Nursing Care of Children ATI Practice Exam with NGN

A nurse on a pediatric unit is caring for a school-age child. Nurses' Notes 0830: Child is alert and responsive to stimuli. Skin is warm and dry. Capillary refill less than 3 seconds. Respirations regular and shallow. Mild intercostal retractions noted. Expiratory wheezes auscultated in the anterior and posterior lung bases. Abdomen is soft, flat, and non-distended. 1100: Child appears restless. Moderate intercostal retractions noted. Scattered rhonchi anterior bases with wheezing noted on inhalation and exhalation. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Vital Signs 0830: Temperature 37.1° C (98.8° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 90/60 mm Hg Pulse oximetry 97% on 2 L of oxygen via nasal cannula 1100: Temperature 37.1° C (98.8° F) Heart

- ABGs - WBC count - Oxygen saturation level - respiratory assessment

The nurse is providing discharge teaching to the child and their parent 36 days after admission Nurses' Notes 0900: Home care consultation and supply delivery arrangements completed by the child's case manager. 1400: Provided discharge teaching to the parent and child regarding medications, skin and wound care, and psychosocial needs. Parent verbalized understanding of teaching. Select 6 statements by the parent that indicate an understanding of the discharge teaching. - I will give my child hydroxyzine to prevent bacterial infection - I should apply a moisturizer to the scar tissue - I will use a measured spoon or medicine cup to give my child hydroxyzine - I can give my child hydroxyzine every 6 hours as needed - puppet play can be helpful for my child - I should avoid giving hydroxyzine at bedtime - I will avoid massage the scar tissue - My child is too young to be concerned about their body image - I need t

- I should apply a moisturizer to the scar tissue - I will use a measured spoon or medicine to give my child hydroxyzine - I can give my child hydroxyzine every 6 hours as needed - puppet play can be helpful for my child - I need to assess for nay redness or open skin areas before paplying my childs left arm splint - my child will need to use a compression garment to decrease blood supply to the scarred tissue ????

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). History and Physical 4-year-old child was in a house fire and rescued by EMS. Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. Child is awake and crying. Lungs are clear bilaterally. Has a non-productive cough. Graphic Record Temperature 37.7° C (99.9° F)Heart rate 150/minRespiratory rate 32/minBlood pressure 100/52 mm HgSaO2 89% on room air The nurse should identify that which of the following findings require immediate follow-up? Select the 3 findings that require immediate follow-up.

- burns on chest and neck - SaO2 89% on room air - HR 150/min

The nurse is caring for the child 14 days after admission Graphic Record 0800: Temperature 37° C (98.6° F) Heart rate 100/min Respiratory rate 20/min Blood pressure 98/56 mm HgSaO2 97% on room air Weight 16.8 kg (37 lb) 1300: Temperature 35.8° C (96.4° F) Heart rate 68/min Respiratory rate 14/min Blood pressure 90/50 mm HgSaO2 88% on room air Nurses' Notes Pediatric Burn Unit 0800: Reinforced preoperative teaching with the child and parent. Child is awake and alert. Moving all extremities. Child limits their range-of-motion of the left arm. Anterior neck and upper chest dressings are dry and intact. Left arm and hand dressings are intact and slightly moist with serous drainage. Breath sounds are clear and equal bilaterally. Abdomen is soft and nondistended. Bowel sounds are active in all quadrants. Child remains NPO for surgery. Right antecubital peripherally inserted central catheter (PICC) line dressing is

- provide 100% oxygen via face mask - check anterior neck & chest dressing for bleeding - place a warm blanket on the child - keep the child's head in a neutral position??

A school nurse is planning to administer atomoxetine 1.2 mg/kg/day PO to a school age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?

1 capsule - convert lb --> kg - 75 lb / 2.2 lb = 34.09 kg - multiply the child's weight in kg (34.09kg) by the amount of medicine ordered per kg (1.2mg/kg) = 40.9 mg/day - available is 40 mg/capsule - therefore, child needs 1 capsule per day

A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (move steps in correct order) - remove tape securing the catheter - turn off the IV pump - occlude the IV tubing - apply pressure over the catheter insertion site

1. turn off the IV pump 2. occlude the IV tubing 3. remove the tape securing the catheter 4. apply pressure over the catheter insertion site

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). History and Physical 4-year-old child was in a house fire and rescued by EMS. Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. Child is awake and crying. Lungs are clear bilaterally. Has a non-productive cough. Graphic Record Temperature 37.7° C (99.9° F)Heart rate 150/minRespiratory rate 32/minBlood pressure 100/52 mm HgSaO2 89% on room air Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? - Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas. - Insert an indwelling urinary catheter. - Provide 100% oxygen via face mask. - Weigh the child.

???? anticipated: - provide 100% oxygen via face mask - weigh the child contraindicated: - apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas - insert an indwelling urinary catheter ATI pg 208-209

A nurse is providing dietary teaching to the parent of a school aged child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? a. wheat crackers b. rye bread c. barley soup d. white rice

d. white rice - celiac disease: gluten free diet - other choices you CAN recommend: rice pudding, usually any rice (white, brown, wild, natural) - to AVOID: wheat, barley, rye

A nurse is caring for a school aged child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angio-edema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? - prednisone - epinephrine - diphenhydramine - albuterol

epinephrine

Severe abdominal pain due to appendicitis. Locate McBurney's point

RLQ

The nurse is caring for the child 4 days after admission. Graphic Record 0800: Temperature 38.8° C (101.8° F) Heart rate 124/min Respiratory rate 22/min Blood pressure 100/56 mm HgSaO2 97% on room air Weight 17.1 kg (37.7 lb) Urine output 15 mL in past hour Nurses' Notes 0800: Child is awake, watching cartoons on television, and parent is at bedside. IV site in right antecubital is without redness or edema and dressing is dry and intact. Dressings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage and several small spots of serosanguineous drainage. Dressings remain intact and smell malodorous. Breath sounds are equal and clear bilaterally. Respirations are unlabored. Abdomen is soft and nondistended. Mucous membranes are moist. Skin turgor is slightly brisk. Pupils are equal, round, and reactive to light and accommodation. Child is oriented to place, time, and

The nurse should first address the client's temperature followed by the client's fluid status. ???????????

A nurse on a pediatric floor is admitting a preschooler. Vital Signs 0715: Temperature 38.3° C (100.9° F)Heart rate 126/minRespiratory rate 26/minPulse oximeter 97% Physical Examination 0715: Guardians report that the child has been tired lately and has been experiencing a sore throat and fever. Child is tolerating sips of liquids, but is refusing solid foods. Guardians report that the child is voiding dark yellow urine. 0730:Child is alert and responsive to verbal stimuli. Mucous membranes are dry and sticky. Skin turgor without tenting. Tonsils enlarged and erythematous. Respirations are regular and non-labored. No accessory muscle use noted. Lungs clear anterior and posterior bilaterally. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Capillary refill greater than 2 seconds. A

The nurse should identify that the child is at risk for developing splenomegaly as evidenced by positive mononucleosis rapid test.

A nurse in a provider's office is caring for a preschooler. Nurses' Notes 0915: Guardians report that lately the child has had severe itching and is breaking out with sores on their eyebrows, wrists, and ankles. The "sores started to bleed." Guardians report no relief with application of the topical hydrocortisone cream. 0930:Child is alert. Multiple small erythematous papules with some scaling noted on the child's eyebrows, forearms, and lower legs bilaterally. 1015:Provider in to evaluate the child. Discharge to home after medication administration of new prescriptions and discharge teaching for atopic dermatitis. Medical History: Family history of atopic dermatitis MAR: 1000: Loratadine (oral solution) 5 mg PO daily. Administer first dose now prior to discharge. Tacrolimus 0.03% ointment. Apply thin layer to affected areas twice daily; rub in gently and completely. Return to primary care provider in 1 to 2 week

a, b, e - apply skkin emollient immediately after bathing the child - keep child's fingernails short - use a mild detergent for laundry (because of the Tacrolimus ointment) - never choose answer that says "rub skin vigorously" - they SHOULD allow a bath prior to bedtime but should AVOID BUBBLE baths - Apply ointment as a "thin layer" - see pg 202-203 ATI book

A nurse is teaching the guardian of a 6 month old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching? a. "I should secure the car seat using lower anchors and tethers instead of the seat belt." b. "I should position the car seat harness 1 inch above my baby's shoulders." c. "I will make sure that the car seat is placed at a 90-degree angle." d. "I will pad my baby's car seat with a blanket for traveling long distances."

a. "I should secure the car seat using lower anchors and tethers instead of the seat belt." - lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infants car5 seat in the vehicle - this system provides anchors between the front cushion & the back rest for the car seat - therefore, if this system is available, the seat belt does not have to be used

A nurse is providing teaching to the parent of a school aged child who has a new prescription for oral nyastatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? a. "Shake the medication prior to administration." b. "Provide the medication through a straw." c. "Rinse the child's mouth with water immediately after giving the medication." d. "Mix the medication with applesauce if the child dislikes the taste."

a. "Shake the medication prior to administration." - to disperse the medication evenly within the suspension

A nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" Which of the following responses should the nurse make? a. "You can sign the consent form because you are married." b. "Your spouse should sign the consent form for you." c. "Your parent should sign the consent form for you." d. "You can appoint a legal guardian to sign the consent form."

a. "You can sign the consent form because you are married." - the nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age

School-age child who is experiencing fatigue. Which finding should nurse recognize as an indication of anemia? a. Hematocrit 28% b. Hemoglobin 13.5 g/dL c. WBC count 8,000/mm^3 d. Platelets 250,000/mm^3

a. Hematocrit 28% - expected range: 32%-44% for a school aged child - the child can also exhibit fatigue, lightheadedness, tachycardia, dyspnea, & pallor due to the decreased oxygen carrying capacity

A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. which of the following laboratory values should the nurse report to the provider? a. Hgb 8.5 g/dL b. WBC count 9,500/mm^3 c. Prealbumin 18 mg/dL d. Platelets 300,000/mm^3

a. Hgb 8.5 g/dL - a child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow - the development of anemia is diagnosed through lab testing of hgb & hematocrit levels - the nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7 year old child and should be reported to the provider

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? a. Provide small, frequent meals for the child. b. Schedule time in the play room for the child. c. Weigh the child weekly. d. Maintain the child in a supine position.

a. Provide small, frequent meals for the child. - The metabolic rate of a child who has heart failure is high because of poor cardiac function. - Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.

A nurse if receiving change-of-shift report for four children. Which of the following children should the nurse see first? a. A school aged child who has sickle cell anemia & reports decreased vision in the left eye b. A school aged child who has cystic fibrosis & a frequent nonproductive cough c. A preschooler who has asthma & a peak flow meter reading in the green zone d. An adolescent who has meningitis & reports a sensitivity to lights & noise

a. a school aged child who has sickle cell anemia and reports decreased vision in the left eye - when using urgent vs non-urgent approach to client care, the nurse should determine the priority finding is a report of decreased vsiion in the left eye - this finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provide immediately

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which actions should the nurse implement for infection control? a. have designated stethoscope in infants room b. place infant in a room equipped with negative airflow c. administer palivizumab as prescribed for the infant d. remove gloves after leaving

a. have a designated stethoscope in infants room - contact or droplet precautions are implemented for RSV??? - RSV is spread through direct contact with respiratory secretions - BP cuff & stethoscope should be placed in infants room

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure, Which of the following actions should the nurse take during the immediate postictal period? a. place the child in a side-lying position b. delay documentation until the child is fully alert c. give the child a high-carb snack d. administer an oral sedative to the child

a. place child in side-lying position

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following tp the effected area? a. zinc oxide b. antibiotic ointment c. talcum powder d. antiseptic solution

a. zinc oxide - diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction & takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal

The nurse is continuing to care for the child. Nurses' Notes 0815: Pediatric Burn Unit Nurses' Notes Provider notified of 0800 assessment and vital signs. Provider will examine child during hydrotherapy. Morphine given for pain rating of 8 on FACES pain rating scale. Child transported via stretcher to hydrotherapy for debridement. Hydrotherapy nurse given SBAR report. 0830: Hydrotherapy Nurses' Notes Anesthesia provided. Dressing is removed. Wound on the palm of the left hand has a moderate amount of green drainage with a foul odor. Provider present to examine child. Medication Administration Record 0815: - Administered morphine IV 1.7 mg for pain 0830: - Administered midazolam IV 1.7 mg upon arrival to hydrotherapy - Administered fentanyl IV 17 mcg upon arrival to hydrotherapy After examining the child during hydrotherapy, the provider enters prescriptions into the child's medical record. For each potential

anticipated: - change the morphine route to family-controlled analgesia via a PCA pump - obtain a wound culture - place the child on a pressure-reduction mattress contraindicated: - limit daily protein intake ???? i know contraindication is correct but not the others yet

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following do you expect to find? (all that apply) a. Negative Babinksi reflex b. Ankle clonus c. Exaggerated stretch reflexes d. Uncontrollable movements of the face e. Contractures

b, c, e - ankle clonus - exag stretch reflexes - contractures

A nurse is teaching a school aged child who has a new diagnosis of type 1 diabetes mellitus, Which of the following statements by the child indicates an understanding of the teaching? a. "I will puncture the pad of my finger when I am testing my blood glucose." b. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." c. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." d. "I will decrease the amount of fluids I drink when I am sick."

b. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." - administer 30 min before meals so that the onset coincides with food intake

A nurse in the ED is caring for a school age child who has appendicitis and rates their abdominal pain as 7/10. Which actions should the nurse take? a. Instill a 500 mL tap water enema. b. Give morphine 0.05 mg/kg IV. c. Administer polyethylene glycol 1g/kg PO. d. Apply a heating pad to the child's abdomen.

b. Give morphine 0.05 mg/kg IV. - pain 7/10 is considered severe --> administer an analgesic med for pain relief

A nurse is assessing a 3 year old toddler at a well child visit. Which of the manifestations should the nurse report to the provider? a. BP 90/50 mmHg b. RR 45/min c. Weight 14.5 kg (32 lb) d. HR 110/min

b. RR 45/min - expected reference age for preschooler age (3-5 year sold) for respiratory rate: 20-25/min - review/study physical assessment findings for different ages in ATI book pages 7-12

A nurse is reviewing the lab report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following lab values indicates effectiveness of the current treatment? a. Potassium 2.9 mEq/L b. Sodium 140 mEq/L c. Urine specific gravity 1.035 d. BUN 25 mg/dL

b. Sodium 140 mEq/L - within expected range of 134-150 mEq/L

A charge nurse is the ED is preparing an in-service for a group of newly licensed nurses about manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? a. Recurrent urinary tract infections b. Symmetric burns of the lower extremities c. Failure to thrive d. Lack of subcutaneous fat

b. Symmetric burns of the lower extremities - the patterns are usually characteristic of the method or object used, such as cigar, cigarrette burns, or burns in the shape of an iron

A nurse is caring for a school-aged child who is receiving a blood tranfusion. Which manifestation should alert the nurse to a possible hemolytic transfusion rxn? a. laryngeal edema b. flank pain c. distended neck veins d. muscular weakness

b. flank pain - flank pain is caused by breakdown of RBCs and is an indication of hemolytic rxn to the blood transfusion

a nurse assessing a school age child who has meningitis. Which of the findings is the priority for nurse to report? a. reports a headache as 6/10 b. petechiae on lower extremities c. nuchal rigidity d. positive kernig's sign

b. petechiae on lower extremities - presence of petechiae or purpuric rash on a child who is ill can indicate the presence of meningococcemia - this type of rash indicates the greatest risk of serious rapid complications form sepsis and should be reported immediately to provider

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? a. negative leukocyte esterase b. serum creatinine 3.0 mg/dL c. negative urine protein d. urine output 40 mL/hr

b. serum creatinine 3.0 mg/dL - Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. - An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. - The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0 to 1 mg/dL for an adolescent and can indicate rejection of the kidney.

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take? a. Place the child in a prone position for the immunization. b. Request that the child's caregiver leave the room during the immunization. c. Administer the immunization using a 24-gauge needle. d. Inject the immunization slowly after aspirating for 3 seconds.

c. Administer the immunization using a 24-gauge needle. - The nurse should administer an immunization for a 4-year-old child using a 24-gauge needle to minimize the amount of pain experienced by the toddler.

A nurse in the ED is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take? a. Insert a nasogastric tube b. Initiate prophylactic antibiotic therapy. c. Cleanse the affected area with mild soap and water. d. Apply a topical corticosteroid to the affected area.

c. Cleanse the affected area with mild soap and water. - nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? a. Identifies right from left hand b. Uses a utensil to spread butter c. Cuts an outlined shape using scissors d. Draws a stick figure with seven body parts

c. Cuts an outlined shape using scissors - The nurse should recognize that an expected develop- mental milestone of a 4-year-old child is using scissors to cut out a shape

A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which actions should the nurse take? a. Use surgical asepsis when providing routine care for the child. b. Administer the measles, mumps, and rubella (MMR) vaccine to the child. c. Screen the child's visitors for indications of infection. d. Infuse packed RBCs.

c. Screen the child's visitors for indications of infection.

A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock? a. BP 130/90 mmHg b. HR 60/min c. Temp 39.1 C (102.4 F) d. Urinary output 100 mL/hr

c. Temp 39.1 C (102.4 F) - above expected range of 37 - 37.5 C (98.6-99.5) for a 10 year old - nurse should expect a child who has early septic shock to have a fever and chills

A nurse is caring for a school-aged child who is in Buck's traction following a leg fracture 24 hr ago. Which actions should the nurse take? a. change childs position every 2 hr b. clean the peripheral pin sites with chlorhexidine solution every 4 days c. assess peripheral pulses every 4 hr d. ensure that the head of the bed is elevated to a 90 degree angle

c. assess peripheral pulses every 4 hr - traction may lead to neurovascular compromise --> the nurse should assess for edema, pulses, pain, color & temp of affected extremity every 4 hours - nurse should report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses and tingling

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? a. expresses a reluctance to leave home b. provides a detailed description of how the burns occurred c. denies discomfort during assessment of injuries d. describes strong relationships with peers

c. denies discomfort during assessment of injuries - The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.

A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? a. decreased cerebrospinal fluid pressure b. decreased WBC count c. increased protein concentration d. increased glucose level

c. increased protein concentration

A nurse s preparing to collect a sample form a toddler for a sickle-turbidity test. Which actions should the nurse plan to take? a. obtain a sputum collection b. perform an Allen test c. Perform a finger stick d. Obtain a stool specimen

c. perform a finger stick - if the test is positive, hemoglobin electrophoresis is required to distinguish between children who has the genetic trait and children who have the disease

A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? a. "Place the infant in a prone position to sleep." b. "Allow the infant to sleep on a large pillow." c. "Use a soft mattress in the infant's crib." d. "Give the infant a pacifier at bedtime."

d. "Give the infant a pacifier at bedtime."

a nurse is teaching the parent of infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. the nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? a. "I should remove the harness at night to allow my infant to stretch her legs." b. "I will need to adjust the straps on the harness once each week." c. "I should apply baby powder to my infant's skin twice daily." d. "I will place my infant's diapers under the harness straps."

d. "I will place my infant's diapers under the harness straps"

a hospice nurse is caring for a preschooler who has a terminal illness, One of the preschoolers parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which fo the following statements should the nurse make? a. "It is important that you provide emotional support for your family at this time." b. "You have to do what you feel is best. Everything will turn out fine." c. "I know how you feel. This is an extremely stressful time for your family." d. "Let's talk about some of the ways you have handled previous stressors in your life."

d. "Let's talk about some of the ways you have handled previous stressors in your life."

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. which of the following statements should the nurse make to explain to the child when their father will return? a. "Your daddy will be back at 7 pm" b. Your daddy will be back after he takes care of your brother" c. Your daddy will be back in the morning" d. "Your daddy will be back after you eat"

d. "Your daddy will be back after you eat" - preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime - therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? a. Increase in anterior convexity of the lumbar spine b. Increased curvature of the thoracic spine c. Lateral flexion of the neck d. A unilateral rib hump

d. A unilateral rib hump - When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. - This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. - Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? a. Elevate the head of the child's bed. b. Insert a large bore IV catheter for the child. c. Determine the allergen that caused the child's reaction. d. Administer epinephrine IM to the child.

d. Administer epinephrine IM to the child. - When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is ad- ministering epinephrine IM to the child - During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation - This is an emergency because ultimately this causes decreased blood return to the heart

A nurse is admitting a school age child who has pertussis. Which actions should the nurse take? a. Place the child in a room with positive-pressure airflow. b. Place the child in a room with negative-pressure airflow. c. Initiate contact precautions for the child. d. Initiate droplet precautions for the child.

d. Initiate droplet precautions for the child. - droplet precaution: pertussis is whooping cough - transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks

A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? a. Playing pat-a-cake b. Using a push-pull toy c. Creating a scrapbook d. Playing dress-up

d. Playing dress-up - the nurse should instruct the parents that at the preschool age, play should focus on social, mental & physical development - preschool = magical thinking years! encourage it (even imaginary friend) do not discourage it

A nurse in the ED is performing a physical assessment on a 2 week old male newborn. Which findings is the priority for nurse to report to provider? a. excoriated scrotal area b. multiple capillary hemangiomas c. depressed posterior fontanel d. substernal retractions

d. Substernal retractions (*priority finding) - When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the infant is experiencing acute respiratory distress and increased respiratory effort, which could quickly progress to respiratory failure. - The nurse should report a depressed posterior fontanel. However, this is not the priority finding.

A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? a. position he infant side-lying with their head at a 0 to 5 degree angle b. perform a neurological assessment every 4 hr c. suction the infants nares to remove secretions d. implement seizure precautions for the infant

d. implement seizure precautions for the infant

A nurse is planning care for a school-aged child who is in the oliguric phase of AKI & has a sodium level of 129 mEq/L. Which interventions should the nurse include in the plan? a. administer ibuprofen to the child for a temperature greater than 38 C (100.4 F) b. assess the child's BP every 8 hr c. weigh the child weekly at various times of the day d. initiate seizure precautions

d. initiate seizure precautions - hyponatremia increases risk for siezures

A nurse is caring for a toddler who is experiencing acute diarrhea & has moderate dehydration. Which nutritional item should the nurse offer the toddler? a. apple juice b. peanut butter c. chicken broth d. oral rehydration solution

d. oral rehydration solution - a toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium - this promotes recovery form dehydration

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? a. instruct parents to decrease calcium in toddlers diet b. prepare the toddler for chelation tehrapy c. refer the family to Child Protective Services d. Schedule the toddler for a yearly rescreening

d. schedule the toddler for a yearly rescreening & educate the family on how to prevent further exposure

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which finding is the nurse's priority? a. skin breakdown b. hypotension c. hyperpyrexia d. tachypnea

d. tachypnea results when the kidneys are unable to excrete hydrogen ions & produce bicarbonate leading to metabolic acidosis

A nurse is interviewing the parent of an 18 month old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? a. The toddler has a vocabulary of 25 words. b. The toddler developed a mild rash following a recent varicella immunization. c. The toddler's Moro reflex is absent. d. The toddler received tobramycin during a hospitalization 2 weeks ago.

d. the toddler received tobramycin during a hospitalization 2 weeks ago - tobramycin is an aminoglycoside, which is an ototoxic med that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment

a nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. for which of the following members of the inter professional team should the nurse initiate a referral?

speech therapist

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as ... (recording of sound)

tachypnea

A nurse in a providers office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse take? Provider Prescriptions: TB skin test (TST) MMR vaccine Inactivated influenza vaccine DTaP vaccine Graphic record: RR 24/min HR 115/min Temp 36.9C (98.4F) Hx/Physical: Age 15 months Height 71.1 cm (28 in) Allergies Neomycin (anaphylactic rxn) caregiver reports rhinitis with clear nasal drainage for 2 days Occasional nonproductive cough for 2 days Hx of asthma answer options: a. withhold MMR b. withhold DTaP c. withhold influenza d. withhold TB skin test (TST)

withhold the measles, mumps, and rubella (MMR) vaccine - b/c child has anaphylactic reaction to neomycin - Review ATI book pages 227-231