Exam 3 study guide
A nurse in the emergency department is caring for a client who has a fruity breath odor, a dry mouth, and extreme thirst. Which of the following assessments should the nurse make? A. Blood glucose level B. Pupillary reaction to light C. Deep tendon reflexes D. Liver function tests
A. Blood glucose level These findings are indications of hyperglycemia and diabetic ketoacidosis. The nurse should check the client's blood glucose level as well as assess the client's respiratory status, vital signs, level of consciousness, and hydration status, including a laboratory assessment of his electrolyte levels.
A nurse is assessing an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing? A. High-pitched cry B. Sunken fontanel C. Tachycardia D. Increased awake time
A. High-pitched cry The nurse should identify that an infant's high-pitched cry is an indication of increased ICP. Other indications include a bulging fontanel, a high-pitched cry, and increased sleeping.
A nurse is providing teaching to a group of new parents about medications. The nurse should include that aspirin is contraindicated for children who have a viral infection due to the risk of developing which of the following adverse effects? A. Reye's syndrome B. Visual disturbances C. Diabetes mellitus D. Wilms' tumor
A. Reye's syndrome Aspirin should not be given to children or adolescents who have a viral infection like chickenpox or influenza due to the risk of developing Reye's syndrome.
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? A. Platelets 150,000/mm^3 B. Hgb 6 g/dL C. WBC 6,000/mm^3 D. Potassium 4.5 mEq/L
B. Hgb 6 g/dL This hemoglobin level is below the expected reference range and is indicative of anemia; therefore, the nurse should report this finding to the provider.
A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." B. "Your child will be unable to participate in recreational activities." C. "Your child will need a botulinum toxin A injection to reduce muscle spasticity." D. "Your child will need throw rugs placed over non-carpeted areas."
C. "Your child will need a botulinum toxin A injection to reduce muscle spasticity." Children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which reduce spasticity.
A nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. Which of the following interventions should the nurse include? A. Use a mobile walker for the toddler B. Discourage activities involving repetitive joint movement C. Use manual jaw control when feeding the toddler D. Discourage the use of wrist splints
C. Use manual jaw control when feeding the toddler The nurse should encourage the parent to include the use of manual jaw control during feedings. Children diagnosed with cerebral palsy can lose jaw control, and more effective control can be achieved by providing stability to the jaws during feeding.
A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect? A. Tonic-clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness
C. Weakness of the lower extremities Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.
A nurse is planning care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. Airborne precautions B. Contact precautions C. Protective environment D. Droplet precautions
D. Droplet precautions The nurse should maintain droplet precautions for a client who has meningococcal meningitis for 24 to 72 hours after the initiation of antibiotic therapy. Disease transmission can occur through large-droplet particles when the client is talking. There is no drainage of infected body fluids with meningitis, so contact precautions are not necessary.
A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room? A. Pulse oximeter B. Oxygen therapy C. Bag valve mask D. Suction equipment
D. Suction equipment When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority item to have in the child's room is suction equipment. If the child experiences a tonic-clonic seizure, the child is at risk for aspiration and airway occlusion due to secretions, food, or fluids. The nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bag valve mask if needed
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? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Notify the provider, Elevate the extremity, Remove the IV line, Stop the infusion
Stop the infusion Elevate the extremity Notify the provider Remove the IV line
A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing
C. Palpate the abdomen for bladder distension A neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess for bladder distension due to the possibility of incomplete emptying of the bladder.
A nurse is providing teaching about home care to the parent of a child who has a newly applied fiberglass leg cast. Which of the following statements should the nurse include? A. "Monitor the color of your child's toes every 4 hours for 24 hours." B. "Your child can scratch the skin inside the cast with a small wooden ruler." C. "Expect the cast to remain damp for 72 hours." D. "You can take your child swimming and give baths as usual."
A. "Monitor the color of your child's toes every 4 hours for 24 hours." The nurse should instruct the parent to monitor the color of the child's toes every 4 hours to check for alterations in perfusion. The nurse should instruct the parent to notify the provider if the child's toes are discolored or cool to the touch.
A nurse is caring for a preschool-age child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take? A. Place viscous lidocaine on the child's oral lesions. B. Instruct the child to use a soft-sponge toothbrush when brushing her teeth. C. Encourage the child to rinse her mouth with hydrogen peroxide every 2-4 hr. D. Give the child lemon glycerin swabs to use after each meal.
B. Instruct the child to use a soft-sponge toothbrush when brushing her teeth. The child should use a soft-sponge toothbrush when brushing her teeth because a regular toothbrush may cause further irritation to the mucosal ulcers. Incorrect Answers:A. Preschool-age children should not take viscous lidocaine because it depresses the gag reflex, increasing their risk of aspiration. C. Children who have mucosal ulcers should not use hydrogen peroxide as a mouth rinse because the drying effects on the mucosa may cause further ulceration. D. Children who have mucosal ulcerations should avoid using lemon glycerin swabs because they are irritating, especially on eroded tissues.
A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of 0 to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak
C. The child reports tightness at the wrist The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome.
A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I can take my brace off to sleep every night at bedtime." B. "I can take my brace off for about an hour daily to shower." C. "I should loosen the straps on my brace if it is rubbing against my skin." D. "I should place the pads of the brace against my skin with a t-shirt over them."
B. "I can take my brace off for about an hour daily to shower." The nurse should instruct the child to wear the brace for 23 hours each day and only to remove it for showering or participating in physical therapy.
A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? A. Bradycardia B. Muscle weakness C. Diarrhea D. Dry skin
B. Muscle weakness Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea.
A nurse is caring for a 2-day-old infant who has myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference B. Position the infant supine C. Place the infant under a radiant warmer D. Tape a piece of plastic over the protruding membranes
A. Monitor the infant's head circumference Infants with myelomeningocele have an increased risk of hydrocephalus. Measuring the infant's head circumference helps determine any increase of fluid.
A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? A. Initiate contact precautions for the child. B. Explain to the child's parents that chemotherapy will start 3 months after surgery. C. Put a "no abdominal palpation" sign over the child's bed. D. Prepare the child for a spinal tap.
C. Put a "no abdominal palpation" sign over the child's bed. The nurse should place a sign over the child's bed stating "no abdominal palpation" because palpation is not necessary to confirm diagnosis and could prompt metastasis.
A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? A. "I will give you an antibiotic before your procedure." B. "I will place you on your side during the procedure." C. "You might have a headache following the procedure." D. "I will place a pressure dressing over the area following the procedure."
D. "I will place a pressure dressing over the area following the procedure." Applying a pressure dressing over the area following the procedure helps prevent bleeding from the site.
A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm^3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? A. Provide foods high in iron B. Avoid people who have infections C. Administer PRN oxygen D. Encourage quiet play
D. Encourage quiet play A platelet count of 20,000/mm^3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk of injury, thereby reducing the chance of hemorrhage.
A nurse is providing teaching to the parents of a school-aged child who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following responses by a parent indicates an understanding of the teaching? A."I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." B. "I will give my child 2 units of regular insulin." C. "I will insist that my child lie down to rest for 30 min." D. "I will check my child's urine for glucose twice daily." Check Answer
A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." Giving the child 10 to 15 g of simple carbohydrates such as 240 mL (8 oz) of milk will elevate the blood glucose level and alleviate hypoglycemia.
A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion B. Give potassium as a rapid IV bolus C. Administer 3 units of ultralente insulin subcutaneously D. Obtain an HbA1c level stat
A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion When the child's blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur.
A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the client's bathroom to strain the client's urine D. Administer folic acid with meals
A. Attach a latex allergy alert identification band Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk of latex allergy; therefore, the nurse should avoid the use of common medical products containing latex such as latex gloves for this client.
A nurse is teaching a newly hired nurse about caring for an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? A. Hydrocephalus B. Congenital hypotonia C. Otitis media D. Osteomyelitis
A. Hydrocephalus In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered. Therefore, the infant is at risk of hydrocephalus, and the nurse should monitor the infant for this condition.
A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? A. Place a plastic bag over the cast when showering B. Insert a dull knitting needle into the cast to rub itchy skin C. Exercise fingers every 8 hr for the first 24 hr D. Draw on the cast using magic markers
A. Place a plastic bag over the cast when showering The nurse should instruct the adolescent to keep the cast dry by placing a plastic bag over it while showering.
A nurse is providing discharge teaching to parents whose infant had a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching? A. "We will check his abdomen daily for signs of fluid accumulation." B. "We will notify the doctor right away if he has a fever." C. "We should keep a helmet on him when he's awake." D. "We can expect him to have occasional seizure episodes."
B. "We will notify the doctor right away if he has a fever." Infection is a risk after ventriculoperitoneal shunt insertion, especially 1 to 2 months after placement. The parents should report fevers, vomiting, seizure activity, and decreased responsiveness, as these findings can indicate infection.
A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? A. Implement droplet precautions B. Administer oral analgesics prior to exercises C. Use humidified oxygen to thin secretions D. Initiate seizure precautions
B. Administer oral analgesics prior to exercises Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause the child discomfort.
A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain B. Check for pulses in the affected leg every 4 hr C. Cleanse the pins every 12 hr D. Inform parents to discourage visitors for the child
B. Check for pulses in the affected leg every 4 hr Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hours.
A nurse is planning care for a preschooler who is immediately postoperative following the placement of a ventriculoperitoneal shunt. Which of the following interventions should the nurse include in the plan? A. Monitor the preschooler's pupils every 8 hours B. Lay the preschooler on the nonoperative side C. Keep the head of the bed elevated to 30° D. Check bowel sounds once per day
B. Lay the preschooler on the nonoperative side The preschooler should not be positioned on the shunt side postoperatively to avoid putting pressure on the shunt or surgical site.
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. Perform nasotracheal suctioning B. Test the nasal secretions for glucose C. Maintain direct lighting on the child D. Lower the head of the bed
B. Test the nasal secretions for glucose The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are a leakage of cerebrospinal fluid (CSF). The leakage of CSF is positive for glucose and occurs if the child has a skull fracture.
A nurse is providing discharge teaching for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? A. "I should apply powder to the folds of skin on my baby's knees and thighs." B. "I should adjust the straps on the harness once a week as my baby grows." C. "I should lightly massage my baby underneath the straps once a day." D."I should place my baby's diaper over the straps of the harness."
C. "I should lightly massage my baby underneath the straps once a day." The parent should lightly massage the skin under the harness daily to promote circulation.
A nurse is providing teaching to the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the teaching? A. "Donepezil might slow the progression of the disorder." B. "My child will prefer group therapy with other children." C. "We can help our child by structuring our daily routine." D. "Our child probably has this condition as a result of prematurity."
C. "We can help our child by structuring our daily routine." Children who have autism spectrum disorder benefit from a structured routine. This environment can minimize the anxiety the child might have with sudden schedule changes and socialization requirements and satisfy a preference for ritualistic behavior.
A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse identify as a manifestation of this complication? A. Slow heart rate B. Protruding eyeballs C. Deep, rapid respirations D. Decreased urinary output
C. Deep, rapid respirations Deep and rapid respirations are known as Kussmaul respirations, which is a manifestation of DKA. This respiratory pattern is caused by the body's attempt to rid itself of the excess carbon dioxide that results from the presence of ketones. The child's breath can be sweet smelling due to the body's attempt to eliminate ketones through the respiratory system.
A nurse is assessing a 24-month-old toddler who has a new diagnosis of autism spectrum disorder (ASD). Which of the following findings should the nurse expect? A. Wanting to be held frequently B. Ability to build a tower of 10 cubes C. Impaired language skills D. Ability to stand on 1 foot
C. Impaired language skills The nurse should expect a 24-month-old toddler who has ASD to exhibit impaired language skills (e.g. failing to respond to his or her name, pointing to objects instead of speaking).
A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? A. Side-lying B. Supine C. Prone D. Semi-Fowler's
C. Prone When providing preoperative care for an infant who has a myelomeningocele, the nurse should maintain the infant in a prone position. This position reduces pressure and the risk of trauma to the sac.
A nurse is providing teaching about home care to the guardian of a school-aged child who has seizures. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will call an ambulance if my child's seizure lasts more than 10 minutes." B. "I will offer my child clear liquids immediately following a seizure." C. "I will tightly hold my child to restrain her during a seizure." D. "I will turn my child onto her side when a seizure begins."
D. "I will turn my child onto her side when a seizure begins." To reduce the risk of aspiration and to improve oxygenation, the guardian should place the child in a side-lying position.
A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short Check Answer
D. Ensure that staff visits with the child are kept short Children who have autism spectrum disorders have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible.
A nurse is caring for a 5-year-old child who has a fever and begins to have a seizure. Which of the following actions should the nurse take? A. Give acetaminophen 240 mg PO immediately following the seizure B. Sponge the child's skin with a mixture of cold water and rubbing alcohol C. Administer rectal diazepam if the seizure lasts longer than 2 minutes D. Place the child in a side-lying position
D. Place the child in a side-lying position The nurse should place the child in a side-lying position to facilitate drainage of oral secretions, which decreases the risk of aspiration.
A nurse is caring for a school-age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hr during the night B. Ensure the child's meal tray contains no high-fiber foods C. Perform passive range-of-motion exercises on the child's involved joints every 4 hr D. Place the child on a pressure-reduction mattress
D. Place the child on a pressure-reduction mattress Placing the child on a pressure-reduction mattress will alleviate the pressure on bony prominences, which decreases the risk of skin breakdown.
A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing
A. Abdominal distention A VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus.
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? A. Maintain the child on bed rest B. Monitor the child for increased temperature C. Administer oxygen to the child D. Monitor the child for bleeding
B. Monitor the child for increased temperature Leukopenia places the child at risk of infection; therefore, the nurse should monitor the child for a fever.
A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take? A. Initiate NPO status for the adolescent B. Place the adolescent in a supine position C. Place a moist, warm pack on the adolescent's lower back D. Apply a eutectic mixture of local anesthetics (EMLA) to the
B. Place the adolescent in a supine position The nurse should place the adolescent in a supine position for 30 minutes to 1 hour following a lumbar puncture to decrease the risk of a post-dural puncture headache.
A nurse is providing discharge teaching to the parent of a school-aged child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will take my child's rectal temperature daily." B. "I will make sure my child gets his MMR vaccine this week." C. "I will inspect my child's mouth every day for sores." D. "I will allow my child to ride his bicycle tomorrow."
C. "I will inspect my child's mouth every day for sores." A child who has leukemia is at an increased risk of mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations. Incorrect Answers:A. The parent should avoid taking rectal temperatures to prevent trauma to the child. B. A child who has leukemia will have a compromised immune system and should not receive the MMR vaccine. D. The nurse should advise the parents to avoid any activities that could cause injury or bleeding, such as riding bicycles or climbing on playground equipment.
nurse is providing teaching to a school-aged child who just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hr? A. "Use a toothbrush to scratch under the cast if your skin itches." B. "Avoid moving your leg and the joints above and below the cast." C. "Keep the cast above the level of your heart." D. "Clean soil from the cast with soapy water."
C. "Keep the cast above the level of your heart." Immediately following the injury (and for at least the first 48 hours), the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return.
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment? A. The infant is grabbing the feet and pulling them to the mouth. B. The infant has a closed posterior fontanel. C. The infant's legs remain crossed and extended when supine. D. The infant's birth weight has doubled.
C. The infant's legs remain crossed and extended when supine. Legs that are crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the infant's legs flex at the knees when the infant is supine. Crossed and extended legs when supine is associated with cerebral palsy.
A nurse is providing teaching to the parent of an infant who has developmental hip dysplasia and a new prescription for a Pavlik harness. Which of the following parent statements indicates an understanding of the teaching? A. "I will apply the harness over a t-shirt and knee socks." B. "I will put my baby's diaper over the harness." C. "I will make the required harness adjustments as my baby grows." D. "I will apply powder around the harness buckles each day."
A. "I will apply the harness over a t-shirt and knee socks." Applying the harness over a t-shirt and knee socks indicates that the parent understands the instructions. This step will prevent the harness straps from rubbing against and causing irritation to the infant's skin.
A nurse is providing teaching to a 13-year-old client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of diabetes mellitus management? A. "I will need to avoid snacks between meals." B. "I should check my blood glucose levels more often when I am sick." C. "I will need to limit my exercise to 1 hour per day." D. "I should consume 30 g of simple carbohydrates if I feel shaky." Check Answer
B. "I should check my blood glucose levels more often when I am sick." Blood glucose levels should be checked every 3 hours during illness for a client who has type 1 diabetes mellitus, even if the client consumes fewer calories than usual. Hyperglycemia often occurs with an infection, requiring additional doses of insulin.
A nurse is teaching an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching? A. "You should drink 8 oz of a regular soft drink if you experience hypoglycemia " B. "You should drink 4 oz of orange juice if you experience hypoglycemia." C. "You should take 2 glucose tablets if you experience hypoglycemia." D. "You should take 3 tsp of sugar if you experience hypoglycemia." Check Answer
B. "You should drink 4 oz of orange juice if you experience hypoglycemia." The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs.
A nurse is caring for a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse perform first? A. Position the child on his side B. Measure the child's vital signs C. Loosen any restrictive clothing D. Check the child for head injuries
A. Position the child on his side Using evidence-based practice, the nurse should first position the child on his side. Salivation increases and the swallowing reflex is lost during a tonic-clonic seizure, placing the child at risk for aspiration. It is essential to maintain the airway during a seizure.
A nurse is caring for a newborn who has spina bifida. The newborn's parents are upset by the diagnosis. Which of the following actions should the nurse take? A. Discuss placement options for the newborn B. Encourage the parents to touch and care for the newborn C. Reassure the parents that everything will be fine D. Avoid talking about the newborn's defect until the parents bring up the subject
B. Encourage the parents to touch and care for the newborn Touching and caretaking will help the parents bond with the newborn.
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? A. Administer 81 mg of aspirin to the toddler B. Give the toddler a cold bath C. Place the toddler in a supine position D. Pad the rails of the toddler's bed
D. 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 school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. Obtain a portable suction machine and suction tubing B. Ease the child to the floor in Sims' position C. Time the length of the seizure D. Notify the child's parents
B. Ease the child to the floor in Sims' position The greatest risk to the child is an injury resulting from a fall; therefore, the nurse should first gently ease the child to the floor to decrease the chance of injury and turn the child on the left side to prevent aspiration.
A nurse is caring for a 7-year-old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books
D. 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 caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints B. Massage the child's pressure areas C. Increase the child's fluid intake D. Encourage the child to use an incentive spirometer
D. Encourage the child to use an incentive spirometer
A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen B. Elevate the adolescent's leg on pillows C. Place an ice pack on the cast D. Assess for manifestations of circulatory impairment
D. Assess for manifestations of circulatory impairment The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern.
A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (Select all that apply.) A. "I should eat extra food on busy days when I am more active." B. "I should wait for 2 hr after eating before going swimming with my friends." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." E. "I should have a 16 oz sports drink if I start feeling weak or shaky."
A. "I should eat extra food on busy days when I am more active." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." The nurse should instruct the adolescent to increase the intake of allowable foods when the level of activity is increased. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. Additionally, the nurse should instruct the adolescent to increase the intake of sugar-free fluids when sick because fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids such as water, broth, and tea. The adolescent should continue with the usual intake at mealtimes and follow the recommended meal plan as much as possible. Finally, the nurse should instruct the adolescent to eat a recommended snack 30 minutes prior to a planned activity such as playing in a baseball game. If the game is prolonged, a snack should be consumed every 45 minutes to 1 hour. If, for some reason, the extra food cannot be tolerated, the next intervention is to decrease the adolescent's insulin dose before baseball games.
A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take? A. Measure the infant's intake and output B. Measure the infant's head circumference C. Check the infant's lower-extremity function D. Monitor the infant's blood pressure
B. Measure the infant's head circumference Increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements.
