ATI: Nursing Care of Children 1

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A nurse is administering the MMR vaccine to a child. Which of the following statements by the parent indicates an understanding of the vaccine?

"I can give my child Tylenol for discomfort associated with the vaccine."

A nurse is teaching a parent of an 18 month old child about safety. Which of the following statements should indicate to the nurse that the parent understands the teaching?

"I have locked my medications in the medicine cabinet."

A nurse is caring for a hospitalized 3 year old child who the parents report is toilet trained. Since admission to the hospital, the child has experienced bed wetting. Which of the following is an appropriate response by the nurse?

"Let's get you cleaned up so you can go to the playroom."

A nurse is teaching a parent of a 12 month old infant about nutrition. Which of the following statements by the parent would indicate the need for further teaching?

"My infant should drink 2 qt of skim milk per day."

A nurse is caring for a child with bacterial endocarditis. The child will receive long-term antibiotics and will require a peripherally inserted central catheter (PICC). Which of the following statements would be appropriate for the nurse to state to the child's parent?

"The PICC line will last several weeks with proper care."

A nurse is caring for a toddler who is scheduled for surgery. The parent asks the nurse for suggestions on how to prepare her child for the upcoming surgery. Which of the following would be an appropriate statement by the nurse to the parent?

"You could read books to your child about being hospitalized."

A nurse is educating a parent of a toddler on development. Which of the following would be an appropriate response by the nurse?

"Your child will begin to scribble spontaneously using a crayon by the age of 18 months."

A nurse is caring for a dehydrated toddler who must receive 100 mL of normal saline over the next 4 hrs. Using a 60 gtt microdrip set, what rate should the nurse regulate the IV to deliver?

25 gtt/min

A nurse is caring for an 18 month old toddler who has been admitted for lead poisoning. An order for a urine specific gravity is written. Which of the following would be the appropriate way for the nurse to collect the urine?

Applying a pediatric urine collector

A nurse is performing a physical assessment on a 6 month old infant. Which of the following reflexes should the nurse expect to find at this age?

Babinski

A nurse is performing a physical assessment on a 30 month old toddler. Which of the following nursing assessments should the nurse not expect to find at this age?

Birth weight is tripled

A nurse is caring for a 2-year-old with cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be the most appropriate for the child?

Building block towers.

A nurse is providing education for a group of parents. A parent is concerned about the development of her 4-year-old child's fine motor skills. Which of the following should the nurse explain to be an expected skill for this age group?

Copying a square and circle

A nurse is teaching a new parent about infant nutrition. The nurse should realize teaching has been effective about food allergens when the parent indicates which of the following food choices as a common allergen in infants?

Cow's milk

A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. Which of the following is an appropriate teaching point for the nurse to give the parents?

Call the poison control center.

A nurse is caring for a 2 month old who is brought to the clinic for routine immunizations. Which of the following should the nurse administer?

DTaP (diptheria, tetanus, pertussis), HIB (Haemophilus influenzae type b), IPV (polio), and HBV (Hepatitis B vaccine)

A nurse is caring for a child who is dying. The child's 4-year-old sibling is visiting. Which of the following statements indicates a 4-year-old's perception of death? (Select all that apply.)

Death is the same as going to sleep. Death is caused by magical thinking. Death is the result of a wish. Death is a punishment.

A nurse is caring for a 3-month-old infant admitted with suspected non-organic failure to thrive (FTT). Which of the following statements is true regarding non-organic failure to thrive?

Disruption in the patient-child bond

The nurse is caring for a 3 year old child newly diagnosed with diabetes mellitus. When writing the care plan, the nurse includes this goal: The child will be provided with opportunities for therapeutic play. Which of the following would be the most appropriate toy to help meet this goal?

Doll and a syringe with no needle

The nurse is caring for a 3 year old child who has a lead level of 15 g/dL. When teaching the toddler's parent about nutrition and the correlation with lead poisoning, which of the following suggestions is appropriate for the nurse to state?

Drink milk

A nurse is taking a history during a routine physical examination. Which of the following would be appropriate to tell the parent?

Establish a set bedtime and follow a nightly routine.

A nurse is performing an assessment on a child at the clinic. When performing this assessment, the nurse should do which of the following?

Have the child sit in the parent's lap, auscultate the heart and lungs, and then examine the ears and throat.

A nurse is caring for an 8 year old child who has fractured his femur. The child is in skeletal traction. To assist with the child's developmental needs, which of the following would be an appropriate action for the nurse to take?

Have the hospital tutor visit daily to assist the child with homework.

The nurse is assessing a 4-month-old infant in the well baby clinic. Which of the following assessments should prompt the nurse to conduct a further evaluation?

Head lag when pulled from a lying to sitting position

A nurse is assessing a 9-month-old infant for potential developmental delay. Which of the following observations should the nurse expect to find to support this condition?

Inability to sit without support

A nurse is working at an immunization clinic. Which of the following would be a contraindication to the pertussis immunization?

Known neurologic or seizure disorder

The nurse is assessing a 6 month old infant in the well child clinic. Which of the following assessments would indicate the infant needs further evaluation?

Legs stay crossed at the knees

A nurse is caring for an 18-year-old adolescent who is going away to college. The adolescent will be living in the dormitory. Which of the following is the most appropriate immunization to suggest that he receive?

Meningococcal polysaccharide

A nurse is caring for a 2-year-old child who was found by his parents crying and holding a container of a toilet bowl cleaner. The client's lips are peeled and oozing, and he is drooling. Which of the following should be the nurse's highest priority?

Monitoring the respiratory status of the child.

A nurse is educating a teenage mother about the care of her newborn. When giving safety information, which of the following information should the nurse provide to the mother? (Select all that apply.)

Move glass objects to a higher shelf. Put a safety gate at the top of the stairs. Keep small objects out of reach.

A nurse is observing an 8 month old infant and parent playing peek a boo. The parent asks the nurses if this game has any developmental significance. The nurse should indicate to the parents that playing peek a boo will develop which of the following concepts?

Object permanence

A nurse is caring for an infant who is crying. The nurse plans to administer a liquid medication. Which of the following administration methods should the nurse use?

Place a needless syringe in the buccal cavity

A nurse is caring for a 4-year-old child who has been admitted to the hospital. Which of the following would be the appropriate toy for the 4-year-old?

Plastic stethoscope

The nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 8 a.m., the client describes the pain at level 3 on the scale of 1 to 10. At 10 a.m., the client describes the pain at level 5. The nurse discovers the client has not pushed the button to deliver the medication in the past 2 hrs. Which of the following actions would be appropriate for the nurse to take?

Reinforce teaching about how to push the button to deliver the medication with the client.

A nurse is performing a physical assessment on a 6-year-old child. Which of the following findings should prompt the nurse to conduct additional follow-up?

Sparse, fine pubic hair

A nurse is assessing an 8-year-old's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluations?

The child complains everyday about going to school.

A nurse is caring for a 12-year-old adolescent who has ingested 60 mL of bleach. Which of the following statements by the nurse would indicate an understanding of this ingestion?

The severity of alkaline burn depends on the pH of the substance.

A nurse is conducting a yearly assessment of a 14-year-old girl. The nurse should understand which of the following findings will require further evaluation?

There is a lateral curvature to her spine.

The nurse is caring for a 3 year old child who is postoperative following revision of a malfunctioning ventriculo peritoneal shunt. Which of the following would be an appropriate way for the nurse to determine if the child is in pain?

Use the FACES scale to rate the pain.

A nurse is caring for an infant on droplet precautions. The nurse understands that she can best prevent the spread of droplet pathogens by doing which of the following?

Wearing a gown and mask when feeding the infant


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