6020 Peds
An eight-year-old has been receiving chemotherapy for six months. During her nursing care she asks: "Am I going to die?" Which of the following responses by the nurse is BEST?
"Are you afraid of dying?"
Which of the following statements, if made to the nurse, indicates parental understanding about the cause of their newborn's diagnosis of cystic fibrosis (CF)?
"Both of us carry a recessive trait for cystic fibrosis."
During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST?
"Children develop trust from birth to 18 months of age."
A father brings his 15-month-old son to the well-baby clinic for a routine check-up. The father confides to the nurse that he is concerned that his son still crawls and does not walk. Which of the following responses, if made by the nurse to the father, is BEST?
"Children frequently set their own pace for development."
A mother tells you that the seven-year-old sibling of her child with cystic fibrosis is having difficulty in school, fights frequently with playmates, and throws his toys. Which of the following would be the BEST response by the nurse?
"Did he have these behaviors before his sister was diagnosed?"
During the nursing history interview, a preschool client's mother reports that the child has frequent bouts of gastroenteritis. It would be MOST important for the nurse to ask which of the following questions?
"Does the child attend a day care center?"
During the discharge planning session for a chronically ill infant, the nurse observes that the single mother nervously paces most of the time while bouncing the infant in her arms. Which of the following suggestions by the nurse is BEST?
"Enroll in a Volunteers of America parenting class."
Following treatment for Addison's disease in a seven-year-old patient, the nurse plans for the client's discharge. The mother asks how long her daughter must continue receiving replacement therapy. The nurse's response should be
"For the rest of her life."
The nurse is working in a pediatric clinic and takes a phone call from the mother of a threeyear- old who has vomited several times today. Which of the following instructions by the nurse is BEST?
"Give your child some apple juice."
The nurse receives a phone call from a nursing assistant who states that her five-year-old child has developed chickenpox. It would be MOST important for the nurse to ask which of the following questions?
"Have you had the chickenpox?" "Do you have someone to watch your child?"
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home. Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?
"He will be well enough to play in his soccer game tomorrow."
The parents of a child who has just been diagnosed with a chronic illness share with the nurse that they are concerned about the sibling's sudden change in behavior. Which of the following is the BEST response by the nurse?
"Her brother is feeling left out right now, but we plan to include him in his sister's care."
A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if the client makes which of the following statements?
"I can remove the brace for one hour a day."
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry. Which of the following comments by the nurse is the MOST appropriate?
"I know you are frightened. It will be over with soon."
The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
"I should induce vomiting if my child swallows lighter fluid."
The school nurse is interviewing a 15-year-old boy. The nurse would be MOST concerned if the adolescent made which of the following statements?
"I'm glad I don't get as sweaty as my friends when I work out."
A six-year-old girl is admitted to the pediatric unit with a diagnosis of bacterial meningitis. As the nurse explains care to the parents, they ask how long their daughter will need to be in a room by herself. Which response by the nurse would be MOST appropriate?
"Isolation can usually be stopped 24 hours after the start of antibiotic therapy."
The mother of an eight-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse?
"It is an unlikely possibility, but if your child doesn't develop normally, your pediatrician will help you with any problems."
The nurse is instructing the parents of a child with celiac disease. The nurse knows that teaching has been effective when the parents make which of the following statements?
"My child's diet should be high in calories, high in protein, and restrict foods containing rye, oats, wheat, and barley."
The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?
"My daughter has almost doubled her birth weight."
An 11-year-old boy fell off his bicycle and sustains a minor head injury, which is treated at the outpatient clinic. The nurse instructs the boy's mother about his care at home. The nurse determines that further teaching is necessary if the mother makes which of the following statements?
"My son can drink carbonated beverages if he vomits."
A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
"My son is fussy and seems hungry all the time."
The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent future asthmatic attacks. The nurse would be MOST concerned if the mother made which of the following statements?
"My son loves to help his dad rake leaves."
While a two-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST?
"The corrective surgery will not change your child's physical disability."
The parents of a child with hemophilia want to know the cause of the disease. Which of the following would be the BEST response by the nurse?
"The mother transmits the gene to her son."
The nurse is caring for clients in outpatient surgery. The mother of a four-year-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST?
"Use dolls or puppets to explain how to get ready for surgery."
The nurse obtains a history from the father of a six-year-old boy with a history of epilepsy admitted with uncontrolled seizures. It is MOST important for the nurse to ask which of the following questions?
"What was your son doing before the seizure?"
The nurse is aware that which of the following statements, if made by the parents of a four-yearold child with sickle cell anemia, indicates a need for further teaching?
"When my daughter complains of pain, I give her baby aspirin."
The parents of a newborn with a meningocele have been grieving the loss of their perfect child. After three days of grieving, the progress in their emotional status would be indicated to the nurse by which of the following comments?
"When will it be safe for us to hold our baby?"
The nurse is preparing an adolescent for a lumbar puncture. It is MOST important that the nurse make which of the following statements?
"You will remain flat in bed for eight hours after the test."
A mother brings her 7-year-old daughter to the outpatient clinic for a routine check-up. The girl weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that she has gained 2.5 pounds and has grown 3 inches in the past year. Which of the following responses by the nurse is BEST?
"Your daughter's height and weight are within normal limits."
The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?
20 months of age.
The nurse in the pediatrician's office observes a child in the waiting room. The nurse notes the child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. The nurse identifies the child's chronological age to be
3 years old.
The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" with the nurse and is starting to say "mama" and "dada." The nurse would expect these behaviors in a child that is
9 months of age.
The nurse is supervising care of a group of children in a day care facility. The nurse would intervene in which of the following situations?
A 4-year-old is given paper to write to a pen pal.
A young child is placed on droplet precautions. The nurse is caring for which of the following clients?
A child with pertussis.
The neonatal nurse is instructing the family of a newborn about an apnea monitor. The nurse should be MOST concerned if a family member makes which of the following statements?
A family member will closely watch the monitor all the time.
The nurse is caring for patients on the pediatric unit. An eight-year-old patient with second- and third-degree burns on the right thigh is admitted. The nurse should assign the new patient with which of the following roommates?
A four-year-old with asthma.
The nurse is caring for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST?
A mother reports that the "soft spot" on the head of her four-day-old infant feels slightly elevated when the baby sleeps.
A three-month-old is placed in Bryant's traction for developmental dysplasia of the hips. Which of the following toys would be appropriate for the nurse to offer the infant during hospitalization?
A rattle.
In planning diet teaching for a child in the early stages of nephrotic syndrome, the nurse should discuss with the parents which of the following dietary changes
Adequate protein intake, low sodium.
A child admitted with failure to thrive has just had a positive sweat test. The nurse would anticipate which of the following changes in the child's plan of care initially?
Administration of replacement enzymes.
The nurse cares for a newborn infant with fetal alcohol syndrome. The nurse would expect to see which of the following physical characteristics?
An infant with a small head circumference, low birth weight, and undeveloped cheekbones.
During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint?
An infant with cleft lip repair.
The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
Assess orientation to person, place, and time every hour.
The nurse is caring for a teenaged boy in Buck's traction. It is MOST important for the nurse to take which of the following actions?
Assess that the elastic bandages are not too loose or too tight.
The nurse is discussing growth and development with the parents of a four-year-old child. The nurse should identify which of the following as the type of play characteristic of this age group?
Associative play.
A mother brings her nine-month-old child to the pediatrician's office for complaints of a fever of 102.2°F (39°C) and frequent vomiting. The nurse would expect which of the following reflexes to still be present?
Babinski's reflex.
The nurse is preparing discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) test?
Breast-fed babies need to be a week old for the test, and infants on formula can be tested in three days.
The infant of a diabetic mother has a blood glucose of 90 mg/dL and a serum calcium level of 7.0 mg/dL. The nurse should anticipate that which of the following medications would be administered IV?
Calcium gluconate
A physician has written an order for an HIV-positive infant to receive an oral polio immunization. Which of the following nursing actions is MOST appropriate?
Call the physician and discuss the rationale for the immunization.
The nurse is caring for a six-year-old boy several hours after the application of a hip spica cast. The atient turns on the call light and complains of pain in his left foot. Which of the following actions should the nurse take FIRST?
Check the blanching sign on both feet
An 8-year-old girl has a closed transverse fracture of her right ulna. Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
Check the radial pulses bilaterally and compare
A 12-year-old boy injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. His right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy has hemophilia A. Which of the following medications would be BEST for this patient?
Codeine phosphate (Paveral).
The nurse knows that which of the following diversional activities is most appropriate for a tenyear- old female client recovering from a sickle-cell crisis?
Collecting pictures of favorite stars from magazines.
A school-aged child informs the school nurse that his right knee "doesn't feel right." Which of the following actions should the nurse take FIRST?
Compare the appearance of the right knee with the left knee.
A four-month-old infant who had a temperature of 103°F (39.4°C) following his last DTP (diphtheria, tetanus, and pertussis) vaccine is seen in the clinic for another immunization administration. Prior to the nurse's administering the DTP, which of the following should be a priority?
Consult the physician about giving pediatric DT (diphtheria and tetanus).
The school nurse notes that one of the children has a copious watery discharge from the left eye, which is red. Which of the following actions, if taken by the nurse, is BEST?
Contact the child's parents to pick up the child.
The nurse is caring for a toddler in traction, and the toddler is receiving chloral hydrate (Noctec). The toddler becomes irritable and extremely restless. Which nursing action is MOST appropriate?
Contact the physician to obtain new orders.
The nurse is preparing a five-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST?
Continue the child's preoperative preparation
During the health history, a teenaged girl states "I have no appetite and I've lost 4 pounds this week." It is MOST important for the nurse to take which of the following actions?
Continue with the interview.
The mother of a seven-year-old child is dying. The nurse should anticipate that the seven-year-old child would have which of the following concepts of death?
Death is punishment for his/her actions.
A 7-year-old girl is seen in the clinic with a diagnosis of pituitary dwarfism. Which of the following clinical manifestations is the nurse MOST likely to observe?
Delicate features.
A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?
Do a mock run-through of the procedure.
Which of the following plans would be MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
Draw a picture of a heart and explain where the tube will go and what the doctor will see.
The nurse is caring for a two-month-old infant. A pH probe test indicates that the infant has reflux. Which nursing action is MOST appropriate?
Elevate the head of the bed.
Which of the following interventions should be the priority during the nursing care of a two-monthold infant after surgery?
Encourage the parents to stroke the infant.
An infant is admitted for vomiting and diarrhea. The infant's anterior fontanelle is depressed, and he has a fever of 103.2°F (39.5°C). Which of the following nursing actions would be MOST appropriate?
Evaluate infant's ability to take in fluids.
The nurse is caring for an eight-year-old child after a tonsillectomy. The nurse would be MOST concerned if which of the following was observed?
Expectorating bright red secretions.
During a well-baby check-up the nurse evaluates the reflexes of a six-month-old child. The nurse would be MOST concerned if which of the following was observed?
Extrusion reflex when feeding.
An 8-year-old boy is brought to the physician's office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
Gently flex the child's head and neck onto the chest.
In planning anticipatory guidance for parents of a beginning school-aged child, it is MOST important for the nurse to include which of the following?
Give the child responsibility around the house.
Which of the following nursing observations would indicate to the nurse that a child with epiglottitis is having an early complication of hypoxemia?
Heart rate of 148 beats per minute.
The nurse is planning a diet for an eight-year-old with cystic fibrosis (CF). Which of the following dietary requirements should be considered?
High protein, low fat, and high calories.
A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure?
High-pitched cry.
A three-month-old patient is experiencing increased intracranial pressure (ICP). Which of the following assessment findings should the nurse report to the physician?
High-pitched cry.
A spica cast has been applied to a 14-month-old with developmental dysplasia of the hips. Which of the following would be MOST appropriate for the nurse to teach the parents?
Inspect the skin around the cast.
A staff member informs the nurse that his six-year-old child has head lice. It is MOST important for the nurse to take which of the following actions?
Inspect the staff member's head for louse and nits.
An 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse should expect to find which of the following early symptoms?
Inspiratory stridor and restlessness
The nurse knows that which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
Intimacy versus isolation.
A 12-year-old client is admitted to the pediatric unit in vaso-occlusive crisis from sickle cell anemia. As the nurse prepares the plan of care, which of the following orders should the nurse question?
Maintain IV at keep open rate.
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
Maintain aseptic technique during procedures.
Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella?
Maintain contact precautions.
A toddler with lead poisoning is admitted to the pediatric unit. There is an order to encourage fluids. Which of the following fluids would be the best for the nurse to offer to the child?
Milk.
A 12-year-old child is receiving intravenous theophylline (Aminophylline). The child presents with signs of tachycardia and irritability. Which of the following nursing actions is MOST appropriate?
Notify and advise the physician of the child's status.
A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST?
Notify the child's parents.
An 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which of the following actions by the nurse is BEST?
Observe the child at mealtime.
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
Perform a family assessment to assist in the planning of intervention.
The public health nurse is caring for a child with impetigo. The nurse would be MOST concerned if which of the following was observed?
Periorbital edema.
The home health nurse has been making home visits to follow the progress of a two-year-old boy with Tetralogy of Fallot. When the nurse visits the home, the child is found diaphoretic and short of breath. What should the nurse do FIRST?
Place the boy in the knee-chest or squatting position.
Which nursing action is MOST appropriate when an infant is admitted for fever, poor feeding, irritability, and a bulging fontanelle?
Place the client on droplet precautions.
Which of the following nursing approaches would be MOST appropriate to use while administering an oral medication to a four-month-old?
Place the medication in an empty nipple and allow the infant to suck.
The nurse is assessing an infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which of the following nursing actions would be MOST appropriate?
Position the infant on one side.
To assist a mother in providing appropriate foods for her three-year-old daughter, the nurse would identify which of the following as the HIGHEST priority?
Provide the child with finger foods.
A two-year-old is admitted to the pediatric unit with numerous bruises, a fractured left humerus, and several lacerations with unexplained origin. The nurse would identify which of the following as a priority nursing action?
Report the findings to the Child Protection Agency.
The nurse cares for an 8 lb, 8 oz newborn boy. The infant's history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed?
Respirations 18.
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM one hour ago?
Results from the incentive spirometer have improved.
A new mother is taking her infant home. The client asks the nurse when she should start giving her child solid foods. The nurse's response should be based on which of the following statements?
Rice cereal is usually the first solid food and is started around four to five months.
A toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate (Calcium EDTA) and dimercaprol (BAL). Which of the following nursing actions should have the highest priority?
Rotate the injection sites.
The nurse should look for which of the following in assessing pain in an eight-month-old infant?
Rubbing a body part and crying.
A six-month-old is brought to the clinic for a well-baby check-up. During the exam, the nurse should expect to assess which of the following?
Sitting with support.
The newborn infant of an HIV-positive mother is admitted to the nursery. Which of the following would the nurse include in the plan of care?
Standard precautions.
A four-year-old is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse would identify which of the following symptoms as indicative of an increase in respiratory distress?
Tachypnea.
While doing a physical examination of a one-year-old child, which of the following assessments should be done by the nurse LAST?
Take a rectal temperature.
A 14-year-old client is admitted for insertion of a Harrington rod due to scoliosis. In preparation for the immediate postoperative care, the nurse should include which of the following in a teaching plan for this client?
Take ten deep breaths every two hours.
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a five-year-old boy?
The boy talks on a toy telephone and imitates his father.
The nurse assesses the development of a three-month-old boy in the well-baby clinic. Which of the following behaviors, if observed by the nurse, would be UNEXPECTED?
The boy tries to grasp a toy just out of reach.
A 13-year-old male with muscular dystrophy (MD) has just developed nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements?
The catheter can be removed during the day.
A mother brings her two-year-old boy to the pediatrician's office. Which of the following symptoms would suggest to the nurse that the child has strabismus?
The child closes one eye to see a poster on the wall.
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
The child is able to state his name when asked who he is.
The nurse is assessing a child with cystic fibrosis. The nurse would be MOST concerned if which of the following was observed?
The child is expectorating thick yellow mucus.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?
The child is placed in a private room.
Which of the following guidelines is appropriate for the nurse to give a mother concerning the developmental stage of her seven-year-old daughter?
The child's periods of shyness are to be expected.
Which of the following assessments would be a priority when documenting the nursing history of a two-year-old child?
The child's rituals and routines at home.
The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations are expected with scoliosis?
The girl's thoracic area is asymmetrical.
The homecare nurse is visiting an infant who had a myelomeningocele repair. The homecare nurse determines that the parents are accepting of their infant if which of the following is observed?
The parents measure the head circumference daily.
A 16-year-old boy is admitted to the hospital after sustaining a concussion due to an auto accident. The nurse would be MOST concerned if which of the following was observed?
The patient's blood pressure changes from 130/88 to 150/74.
The nurse performs the Rinne tests on a 6-year-old girl. Which of the following is an accurate statement of how this test should be performed?
The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal.
The nurse is performing a homecare visit on the family of a toddler. The nurse would be MOST concerned if which of the following was observed?
The toddler's immunizations are not up-to-date.
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?
There is clear fluid draining from the client's right ear.
A 5-year-old boy is brought to the emergency room after ingesting a bottle of baby aspirin. The nurse should observe the boy for which of the following signs and symptoms?
Tinnitus and gastric distress.
A six-month-old infant has had all of the required immunizations. The nurse knows this would include which of the following?
Two doses of diphtheria, tetanus, and pertussis vaccine.
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip. If a diagnosis of unilateral dislocation of the right hip is made, which of the following symptoms will the nurse observe?
Uneven gluteal fold and thigh creases.
The nurse is caring for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked." The nurse should assess which of the following cranial nerves?
VII.
The nurse is obtaining a health history from the mother of a child with failure to thrive. Which of the following assessments would provide the MOST pertinent data?
Weight and height.
A three-year-old boy was shown to have delays on the Denver Development Screening Test (DDST). The mother asks the nurse, "Does this mean my child is going to be slow?" Which of the following responses by the nurse is BEST?
What are your thoughts about how your child performed on the test?"
The clinic nurse is giving instructions to the family of a school-aged child who was diagnosed two weeks ago with hepatitis A. The family asks if the child can return to school. Which of the following responses by the nurse is BEST?
Your child may return to school this week."
To minimize the side effects of a DPT immunization for a six-month-old, the nurse should instruct the parents to
administer antipyretics for discomfort, irritability, and fever.
A six-year-old boy comes to the outpatient clinic for a routine exam. His mother is concerned because her son often talks to an "imaginary best friend." The nurse should advise the mother to
allow her son to engage in imaginary play.
The nurse talks to a 26-year-old woman in the emergency department (ED) immediately after her son's death from Sudden Infant Death Syndrome (SIDS). The nurse should
allow her to cry and talk about her son.
A child has pediculosis capitis (head lice) and is being treated with 1% gamma benzene hexachloride (Kwell) shampoo. The nurse should explain to the child's parents that
application of the shampoo is repeated in 7 to 10 days.
A four-month-old child is admitted with a tentative diagnosis of meningitis. To confirm the diagnosis,a lumbar puncture (LP) is ordered. While assisting the physician with the procedure, it is MOSTimportant for the nurse to
appropriately restrain the child.
A 10-year-old boy, weighing 50 lbs (23.6 kg), returns from surgery for a skin graft to his left leg. The patient has an IV of D5W infusing into his left arm. The physician's orders read, "D5W 2,000 cc/24 h." It is MOST important for the nurse to
call the physician to clarify the IV fluid order.
The mother of a 10-year-old boy with IDDM (insulin-dependent diabetes mellitus) calls to discuss the child's self-monitoring blood glucose (SMBG) home readings. He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two mornings his blood sugar readings were 220 mg/dl and 210 mg/dL. The nurse should advise the mother to
check his blood sugar during the night.
The nurse is caring for patients on the pediatric unit. The mother of a two-year-old who is one-day postoperative tells the nurse, "My child is so restless and overactive." The nurse should
check to see when the child last received pain medication.
The nurse is caring for a child following a hernia repair. Several hours after surgery, the nurse finds the knee gatch on the patient's bed elevated. The patient says he feels better with it elevated. The nurse should
check to see when the patient last received pain medication.
A mother brings her 10-year-old and 3-year-old daughters to the pediatrician's office because the younger girl complains of dysuria. The physician orders a catheterization to obtain a urine specimen. The nurse should
describe the procedure to the child in short, concrete terms while talking calmly.
The nurse in the outpatient clinic assists with the application of a cast to the left arm of a five-year old girl. After the cast is applied, the nurse should
elevate the client's left arm on two pillows.
A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident.The nurse knows preoperative teaching for this client should include
encouraging the client to share his feelings and fears about the surgery.
A two-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse. An appropriate nursing diagnosis is high risk for.
fluid volume deficit.
A baby girl weighing 7 lb 4 oz with Apgar scores of 7 and 8 at one and five minutes is admitted to the nursery. Because her mother is a type I diabetic, the nurse knows the infant is at GREATEST risk for developing
hypoglycemia.
A 2-month-old boy with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that her son had a DPT injection one week ago, and asks if this fever is related to the immunization. The nurse's response should be based on the knowledge that
if there is a fever after a DPT, it is usually low-grade and appears within the first 48 hours.
The nurse enters the room of a 12-year-old girl and finds that the tracheostomy tube inserted 2 days ago has been accidentally dislodged. The nurse should
immediately replace the tracheostomy tube.
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
in semi-Fowler's position.
A 14-year-old girl is brought to the hospital for treatment of second- and third-degree burns sustained in a house fire. An intravenous infusion is started in the patient's left forearm. The nurse knows that the primary purpose of the IV is to
maintain fluid balance.
The nurse is caring for a three-month-old infant that is scheduled for a barium swallow in the morning. Prior to the procedure, the MOST appropriate nursing action would be to
make the infant NPO for three hours.
The mother of a child with chickenpox asks the physician's office nurse why her child will not come down with chickenpox again if exposed to the virus at school at a later date. The nurse's response should be based on the information that
natural active immunity occurs because the child's body actively makes antibodies against the ___?? (missing)
The nurse is caring for a child in Bryant's traction. During the neurovascular assessment, the nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse should
notify the physician.
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient's left leg is externally rotated. The nurse should
place a trochanter roll on the outer aspect of the thigh.
The nurse is teaching a well-baby class to a group of parents with toddlers. The nurse should encourage the parents to
provide a safe play area for their children.
The nurse is caring for clients in the pediatric clinic. The mother of a child calls the nurse to say that after administering Dimetane-DC cough syrup to her child, her child becomes very excitable and restless. The MOST appropriate action for the nurse to take is to
report the child's behavior to the physician to alert the physician to the potential need for a change in medication.
The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. When the nurse checks the patient, the nurse finds the weights on the floor, and the girl's feet touching the foot of the bed. The nurse should
steady the traction and have the girl bend her left leg and push up in bed.
An 18-year-old client with anorexia nervosa is admitted to the hospital. In planning to care for the client, the nurse would expect the client to
want to talk about and plan her meals.
The clinic nurse observes that a ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister. The nurse should
wash the burn with soap and water to remove the oil.
To best evaluate home compliance with metoclopramide (Reglan) for a three-month-old, the nurse should
weigh the baby and compare to baseline weight.
The physician suggests play therapy for a 7-year-old girl who is having some difficulty adjusting to her parents' impending divorce. The nurse knows this type of therapy is useful because
young children have difficulty verbalizing emotions.
