ATI Ped's Ch. 8-11

a nurse is assessing an infant. Which of the following are manifestations of pain in an infant? (Select all that apply.) a. Pursed lips B. Loud cry C. Lowered eyebrows D. Rigid body e. Pushes away stimulus

3. a. infants who experience pain have their mouth open in a squarish shape. B. CORRECT: infants who experience pain exhibit a loud cry. C. CORRECT: infants who experience pain lower and draw together their eyebrows. D. CORRECT: infants who experience pain exhibit a rigid body. e. infants who experience pain exhibit a local reflex to withdraw from the stimulus.

1. a nurse is caring for a child who is dying. Which of the following are findings of impending death? (Select all that apply.) a. heightened sense of hearing B. tachycardia C. Difficulty swallowing D. Sensation of being cold e. Cheyne‐Stokes respirations

1. a. a decrease in the senses of smell, sight, and hearing are physical manifestations of approaching death. B. Bradycardia is a physical manifestation of approaching death. C. CORRECT: Difficulty swallowing is a physical finding of approaching death. D. a client's sensation of heat when the body feels cool is a physical manifestation of approaching death. e. CORRECT: Cheyne‐Stokes respirations are an abnormal breathing pattern with periods of apnea that is a physical finding of impending death.

5. a nurse is caring for a child who has a terminal illness and reviews palliative care with an assistive personnel (aP). Which of the following statements by the aP indicates understanding of this review? a. "i'm sure the family is hopeful that the new medication will stop the illness." B. "i'll miss working with this client now that only nurses will be caring for him." C."i will get all the client's personal objects out of his room." D."i will listen and respond as the family talks about their child's life."

5. a. Palliative care is provided when there is no longer hope for a disease cure. B. Palliative care focuses on providing consistency among the interprofessional team to offer supportive care and a normal environment. C. Palliative care focuses on offering support and a normal environment as the dying process occurs. D. CORRECT: Palliative care focuses on the process of dying and grieving, which includes using therapeutic communication.

5. a nurse is caring for an infant who needs otic medication. Which of the following is an appropriate action for the nurse to take? a. Hold the infant in an upright position. B. Pull the pinna downward and straight back. c. Hyperextend the infant's neck. d. ensure that the medication is cool.

5. a. Position the infant supine or prone for administration of otic medication. B. CORRECT: Pulling the pinna downward and straight back will straighten the ear canal to allow medication to flow into the ear. c. Hyperextending the infant's neck could occlude the airway and should not be performed during otic medication administration. d. allowing the otic medication to warm up to room temperature is recommended to provide atraumatic care.

1. a nurse is planning to administer the influenza vaccine to a toddler. Which of the following actions should the nurse take? a. administer subcutaneously in the abdomen. B. Use a 20-gauge needle. c. divide the medication into two injections. d. Place the child in the supine position.

1. a. the influenza vaccination is administered im. B. a 22- to 25-gauge needle is recommended for im injections. c. the total volume of the influenza vaccination is 0.5 mL, which can be administered in the vastus lateralis. d. CORRECT: the vastus lateralis is recommended for administering im medications. Placing the toddler in a supine position is the appropriate action for the nurse to take.

1. a nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool‐age child? a. describing manifestations of illness B. Relating fears to magical thinking C. Understanding cause of illness d. awareness of body functioning

1. a. preschool‐age children have limited ability to describe manifestations of illness. B. CORRECT: preschool‐age children are egocentric and relate fears to magical thinking. C. preschool‐age children have limited understanding of cause‐and‐effect relationship, but understand what illness feels like. d. awareness of body functioning is a behavior of an adolescent.

1. a nurse is completing a pain assessment of an infant. Which of the following pain scales should the nurse use? a. FaCeS B. FLaCC C. Oucher D. non‐communicating children's pain checklist

1. a. the FaCeS pain assessment scale is recommended for children 3 years or older. B. CORRECT: the FLaCC pain assessment scale is recommended for infants and children between 2 months and 7 years of age. C. the Oucher pain assessment scale is recommended for children between the ages of 3 and 13 years. D. the non‐communicating children's pain checklist is recommended for non‐communicating children between the ages of 3 and 18 years.

2. a nurse is teaching a parent about complicated grief. Which of the following statements should the nurse make? a. "it is considered complicated grief if you are still grieving 6 months after your loss." B. "Personal activities are affected when experiencing complicated grief." C."Parents will experience complicated grief together." D."Complicated grief self‐resolves in 12 months."

2. a. a parent who is still experiencing intense grieving after 1 year should be evaluated for complicated grief. B. CORRECT: a parent who is experiencing complicated grief experiences intense emotions that affect personal activities. C. Parents grieve differently, and not all parents experience complicated grief. D. a nurse should refer the parent to an expert in grief counseling if complicated grief is identified.

2. a nurse is planning care for a child following a surgical procedure. Which of the following interventions should the nurse include in the plan of care? a. administer nSaiDs for pain greater than 7 on a scale of 0 to 10. B. administer intranasal analgesics PRn. C. administer iM analgesics for pain. D. administer iV analgesics on a schedule.

2. a. nSaiDs are used for mild to moderate pain. B. intranasal analgesics are used for clients older than 18 years. C. iM analgesics are not recommended for pain management in children. D. CORRECT: iV analgesics should be administered on a schedule to achieve optimal pain management.

2. a nurse on a pediatric unit is caring for a toddler. Which of the following behaviors is an effect of hospitalization? (select all that apply.) a. Believes the experience is a punishment B. experiences separation anxiety C. displays intense emotions d. exhibits regressive behaviors e. Manifests disturbance in body image

2. a. preschool children believe hospitalization is a punishment. B. CORRECT: separation anxiety is a potential effect of hospitalization in a toddler. C. CORRECT: intense emotions are a potential effect of hospitalization in a toddler. d. CORRECT: Behavior regression is a potential effect of hospitalization in a toddler. e. Body image disturbances can be seen in adolescents who are hospitalized.

2. a nurse is preparing to administer an intramuscular (im) injection to a child. Which of the following muscle groups is contraindicated? a. deltoid B. Ventrogluteal c. Vastus lateralis d. dorsogluteal

2. a. the deltoid muscle can be used once developed for im injections in children for medication containing up to 1 mL fluid. B. the ventrogluteal muscle can be used for im injections in children for medication containing up to 2 mL fluid. c. the vastus lateralis muscle can be used for intramuscular injections in children for medication containing up to 2 mL fluid. d. CORRECT: the dorsogluteal site has major nerves and blood vessels and is not a recommended site for im injections for children.

3. a nurse is teaching a parent of an infant about administration of oral medications. Which of the following should the nurse include in the teaching? (Select all that apply.) a. Use a universal dropper for medication administration. B. ask the pharmacy to add flavoring to the medication. c. add the medication to a formula bottle before feeding. d. Use the nipple of a bottle to administer the medication. e. Hold the infant in an semireclining position.

3. a. medication has different viscosities, and droppers do not have a standard opening. a universal dropper is not an accurate way to measure medications. B. CORRECT: multiple flavorings are available to add to medications and can assist in masking the taste. c. Because an infant might not finish an entire bottle of formula, it is not recommended to add medication to the bottle. d. CORRECT: administering medications through an empty nipple can assist with successful administration of the medication. e. CORRECT: for successful medication administration, the infant should be held in a semireclining position, similar to feeding.

3. a nurse is teaching a parent about parallel play in children. Which of the following statements should the nurse include in the teaching? a. "Children sit and observe others playing." B. "Children exhibit organized play when in a group." C."the child plays alone." d."the child plays independently when in a group."

3. a. onlooker play is when a child sits and observes others playing. B. Cooperative play is when a child exhibits organized play in a group. C. solitary play is when a child plays alone. d. CORRECT: parallel play is when the toddler plays independently but is among other children in a group.

3. a nurse is teaching a parent of a preschool child about factors that affect the child's perception of death. Which of the following factors should the nurse include in the teaching? a. Preschool children have no concept of death. B. Preschool children perceive death as temporary. C. Preschool children often regress to an earlier stage of behavior. D. Preschool children experience fear related to the disease process.

3. a. toddlers have no concept of death. B. CORRECT: Preschool children perceive death as temporary because they have no concept of time. C. toddlers often regress to an earlier stage of behavior. D. School‐age children experience fear related to the disease process.

5. a nurse is preparing a toddler for an intravenous catheter insertion using atraumatic care. Which of the following actions should the nurse take? (Select all that apply.) a. explain the procedure using the child's favorite toy. B. ask the parents to leave during the procedure. C. Perform the procedure with the child in his bed. D. allow the child to make one choice regarding the procedure. e. apply lidocaine and prilocaine cream to three potential insertion sites.

5. a. CORRECT: explaining the procedure using the child's favorite toy can assist the child to manage fears and provides atraumatic care. B. the parents should be allowed to remain for procedures to offer comfort to the child. C. Safe places, such as the child's bed, should be avoided. D. CORRECT: allowing the child to make choices offers a sense of control over the situation and should be used to provide atraumatic care. e. CORRECT: a topical analgesic, such as lidocaine and prilocaine cream, decreases pain and should be used to provide atraumatic care.

a nurse often cares for children who are dying. Which of the following are appropriate actions for the nurse to take to maintain professional effectiveness? (Select all that apply.) a. Remain in contact with the family after their loss. B. Develop a professional support system. C. take time off from work. D. Suggest that a hospital representative attend the funeral. e. Demonstrate feelings of sympathy toward the family.

4. a. CORRECT: Maintaining contact with the family after their loss is an act of support for the family. B. CORRECT: Developing professional support systems is a strategy the nurse can use to maintain effectiveness when working with the client who is dying and their family. C. CORRECT: taking time off from work is a strategy the nurse can use to maintain effectiveness when working with the client who is dying. D. nurses should be encouraged to participate in funeral rituals as an act of support for the family. e. a nurse should develop the ability for empathy when dealing with dying clients.

a nurse is planning care for an infant who is experiencing pain. Which of the following interventions should the nurse include the plan of care? (Select all that apply.) a. Offer a pacifier. B. Use guided imagery. C. Use swaddling. D. initiate a behavioral contract. e. encourage kangaroo care.

4. a. CORRECT: nonnutritive sucking is a therapeutic nonpharmacological strategy for pain management with infants. B. guided imagery is a nonpharmacological strategy used with children. C. CORRECT: Swaddling the infant is a therapeutic nonpharmacological strategy for pain management. D. Behavioral contracts are a nonpharmacological strategy used with children. e. CORRECT: Skin‐to‐skin touch is a relaxation technique and should be encouraged for infants who have pain.

4. a nurse is preparing to administer medication to a toddler. Which of the following actions should the nurse take? (Select all that apply.) a. identify the toddler by asking the parent. B. tell the parent to administer the medication. c. calculate the safe dosage. d. ask the toddler what toy he wants to hold during administration. e. offer juice after the medication.

4. a. for safe medication administration, confirm two identifiers by looking at the identification band or having the toddler state his name and date of birth. B. the nurse should assess the preferred level of involvement of the parents prior to medication administration. c. CORRECT: for safe medication administration, the nurse should calculate safe dosage prior to administering medication. d. CORRECT: offering choices to the toddler is an example of atraumatic care. e. CORRECT: offering juice after the medication is an example of atraumatic care.

4. a nurse is teaching a group of parents about separation anxiety. Which of the following information should the nurse include in the teaching? a. it is often observed in the school‐age child. B. detachment is the stage exhibited in the hospital. C. it results in prolonged issues of adaptability. d. Kicking a stranger is an example.

4. a. separation anxiety is commonly observed in the toddler. B. the detachment stage is rarely seen in the hospital setting. C. Children are adaptable and permanent issues are rare. d. CORRECT: physical aggression toward strangers is a behavior seen in the protest stage of separation anxiety.