply warm compresses to his eyes at bedtime. d. elevate the head of the bed.
d
A 6-month-old girl is diagnosed as having atopic dermatitis. When interviewing her parents, they describe the following care measures. Which one would lead you to think more health teaching is needed? a. The mother gives her a daily bath without using soap. b. After a bath, the mother applies Eucerin cream. c. To aid healing, the father applies hydrocortisone cream to the lesions. d. To dry lesions, the father applies alcohol to lesions daily.
d
A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described? a. Refusal to eat b. Vomiting about 2 hours after feeding c. Chronic diarrhea d. Vomiting immediately after feeding
d
The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is: a. steatorrhea. b. severe diarrhea. c. currant jelly stools. d. projectile stools.
a
The mother of a 5-year-old girl brings the child to the clinic for an evaluation. The mother tells the nurse, "She seems to be so tired and irritable lately. And she looks so pale." Further assessment reveals pale conjunctiva and oral mucous membranes. The nurse suspects iron-deficiency anemia. Which additional finding would help provide additional evidence for this suspicion? a. Spooned nails b. Negative splenomegaly c. Oxygen saturation: 99% d. Bradycardia
a
An 11-year-old girl arrives at the doctor's office with fever, a sore throat, chills, and malaise. A throat culture indicates scarlet fever. Which other symptom should the nurse notice in this client that clearly indicates scarlet fever? a. The tongue has a white or red "strawberry" appearance b. There is pain along the jawline just in front of the ear lobe c. Vesicles that become purulent, ooze, and form honey-colored crusts d. Fever blisters on the lips
a
In caring for a child with nephrotic syndrome, which intervention will be included in the child's plan of care? a. Weighing on the same scale each day b. Ambulating 3 to 4 times a day c. Increasing fluid intake by 50 ml per hour d. Testing the urine for glucose levels regularly
a
Nursing students correctly label the group of cells whose job is to ingest, engulf, and neutralize pathogens as: a. macrophages. b. immunogens. c. immunoglobins. d. red blood cells.
a
While observing the parents feeding a neonate with pyloric stenosis, the nurse notes that the parents are becoming frustrated. The nurse identifies a nursing diagnosis of risk for impaired parenting related to frustration and difficulty feeding the neonate. Which would be appropriate for the nurse to include in the plan of care? Select all that apply. a. encouraging rooming in with the neonate b. helping them understand their stress level contributes to the neonate's vomiting c. assisting the parents in holding and feeding their neonate d. pointing out positive aspects about their neonate e. informing the parents that the condition will require them to adjust their lifestyles
a, c, d
The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis? a. Explosive diarrhea b. Projectile vomiting c. Severe abdominal pain d. Frequent urination
b
The nurse is caring for a child whose family recently emigrated from a developing country. While completing the admission history, the parents report all the child's immunizations are up to date. Which nursing action is most appropriate? a. Administer varicella and meningococcal vaccines. b. Ask parents which immunizations have been given. c. Document that immunizations are up to date in the chart. d. Request parents follow WHO vaccine recommendations.
b
The parents ask the nurse how to prevent their child from becoming sick. Which response by the nurse is most appropriate? a. "A daily multi-vitamin will boost the immune system." b. "Handwashing is an effective way to prevent infection." c. "Remind your child to cover the mouth when coughing." d. "Clean your bathroom and kitchen when they look dirty."
b
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? a. Sausage-shaped mass in the upper mid-abdomen b. Hard, moveable, olive-shaped mass in the right upper quadrant c. Tenderness over the McBurney point in the right lower quadrant d. Abdominal pain in the epigastric or umbilical region
b
A nurse is teaching a group of caregivers about Salmonella. What info should the nurse include in the teaching? SATA a. incubation period is nonspecific b. it is a bacterial infection c. it is common to have bloody diarrhea d. transmission can be from pets in the home e. antibiotics are used for tx
b, c, d
A nurse is teaching a mother of a child that has a UTI. Which of the following should the nurse include in the teaching? SATA a. wear nylon underwear b. avoid bubble baths c. empty bladder completely every time voids d. watch for s/s of infection e. wipe back to front
b, c, d
Which of the following are s/s of a UTI in a child? SATA a. night sweats b. swelling of the face c. pallor d. pale colored urine e. fatigue
b, c, e
Which of the following s/s would the nurse expect to see in a child with acute post-streptococcal glomerulonephritis (APSGN)? SATA a. pale urine b. periorbital edema c. ill appearance d. decreased creatinine e. HTN
b, c, e
A nurse is caring for an infant suspected of having a UTI. Which of the following is an expected s/s? SATA a. increased hunger b. irritability c. decreased urination d. vomiting e. fever
b, d, e
A 9-month-old infant with iron-deficiency anemia is given ferrous sulfate therapy. Which assessment would best help the nurse determine that the infant is actually taking it daily? a. The reticulocyte count will have decreased. b. The infant will develop diarrhea. c. The stools will appear black. d. The infant will be more irritable than at the last visit.
c
A nurse is conducting a class to a group of parents on sickle cell anemia. Which statement by a parent indicates teaching has been effective? a. "This is a hereditary disease that is transmitted by one affected gene." b. "Sickle cell anemia is common in people of Asian descent." c. "The sickle shape of red blood cells decreases oxygen to tissues." d. "Fluid restriction is necessary to control sickle cell anemia."
c
An adolescent asks the nurse how to best prevent vulvovaginitis. The nurse's best answer would be to: a. apply personal hygiene sprays if vaginal odor develops. b. use nylon rather than cotton underpants to decrease moisture. c. wipe from front to back after urinating or defecating. d. soak in a strong bubble bath solution to maintain hygiene.
c
The nurse is preparing a child for discharge following a sickle cell crisis. Which statement by the mother indicates a need for further teaching? a. "She loves popsicles, so I'll let her have them as a snack or for dessert." b. "I bought the medication to give to her when she says she is in pain." c. "She has been down, but playing in soccer camp will cheer her up." d. "I put her legs up on pillows when her knees start to hurt."
c
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? a. Greasy b. Clay-colored c. Currant jelly-like d. Bloody
c
The parents are concerned their child with atopic dermatitis is having an allergic reaction to diphenhydramine because the child became "sleepy and has a dry throat" after receiving the medication. Which education provided to the parents by the nurse is most important? a. "Children with eczema are more likely to have a medication allergy." b. "Your child is exhibiting signs and symptoms of an allergic reaction." c. "Side effects, such as drowsiness and dryness, do not indicate an allergy." d. "Toxic amounts of diphenhydramine can cause this response in children."
c
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? a. Asking if she has a rash anywhere b. Checking if she has any nausea c. Determining if her throat itches d. Asking if she has abdominal pain
c
While caring fo a child with acute glomerulonephritis, the nurse knows which clinical assessment finding is priority to monitor? a. proteinuria b. urine output c. blood pressure d. daily weight measurements
c