Fall 2021 Nursing Level 3 Theory Test 1
A nurse is planning care for an infant who is experiencing pain. Which of the following interventions should the nurse include the plan of care? (Select all that apply)
* Offer a pacifier * Use Swaddling * Encourage kangaroo care
A nurse is conducting a well baby visit with a 4 month old infant. Which of the following immunizations should the nurse plan to administer to the infant? (Select all that apply)
* Polio * Pneumococcal vaccine (PV) * Rotavirus vaccine (RV)
appropriate toys and activities that stimulate the senses and encourage development include
* Rattles * Soft Stuffed Toys * Teething Toys * Nesting Toys * Playing pat-a-cake * Mirrors * Brightly colored toys * Playing with blocks
A nurse is teaching a group of parents about complications of communicable diseases. Which of the following communicable diseases can lead to pneumonia? (Select all that apply)
* Rubeola (German measles) * Pertussis (whooping cough) * Varicella (Chickenpox)
A nurse is assessing a client who has pertussis. Which of the following findings should the nurse expect? (Select all that apply)
* Runny nose * Mild fever * Cough with whooping sound
groups with higher morbidity rate
* children who are homeless * children who are poor * children who are chronically ill * Foreign born children who were adopted * children in daycare
BP in infants
****LOW**** systolic: 65-78 diastolic: 41-52
communicable disease caused by bacteria
***DPS*** Diphtheria Scarlet Fever Pertussis
communicable disease caused by viruses
***RRRCFMP*** Chicken pox Rubeola Roseola Mumps Polio Rubella Fifth Disease
HR Infants to 2 years
**HIGH** 120-160 bpm
Car seat placement
*Axilla upright 30-45 degrees *Rear facing in the rear seat w/seat belt * Shoulder harness are placed in the slots at or below the level of the infant's shoulders. * Harness should be snug and the retainer clip is placed at the level of the infant's armpit.
immunization given at 2 months
*DTaP * RV *IPV * Hib * PVC * Hep B
What is the family systems theory?
*The family is a system that CONTINUALLY INTERACTS with its members and the environment *Emphasis on INTERACTION *Problems do not lie in any one member but in the TYPE OF INTERACTIONS used by the family
the primary reason for anticipatory guidance is to provide education regarding
*prepares families for what to expect next in their child's development.* *Safety *Nutrition *Sleep *Development
Primary prevention examples
- Discuss a low-fat diet and the need for regular physical exercise with clients. - when a nurse provides health education and training for daycare workers about issues of health and hygiene, such as proper hand hygiene, diapering, and food preparation and storage - Immunizations, importance of wearing seatbelts, taking folic acid supplementation at preconception to prevent neural tube defects, fluoridation of water supplies to prevent dental caries, and actions taken to reduce human exposure to agents that may cause cancer - Implement a community level program like walking for exercise to assist citizens in improving health behaviors related to lifestyle. - Use the Code of Ethics for Nurses to guide your nursing practice - Use the information exchange process to increase the client's understanding of how to use the health care system and the health promotion strategies that will maintain health. - Complete a family genogram and assess health risks with the family to contract for family health activities to prevent diseases from developing
tertiary prevention
-aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning
Complications of Mumps
-encephalitis -myocarditis -sterility -meningitis
FLACC pain scale is used for what age group
0-1 yr old or nonverbal
Paroxymal Stage of Pertussis
Severe and violent coughing, vomiting and whooping sound
A nurse is teaching a parent of an infant about treatment of seborrhea dermatitis (cradle cap). Which should the nurse include in the instructions?
Shampoo every day with an antiseborrheic shampoo.
Clinical Manifestations of fifth disease
Slapped cheek appearance (day 1-4) Red lacy rash, spreads proximal to distal (day 2- greater than week) Rash comes and goes
Clinical manifestations of chicken pox (varicella)
Slight fever, malaise and anorexia for 1st 24 hours Highly pruritic rash (centripedal) Lesions in three stages present
Which is most suggestive that a nurse has a nontherapeutic relationship with a patient and family?
Staff is concerned about the nurse's actions with the patient and family.
family
in classification, group of similar general whatever the client says it is; as a Biology , psychology, economics, sociology
Definition of growth
increase in size
What is folliculitis?
inflammation of a hair follicle
orchitis
inflammation of the testes due to mumps
artificial passive immunity
injection of antibodies (gabioglobin)
Which solid food should you introduce first
iron fortified cereal
Alternative to breast milk
iron fortified formula
head circumference is done by
is a measurement of a child's head around its largest area. It measures the distance from above the eyebrows and ears and around the back of the head.
The agent of mumps can infect the testes?
it can cause infertility
anticipatory guidance is important because
it empowers families to build competence in their parenting abilities
prutitus
itching
detachment
lack of interest or involvement
A school nurse assesses a case of tinea capitis (ringworm) on a 6-year-old child. Which figure depicts the characteristic lesion of tinea capitis?
large open lesion on the head
What is the best way to prevent the spreading of head lice?
limit head to head contact
A clinic nurse is assessing a child with erythema infectiosum (fifth disease). Which figure depicts the rash the nurse should expect to assess?
little girl with the red cheeks
despair
loss of hope
Avoid warming formula in the
microwave
Guide to assess number of teeth:
months-6= number of teeth
indication that there is an airway obstruction in infants
nasal flaring
Convalescent stage of Pertussis
not contagious; coughing decreases
Complete head lag at
one month
Freud stage for infants
oral psychosexual
Mumps classical manifestation include
parotid swelling
In the sensory motor stage children react on
perception
Oral Stage (0-18 months) Freud
pleasure centers on the mouth- sucking, biting, chewing
Which finding with a nurse consider abnormal and performing a physical exam on a six month old.
posterior fontanel is open
Herpes zoster is caused by the varicella virus and has an affinity for:
posterior root ganglia and posterior horn of the spinal cord.
The nurse uses developmental theory by evaluating the families.
prospective tasking progression through cycles.
The nurse uses developmental theory by evaluating the family's
prospective tasks and progression through cycles
list 3 stages of separation anxiety
protest despair detachment
Child is agitated, resists caregivers, cries, and is inconsolable.
protest stage
The nurse is taking care of a child with scabies. Which primary clinical manifestation should the nurse expect to assess with this disease?
pruritus (itch)
Which is most descriptive of clinical reasoning?
purposeful and goal directed
Plantar Grasp Reflex
reaction to stimulation of the sole of the foot that causes the toes of the feet to "grasp" or curl up
Piaget: Sensorimotor Stage
reflex stage: 0-1 month primary circular reactions: 1-4 months secondary circular reactions:4-8 months
Cultural beliefs and values often influence infant feeding practices. the nurse should?
respect the family cultural beliefs
A nurse is performing an assessment on a 1 day old newborn in the nursery. Which findings would be a cause for concern for the nurse?
respiratory distress
anticipatory guidance 4 months infants
rolling- do not leave in high surfaces (fall)
A school nurse is conducting vision and hearing testing on fifth-grade children. Which level of prevention is the nurse demonstrating?
secondary (screening and early diagnosis)
sensorimotor stage
senses
Piaget's stage for infancy
sensorimotor - cognition - 6 sub stages of learning development - from reflex to simple repetitive behaviors
Piaget Cognitive Development birth to 24 months
sensorimotor stage Infant progress from reflexive to simple repetitive to imitative activities.
When is object permanence developed?
sensorimotor stage (piaget) 9-10 months
greatest stressor for ages 6-30 months
separation anxiety
A nurse is conducting a health history on an adolescent. Components of the health history include
sexual history. review of systems. family medical history.
clinical manifestation of fifth disease
slapped face appearance followed by lacy net like rash
Koplik spots
small, blue-white spots with red halo over oral mucosa; early sign of measles
Type of play for infants
solitary play
What kind of play do infants engage in ?
solitary play
blended/reconstituted family
spouses and their children from former marriages live together as a single nuclear family
Catarrhal stage of pertussis
stage of whooping cough characterized by fever, sneezing, vomiting, and mild, dry persistent cough
Duvall's theory
states that all families have certain basic task for survival and continuity and the specific tasks related to the sequential stages of development throughout the life. If the family does not meet certain developmental task then society disapproval may lead to involvement by children's services, social services, welfare agencies, police dept, .or health dept.
authoritarian parenting
style of parenting in which parent is rigid and overly strict, showing little warmth to the child
object permanence
the awareness that things continue to exist even when not perceived
stranger anxiety
the fear of strangers that infants commonly display, beginning by about 8 months of age
Craniosynostosis
the premature fusing of the skull bones
Propping a baby bottle can cause
tooth decay limit physical contact ear infections
At 2 months of age, an infant should be able to?
track objects with his or her eyes
Infant (Erikson)
trust vs mistrust
Erikson's stage for infancy
trust vs mistrust psychosocial
tonic neck reflex
turning the head to one side, extending the arm and leg on that side, and flexing the limbs on the opposite side (fencing)
Which is the major cause of death for children older than 1 year?
unintentional injuries
Nursing Diagnosis
used to evaluate the response of the whole person to actual or potential health problems
The nurse is taking care of a 7-year-old child with a skin rash called a papule. Which clinical finding should the nurse expect to assess with this type of skin rash?
A lesion that is elevated, palpable, firm, and circumscribed; less than 1 cm in diameter
reconstituted families
A new family that forms after the remarriage of a single parent, sometimes involving the blending of two families into a new one.
permissive parenting
A parenting style characterized by the placement of few limits on the child's behavior.
authorative parenting
A parenting style that encourages the child to be independent but that still places limits and controls on behavior.
A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?
A topical anesthetic, EMLA, can be applied before injections are given.
Developmental pace infant
Has a fixed precise order but not pace
During the first 4 days of hospitalization, Eric, age 18 months, cried inconsolably when his parents left him, and he refused the staff's attention. Now the nurse observes that Eric appears to be "settled in" and unconcerned about seeing his parents. The nurse should interpret this as which statement?
He may be experiencing detachment, which is the third stage of separation anxiety.
primary prevention
Health promotion and prevention of disease or injury.
What is a common initial reaction of parents to illness or injury and hospitalization in their child?
Helplessness
Immunization given at birth
Hepatitis B
Clinical Manifestations of Scarlet fever
High fever, high HR Tonsils enlarged, edematous and beefy red White coated tongue (1st 1-2 days), then strawberry tongue rash appears within 12 hours (red, pin point) Skin sloughs off tongue at the end of the 1st week.
A nurse is planning a teaching lesson for parents of preschool children. Which statement explains why the nurse should include information about morbidity and mortality?
High risk groups for certain disorders or hazards are identified.
agent of fifth disease
Human Parvovirus B19 (virus)
A nurse is teaching a class on breastfeeding to expectant parents. Which are contraindications for breastfeeding? (Select all that apply.)
Human immunodeficiency virus (HIV) in mother Maternal cancer therapy
Which statement regarding infant breastfeeding, and iron requires further education.
I will need to add iron at 2months
immunization at 12 months
Flu shot
Therapeutic Management of Scarlet fever
Full course antibiotics Supportive (analgesics and antipyretics) Rest
Family systems theory examines
Functions and Patterns
What causes tinea capitis (ringworm)?
Fungus
Who has Scarlet Fever
GABHS
Clinical Manifestations of Polio
General illness in varying degrees May have pain and stiffness CNS paralysis
Rubella is also called
German measles
Which intervention for teething pain would the nurse recommend first?
Give the child teething ring
What is the medication for tinea capitis
Griseofulvin (fungal)
Which is the causative agent of scarlet fever?
Group A -hemolytic streptococci (GABHS)
Scarlet fever is caused by
Group A beta hemolytic strep bacteria
agent of scarlet fever
Group A beta-hemolytic streptococci
In which way would the nurse describe growth in the first year of life?
Growth is rapid in the first 6 months of life
8 days old admitted with vomiting/dehydration: Newborn HR 170, RR44, BP 85/52, Temp: 99. The nurse answers
HR high (120-160) all others WNL
Therapeutic Management of Polio
Immunization Bed rest Sedatives (anxiety over paralysis) Ventilation (respiratory paralysis) Physical therapy
Therapeutic Management of chicken pox
Immunization Supportive anti-itch therapy Distraction Antiviral
Therapeutic Management of Mumps
Immunization (MMR) Analgesics Antipyretics IV fluids
Therapeutic Management of Rubella (German Measles)
Immunization (MMR) Antipyretics Analgesics
Therapeutic Management of Pertussis
Immunization (TDAP) Antibiotics Supportive (O2 and humidity) Fluids
Therapeutic Management of Measles
Immunizations (MMR) Vit A supplement (reduces morbidity and mortality) Supportive
A nurse is establishing several health programs, such as bicycle safety, to improve the health status of a target population. This describes which step in the community nursing process?
Implementation
Which developmental finding in a 5 month old infants warrants further investigation by the nurse?
Inability to hold head erect and steady when sitting
This supplement are recommended for infants who are being exclusively breastfed after the age of 4 months
Iron
A nurse is providing education about introducing new foods to the parent of a 4 month old infant. The nurse should recommend that the parents introduce which of the following foods first?
Iron-fortified cereal
A nurse is preparing to administer routine immunizations to a 4-month-old infant. The infant is currently up to date on all previously recommended immunizations. Which immunizations will the nurse prepare to administer? (Select all that apply.)
Rotavirus (RV) Diphtheria, tetanus, pertussis (DTaP) Haemophilus influenzae type b (HIB) Inactivated poliovirus (IPV)
Who has the measles
Rube
Which is a common childhood communicable disease that may cause severe defects in the fetus when it occurs in its congenital form?
Rubella
Who is from Germany
Rubella
Agent of Rubella (German Measles)
Rubella virus
What is the causative agents of measles?
Rubeola
Cellulitis is commonly caused by
S. aureus Group A strep
After the introduction of the Back to Sleep campaign in 1992, an increased incidence has been noted of which of the following pediatric disorders? (Select all that apply.)
SIDS Plagiocephaly
Topics included in anticipatory guidance include
Safety Nutrition Development Sleep
Parents tell the nurse that their child keeps scratching the areas where he has poison ivy. The nurse's response should be based on which knowledge?
Scratching the lesions may cause them to become secondarily infected.
Which following function of play is a major component of play at all ages?
Sensorimotor activity
A nurse is completing a pain assessment of an infant. Which of the following pain scales should the nurse use?
FLACC
How to protect and prevent sunburns EXCEPT
Face and body painting
The pediatric palliative care nurse would primary care for a child who
add life to the child's years and provide comfort
When does the child start to develop attachment to parent?
after 6 months
self-concept
all our thoughts and feelings about ourselves, in answer to the question, "Who am I?"
A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic is the priority for this class?
appropriate use of car seat restraints
A 10 month old infant has positive stool for occult blood. The nurse should
ask the parents if they are feed the child has been drinking whole milk
most common causes of injury and death for a seventh model month old.
aspiration
Infants are at risks for
aspiration (putting objects in mouth)
most important routine for children
bedtime routine
A nurse is assessing an infant. Which of the following are manifestations of pain in an infant? (Select all that apply)
* Loud cry * Lowered eyebrows * Rigid body
A nurse makes the decision to apply a topical anesthetic to a child's skin before drawing blood. Which ethical principle is the nurse demonstrating?
beneficence
3-5 words with meaning
by 1 year
When does an infant double their weight?
by 6 months
how to measure a BP cuff on an infant
by the circumference
A nurse is providing teaching about dental care and teething to the parent of a 9 month old infant. Which of the following statements by the parent indicates an understanding of the teaching?
"I should clean my baby's teeth with a cool wet wash cloth."
A nurse is preparing a toddler for an intravenous catheter insertion using atraumatic care. Which of the following actions should the nurse take? (Select all that apply)
* Explain the procedure using the child's favorite toy * Allow the child to make one choice regarding the procedure * Apply lidocaine and prilocaine cream to three potential insertion sites.
When discharging a newborn, which injury prevention instruction would be of highest priority to tell the parents?
"Never leave the baby unattended on a raised, unguarded area."
A nurse is performing a developmental screening on a 10 month old infant. Which of the following fine motors skills should the nurse expect the infant to perform? (Select all that apply)
* Grasp a rattle by the handle * Use a crude pincer grasp
The nurse is talking to a parent of an infant with severe atopic dermatitis (eczema). Which response(s) should the nurse reinforce with the parent? (Select all that apply.)
"You will need to keep your infant's skin well hydrated by using a mild soap in the bath." "You will need to prevent your baby from scratching the area by using a mild antihistamine." "You should apply an emollient to the skin immediately after a bath."
Proximodistal
"inside-to-outside rule" motor skills emerge in a sequence of center moving outward
Piaget secondary circular reactions
(repeated/prolonged) imitation, play affect
A nurse is teaching a parent of an infant about administration of oral medications. Which of the following should the nurse include in the teaching. (Select all that apply)
* Ask the pharmacy to add flavoring to the medication * Use the nipple of a bottle to administer the medication * Hold the infant in a semi reclining position.
Which behavior by the nurse indicate a therapeutic relationship with children and families.
* Asking questions if the family is not participating in the care. * Clarifying information to families * Learning more about the family's religious preferences.
Which behaviors by the nurse indicate therapeutic nurse-family boundaries?
* House rules are negotiated * Communication is open and two-way.
A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age?
1 to 2 years
Whole milk is introduced at
1 year of age
When does child recognize he is distinct from parent?
1 year old
When do infants recognize that they are distinct from their parents?
1 year- at same time they have increased interest in their image in the mirror
Order in which to do physical on child:
1)count respirations first (before the infant is disturbed), 2)take the pulse next, 3)measure temperature last. If vital signs cannot be taken without disturbing the child, record the child's behavior (e.g., crying) along with the measurement
What are the 2 components of cognitive development required for attachment?
1. Ability to discriminate the mother from others 2. Achievement of object permanence
3 leading cause of accidental death 6-12 months
1. Suffocation 2. Automobile 3. Drowning
Secondary prevention examples
1. communicable disease screenin, case finding. 2. early detection and tx of DM 3. exercise program for older adults who are already frail 4. screenings--cholesterol, etc. 5. medication therapy
FLACC highest score
10
Move from prone to sitting position
10 months
grasps rattle by its handle
10 months
mama/dada
10 months
What is the incubation period for chicken pox or varicella
10-20 days
Incubation period for Measles
10-21 days
infant pulse rate
100-160 beats/min
Places object into a container
11 months
walking with assistance
11 months
At which age can the infant intimidate the mothers departure by watching her behaviors and begin to protest before she even leaves?
11-12 months
Birth weight is tripled by
12 months
How old is an infant when they are learning to walk?
12 months
Six to eight teeth should erupt in infants' mouths by ____________________________.
12 months
Tries to build a two block tower
12 months
walk alone
12 months
Children need to breast or formula feed until:
12 months at least
When does the anterior fontanel close?
12-18 months
normal infant HR
120-160 bpm 85-100 when sleeping, >180 when crying
The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately how many pounds?
15
begins to use pincer grasp
8 months
creeping
8 months
sitting unsupported
8 months
the first teeth typically erupt between the ages of
8 months
When do infants pull up on to furniture to stand?
9 months
Partial head lag __ months
2 months
makes single vowel sounds by
2 months
stepping reflex disappears
2 months
When does the posterior fontanelle close?
2 months (8wks)
premature babies needs iron supplements at
2 months of age
How many naps do most infants take up to 1 year?
2 per day
Incubation period for chicken pox
2-3 weeks
Incubation period period for Mumps and Rubella
2-3 weeks
Incubation period for Diphtheria and Scarlet Fever
2-5 days
Foods known to be allergenic should be introduced after
9 months - ex. Peanuts, eggs, seafoods, fish
Sleeping range of time for a 6-12 month old:
9-17 hours Average 13
At what age does an infant start to recognize familiar faces and objects, such as a feeding bottle?
3 months
At which age do primitive reflexes begin to fade?
3 months
By what age can infants hold their heads well beyond the plane of their bodies?
3 months
normal infant respiratory rate
30-60 min
newborn- 1 yr respiratory rate
30-60 per min
head circumference
33-35.5 cm [13-14 inches]
normal infant blood pressure
60/40 mmHg
Infant blood pressure systolic
65-78
You should introduce different types of solid food____days apart to check for food allergies
7
Moves object from hand to hand
7 months
When does the parachute reflex appear?
7 months
By what age should a head lag on pull to sit disappear?
4 months
Grasp object with both hands
4 months
When do infants laugh aloud?
4 months
no head lag
4 months
By what age does birth length usually double?
4 years
associative play is at what age
4 yo
Incubation period for fifth disease
4-14 days
Solids are introduced around _ to _ months of age.
4-6 months
When to add iron
4-6 months
When to introduce solid foods
4-6 months
After the age of 6 months, 100% fruit juice should be limited to...
4-6 oz per day
When do infants progress through the first phase stage of separation-individualizations and begin to have awareness of themselves and mothers as separate beings?
4-8 months
sitting alone using hands
7 months
Incubation period for polio
7-14 days
When Will generally an infant start crawling.
7-9 months
Normal Infant Glucose Levels
40-80 mg/dL
infant blood pressure diastolic
41-52
head to heel length of infants
48-53 cm (19-21 in)
How long may expressed breast milk be stored in the fridge?
5 days
Do newborns usually lose weight?
5-10% in the first 5 days
Incubation period for Roseola
5-15 days
rolling over
5-6 months
first vocalization occurs at
5-6 weeks
How much has the birth length increased by 12 months?
50%
Attachment to parent and stranger danger
6 months
Birth weight is doubled by
6 months
Breast milk feeding until
6 months
Holds bottle
6 months
How long may breast milk be stored in the freezer?
6 months
When can play peek-a-boo?
6 months
object permanence occurs at
6 months
when do infants generally go from prone to sitting?
6 months
At which age do infants show a distinct preference for the mother?
6 months - cry when she leaves - feel most secure in her arms etc... - about a month after they attach to other members of the family, usually the father
infants teeth starts erupting at
6 months ( # of months -6)
A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at which age?
6 to 8 weeks
When is the first tooth eruption?
6-10 months (average 8)
Cooperative play age
6-12
Children should continue iron fortified cereal from
6-18 months
Incubation period for Pertussis (whooping cough)
6-20 days
crawling
6-7 months
vegetables and fruits are started first between
6-8 months
Newborn weight averages
6-9 lbs
how to remember causative agents for chicken pox
A CHICKEN named Varicella
A nurse is planning care for a child following a surgical procedure. Which of the following interventions should the nurse include in the plan of care?
Administer IV analgesic on a schedule
The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. What should the nurse expect the therapeutic management of this child to include?
Administering oral griseofulvin
Which are the clinical manifestations of scarlet fever in the prodromal stage?
Abrupt high fever
A nursing student is discussing the technique of interviewing with his instructor and conveys that he is somewhat reluctant to talk with potential patients as he fears he may have nothing to say and there would be periods of silence. Which statement represents the best response by the nursing instructor in response to the students' expressed concerns?
Acknowledge that his reluctance is normal but that the utilization of silence may well eventually represent the ability of a confident interviewer in knowing that sometimes it is equally important to listen rather than to keep talking
general appearance
Age, height, weight, and nourishment
Nursing Management of Measles
Airborne Precautions Rest and quiet environment Antipyretics Skin care and assessment Airway assessment
Nursing Management of chicken pox
Airborne and contact precautions Hx of immunization and exposure Change linen frequently Avoid Aspirin (Reye's syndrome) Skin assessment
Therapeutic Management of Diphtheria
Antibiotics Immunization (TDAP) Bed Rest (myocarditis prevention)
Therapeutic Management of Roseola
Antipyretics
Therapeutic Management of Fifth disease
Antipyretics Analgesics Anti-inflammatory
tonic neck reflex happens
Appears at 2 months Decreases at 4 months Disappears no later than 4 months
A child has a postoperative appendectomy incision covered by a dressing. The nurse has just completed a prescribed dressing change for this child. Which description is an accurate documentation of this procedure?
Appendectomy incision non-reddened, sutures intact, no drainage noted on old dressing, new dressing applied, procedure tolerated well by the child.
Complications of Fifth disease
Arthritis Anemia
A 10-month-old female is carried into the emergency department by her parents after she fell down 15 stairs in her walker. Which would be your highest priority nursing intervention?
Assess airway while simultaneously maintaining cervical spine precautions.
Best method for assessing a 12 month old?
Assess the child while in mother's lap
A nurse is collecting subjective and objective information about target populations to diagnose problems based on community needs. This describes which step in the community nursing process.
Assessment
In which type of play are children engaged in similar or identical activity, without organization, division of labor, or mutual goal?
Associative
The nurse is ready to begin a physical examination on an 8-month-old infant. The child is sitting contentedly on the mother's lap, chewing on a toy. What should the nurse do first?
Auscultate heart and lungs
Which would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater?
Axillary sensor
gay and lesbian families
Family group involving same-sex parents and children, such as those from a previous heterosexual relationship.
What is the Family Stress theory?
Based on how families react to stress Internal: issues the family can control i.e. values, beliefs External: issues the family can't control i.e. economy, current events
At what age is fluoride needed?
Beginning at 6 months (if not already inn water)
Which is now referred to as the "New Morbidity"?
Behavioral, social, and educational problems that alter health
A nurse is assessing a 12 month old infant during a well child visit. Which of the following findings should the nurse report to the provider?
Birth weight doubled
A nurse is assessing a 12-month-old infant. Which statement best describes the infant's physical development a nurse should expect to find?
Birth weight doubles by age 5 months and triples by age 1 year.
Family Assessment
Family interview, survey, or discussion used to obtain the families insights regarding a patient, especially a child; family history, relationships, concerns, needs, resources
Clinical manifestations of mumps
Fever, headache, anorexia (day 1) "ear ache" (day 2) Parotid gland(s) enlarge (day 3) for 1-3 days
Clinical manifestations measles (rubeola)
Fever, malaise (1st 24 hours) Cough, conjunctivitis, Koplik spots (next two days) Rash begins on face and moves downward (days 3-4) Abdominal pain
agent of pertussis (whooping cough)
Bordetella pertussis (bacteria)
My dog gets _________shot to stop his Whopping Cough
Bortella
It provides a complete diet for infants during the first 6 months
Breastfeeding
Purpose of childhood immunizations:
Build body's defenses; Protect from certain infectious diseases
When does the infant triple their weight?
By 12 months
The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. What is most likely the cause of the diaper rash
Candida albicans
Which nursing consideration is important when caring for a child with impetigo contagiosa?
Carefully wash hands and maintain cleanliness when caring for an infected child.
Which diet alternative would recommend for children who are allergic to cow milk?
Casein hydrolysate milk formula
Parvo is _________ years old
Fifty
The nurse is conducting a staff in-service on appearance of childhood skin conditions. Lymphangitis ("streaking") is frequently seen in which condition
Cellulitis
Who in the hospital is responsible for teaching parents about proper instalment of child seat?
Certified car safety officer
Weaning:
Changing from drinking from the bottle or breast to a cup
Where do the lesions of atopic dermatitis (eczema) most commonly occur in the infant? (Select all that apply.)
Cheeks Extensor surfaces of arms and legs Trunk Scalp
My _________is named Varicella
Chicken
Strict isolation is required for a child who is hospitalized with which disease?
Chickenpox
Child becomes interested in environment; may ignore parents' return
Child becomes interested in environment; may ignore parents' return
Which leading cause of death topic should the nurse emphasize to a group of African-American boys ranging in age from 15 to 19 years?
Firearm homicide
neonatal period
First 4 wks of life
Clinical manifestations of Diphtheria
Common cold symptoms Sore throat Lymphadenitis (bull's neck) Fever, hoarseness, cough Thick gray mucous
Which is the leading cause of death of infants younger than 1 year?
Congenital abnormalities
Precautions used for Measles, chicken pox and TB
Contact Droplets airborne
What is impetigo
Contagious bacterial infection marked by clusters of small blisters
Who has diphtheria
Cory
Agent of Diphtheria
Corynebacterium diphtheriae (bacteria)
CRIES pain scale
Crying- characteristic of pain Requires O2 for SaO2 ,95% Increased Vital signs Expression Sleepless
immunization given at 6 months
DTaP IPV PCV Hep B RV Hib
immunization given at 4 months
DTaP RV IPV Hib PCV
General amount of feedings and formula per day:
Decrease from 6 at one month to four or five at 6 months
FLACC pain scale
F: Faces. L: Legs. A: Activity. C: Cry C: Consolability
Which factor most impacts the type of injury a child is susceptible to, according to the child's age?
Developmental level of the child
Which family theory is described as a series of tasks for the family throughout its life span?
Developmental theory
cultural beliefs and values often influence infant feeding practices. the nurse should?
Discussions regarding infant feeding often are the initial interaction between clinician and mother and, as such, are important in building a foundation of trust and rapport .
Fruit juices and infants:
Do not exceed 4-6 ounces a day - do not give younger than 6 months
Nursing Management of Pertussis (whooping cough)
Droplet Precaution Nasopharyngeal culture for Dx Assess for obstruction of airway
Nursing Management of Diphtheria
Droplet Precaution Observe for respiratory distress/obstruction
Nursing Management for Rubella (German Measles)
Droplet precaution Avoid contact with pregnant woman
Nursing Management for Scarlet fever
Droplet precaution Encourage fluids Soft diet Education (prevent the spread of infection; discard toothbrush, no sharing eating/drinking utensils)
The community health nurse is teaching parents about prevention of the spread and reoccurrence of pediculosis (head lice). Which should the nurse include in the teaching session? (Select all that apply.)
Dryclean nonwashable items. Boil combs and brushes for 10 minutes. Discourage sharing of personal items.
Nursing Management of Roseola
Educate on antipyretic use Seizure Precaution
Duvall's developmental theory
Emphasizes the developmental stages that all families go through, beginning with marriage; the longitudinal career of the family is also known as the family life cycle
Complications of chicken pox (Varicella)
Encephalitis Secondary infection ***Herpes Zoster lies dormant in nerves and can become Shingles later in life. Immunization is available for shingles, recommended for those 60 years and older.
Agent of Polio
Enteroviruses
Which term best describes the identification of the distribution and causes of disease, injury, or illness?
Epidemiologic process
Trust vs. Mistrust
Erikson's first stage during the first year of life, infants learn to trust when they are cared for in a consistent warm manner
What to do if infant does not pull to stand by 12 months?
Evaluate and refer to specialist
The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention?
Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
Moro reflex
Infant reflex where a baby will startle in response to a loud sound or sudden movement.
family value system
Influenced by society's core values and family's subculture Impacts how family copes with health and other stressors
Which is usually the only symptom of pediculosis capitis (head lice)?
Itching
A nurse is teaching a group of parents about separation anxiety. Which of the following information should the nurse included in the teaching?
Kicking s stranger is an example
For which condition is an infant at risk if the diet has limited protein based sources?
Kwashiorkor
Which condition would the nurse suspect if an infant has thin limbs, protruding abdomen and a diet rich in carbs and low in protein
Kwashiorkor
Which statement is descriptive of Kwashiorkor
Kwashiorkor is multifactorial origin
A parent has asked the nurse about how her child can be tested for pinworms. The nurse responds by stating that which is the most common test for diagnosing pinworms in a child?
Laboratory examination of a fecal smear
A patient arrives in the emergency department unconscious. How should you help the family?
Let the family stay with the patient for a while and explain the situation
Which is the most immature gastro organ during infancy?
Liver
Signs and symptoms of paralytic Polio
Loss of reflexes Loose and floppy limbs Muscle pain
A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infant's risk of a sudden infant death syndrome incident? (Select all that apply.)
Low Apgar scores Male sex Recent viral illness
Clinical Manifestations of Rubella (German Measles)
Low-grade fever, headache, malaise (1-5 days) Rash (face then rapidly spreads downward until body is spread in pinkish red maculopapular exanthema within a day).
Which of the following describes the rash associated with Roseola?
Maculopapular, rose colored rash that last for 1-3 days that appears as fever fades
Refeeding syndrome
Marasmus
When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How should the nurse assess this diet?
May provide sufficient amino acids
Communicable disease that requires isolation (contact/droplets
Measles Chicken Pox Tinea capitis
A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases are Koplik spots present?
Measles (rubeola)
Viral lesions red to purple, starts on face and spreads to trunk and limbs with oral Kolplik spots
Measles (rubeola)
Vitamin A supplementation may be recommended for the young child who has which disease?
Measles (rubeola)
Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?
Measuring head circumference
Which is a consequence of the physical punishment of children, such as spanking?
Misbehavior is likely to occur when parents are not present.
nuclear family
Mother, father and children living as a unit
Which is the leading cause of death from unintentional injuries for children ranging from 1-14 years old?
Motor vehicle related fatalities
Who climbed the PARAMIDS
Mumps
Which toy is the best choice for a 12-month-old?
Musical rattle.
Anticipatory guidance for parents of an infant at 4 months include
Never leave infant unattended on a high surface
anticipatory guidance for parents, but infinite four months includes.
Never leave the infant unattended on a high surface
Nursing Management of Fifth disease
No isolation Pregnant woman should not be around children
The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. How should the nurse interpret this finding?
Normal finding
Infant mortality
Number of infant deaths per thousand live births.
The primary reasons for anticipatory guidance are to provide education regarding
Nutrition
The primary reason for anticipatory guidance are to provide education regarding
Nutrition Development Injury Prevention
how to remember causative agents for Roseola
OLA loves roses
Complications of measles (rubeola)
Obstructive laryngitis Obstructive laryngo-tracheitis
A nurse is teaching a group of parents about communicable diseases. The nurse should include that which of the following is the best method to prevent a communicable disease?
Obtaining immunizations
Which is most important to document about immunizations in the child's health history?
Occurrence of any reaction after an immunization
The nurse is taking care of a 7-year-old child with herpes simplex virus (type 1 or 2). Which prescribed medication should the nurse expect to be included in the treatment plan?
Oral antiviral agent
How should frozen breast milk be thawed?
Overnight in fridge or under lukewarm water
agent of mumps
Paramyxovirus
Name the reflexes of a newborn
Rooting Sucking Moro Babinski Palmer grasp
When discussing discipline with the mother of a 4-year-old child, which should the nurse include?
Parental control should be consistent.
Complications of scarlet fever
Peritonsillar abscess Acute glomerulonephritis Rheumatic fever (inflammatory disease that can involve the heart, joints, skin and brain).
Complications of Polio
Permanent paralysis Respiratory arrest
Clinical Manifestations of Pertussis
Persistent Cough Symptoms of respiratory tract infection Cough mostly at night, thick mucous plug
Clinical manifestations of Roseola
Persistent high fever for 3-4 days Drop in fever, rash appears for 1-2 days (trunk, then spreads to neck, face & extremities). bulging Fontanels
A nurse is assessing a 6 month old infant. Which of the following reflexes should the infant exhibit?
Plantar grasp reflex
Complications of Pertussis
Pneumonia (usual cause of death) Atelectasis Hemorrhage, hernias (from forceful coughing) Dehydration
Nursing Management for Polio
Positioning (prevent contractures) Skin assessment Observe for respiratory paralysis
Types of food introduced at 4-6 months old:
Poured, strained, finely mashed
The nurse is preparing an inservice education to staff about atraumatic care for pediatric patients. Which intervention should the nurse include?
Prepare the child before any unfamiliar treatment or procedure demonstrating on a stuffed animal.
The Moro reflex happens when:
Present at birth Decreases at 4 months Disappears at 6 months
Palmar grasp reflex happens when
Present at birth Disappears around 3 months
Plantar grasp reflex happens when
Present at birth Disappears at around 8 months
babiski reflex happens when?
Presents at birth Disappears at around 1 year of age or when locomotion occurs
What are the goals of healthcare for pediatric nursing?
Promote development Improve childhood nutrition Improve oral health prevent injuries
A nurse is preparing to administer immunizations to a 4 months old infant. Which of the following is an appropriate action for the nurse to take in providing atraumatic care?
Provide sucrose solution on the pacifier
Child health promotion
Provides opportunities to reduce differences in current health status among members of different groups and ensure equal opportunities and resources to enable all children to achieve their fullest health potential
A nurse is caring for an infant who needs otic medication. Which of the following is an appropriate action for the nurse to take?
Pull the pinna downward and straight back
Which action by the nurse demonstrates the use of evidence-based practice (EBP)?
Questioning the use of daily central line dressing changes
how to remember causative agents for German measles
RUBELLA is from Germany
how to remember causative agents for Measles
RUBY has the measles
Symptoms of Measles (Rubeola)
Rash Cough Runny nose Fever watery eyes
A nurse on a pediatric unit is practicing family-centered care. Which is most descriptive of the care the nurse is delivering?
Recognizing that the family is the constant in a child's life
A nurse on a pediatric unit is practicing family centered care. Which is the most descriptive of the care the nurse is delivering?
Recognizing that the family is the constant in a child's life.
During a routine health assessment, the nurse notes that the eight month old infant has significant head leg. Which of the following is the nurse most appropriate action?
Refer child for further evaluation
length
Refers to the measurement taken when children are supine. (Also referred to as recumbent length)
stepping reflex
Reflex that causes newborn babies to make little stepping motions if they are held upright with their feet just touching a surface
When communicating with other professionals, what is important for the nurse to do?
Restrict communication to clinically relevant information
A nurse is admitting a toddler to the hospital. The toddler is with both parents and is currently sitting on a parent's lap. The parents state that they will have to leave for a brief period. Which type of nursing diagnosis should the nurse formulate for this child?
Risk for anxiety
In terms of gross motor development, which should the nurse expect a 5-month-old infant to do? (Select all that apply.)
Roll from abdomen to back. Put feet in mouth when supine.
What is cellulitis often caused by?
Streptococcus or Staphylococcus organisms.
agent of impetigo
Streptococcus pyogenes and Staphylococcus aureus
Position of sleep for infants
Supine- never prone- increased risk sids
Typed of food introduced at 6-7 months old:
Teething crackers, raw fruits or veg
complications of rubella
Teratogenic effects on fetus: -Deafness = MC complication -Glaucoma-Cataracts -Heart problems (PDA, pulmonary artery stenosis) -Motor dysfunction 80% acquisition rate from mother and 50% show complications (younger fetus = more problems) Rarely encephalitis
A nurse is teaching a parent about parallel play in children. Which of the following statements should the nurse include in the teaching?
The child plays independently when in a group
When interviewing a patient, which statement/action indicates that the nurse is displaying empathy?
The patient appreciates that the nurse sat by her bedside and held her hand while they spoke about health concerns
single-parent family
a family in which only one parent is present to care for the children
binuclear family
a type of family consisting of divorced parents living in two separate households but remaining one family in spirit for the sake of the children
Which statement is true of shaken baby syndrome?
There may be absence of external signs of injury
The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their child's skin after the infection has subsided and healed. Which answer should the nurse give?
There will be no scarring.
The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infant's stools. The nurse's explanation of this is based on which statement?
This is normal because of the immaturity of digestive processes at this age.
Complications of Diphtheria
Toxic cardiomyopathy Toxic neuropathy Obstructed airway
tertiary prevention examples
Treatment of major depression, reducing disruption of family processes, and suicide prevention, rehabilitation
Pertussis (whooping cough) is a high contagious bacterial infection
True
A clinic nurse is planning a teaching lesson about childhood obesity prevention for parents of school age children. The nurse should include which associated risk of obesity in the teaching plan?
Type II diabetes
rubella is most dangerous to
Unborn babies
Which may be given to high-risk children after exposure to chickenpox to prevent varicella?
VCZ immune globulin (VariZIG)
The nurse should expect to assess which causative agent in a child with warts?
Virus (human papillomavirus)
Which vitamin supplement is recommended for children with measles?
Vitamin A
These sources of fluids are not needed during the first 4 months of life
Water or juice
where do you assess skin turgor on an infant
abdomen
A nurse is teaching parents about caring for their child with chickenpox. The nurse should let the parents know that the child is considered to be no longer contagious when which occurs?
When lesions are crusted
Palmar grasp reflex
When something touches infants' palms, they grip it tightly.
The family system theory is described as
When the family system is disrupted, change can occur at any point in the system.
which is descriptive of family system theory
When the family system is disrupted, change can occur at any point in the system.
Babiski reflex
When you stroke the bottom of the foot and big toe dorsiflexes (bends back) and other toes fan out.
Nursing Management of Mumps
acetaminophen or ibuprofen for fever reduction pain management Droplet and Contact isolation Precaution Rest Fluids Neuro and hydration assessment -if orchitis occurs, use ice packs to the testicles
natural passive immunity
acquired by a child through placenta and breast milk
cooperative play
activity in which children actually play with one another
The nurse is talking to the parents of a child with pediculosis capitis. Which should the nurse include when explaining how to manage pediculosis capitis?
You will need to remove nits with an extra-fine-tooth comb or tweezers."
What is diphtheria?
a disease in the throat, lungs and makes it hard to breathe ****airway obstruction*****
polygamous family
a family consisting of one man, several wives, and their children
phases of pertussis
catarrhal paroxysmal cough convalescent
movement start from head to foot is called
cephalocaudal
infant growth happens these ways
cephalocaudal and proximal/ distal
growth charts
charts that show average values of height, weight, and other measures of growth, based on large samples of normally developing infants; the charts are used to evaluate an infant's development
Airborne isolation is required for a child who is hospitalized with
chickenpox.
Nurses are mandatory to report suspected cases of
child abuse
associative play
children engage in separate activities but exchange toys and comment on one another's behavior
Protest separation anxiety phase
clinging
With regards to separation anxiety in a child who is hospitalized, which behavior would indicate the stage of protest?
clinging
Evidence-Based Practice (EBP
clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences
extended family
closely related people of several generations
Which observable behaviors would indicate to the nurse that the patient is experiencing information overload?
constant fidgeting repetitive yawning avoidance of eye contact while looking away from the interviewer scanning the environment.
How is diphtheria transmitted?
contact Inhalation of respiratory droplets
A nurse is performing an assessment on a 1 day old newborn in the nursery. Which findings would be the cause for concern for the nurse?
creases over two-thirds of the soles of the feet molding of the head. lanugo on the shoulders
first vocalization
crying
Acyclovir (Zovirax) is given to children with chickenpox to:
decrease the number of lesions.
Sequential trends
definite, predictable sequence that each child normally passes through
Child feels hopeless and becomes quiet, withdrawn, and apathetic
despair
How to treat head lice
dry all non washable items (seal for 14 days) stop sharing items boil brushes and combs pick out nits
natural active immunity
exposure to the infectious agent occurs through infection
Complications of Roseola
febrile seizures
A nurse is doing developmental screen for a 10 month old she's fat fine motor skills from infant. What should she expect
fine pincher grass places objects into container grass rattle by handle and rakes objects
abdomen to back rolling over occurs
first
Piaget reflex stage
focus on reflexes
Family system theory exames
functions and patterns
skin assessment of infants
general appearance unusual lesions
Family functions refers to
how families care for and live together
family functions refers to
how families care for and live together
Agent of roseola
human herpesvirus type 6
What patients should not receive attenuated vaccines
immunocompromised patients
artificial active immunity
vaccination
Shingles is a reactivation of this disease
varicella (chicken pox)
Agent of chicken pox/shingles
varicella zoster virus
agent of measles (rubeola)
virus
Recent studies indicate that a deficiency of which vitamin correlates with increased morbidity and mortality in children with measles?
vitamin A
For which nutritional deficiency is an infant who eats strictly vegan diet at risk?
vitamin B12
It is recommended to give this vitamin supplements within the first few days of life to prevent rickets
vitamin D
Parents report that they have been giving a multivitamin to their 1-year-old infant. The nurse counsels the parents that which vitamin can cause a toxic reaction at a low dose?
vitamin D
Piaget Primary Circular Reactions 1-4 months
voluntary actions
how do you prevent spread impetigo.
wash hands avoid sharing towels
Overall goal of feeding schedule is to
ween off of breast milk
