ATI CHILD,

A nurse is caring for a school age child who has experienced a tonic clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?

place the child in a side lying position

A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?

playing dress-up

A nurse is assessing a 3 year old toddler at a well child visit. Which of the following manifestations should the nurse report to the provider?

respiratory rate 45/min

A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?

screen the child's visitors for indications of infection

After reviewing the information in the medical record, the nurse should identify that the child is at risk for developing which of the following conditions?

splenomegaly positive mononucleosis rapid test

A nurse is teaching the parent of an infant about ways to prevent SIDS. Which of the following instructions should the nurse include?

Give the infant a pacifier at bedtime.

The nurse should identify that which of the following findings require immediate follow-up? Find 3.

Partial and full thickness burns to the left upper anterior chest and anterior neck SaO2 89% on room air Heart rate 150/min

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. which of the following actions should the nurse plan to take?

Perform a finger stick

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?

flank pain

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?

initiate seizure precautions

The nurse is caring for the child 14 days after admission. The child has returned to the unit following the procedure. which of the following actions should the nurse take?

monitor sao2 every 2 hr 100% oxygen via face mask check neck and chest for bleeding place warm blanket keep childs head in neutral position

A nurse is assessing a school age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?

petechiae on the lower extremities

A nurse is providing discharge teaching to the parents of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the inter professional team should the nurse initiate a referral?

speech therapist

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following?

tachypnea

The nurse is caring for the child 4 days after admission. After reviewing the child's assessment, which of the following findings should the nurse address first?

temperature first pain second

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parents to apply which of the following to the affected area?

zinc oxide

A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?

" I should secure the car seat using the lower anchors and tethers instead of the seat belt."

A nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?

" I will give myself a shot of regular insulin 30 minutes before I eat breakfast"

A nurse is teaching the parent of an infant who has a pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?

" I will place my infant's diapers under the harness straps."

A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschoolers parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make?

" lets talk about some of the ways you have handled previous stressors in your life"

A nurse is assisting with the care of a child who is postoperative and received a transfusion during a surgical procedure. Which of the following findings indicates the child is having a hemolytic reaction?

Chills and flank pain Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify this finding as an indication that the child is having a hemolytic reaction.

A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect?

Hgb 9.0 g/dL The nurse should expect a child who has iron deficiency anemia to have an Hgb level below the expected reference range of 9.5 to 15.5 g/dL. An Hgb of 9.0 g/dL is below the expected reference range.

The nurse is caring for the child 4 days after admission. After examining the child during hydrotherapy, the provider enters prescriptions into the childs medical record. For each potential providers prescription, click to specify if the potential prescription is anticipated or contraindicated for the child.

PCA pump-anticipated Wound culture-anticipated Pressure reduction mattress-anticipated Limit protein intake-contraindicated

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. which of the following is the priority action by the nurse?

Administer epinephrine IM to the child

Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated?

Apply sterile gauze-contraindicated Indwelling catheter-anticipated 100% oxygen via face mask-anticipated Weigh the child-anticipated

A nurse in a pediatric clinic is talking on the telephone with the parent of a 6-month-old infant who has a UTI and started taking an oral antibiotic the day before. Listen to the (audio clip) and determine which of the following responses the nurse should make?

"Mix the medicine with 1 teaspoon of applesauce before giving it to your baby." To enhance acceptance of an oral medication, the parent can mix the medication with a small amount of a sweet, nonessential food item.

A nurse in a pediatric clinic is caring for an infant who has heart failure and a prescription for digoxin. Which of the following statement by the parent indicates the desired therapeutic effect of the medication?

"My baby is breathing easier than she used to." The nurse should identify that the desired effect of digoxin is to increase cardiac output and decrease venous pressure and pulmonary edema, which will reduce respiratory demands.

A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the following statements by the parent requires immediate intervention by the nurse?

"My child has refused to drink any fluids for the past 8 hours." An inadequate fluid intake indicates the child is at greatest risk for dehydration and electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention by the nurse.

A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when his child will no longer be contagious. Which of the following responses should the nurse make?

"Six days after lesions appear if they are crusted." The nurse should inform the guardian that a child will stop being contagious around 6 days after the lesions appeared, as long as they are crusted over.

A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse, "I'm a bad parent, and I can't deal with this." Which of the following responses should the nurse make?

"Tell me more about what you are feeling." The nurse should use open-ended statements that will allow the parent to share his feelings and emotions. During times of grief, the parent needs to express his emotions. The use of an open-ended statement relays the message that it is safe to do so with the nurse.

A nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure. The client ask, " who should sign my surgical consent?" which of the following responses should the nurse make?

"you can sign the consent form because you are married."

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?

1 capsule

A nurse is reinforcing dietary teaching with an adolescent who is a lacto-vegetarian and has iron deficiency anemia. The nurse should recommend which of the following as the best source of iron?

1 cup (8 oz) shredded wheat cereal The nurse should determine that shredded wheat cereal is an iron-fortified food. Therefore, it is the best option to recommend because it contains 1 g of iron per serving.

A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22 lb). The prescription reads phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer with each dose?

6.25 mL

A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. which of the following locations should the nurse identify as McBurney's point?

A

A school nurse is assessing an adolescent who has scoliosis. which of the following findings should the nurse expect?

A unilateral rib hump.

A nurse is caring for a toddler who has otitis media and a temperature of 39.1 C (102.4 F). Which of the following actions should the nurse take first?

Administer an antipyretic When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature.

A nurse is caring for a toddler who has a spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect?

Ankle clonus Exaggerated stretch reflexes Contractures

Select 6 statements by the parent that indicate an understanding of the discharge teaching.

Apply moisturizer to scar tissue Measure spoon or med cup to give hydroxyzine Give hydroxyzine every 6 hours as needed Puppet play can be helpful Assess for any redness or open skin Use compression garment to decrease blood supply

A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler?

Ask the guardian to verify the child's name. Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should ask the guardian to verify the identity of the child and use the identification band as the second identifier.

A nurse is reinforcing anticipatory guidance to the parents of an adolescent. Which of the following recommendations should the nurse include?

Be open to the adolescent's point of view. During this stage of development, adolescents are developing autonomy and self-identity. The nurse should recommend that the parents actively listen and be open to the adolescent's point of view, even if the parents disagree with his viewpoint.

A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further?

Blood pressure 120/80 mm Hg A blood pressure of 120/80 mm Hg is outside the expected reference range for an 18-month-old toddler and requires further investigation by the nurse.

A nurse is reinforcing teaching with the parent of a 4-month-old infant who has a new prescription for nystatin to treat oral candidiasis and is breastfeeding. Which of the following instructions should the nurse include in the teaching?

Continue nystatin for 2 weeks after the symptoms disappear. To prevent relapse, nystatin therapy should continue for at least 2 weeks after the lesions disappear.

A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate?

Droplet precautions The nurse should plan to initiate droplet precautions for this child, because bacterial meningitis caused by Haemophilus influenzae type B is transmitted through the air via large-particle droplets.

A nurse is reinforcing teaching with the parent of a child who is being treated with diphenhydramine for allergic rhinitis. The nurse should tell the parent to monitor the child for which of the following?

Drowsiness Diphenhydramine can cause drowsiness due to CNS depression. The nurse should reinforce with the parent to administer the medication at bedtime to avoid daytime sedation.

A nurse is reviewing the laboratory report of school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?

Hematocrit 28% (it's below 35%)

A nurse is administering an injection of epinephrine to a child who is experiencing manifestations of anaphylaxis. The nurse should monitor for which of the following adverse effects?

Increased systolic blood pressure Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should expect the child to have an increased systolic blood pressure following administration of epinephrine.

A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?

Initiate droplet precautions for the child

A nurse is preparing to administer levabuterol via nebulizer to a child with asthma. Which of the following data should the nurse collect prior to administering the medication?

Lung sounds Levalbuterol is a bronchodilator used to increase air exchange. The nurse should evaluate lung sounds prior to and after the administration of the medication to determine changes in respiratory status.

A nurse is contributing to the plan of care for a child who is in Buck's traction. Which of the following interventions should the nurse include in the plan?

Maintain the leg in an extended position. The nurse should have the child maintain her affected leg in an extended position while in Buck's traction. This position decreases the risk for further injury to the extremity and minimizes the occurrence of muscle spasms.

A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints?

Mummy restraint The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the toddler that involves the head and neck. The nurse should always use the least amount of restraint necessary.

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?

Provide small, frequent meals for the child.

During a well-child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make?

Provide the toddler with a favorite toy at bedtime. The nurse should recommend to the parent that providing the toddler with a favorite toy at bedtime will help the toddler to feel more secure and facilitate sleep.

A nurse is reinforcing teaching with the parents of a 2-year-old toddler at a well-child visit. Which of the following should the nurse recommend as an age-appropriate activity for the toddler?

Putting together a large-piece puzzle The nurse should recommend putting together a large-piece puzzle as an age-appropriate activity for a 2-year-old toddler. Puzzles provide the child an opportunity to develop fine motor skills. Other fine motor skill activities include finger painting and coloring with thick crayons.

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?

Schedule the toddler for a yearly rescreening.

A nurse is collecting data from a child during a well-child visit. The nurse should recognize that which of the following findings places the child at a higher risk for abuse?

The child was born at 30 weeks of gestation. The nurse should identify that children who are born prematurely are at greater risk for abuse because of the potential for impaired bonding during early infancy.

A nurse is collecting data from an 18-month-old toddler. Which of the following is a deviation from expected growth and development that the nurse should report to the provider?

The toddler is unable to recognize familiar objects by name. The nurse should report that the toddler is unable to recognize familiar objects by name, because this is a deviation from expected growth and development. The toddler should be able to accomplish this task by 12 months of age.

A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take?

Turn off Occlude Remove tape Apply pressure

A nurse is preparing to administer an IM injection to an 11-month-old infant. In which of the following areas should the nurse administer the injection?

Vastus lateralis The nurse should administer an IM injection in the vastus lateralis muscle of an 11-month-old infant. The vastus lateralis is a well-developed muscle that is safe to use for infants and small children.

Which of the following statements by a guardian indicate that the discharge teaching was effective?

We should apply a skin emollient immediately after bathing our child We should keep our child's fingernails trimmed short. We should use a mild detergent for our laundry.

A nurse is providing dietary teaching to the parent of a school age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

White rice

A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend?

Yellow corn A client who has celiac disease is unable to process gluten, a protein found in wheat, barley, rye, and oats. The nurse should instruct the family that the client's diet is restricted to foods that are free of gluten, such as corn, rice, and millet.

A nurse is receiving change of shift report for four children. which of the following children should the nurse see first?

a school age child who has sickle cell anemia and reports decreased vision in the left eye

A nurse is preparing to administer an immunization to a 4 year old child. Which of the following actions should the nurse plan to take?

administer the immunization using a 24 gauge needle

A nurse is caring for a school age child who is in bucks traction following a leg fracture 24 hr ago. which of the following actions should the nurse take?

assess peripheral pulses once every 4 hour

After reviewing the information in the child's medical record, which of the following findings should the nurse report to the provider? Select 4.

Arterial blood gases WBC count Oxygen saturation Respiratory assessment

A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. which of the following nutritional items should the nurse offer to the toddler?

oral rehydration solution

A nurse is caring for an adolescent who received a kidney transplant. which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?

serum creatinine 3.0 mg/dl

A nurse in an emergency department is performing a physical assessment on a 2 week old male newborn. Which of the following findings is the priority for the nurse to report to the provider?

substernal retractions

A charge nurse in an emergency department is preparing an inservice for a group of newly licensed nurses about the manifestation of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?

symmetric burns of the lower extremities

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?

tachypnea

A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock?

temperature 39.1 (102.4 F)

A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?

the toddler received tobramycin during a hospitalization 2 weeks ago.

A nurse in a providers office is preparing to administer immunizations to a toddler during a well child visit. which of the following actions should the nurse plan to take?

withhold MMR vaccine

A nurse is reinforcing teaching about liquid oral supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will give this medication to my child with a straw." The nurse should reinforce with the guardian to administer this medication with a straw to prevent staining the child's teeth.

A nurse is reinforcing teaching about vital signs with the guardian of a 1-year-old toddler. Which of the following statements by the guardian indicates an understanding of the teaching?

"My child's pulse could increase to 150 beats a minute with activity." A pulse rate of 150/min is within the expected reference range for a toddler during physical activity.

A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate?

Apical The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line.

A nurse is reinforcing teaching with the guardians of a school-age child who has frequent nosebleeds. Which of the following instructions should the nurse include?

Apply pressure to the child's nose. The nurse should instruct the guardians to apply pressure to the child's nose for at least 10 min to decrease bleeding. The nurse should also instruct the guardians to tilt the child's head forward, because this position prevents aspiration of the blood.

A nurse is reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetaminde. Which of the following instructions should the nurse include?

Instill medication immediately after cleansing the eye. The nurse should instruct the guardian to place the medication in the eye immediately after cleansing.

A nurse is providing teaching to the parent of a school-aged child who has a new prescription for oral nystatin for the treatment of oral candidiasis. which of the following instructions should the nurse include?

Shake the medication prior to administration

A nurse is collecting data from a 10-month-old infant. Which of the following findings should the nurse report to the provider?

Sits with support by leaning on hands The nurse should identify that sitting with support can indicate a developmental delay, because an infant should be able to sit unsupported by 8 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. the nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?

Sodium 140 mEq/L

A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance. Which of the following supplements should the nurse instruct the parent to include in the child's diet?

Vitamin D Lactose intolerance is managed by eliminating dairy products from the diet. However, this can result in a decrease in bone density because of the lack of calcium and vitamin D in the diet. The nurse should instruct the parent to administer a vitamin D supplement to the child to enhance the absorption of calcium from foods other than those containing lactose.

A nurse is assisting with the development of a health promotion program for the guardians of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program?

The leading cause of death in adolescents is physical injury. The nurse should recommend including this information, because injuries from motor-vehicle crashes are the leading cause of death in the adolescent population.

A nurse is caring for a preschooler whose father is going home for few hours while another relative stays with the child. which of the following statements should the nurse make to explain to the child when their father will return?

You daddy will be back after you eat.

A nurse in an emergency department is caring for a toddler who has partial thickness burns on their right arm. Which of the following actions should the nurse take?

cleanse the affected area with mild soap and water

A nurse is assessing a 4-year-old child at a well-child visit. which of the following developmental milestones should the nurse expect to observe?

cuts an outlined shape using scissors

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?

denies discomfort during assessment of injuries

A nurse is caring for a school-age child who is receiving cefazolin via intermittent I.V bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?

epinephrine

A nurse in an emergency department is caring for a school age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. which of the following actions should the nurse take?

give morphine 0.05 mg/kg IV

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control?

have a designated stethoscope in the infants room.

A nurse is reviewing the laboratory report of a 7 year old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

hgb 8.5 g/dl

A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan?

implement seizure precautions for infant

A nurse is assisting with the care for a 7-month-old infant who has a cleft palate. Which of the following actions should the nurse take to decrease the infant's risk for aspiration?

Burp the infant frequently during feedings. Infants with a cleft palate have difficulty creating a seal around a bottle. Burping the infant frequently, following every ounce of fluid consumed, dissipates swallowed air and helps to prevent aspiration.

A nurse is assisting with the care of a 4-year-old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure? (Select all that apply.)

Discuss the benefits of the procedure. The nurse should discuss the benefits of the procedure with the child, because this action is an age-appropriate activity that will decrease the child's anxiety about the procedure. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Give the child needleless IV supplies to play with. The nurse should allow the child to see, hold, and collect the supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. Allow the child to perform the procedure with a doll. The nurse should allow the child to mimic the procedure with a doll to alleviate anxiety. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure.

A nurse is reinforcing teaching about home care with the guardian of a 14-month-old toddler who has spastic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will perform daily stretching exercises to my toddler's affected muscles." The nurse should reinforce that performing stretching exercises of the toddler's affected muscles will prevent muscle contractures.

A nurse is reviewing the plan of care for a child who has cystic fibrosis. Which of the following is the priority goal for this child?

The child will maintain an effective breathing pattern. Manifestations of cystic fibrosis, such as chronic cough, pulmonary infection, and bronchiolar obstruction lead to severely impaired ventilation and gas exchange, which causes long-term pulmonary complications. Therefore, when utilizing the airway, breathing, circulation approach to client care, maintaining an effective breathing pattern is the priority goal for the child who has cystic fibrosis.

A nurse is collecting physical data from a 4-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child's skin turgor?

The child's abdomen. The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. To check skin turgor, the nurse should grasp the skin on the child's abdomen, pull it taut, and release it quickly. The child who is dehydrated will have a prolonged period of tenting.

A nurse is collecting data from a 12-month-old infant during a well-child visit. At birth, the infant's weight was 3.6 kg (8 lb) and his length was 50.8 cm (20 in). Based on this data, which of the following findings should the nurse expect?

The infant is 76.2 cm (30 in) long The nurse should expect a length of 76.2 cm (30 in), because the infant's length should increase by about 50% by 12 months of age.

A nurse is reviewing the lumbar puncture results of a school age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?

increased protein concentration