NR328 quiz 3

A nurse is teaching a new unlicensed assistive personnel (UAP) how to obtain vital signs on an infant. Which statement by the UAP demonstrates to the nurse that no further teaching is required?​

"Count respirations first, count apical heart rate second, measure blood pressure third, and measure temperature last."​

The nurse is performing an assessment on a sleeping newborn. Which of the following should the nurse do first?​

Auscultate the heart, lungs, and abdomen

The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statement accurately describes a recommended guideline for setting the tone of the examination for a school-age child?​

Include the child in all parts of the examination; speak to the caregiver before and after the examination.​

Which clinical manifestations might be observed in a child with anemia? Select all that apply.​

Increased heart rate​ Fatigue Pallor Dizziness Increased breathing rate​

The nurse has just admitted a client with sickle cell crisis. What is the nurse's highest priority action at this time?​

Increasing fluid intake ​

A nurse is preparing to perform a physical assessment on a toddler. Which techniques should the nurse include in the assessment? Select all that apply.​

Introduce the stethoscope slowly to the toddler and allow the child to touch it before placing it against the body​. Use play as a technique for inspection of the body​. Minimize physical contact when beginning the assessment​

During a routine annual visit of a 2-year-old client, what is the correct order the nurse should perform the tasks in a health assessment? ​

Introduce yourself, ask about problems or concerns, take a history, and perform the exam.

clinical manifestations of anemia?​expected

Irritability Dizziness Tachycardia Headache Fatigue Decreased attention span​ Pallor

A child with sickle cell anemia comes to the emergency department for evaluation. The nurse suspects that the child is experiencing a vaso-occlusive crisis based on assessment of which signs and symptoms? Select all that apply. ​

Low back pain ​ Distended abdomen ​ Fever

Which of the following nursing actions are appropriate when caring for a child with Tetralogy of Fallot? Select all that apply.​

Maintain vasopressors to increase systemic vascular resistance Improve oxygenation through clustering of care Maintain sedative or morphine sulfate to decrease agitation

The nurse is assessing a 3-year-old with uncorrected Tetralogy of Fallot who is crying. Which finding requires immediate action?​

The lips and oral mucosa are dusky in color

The nurse is assessing a pediatric client's heart sounds for the characteristic S1 and S2. If the nurse is having difficulty hearing the S2, the nurse should move the stethoscope to which anatomic location? ​

The second intercostal space ​

he nursing professor is observing the student nurse measure the vital signs of several children. Which actions by the student demonstrate knowledge of the procedure? Select all that apply

The student auscultates a 7-year-old's apical pulse for 60 seconds​. The student assesses the child's femoral pulses bilaterally at the same time. The student listens to the 12-month-old's heart for 10-20 seconds before beginning to count the rate for a minute​.

Which client is at highest risk of developing iron deficiency anemia?​

Toddler who drinks 30 ounces of whole milk daily and has a poor appetite​

A nurse is performing a physical assessment on a pediatric client. Which assessment finding requires follow-up by the nurse?​

Unequal pulses in the upper and lower extremities​

Nutritional Anemia

Vitamin B-12 (folic acid​) Iron deficiency​

Which assessment data is consistent with the clinical manifestations of sickle cell anemia?​

chest pain​ dizziness pallor fatigue cool extremities​ yellow sclera​ priapism

Which assessment data is consistent with the clinical manifestations of Kawasaki disease?​

edema and erythema on the hands and feet​ irritability strawberry tongue​ cervical lymphadenopathy​ exanthem conjunctivitis​ mucositis

A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify what as a factor? ​

infection

When teaching about iron deficiency anemia, the nurse should tell the caregiver of a young child about which rich source of iron?​

liver

A nurse is caring for a child who has been diagnosed with heart failure. Which assessment findings should the nurse expect? Select all that apply.​

nasal flaring hypoTN peripheral edema cool extremities

A nurse reviewing an infant's progress notes identifies a one-month-old infant is at 10% for weight and 95% for height on a growth chart and has peripheral cyanosis. The parent reports that the infant has frequent episodes of very fast breathing and is breastfeeding every 4 hours but takes over 30 minutes on each side to finish feeding. What data leads the nurse to suspect that this infant has a ventricular septal defect? Select all that apply.​

ncreased length of time to finish breastfeeding​ Plots at the 10th percentile for weight on growth chart​ tachypnea

A child with multisystem inflammatory syndrome in children (MIS-C) is admitted to the pediatric unit. To promote comfort, the nurse should do which of the following?​ Select all that apply.

Cluster care to allow for adequate rest periods​ Monitor respiratory status​ Administer medications as ordered​

A nurse is caring for a child with Kawasaki disease. Which of the following clinical manifestations should the nurse be continually assessing for?​ Select all that apply.

Elevated blood pressure​ Decreased urine output​ Respiratory distress​ Bleeding Tachycardia

The nurse is instructing the caregivers of a child with sickle cell anemia. What should the nurse emphasize during this teaching? ​

Ensure a consistent and daily intake of adequate fluids to prevent dehydration

An 8-year-old child asks the nurse how the blood pressure apparatus works. Which response by the nurse is most appropriate?​

Explain in simple terms how it works

The nurse is caring for a pediatric client with cardiac dysfunction. For each assessment finding, drag to indicate whether the data is expected

FTT, tachy, poor wt gain, poor feeding, prenatal RF, fam Hx of cardiac diseases, activity intolerance, developmental delays, tachypnea

After birth, which structures in the newborn heart need to close to allow for normal blood circulation and make the lungs become fully operational? Select all that apply.​

Foramen ovale Ductus arteriosus

A toddler with hemophilia is hospitalized with multiple injuries after falling off a slide. No bone fractures are noted on x-rays. When caring for the child, what is the nurse's highest priority?​

Frequently assessing the child's level of consciousness​

An infant with an unrepaired Tetralogy of Fallot defect becomes extremely cyanotic during a routine blood draw. Which priority interventions will the nurse implement? Select all that apply.​

Give morphine via the peripheral intravenous (IV) line Place infant in knee-chest position Administer 100% oxygen by blow-by

In a child diagnosed with sickle cell disease, which clinical manifestations would the nurse most likely see? Select all that apply.

Hands and feet cool to the touch​ Pain Pallor

The nurse is providing education to the family of a 5-year-old child with hemophilia A. The parents state the child is active and they are concerned about injuries while the child is playing outside. Which interventions should the nurse include in the teaching, should the child get injured while playing outside? Select all that apply.

Have the child take rest periods Begin prophylactic factor VIII therapy

The nurse is preparing a child for discharge after treatment for Kawasaki disease. The child had been receiving high doses of aspirin. The nurse instructs the parents to report any toxic effects of the aspirin therapy, which may include:

Headache, confusion, dizziness, or tinnitus

A toddler with Kawasaki disease is admitted to the pediatric unit. The caregivers inquire about why the child is receiving aspirin when it is contraindicated for other minor illnesses. The nurse's best response would be which of the following? Select all that apply.​

High doses of aspirin will be given while the fever is high​ Aspirin therapy is not contraindicated and necessary for treatment​ Length of aspirin therapy is related to the child's response​

An 18-month-old child diagnosed with Kawasaki disease is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. What should the nurse do first?​

Place the toddler in a quiet environment

A registered nurse (RN) is working with a licensed practical nurse (PN) who is caring for a 10-year-old who has severe abdominal, hip, and knee pain caused by a sickle cell crisis. Which action taken by the PN requires immediate intervention?​

Positioning cold packs on the client's knees​

A 2-year-old with a congenital heart defect requires home oxygen as part of the treatment plan. What should the nurse include in the caregiver teaching?​

Promoting mobility while providing supplemental oxygen​

Which educational points should the nurse include when teaching the family of a child with hemophilia? Select all that apply.​

Protect toddlers with soft helmets and knee pads Involve the toddler in the treatment plan in a developmentally appropriate way Encourage the child to participate in activities such as swimming

The nurse is caring for a pediatric client with cardiac dysfunction. For each assessment finding, drag to indicate whether the data is unexpected

brady, increased appetite, hyperthermia, bradypnea

Which comment made by the caregiver of a 1-month-old infant would alert the nurse about the presence of a congenital heart defect?​

"She tires out during feedings."

A nurse is assessing the apical pulse of a toddler. View the four labeled areas on the image below. Which spot should the nurse auscultate the apical pulse?

4th intercostal space at the left midclavicular line

A newly-married couple, who are both carriers of the sickle cell trait, ask what the risk is of their children having sickle cell anemia. What is the best response by the nurse?​

A newly-married couple, who are both carriers of the sickle cell trait, ask what the risk is of their children having sickle cell anemia. What is the best response by the nurse?​

The nurse is caring for a child diagnosed with hemophilia. Which action should the nurse perform first if the child begins bleeding?​

Apply pressure to the area​

The nurse is preparing to perform a physical assessment on a 15-year-old client. The nurse gives the adolescent the option of her caregiver either staying in the room or leaving. Which statement best describes the appropriateness of the nurse's action?

Appropriate because of the child's age​

A nurse is teaching a nursing student about the four main mechanisms of anemia. The nurse should include which mechanisms of anemia? Select all that apply.​

Blood loss​ Sequestration Decreased production​ Accelerated hemolysis​

Aplastic Anemia

Bone marrow depression​

Multisystem inflammatory syndrome in children (MIS-C) is caused by which of the following? Select all that apply.

COVID-19​ unknown cause

Using knowledge of child development, which approach is best when preparing a toddler for a physical assessment?​

Demonstrate the procedure on a doll

When caring for a child with Kawasaki disease, the nurse would identify which of the following as appropriate during treatment?​

Management includes administration of aspirin and intravenous immunoglobulin (IVIG).

Which of the following should be included in the nursing management and care of a child diagnosed with Kawasaki disease? ​

Monitor intake and output ​

When teaching the caregivers of a child diagnosed with Tetralogy of Fallot about this condition, which cardiac defects should the nurse describe? Select all that apply. ​

Overriding aorta Ventricular septal defect Pulmonary stenosis Right ventricular hypertrophy

A caregiver brings their 4-year-old son in for a check-up. Which assessment finding should the nurse be concerned about?​

Resting pulse rate of 130

The nurse is reviewing the health history and physical examination of a child diagnosed with heart failure. What assessment findings should the nurse expect to find? Select all that apply. ​

Shortness of breath when playing ​ Crackles on lung auscultation ​ Tachycardia Tiring easily when eating ​

Hemolytic Anemia

Sickle cell​ Hemolytic ​ Thalassemia

When conducting a physical examination of a child with suspected Kawasaki disease, which finding would the nurse expect to assess? ​

Strawberry tongue ​

After teaching the caregivers of a child diagnosed with sickle cell disease, the nurse determines that the teaching was successful when the caregivers state that they will contact the primary health care provider if the child develops which signs or symptoms? Select all that apply. ​

Sudden change in vision ​ Severe dizziness ​ Chest pain

The caregivers of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's best reply should be based on which fact?​

The child needs opportunities to play with peers