ATI proctored exam Pediatrics
A nurse is assessing a child who is receiving IV chemotherapy. assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions? -Remove IV line -Elevate the extremity -Stop the infusion -Notify the provider
Stop the infusion Elevate the extremity Notify the provider Remove the IV line
A nurse in a providers office enters an examination room to assess an 8 month old infant for the first time. which of the following reactions by the infant should the nurse expect. -The infant gives the nurse a social smile -the infant turns away when the nurse approaches -The infant reaches out to the nurse to be held -The infant is responsive and alert as the nurse comes closer
the infant turns away when the nurse approaches (the nurse should expect an 8 month old infant to have a heightened fear of strangers. the infant is expected to cling to her parent and turn away when approached by a stranger.)
A nurse is caring for an 8 year old child who has sickle cell anemia. which of the following actions should the nurse take? -Apply cool compresses to the painful area -Initiate contact isolation precautions -Give the child flavored popsicles -Administer phytonadione
Give the child flavored popsicles (Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. children often accept flavored popsicles as a source of fluid
A nurse is caring for a toddler who has gastroenteritis caused by salmonella. which of the following is the priority action for the nurse? -Weigh the child -Initiate contact precautions -Establish a skin care routine -Obtain a recent food history
Initiate contact precautions (Salmonella is a type of bacteria that is transmitted via contaminated feces, making contact precautions essential for preventing transmission. This client is at great risk for transmission of salmonella to others; therefore, contact precautions are the nurse's priority)
A school nurse is assessing a child who has been stung by a bee. the childes hand is swelling and the nurse notes that the child is allergic to insect stings. which of the following findings should the nurse expect if the child develops anaphylaxis -Bradycardia -Nausea -Hypertension -Urticaria -Stridor
Nausea, Urticaria, and stridor (A common gastrointestinal response to excessive histamine release is nausea. A common skin manifestation of excessive histamine release is hives, also known as urticaria. A serious, life threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor)
A nurse is caring for a toddler who has a fever, a high pitched cry, irritability, and vomiting. which of the following actions should the nurse take? -Administer 81 mg of aspirin to the toddler -Give the toddler a cold bath -Place the toddler in a supine position -Pad the rails of the toddler's bed
Pad the rails of the toddler's bed (When caring for a toddler who has manifestations of bacterial meningitis, the nurse should implement seizure precautions, which includes padding the side rails of the bed)
A nurse is caring for a 4 month old child who is hospitalized. which f the following toys hsould the nurse provide for the child? -A board book with large pictures -A toy with movable parts -A plastic mirror -Push pull toy
A plastic mirror (A 4 month old infant can recognize herself and will also attempt to play with the baby in the mirror. a mirror is a bright object that provides appropriate visual stimulation for this age group. For the infants safety, however, the mirror must be unbreakable)
A nurse is caring for a toddler who has otitis media and a temperature of 39.1 (102.4F). Which of the following actions should the nurse take first? -Reduce the temperature of the Childs room -redress the child in minimal clothing -apply cool compresses to the Childs forehead -administer an antipyretic to the child
Administer an antipyretic to the child (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 discussing the causes of chronic diarrhea with a client. which of the following conditions is caused by malabsorption -Celiac disease -Ulcerative colitis -Hirschsprung's disease -Crohn's disease
Celiac Disease (the nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. other malabsorption conditions include short bowel syndrome, lactose intolerance, and congenital enzyme deficiency)
A nurse is caring for a 7 year old child who is in skeletal traction following a complete fracture of the femur. which of he following diversional activities should the nurse offer the child? -Puzzle with large pieces -Building blocks -Finger paints -Chapter books
Chapter books (the nurse should offer chapter books as an appropriate diversional activity for a school age child who has limited movement due to skeletal traction)
A nurse is planning care for a 3 month old infant who has an ileostomy. which of the following interventions should the nurse include in the plan? -Avoid laying the infant on his abdomen -avoid tucking the appliance into the infants diaper -check the bag for stool every 4 hours -Replace the appliance every 3 days
Check the bag for stool every 4 hours (the nurse should check the bag for stool every 4 hours or less to prevent the bag from overfilling and leaking stool from an ileostomy is acidic and can cause excoriation of the skin)
A nurse is creating a plan of care for a 6 month old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include. -Reposition the sensor to a new site once every 24 hr -Secure the oximetry sensor to the infant's wrist -apply conduction gel to the skin before attaching the sensor -Cover the oximetry sensor with clothing
Cover the oximetry sensor with clothing (the nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading)
A Nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. which of the following pieces of information should the nurse give to guardian? -children commonly begin having imaginary friends when they reach school age -Notify your provider if the imaginary friend persists longer than 6 months -Have your child take responsibility for actions if he tries to blame the imaginary friend -Set limits by not allowing your child to have the imaginary friend present during family meals
Have your child take responsibility or actions if he tries to blame the imaginary friend (the nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. the nurse should inform the guardian of the need to have the preschooler take responsibility for his actions)
a nurse is caring for a child who has tetralogy of Fallot. which of the following laboratory values should the nurse expect to find? -Platelet count of 20,000/mm^3 -WBC 4,000/mm^3 -Thyroid stimulating hormone 7.0 microunits/mL -RBC 6.8 million/uL
RBC 6.8 million/uL (A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts)
A nurse is teaching an adolescent about various strategies for chironic pain management. which of the following activities should the nurse use as an example of the nonpharmacological strategy of thought stopping? -Assemble a puzzle -Discuss a recent pleasurable event -Tighten and then relax each body part -Repeat memorized facts about the painful event
Repeat memorized facts about the painful event (Having the adolescent repeat memorized facts about the painful event is an example of the non pharmacological pain management strategy of thought stopping. Thoughts such as the pain will be gone soon or ill be home by this time tomorrow can help the adolescent control the pain. after listing the facts, the nurse should then have the adolescent condense and memorize the facts to repeat them whenever pain occurs.
A nurse is providing teaching to a 12 y3ear old client who is recovering from an acute episode of hemophilia A. which of the following statements should the nurse include in the teaching? -have your parent stretch and mover your legs for you -apply heat to joints that become painful, stiff, and swollen. -take aspirin at the first sign of a headache -you will be able to participate in physical exercises
You will be able to participate in physical exercises (physical exercise is important for the maintenance of joint mobility and muscle strengthen. participation in non contact sports and the use of protective equipment such as knee pads are encouraged, although high impact athletic activities such as karate should be avoided)
A nurse is caring for an infant who has gastroenteritis and is dehydrated. which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client? -Less extracellular fluid -Reduced body surface area -Longer intestinal tract -Decreased rate of metabolism
Longer intestinal tract (Compared to adults or older children, infants have a longer intestinal tract. this results in greater fluid losses, especially through diarrhea)
A nurse is caring for an infant who has pertussis. which of the following actions should the nurse take? -assess for edema of the extremities -apply warm compresses to the neck area -initiate airborne precautions -maintain a cardiorespiratory monitor
Maintain a cardiorespiratory monitor (Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidified oxygen and suction equipment should be used as needed)
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso occlusive crisis. which of the following interventions should the nurse include in the plan? -Apply cold compresses to the child's extremities -Administer meperidine every 4 hr until the crisis has resolved -Maintain the child on bed rest -Decrease the child's fluid intake for 8 hours
Maintain the child on bed rest (The nurse should maintain bed rest for this child who is experiencing a vaso occlusive crisis to minimize energy expenditure and avoid additional oxygen needs
A nurse is caring for an adolescent following a lumbar puncture. which of the following actions should the nurse take? - initiate NPO status for the adolescent - place the adolescent in a supine position - place a moist, warm pack on the adolescents lower back - apply a eutectic mixture of local anesthetics to the adolescent's puncture site
Place the adolescent in supine position (The nurse should place the adolescent in a supine position for 30 minutes to an 1 hour following a lumbar puncture to decrease the risk of a post Dural puncture headache)
A nurse is reviewing recommended immunizations with the guardian of a 2 month old infant. which of the following statements should the nurse make? -your baby can receive the varicella vaccine at 6 months of age -your baby can start the pneumococcal vaccine now -Your baby should receive the flu vaccine before 6 months of age -you baby can start eh measles, mumps, and rubella vaccine
Your baby can start eh pneumococcal vaccine now (The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age)
A nurse is developing a health education program for the parents of school aged females. which of the following pieces of information regarding sexual maturation should the nurse include -hgihe4r body fat content is associated with earlier onset of menarche -pubic hair is typically present prior to breast development -ovulation begins after sexual maturation is complete -menarche signals the beginning of puberty
higher body fat content is associated with earlier onset of menarche (the nurse should inform the parents that the onset of menarche is expected to occur around 10.5 to 15.5 years of age. females who have a higher body fat content have been shown to have earlier onset of menarche)