ATI RN Nursing Care of Children A and B
A nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? "I will offer my child small amounts of fruit juice frequently." "I will avoid giving my child solid foods until the diarrhea has stopped." "I will monitor my child's number of wet diapers." "I will give my child polyethylene glycol daily for 7 days."
"I will monitor my child's number of wet diapers."
A nurse is caring for a toddler who has acute otitis media and a temperature of 40 degree C (104 degrees F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? Apply a cooling blanket to the toddler. Dress the toddler in minimal clothing. Give the toddler a tepid bath. Administer diphenhydramine to the toddler.
Dress the toddler in minimal clothing.
A nurse is receiving change-of-shift report on 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. School age child who has cystic fibrosis and a frequent nonproductive cough. A preschooler who has asthma and a peak flow meter reading in the green zone. An adolescent who has meningitis and reports a sensitivity to lights and noise.
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? Place the child in a prone position for the immunization. Request that the child's caregiver leave the room during the immunization. Administer the immunization using a 24 gauge needle. Inject the immunization slowly after aspiration for 3 seconds.
Administer the immunization using a 24 gauge needle.
A nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize that infant's pain? Use a manual lancet to obtain the heel blood sample. Apply an ice pack to the infant's heel prior to obtaining the sample. Allow the mother to breastfeed while the sample is being obtained. Apply a topical lidocaine cream prior to obtaining the sample.
Allow the mother to breastfeed while the sample is being obtained.
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? An 18-month-old toddler who has unintelligible speech A 3-month-old infant who has an exaggerated startle response A 4-year-old preschooler who prefers playing with others rather than alone An 8-month-old infant who is not yet making babbling sounds
An 8-month-old infant who is not yet making babbling sounds
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all the apply) Negative Babinski reflex Ankle clonus Exaggerated stretch reflexes Uncontrollable movements of the face Contractures
Ankle clonus Exaggerated stretch reflexes Contractures
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? Place a cardiac monitor on the adolescent prior to the procedure. Apply topical analgesic cream to the site 1hr prior to the procedure. Keep the adolescent in a semi-fowler's position for 4hrs following the procedure. Restrict fluids for 2hrs following procedure.
Apply topical analgesic cream to the site 1hr prior to the procedure.
A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data). Episodes of vomiting Formula consumption Weight Temperature
Episdoes of vomiting
A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? Inform the parents that written consent is required prior to organ donation. Provide written information to the parents about organ donation. Ask the provider to explain misconceptions of organ donation to the parents. Explore the parents' feelings and wishes regarding organ donation.
Explore the parents' feelings and wishes regarding organ donation.
A nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? Palpate the dorsum of the child's feet. Weigh the child daily using the same scale. Assess the child's skin turgor. Observe the child for periorbital swelling.
Palpate the dorsum of the child's feet.
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? Reports a headache as 6 on a 0 to 10 pain scale Petechiae on the lower extremities Nuchal rigidity Positive Kernig's sign
Petechiae on the lower extremities
A nurse is assessing a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? Presence of a central incisor tooth Presence of strabismus Presence of an open anterior fontanel Presence of external cerumen
Presence of strabismus
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? potassium 2.9 mEq/L sodium 140 mEq/L urine specific gravity 1.035 BUN 25 mg/dL
Sodium 140 mEq/L
A nurse is assessing a school age child who has peritonitis. Which of the following findings should the nurse expect? hyperactive bowel sounds abdominal distention bradycardia bloody stool
abdominal distension
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?a pply topical antimicrobial ointment to the child's wound place a mesh gauze dressing over the child's wound administer an analgesic to the child initiate prophylactic antibiotic therapy for the child
administer an alagesic to the child
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? "Place the infant in a prone position to sleep." "Allow the infant to sleep on a large pillow." "Use a soft mattress in the infant's crib." "Give the infant a pacifier at bedtime."
"Give the infant a pacifier at bedtime."
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by a parent indicates an understanding of the teaching? "My child will have a cast until healing is complete." "My child will receive antibiotics for several weeks." "My child can return to playing sports once they have been discharged." "My child needs to be in contact isolation."
"My child will receive antibiotics for several weeks."
A nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure. The client asks, "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" "Your spouse should sign the consent form for you." "Your parent should sign the consent form for you" "You can appoint a legal guardian to sign the consent form."
"You can sign the consent form because you are married."
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? expresses a reluctance to leave home provides a detailed description of how the burns occurred denies discomfort during assessment of injuries describes strong relationship with peers
denies discomfort during assessment of injuries
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis? inflamed throat with exudate purulent eye drainage dry, hacking cough koplik spots on buccal mucosa
dry, hacking cough
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? laryngeal edema flank pain distended neck veins muscular weakness
flank pain
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? decreased cerebrospinal fluid pressure decreased WBC count increased protein concentration increased glucose level
increased protein concentration
A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? place the child in a room with a positive pressure airflow place the child in a room with a negative pressure airflow initiate contact precautions for the child initiate droplet precautions for the child
initiate droplet precautions for the child
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? loud, harsh murmur dysrhythmias weak femoral pulses high BP
loud, harsh murmur
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? apple juice peanut butter chicken broth oral rehydration solution
oral rehydration solution
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 pat-a-cake using a push-pull toy creating a scrapbook playing dress-up
playing dress up
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? instruct the parents to decrease the calcium in their toddler's diet prepare the toddler for chelation therapy refer the family to child protective services schedule the toddler for a yearly rescreening
schedule the toddler for a yearly rescreening
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? negative leukocyte esterase serum creatinine 3.0 mg/dL negative urine protein urine output 40ml/hr
serum creatinine 3.9 mg/dL
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? zinc oxide antibiotic ointment talcum powder antiseptic solution
zinc oxide
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? ½ cup whole milk 1 cup orange juice ½ cup raisins 1 cup raw carrots
½ cup raisins
A nurse is providing discharge teaching to he parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include? "Clean your baby's sutures daily with a mixture of chlorhexidine and water." "Expect your baby to swallow more than usual over the next few days." "Inspect your baby's tongue for white patches using a tongue depressor every 8 hours." "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."
"Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."
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? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero).
1 capsule
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 caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? Check the child for a head injury. Observe for oral bleeding. Check the child's respiratory rate. Observe for extremity weakness.
Check the child's respiratory rate.
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? Insert a nasogastric tube Initiate prophylactic antibiotic use Cleanse the affected area with mild soap and water Apply a topical corticosteroid to the affected area
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? Identifies right from left hand Uses a utensil to spread butter Cuts an outlined shape using scissors Draws a stick figure with seven body parts
Cuts an outlined shape using scissors
A nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? Decreased edema Increased abdominal girth Decreased appetite Increased protein in the urine
Decreased edema
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 has a vocabulary of 25 words. The toddler developed a mild rash following a recent varicella immunization. The toddler's Moro reflex is absent. The toddler received tobramycin during a hospitalization 2 weeks ago.
The toddler received tobramycin during a hospitalization 2 weeks ago.
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? (Place in order of performance. Use all the steps.) Remove the tape securing the catheter. Occlude the IV tubing. Turn off the IV pump. Apply pressure over the catheter insertion site.
Turn off the IV pump. Occlude the IV tubing. Remove the tape securing the catheter. Apply pressure over the catheter insertion site.
A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? Use sterile scissors to remove the dressing from the site. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. Access the site using a noncoring angled needle. Use a semipermeable transparent dressing to cover the site.
Use a semipermeable transparent dressing to cover the site.
A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (select all that apply) Steatorrhea Vomiting Lethargy Constipation Weight gain
Vomiting Lethargy
A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority? Length of stay Treatment schedule Disease process Self-care ability
Disease process
A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? "Use a kitchen teaspoon to measure the medication." "Brush the child's teeth after giving the medication." "Double the next dose if the child misses a dose." "Repeat the dose if the child vomits."
"Brush the child's teeth after giving the medication."
A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." "Choose a waterproof sunscreen with a minimum SPF of 15." "Dress your child in loose weave polyester fabric prior to sun exposure." "Reapply sunscreen every 4 hours."
"Choose a waterproof sunscreen with a minimum SPF of 15."
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching? "Limit movement of the child's large joints." "Encourage the child to perform independent self-care." "Provide the child with a soft mattress for sleeping." "Schedule a 2-hour daily nap for the child in the afternoon."
"Encourage the child to perform independent self-care."
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching? "I will use a humidifier in my child's room at night." "I will give my child a cough suppressant Q6hrs if he has a cough." "I should avoid using a wet mop on my floors when I am cleaning." "I house keep my child indoors when I mow the yard."
"I house keep my child indoors when I mow the yard."
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 lower anchors and tethers instead of the seat belt." "I should position the car seat harness 1" above my baby's shoulders." "I will make sure that the car seat is placed at a 90 degree angle." "I will pad my baby's car seat with a blanket for traveling long distances"
"I should secure the car seat using lower anchors and tethers instead of the seat belt."
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? "I should buy plastic shoes to wear at the swimming pool." "I should wear sandals as much as possible." "I should place the permethrin cream between my toes twice daily." "I should seal my nonwashable shoes in plastic bags for a couple of weeks."
"I should wear sandals as much as possible." Sandles allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection.
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 puncture the pad of my finger when I am testing my blood glucose." "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." "I will decrease the amount of fluids I drink when I am sick."
"I will give myself a shot of regular insulin 30 minutes before I eat breakfast."
A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? "My child can resume usual activities since this was just an outpatient surgery." "My child will be able to drink the chocolate milkshake I promised to get for them tonight." "I will notify the doctor if I notice that my child is swallowing frequently." "I will have my child gargle with warm salt water to relieve their sore throat."
"I will notify the doctor if I notice that my child is swallowing frequently."
A nurse is teaching the parent of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? "I should remove the harness at night to allow my infant to stretch her legs." "I will need to adjust the straps on the harness once a week." "I should apply baby powder to my infant's skin twice daily." "I will place my infant's diaper under the harness straps."
"I will place my infant's diaper under the harness straps."
A school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? "I will plan to increase the amount of homework I assign to students who have ADHD." "I will give students who have ADHD the same amount of time as other students to complete tests." "I will allow students who have ADHD one rest break throughout the day." "I will teach challenging academic subjects to students who have ADHD in the morning."
"I will teach challenging academic subjects to students who have ADHD in the morning."
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's 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? "It is important that you provide emotional support for your family at this time." "You have to do what you feel is best. Everything will turn out fine." "I know how you feel. This is an extremely stressful time for your family." "Let's talk about some of the ways you have handled previous stressors in your life."
"Let's talk about some of the ways you have handled previous stressors in your life."
A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include? "You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy." "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." "When using the peak expiratory flow meter, record your child's average of three readings."
"Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy."
A nurse is providing teaching to the parent of a school-age 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.". "Provide the medication through a straw." "Rinse the child's mouth with water immediately after giving the medication." "Mix the medication with applesauce if the child dislikes the taste."
"Shake the medication prior to administration."
A nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? "Stay home from school for 1 week following the procedure." "Follow a diet that is low in fiber for 1 week." "Wait 3 days before taking a tub bath." "Apply a pressure dressing to the site for 3 days."
"Wait 3 days before taking a tub bath."
A nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? "When your child no longer has an increased temperature." "Three days after you first noticed the rash appear on your child." "When your child's lesions are crusted, usually 6 days after they appear." "Two to three weeks, when your child's lesions completely disappear."
"When your child's lesions are crusted, usually 6 days after they appear."
A nurse is providing dietary teaching to the guardian of a school age child who has cystic fibrosis. Which of the following statements should the nurse make? "You should offer your child high-protein meals and snacks throughout the day." "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." "You should restrict your child's calorie intake to 1,200 per day." "You should give your child a multivitamin once weekly."
"You should offer your child high protein meals and snacks throughout the day."
A nurse is caring for a preschooler whose father is going home for a 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? "Your daddy will back at 7pm." "Your daddy will be back after he takes care of your brother." "Your daddy will be back in the morning" "Your daddy will be back after you eat."
"Your daddy will be back after you eat."
A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? Avoid palpating the abdomen when bathing the child before surgery. Refrain from auscultating the child's bowel sounds during the postoperative assessment. Encourage the child to play with other children on the unit prior to surgery. Explain to the child that their pain will be managed after the surgery.
Avoid palpating the abdomen when bathing the child before surgery.
A nurse is caring for a school age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? Deep respirations of 32/min Shallow respirations of 10/min Paradoxic respirations of 26/min Periods of apnea lasting for 20 seconds
Deep respirations of 32/min (kussmaul
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? Controls impulsive feelings Understands right from wrong Easily separates from parents for long periods of time Expresses likes and dislikes
Expresses likes and dislikes
A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use? FACES Numeric CRIES Visual Analog
FACES
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? Until the adolescent is afebrile For 7 days following admission to the facility Until the adolescent has a negative blood culture For 24 hr following initiation of antimicrobial therapy
For 24 hr following initiation of antimicrobial therapy
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take? Instill a 500ml tap water enema Give morphine 0.05mg/kg IV Administer polyethylene glycol 1g/kg PO Apply a heating pad to the child's abdomen
Give morpine 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 a infection control? Have a designated stethoscope in the infant's room. Place the infant in a room equipped with negative airflow. Administer palivizumab as prescribed for the infant. Remove gloves after leaving the infant's room.
Have a designated stethoscope in the infant's room.
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? Have the adolescent sign a consent form for treatment. Instruct the adolescent to return with a guardian. Obtain consent from the adolescent's guardian over the phone. Treat the adolescent without a consent form.
Have the adolescent sign a consent form for treatment.
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? Hematocrit 28% Hemoglobin 13.5 g/dL WBC count 8,000 Platelets 250,000
Hematocrit 28%
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 8.5g/dL WBC 9500/mm³ Prealbumin 18mg/dL Platelets 300000/mm³
Hgb 8.5g/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? Position the infant side-lying with their head at a 0° to 5° angle. Perform a neurological assessment every 4 hr. Suction the infant's naers to remove secretions. Implement seizure precautions for the infant.
Implement seizure precautions for the infant.
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? Administer pancreatic enzymes 2 hr after meals. Discontinue the use of pancreatic enzymes if steatorrhea develops. Limit fluid intake to 750 mL per day. Increase fat content in the child's diet to 40% of total calories.
Increase fat content in the child's diet to 40% of total calories.
A nurse is assessing an 8 year old child who has early indication of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? Insert an indwelling urinary catheter. Measure weight and height. Initiate IV access. Maintain ECG monitoring.
Initiate IV access.
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? Administer ibuprofen to the child for a temperature greater than 38° C (100.4° F). Assess the child's blood pressure every 8hr. Weigh the child weekly at a various times of the day. Initiate seizure precautions for the child.
Initiate seizure precautions for the child.
A nurse is caring for a 15 year old client following a head injury. Which of the following should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)? Sodium 148 mEq/L Urine specfic gravity 1.020 Mental confusion Weak peripheral pulses
Mental confusion
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider? Nasal flaring WBC count 11,300/mm3 Diarrhea Abdominal distension
Nasal flaring
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-laying position. Delay documentation until the child is fully alert. Give the child a high-carb snack. Administer an oral sedative to the child.
Place the child in a side-lying position.
A community health nurse is assessing an 18 month old toddler in a community day care. Which of the following findings should a nurse identify as a potential indication of physical neglect? Resists having an axillary temperature taken Exhibits withdrawal behaviors when their parent leaves Has multiple bruises on their knees Poor personal hygiene
Poor personal hygiene
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. Schedule time in the play room for the child. Weigh the child weekly. Maintain the child in a supine position.
Provide small, frequent meals for the child.
A nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? Desmopressin Luteinizing hormone-releasing hormone Recombinant growth hormone Levothyroxine
Recombinant growth hormone
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? Blood pressure 90/50 mm Hg Respiratory rate 45/min Weight 14.5 kg (32lbs) Heart rate 110/min
Respiratory rate 45/min
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? Reports an absence of nausea and vomiting Reports experiencing an onset of loose stools within 15 min of administration Serum potassium level 4.1 mEq/L Blood pressure 86/52 mm Hg
Serum potassium level 4.1 mEq/L
A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? Urine specific gravity 1.045 Sodium 155 mEq/L Blood glucose 45 mg/dL Urine output 35 mL/hr
Sodium 155 mEq/L
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? Heart rate 124/min Increased tear production Sunken anterior fontanel Capillary refill 2 seconds
Sunken anterior fontanel
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? Blood pressure 130/90 mm Hg Heart Rate 60/min Temp 39.1° C (102.4° F) Urinary output 100ml/hr
Temp 39.1° C (102.4°F)
A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? Withhold the measles, mumps, and rubella (MMR) vaccine. Withhold the diphtheria, tetanus, and pertussis (DTAP) vaccine. Withhold the influenza vaccine. Withhold the tuberculin skin test (TST).
Withhold the measles, mumps, and rubella (MMR) vaccine.
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? increase anterior convexity of the lumbar spine increased curvature of the thoracic spine lateral flexion of the neck a unilateral rib hump
a unilateral rib hump
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? purulent nasogastric drainage absence of peristalsis passage of dark stool with mucus WBC count 6000mm³
absence of peristalsis
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? elevate the head of the child's bed insert a large bore IV catheter for a child determine the allergen that caused the child's reaction administer epinephrine IM to the child
administer epinephrine IM to the child
A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take? change the child's position every 2hrs clean the peripheral pin sites with chlorhexidine solution every 4 days assess peripheral pulses once every 4 hours ensure that the head of the bed is elevated to a 90 degree angle
assess peripheral pulses once every 4 hr
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV 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? prednisone epinephrine diphenhydramine albuterol
epinephrine
A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the following actions should the nurse plant to take? obtain a sputum specimen perform an Allen test perform a finger stick obtain a stool specimen
perform a finger stink
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? use surgical asepsis when providing routine care for the child administer the measles, mumps, and rubella (MMR) vaccine to the child screen the child's visitors for indications of infection infuse packed RBCs
screen the child's visitors for indications of infection
A nurse is providing discharge teaching to the parent 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? occupational therapist speech therapist respiratory therapist physical therapist
speech therapist
A nurse in an emergency department is performing a physical assessment on a 2 week old male newborn. Which of the following findings is priority for the nurse to report to the provider? excoriated scrotal area multiple capillary hemangiomas depressed posterior fontanel substernal retractions
substernal retractions
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? recurrent urinary tract infections symmetric burns of the lower extremities failure to thrive lack of subcutaneous fat
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? skin breakdown hypotension hyperpyrexia tachypnea
tachypnea
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? biot respiration Cheyne-Stokes respiration Tachypnea Bradypnea
tachypnea
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? wheat crackers rye bread barley soup white rice
white rice