CLO 3 VN 34
The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?
Between the sternum and the left nipple
The nurse in the well-child clinic observes that a 5-year-old child in the waiting room is having trouble using a crayon to color. During the visit, the same child climbs off the table several times even after the nurse has asked him to stay on the table. Each time the nurse reminds him he says, "Oh, yeah," and happily climbs back up. The nurse suspects that the child has:
o attention deficit hyperactive disorder (ADHD).
In discussing the treatment for children with scoliosis, a group of pediatric nurses makes the following statements. Which statement is most accurate related to the treatment of scoliosis?
"Children treated for scoliosis by using braces have to wear the brace almost all the time."
The nurse is caring for a child admitted to the emergency center in diabetic ketoacidosis. Which clinical manifestations would the nurse most likely note in this child?
Drowziness and fruity odor to breath
The caregiver of a 2-year-old who has a polyurethane resin cast on her arm calls the clinic to report that her child is crying and says that the cast has sand in it. The caregiver states that she has had casts herself and knows how badly they can itch. She says she always used a hanger to scratch but is worried that it will be too sharp for the child. Which statement would be appropriate for the nurse to make to this caregiver?
"Nothing should be put into the cast. You can blow cool air into it with a hair dryer."
A school-aged child is brought to the office of the camp nurse with a small, superficial burn. Which action by the nurse would be the most appropriate action for the nurse to do first?
Apply cold compresses to the area
The nurse is teaching the caregivers of a child with cystic fibrosis. What is most important for the nurse to teach this family?
Encourage everyone in the family to use good hand-washing techniques.
The nurse is discussing medications to be given to a child who has been diagnosed with candidiasis. Which of the following medications would most likely be prescribed for the child?
Nystatin
In developing a plan of care for the child diagnosed with rheumatic fever, the nursing intervention that takes highest priority for this child is to:
Promote rest periods and bed rest
The nurse is caring for a child who is being evaluated for a possible nephroblastoma. Which nursing intervention would be important for this child?
Protect the child from having the abdomen palpated.
The caregiver of a fifth-grade boy calls the pediatrician's office and reports that her son has been scratching at his groin for a week or so. Despite his need for privacy, he's finally allowed the caregiver to look at the groin area. The caregiver describes the area to the nurse saying, "It looks like black pin dots that seem to have dark tails." The nurse suspects that the child may have which of the following?
Scabies
The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy, the process of digitalization is done for which reason?
To build the blood levels to a therapeutic level
The nurse is caring for a child diagnosed with a urinary tract infection. The caregiver asks the nurse why it is so important for the child to have so much fluid. The nurse tells the caregiver that the most important reason the child needs increased fluids is to:
To dilute the urine and flush the bladder.
A nurse is preparing to administer an intramuscular (IM) injection to a child. Which of the following muscle groups is contraindicated?
dorsogluteal
A symptom often seen in the child diagnosed with Haemophilus influenzae meningitis occurs when the child has a stiff neck. This symptom is referred to as which of the following?
nuchal rigidity
The caregivers of a 2-year-old who has had a common cold for 4 days calls the nurse in the emergency department at 2 AM on a cold winter night to say that the child has awakened with a barking cough and an elevated temperature; she seems blue around her mouth. The nurse would most appropriately recommend what action to the caregiver?
o "Bring the child to the emergency room immediately."
The nurse is collecting data on an 18-month-old child admitted with a diagnosis of possible seizures. When interviewing the caregivers, which questions would be most important for the nurse to ask?
o "Have you checked your child's temperature?" page 635
A 5-yr-old child is scheduled for a dressing change that will produce moderate pain. What pre-procedural intervention should the nurse prioritize?
o Administer pain medication prior to the procedure.
The nurse is assisting with the physical exam on a 2-year-old child. The nurse predicts the order of the exam will be in which sequence?
o Back and extremities; head and neck; then the eyes, ears, nose, and mouth
If the child is following a normal development process, visual acuity gradually increases from birth. What is most accurate regarding the age children develop 20/20 vision?
Children usually develop 20/20 vision by 5 years of age.
The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child?
Following guidelines for protective isolation
In caring for the child with asthma, the nurse recognizes that bronchodilator medications are administered to children with asthma for which reason?
Relief of acute symptoms
The nurse is collecting data on an 18-month-old old child with a diagnosis of autism spectrum disorder (ASD). What clinical manifestation would likely have been noted in the child with this diagnosis?
The child does not make eye contact.
The nurse is assisting with a physical exam on a child who has been admitted with a diagnosis of possible child abuse. Which finding might alert the nurse to this possibility that the child may have been abused?
The child has a burn that has not been treated.
What assessment tools should the nurse prioritize to measure pain in children? Select all that apply.
The faces scale, The numeric Scale
The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing intervention is the highest priority for this child?
The nurse follows contact precautions.
The mother of 2-year-old triplets is anxious and worried because one of the trio does not seem to be developing at the same rate as the other two. Which assessment finding would lead the nurse to question the need for further diagnostic testing for this child?
The tops of her ears are below the corners of her eyes.
The nurse is administering an intramuscular injection of an antibiotic to a 3-month-old child. Which would be the best site for the nurse to give this medication?
Thigh
The care provider has ordered the drug furosemide to treat a child diagnosed with congestive heart failure. The nurse knows that this drug will be used to:
eliminate excess fluids
The nurse has admitted a child with a diagnosis of severe gastroenteritis. To help prevent the risk of transmitting infection to other clients, the nurse should:
follow standard precautions
The nurse is caring for a child admitted with juvenile idiopathic arthritis (JIA). Which of the clinical manifestation would likely have been noted in the child with this diagnosis?
inflammation of the joints
What are some signs of abuse or neglect that may be assessed on a child? Select all that apply.
o The child is suffering from malnutrition o Attending school in shorts and t-shirt in January while its snowing The child has a spiral fracture
A nurse stops at her friend's house one evening to visit. Her friend isn't home but a teenager watching TV says she is babysitting for the family's three children. The nurse notices that one of the children is chewing several pieces of something white. He is also drooling and crying. A container that looks like an empty pill bottle is on the floor. The first action by the nurse would be to:
remove the substance from the child's mouth