Nursing care of Children B

A nurse in a provider's office is caring for a preschooler. Exhibit 1 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. Exhibit 2 Medical History Family history of atopic dermatitis Exhibit 3 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 weeks for evaluation. Which of the following statements by a guardian indicates that the discharge teaching was effective? Select all that apply. "We should apply a skin emollient immediately after bathing our child." "We should keep our child's fingernails

"We should apply a skin emollient immediately after bathing our child" is correct. An emollient is an oil that moisturizes the skin and should be applied immediately after bathing while the skin is damp to prevent drying. Therefore, this statement by the guardian indicates the teaching has been effective. "We should keep our child's fingernails trimmed short" is correct. The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. Therefore, this statement by the guardian indicates the teaching has been effective. "We should rub the sores vigorously to remove scabs" is incorrect. The sores or lesions should be patted dry after bathing, rather than scrubbed vigorously. The scabs should not be removed because this could cause infection. Therefore, this statement by the guardian indicates the need for further teaching. "We should allow our child to take a bubble bath prior to bed" is incorrect. The use of bubble baths and powders should be avoided because this can cause skin irritation. Therefore, this statement by the guardian indicates the need for further teaching. "We should use a mild detergent for our laundry" is correct. The use of mild detergents for laundry helps prevent allergens and itching. Therefore, this statement by the guardian indicates the teaching has been effective. "We should apply a large amount of the ointment to the sores" is incorrect. Tacrolimus is a topical steroid that should only be applied in a thin layer. Therefore, this statement by the guardian indicates the need for further teaching.

A nurse on a pediatric unit is caring for a school-age child. Exhibit 1 Vital Signs 1230: Temperature 38.2° C (100.8° F)Heart rate 110/minRespiratory rate 20/minBlood pressure 90/60 mm HgPulse oximetry 97%1330: Temperature 38.2° C (100.8° F)Heart rate 100/minRespiratory rate 22minPulse oximetry 92% Exhibit 2 Physical Examination Child is restless and crying. Swelling noted at hand joints. Capillary refill less than 3 seconds. Mucous membranes dry and sticky. Respirations regular and unlabored. Abdomen soft, flat, and non-distended. Tenderness with light palpation. Child reports pain as 8 on a scale of 0 to 10. Exhibit 3 Diagnostic Results CBC: Hemoglobin 8.0 g/dL (10 to 15.5 g/dL)Hematocrit 28% (32% to 44%)RBC count 4.2 million/mm3 (4 to 5.5 million/mm3)WBC count 12,000/mm3 (5,000 to 10,000/mm3)Platelets 350,000/mm3 (150,000 to 400,000/mm3)Reticulocyte count 3% (0.5% to 2%) Exhibit 4 Sickle Cell anemia After reviewing the information in the child's medical record, which of the following findings should the nurse address first? Complete the following sentence by using the list of options. The nurse should first address the child's Select... followed by the child's Select....

Dropdown 1: Oxygen saturation is correct. The child's pulse oximeter reading is below the expected reference range. The nurse should take action to maintain the child's oxygen saturation above 95%. When using the urgent vs. non-urgent approach to client care, the nurse should identify that addressing the child's hypoxia is the priority intervention. Joint swelling and fever are incorrect. Swelling of the joints is non-urgent because it is an expected finding for a child who has sickle cell disease. A low-grade fever is an expected finding for a child who is experiencing a vaso-occlusive crisis. Therefore, there is another finding that is the nurse's priority. Dropdown 2: Pain is correct. The child reported their pain as 8 on a scale of 0 to 10, which indicates severe pain. Vaso-occlusive crises can cause severe pain due to tissue ischemia from sickled cells obstructing blood flow. When using the urgent vs. non-urgent approach to client care, the nurse should identify that addressing the child's pain is the priority after addressing the child's hypoxia. Anemia and hydration are incorrect. The child's hemoglobin and hematocrit levels are below the expected reference range. Medications are often prescribed to increase the production of red blood cells. However, this is a non-urgent finding. The child's oral mucosa indicates dehydration, which can worsen the manifestations of a vaso-occlusive crisis. However, this is a non-urgent finding. Therefore, there is another finding that is the nurse's priority.

A nurse on a pediatric unit is admitting a preschooler. Exhibit 2 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 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. Abdomen flat and non-distended. Bowel sounds active in all four quadrants. Extremities are warm and dry to touch. After reviewing the information in the medical record, the nurse should identify that the child is at risk for developing which of the following conditions? Complete the following sentence by using the list of options. The nurse should identify that the child is at ris

Dropdown 1: Splenomegaly is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Acute poststreptococcal glomerulonephritis (APSGN) and dysrhythmias are incorrect. APSGN can occur following a streptococcal infection. A positive mononucleosis rapid test indicates that the child has mononucleosis, which is caused by the Epstein-Barr virus, rather than streptococcus bacteria. The child's cardiovascular assessment reflects expected findings for a preschooler. Therefore, there is no indication that the child is at risk for developing dysrhythmias. Dropdown 2: Positive mononucleosis rapid test is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Urinary output and cardiovascular assessment are incorrect. Although decreased urine output is a potential indication of APSGN, this finding can also be caused by dehydration. The child is experiencing other manifestations of dehydration, including decreased oral intake, fever, tachycardia, tachypnea, and dry mucous membranes. The child's cardiovascular assessment reflects expected findings for a preschooler. Therefore, there is no indication that the child is at risk for developing dysrhythmias.

A nurse is caring for a preschooler who was recently admitted to a pediatric unit. Exhibit 1 Nurses' Notes The preschooler's guardians report that their child had a gastrointestinal illness with some vomiting and diarrhea about 1 week ago. Their child started to feel better. However, within the last 2 days, they noticed several small bruises that appeared on their child's arms and legs. Additionally, the guardians report the child is lethargic. The nurse is reviewing the information in the child's electronic medical record (EMR). For each EMR finding, click to specify if the finding is consistent with nephrotic syndrome, acute poststreptococcal glomerulonephritis, or hemolytic uremic syndrome. Each finding may support more than one disease process. Exhibit 2 Vital Signs 0900: Temperature 37.2° C (99.0° F)Heart rate 110/minRespiratory rate 22/minBlood pressure 108/70 mm HgOxygen saturation 98% on room airPain rating per FLACC scale 01000: Temperature 38.2° C (100.8° F)Heart rate 108/minRespiratory rate 22/minBlood pressure 114/74 mm HgOxygen saturation 98% on room airPain rating per FLACC scale 0 Diagnostic Results Hemoglobin 8.8 g/dL (9.5 to 14 g/dL)Hematocrit 28% (30% to 40%)WBC count

Temperature is consistent with acute poststreptococcal glomerulonephritis and hemolytic uremic syndrome. According to the EMR, the child's temperature is outside the expected reference range and is increasing. The child who has acute poststreptococcal glomerulonephritis may present with a low-grade fever. The child who has hemolytic uremic syndrome may experience fever that is high enough to cause hallucinations and lethargy. BUN level is consistent with acute poststreptococcal glomerulonephritis and hemolytic uremic syndrome. According to the EMR, the child's BUN level is elevated, which indicates an impairment of kidney function. With acute poststreptococcal glomerulonephritis, a streptococcal infection invades the inner membranes of the kidney, which affects filtration and blood flow. With hemolytic uremic syndrome, intravascular coagulation occurs in the endothelium of the glomeruli of the kidneys, which impairs filtration and blood flow. Platelet count is consistent with hemolytic uremic syndrome. According to the EMR, the child's platelet count is low, which indicates thrombocytopenia. With hemolytic uremic syndrome, intravascular coagulation occurs in the endothelium of the glomeruli of the kidneys, which impairs filtration and blood flow due to the aggregation of platelets. Blood pressure is consistent with nephrotic syndrome, acute poststreptococcal glomerulonephritis, and hemolytic uremic syndrome. According to the EMR, the child's blood pressure is elevated, which indicates narrowing of the blood vessels, possibly due to kidney impairment from these conditions. Cholesterol level is consistent with nephrotic syndrome. According to the EMR, the child's cholesterol level is slightly elevated. This could be related to diet or increased liver production of lipoproteins to compensate for proteins lost in the urine.

A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? Inform the parents that written consent is required prior to organ donation. Provide written information to the parents about organ donation. Ask the provider to explain misconceptions of organ donation to the parents. Explore the parents' feelings and wishes regarding organ donation.

The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family.

A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? Use sterile scissors to remove the dressing from the site. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. Access the site using a noncoring angled needle. Use a semipermeable transparent dressing to cover the site.

The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.

A nurse is providing discharge teaching to the parents of a 3-month-old infant following a cheiloplasty. Which of the following instructions should the nurse include? "Clean your baby's sutures daily with a mixture of chlorhexidine and water." "Expect your baby to swallow more than usual over the next few days." "Inspect your baby's tongue for white patches using a tongue depressor every 8 hours." "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."

The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.

A nurse in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? Obtain a throat culture from the child. Monitor the child's oxygen saturation. Put a warm mist humidifier in the child's room. Place the child in the supine position.

The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment.

A nurse is creating a plan of care for a newly-admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? Until the adolescent is afebrile For 7 days following admission to the facility Until the adolescent has a negative blood culture For 24 hr following initiation of antimicrobial therapy

The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.

A nurse is planning care for a newly admitted school-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? Ensure that a padded tongue blade is at the child's bedside. Allow the child to play video games on a tablet computer. Allow the child to take a tub bath independently. Ensure the oxygen source is functioning in the child's room.

The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure.

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? 3m who has exaggerated startle response 18m who has unintelligible speech 4yo preschooler who likes to play with others rather than alone 8m who is not yet making babbling sounds

The nurse should refer a preschooler who prefers playing alone and avoids interaction with others to a provider for a more extensive evaluation of hearing.

A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? "I will offer my child small amounts of fruit juice frequently." "I will avoid giving my child solid foods until the diarrhea has stopped." "I will monitor my child's number of wet diapers." "I will give my child polyethylene glycol daily for 7 days."

The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status.

A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? The child should be able to stand on the balls of their feet when sitting on the bike. The child should ride their bike 2 feet to the side of other bike riders. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. The child should ride the bike facing traffic when it is necessary to ride in the street.

To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar.

A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain? Use a manual lancet to obtain the heel blood sample. Apply an ice pack to the infant's heel prior to obtaining the sample. Allow the mother to breastfeed while the sample is being obtained. Apply a topical lidocaine cream prior to obtaining the sample.

he nurse should allow the mother to breastfeed the infant prior to or during the procedure. Evidence-based practice indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants.

A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the biceps reflex. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) C. Wrist A. Inner Antecubital B. Elbow

A is correct. The nurse should identify that this is the location to tap to elicit the biceps reflex.B is incorrect. The nurse should tap this location to elicit the triceps reflex.C is incorrect. The nurse should tap this location to elicit the brachioradialis reflex.

A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? Decreased edema Increased abdominal girth Decreased appetite Increased protein in the urine

A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema.

A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperatures above 38.0º C (100.5º F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100 mg/5 mL. How many mL should the nurse administer to the infant per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2ml

A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching? "Scold your child when they have a toileting accident." "Award your child with a sticker when they sit on the potty chair." "Play your child's favorite song while teaching them to use the potty chair." "Teach multiple steps of the skill at the same time."

A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair.

A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? Administer pancreatic enzymes 2 hr after meals. Discontinue the use of pancreatic enzymes if steatorrhea develops. Limit fluid intake to 750 mL per day. Increase fat content in the child's diet to 40% of total calories.

A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.

A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? Deep respirations of 32/min Shallow respirations of 10/min Paradoxic respirations of 26/min Periods of apnea lasting for 20 seconds

A. Deep respirations of 32/minMY ANSWERThe nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis. Shallow respirations of 10/minThe nurse should expect shallow respirations in a child who has respiratory depression related to opioid administration. However, shallow respirations are not an expected finding in a child who has ketoacidosis. Paradoxic respirations of 26/minThe nurse should expect paradoxic respirations in a child who has flail chest. However, paradoxic respirations are not an expected finding in a child who has ketoacidosis. Periods of apnea lasting for 20 secondsThe nurse should expect periods of apnea lasting 20 seconds or more in a child who has sleep apnea. However, periods of apnea are not an expected finding in a child who has ketoacidosis.

A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use? FACES Numeric CRIES Visual analog

A. FACES The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management. NumericThe nurse should use the numeric pain rating scale when assessing the need for pain management in pediatric clients who are 8 years old and older. The nurse should identify that a 3-year-old toddler does not yet possess a concept of numbers and numerical value to effectively use this pain rating scale. CRIESThe nurse should use the CRIES pain assessment scale when assessing the need for pain management in infants who are less than 40 weeks of age. Visual analogThe nurse should use the visual analog scale to assess pain for a child who is greater than 8 years of age. The visual analog scale allows the child to mark their pain on a centimeter ruler.

A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? Palpate the dorsum of the child's feet. Weigh the child daily using the same scale. Assess the child's skin turgor. Observe the child for periorbital swelling.

A. Palpate the dorsum of the child's feet.The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema. Weigh the child daily using the same scale.MY ANSWERWeighing the child daily might indicate that the child has retained fluid. However, this is not a method the nurse should use to assess for peripheral edema. Assess the child's skin turgor.Assessing the child's skin turgor measures the elasticity and mobility of the skin. However, this is not a method the nurse should use to assess for peripheral edema. Observe the child for periorbital swelling.Observing the child for periorbital swelling is a method used to assess for generalized edema. However, this is not a method the nurse should use to assess for peripheral edema.

A nurse on a pediatric unit is caring for a toddler. Exhibit 1 Medical History Hemophilia A Exhibit 2 Nurses' Notes 1100: Guardian reports that the toddler fell at home while playing with toys. Since the fall, the toddler has been very irritable, crying uncontrollably, and grabbing at their left knee. The toddler can walk but insists on being picked up. Exhibit 3 Physical Examination 1115:Toddler is alert during the exam. Extremities are warm and dry to touch. Decreased movement of the left leg observed. Tenderness noted with palpation of the left knee joint. Pain level assessed as 6 on a scale of 0 to 10 using the FLACC scale.1145:Toddler is fussy and crying. Pain assessed as 8 on scale of 0 to 10 using the FLACC scale. Left knee observed to be ecchymotic and edematous. Exhibit 4 Vital Signs 1115: Temperature 36.9° C (98.4° F)Heart rate 110/minRespiratory rate 28/minOxygen saturation 98% on room air Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the toddler. Potential Provider's Prescripti

Administer factor VIII is anticipated. The child is experiencing an acute episode of hemophilia due to a recent fall. During this acute episode, there is potential for internal bleeding into the joint spaces. Therefore, administering factor VIII is anticipated to control bleeding. Apply ice packs to the affected joints is anticipated. The child is experiencing an acute episode of hemarthrosis due to a recent fall, as evidenced by the bruising and swelling of the knee joint. Therefore, applying ice packs to the affected joints is anticipated to manage discomfort and decrease bleeding into the joint. Administer morphine PRN pain is anticipated. The child is experiencing severe pain. Opioids can be administered in the inpatient setting to relieve pain. Otherwise, acetaminophen can be given at home for pain. Aspirin and NSAIDs should be avoided because they inhibit platelet function and might increase bleeding. Perform passive range-of-motion (ROM) exercises during the first 12 hr following injury is contraindicated. The child is experiencing an acute episode of hemarthrosis. Passive ROM exercises can increase bleeding into the joint for the first 48 hr following injury. The toddler should be encouraged to exercise the joint as tolerated. Elevate the affected joints is anticipated. The child is experiencing an acute episode of hemarthrosis due to a recent fall, as evidenced by the bruising and swelling of the knee joint. Elevation of the joint, along with the application of ice, is anticipated to help decrease bleeding and swelling in the joint.

A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? Insert an indwelling urinary catheter. Measure weight and height. Initiate IV access. Maintain ECG monitoring.

After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume.

A nurse in a pediatric emergency department is planning care for an adolescent. Exhibit 1 Nurses' Notes 2245: Adolescent arrived via stretcher by Emergency Medical Transport (EMT) following a motor-vehicle crash.EMT personnel report: Client was found conscious at the scene inside of the vehicle with airbag deployed, wearing a seat belt. Vital signs: heart rate: 94/min, respiratory rate 20/min, blood pressure 100/60 mm Hg 18-gauge peripheral IV inserted in left antecubital. Guardians contacted and report the child has no medical conditions.2300:Adolescent reports sharp pain in chest. Rates pain as 6 on a scale of 0 to 10. Respirations fast and shallow. Diminished breath sounds in left lung. S1 and S2 regular and rapid. Exhibit 2 2300: Temperature 38.0° C (100.4° F)Heart rate 110/minRespiratory rate 30/minBlood pressure 90/60 mm HgOxygen saturation 94% on room air Exhibit 3 Chest x-ray: Air present in left pleural space; suggestive of pneumothorax. CT scan recommended for definitive diagnosis. Based on the information in the adolescent's medical record, which of the following actions should the nurse plan to take? Select all that apply. Apply supplemental oxygen. Place the adolescent in

Apply supplemental oxygen is correct. According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. Also according to the medical record and chest x-ray report, the adolescent's oxygen saturation level is decreasing, which indicates hypoxia. Therefore, the nurse should plan to administer supplemental oxygen. Place the adolescent in supine position is incorrect. According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. The nurse should plan to position the adolescent in semi-Fowler's position to allow for lung expansion. Prepare for chest tube insertion is correct. According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. A pneumothorax is the presence of air in the pleural cavity, which results in decreased lung expansion. The adolescent could experience dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt intervention by the provider, such as the placement of a chest tube into the thoracic cavity to remove air and fluid from the pleural space, if present, allowing the lung to re-expand. Obtain consent for a pericardiocentesis is incorrect. A pericardiocentesis is a procedure to remove blood or fluid from the pericardial sac around the heart. It is used to manage conditions such as cardiac tamponade. The chest x-ray reveals air in the pleural cavity. Therefore, the nurse should not plan to obtain consent for a pericardiocentesis. Administer a levalbuterol metered dose inhaler is incorrect. A levalbuterol metered dose inhaler is used for acute asthma attacks. The manifestations the adolescent is experiencing do not indicate asthma. Therefore, the nurse should not plan to administer a levalbuterol metered dose inhaler.

A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? Desmopressin Luteinizing hormone-releasing hormone Recombinant growth hormone Levothyroxine

Desmopressin is used to treat hyposecretion of antidiuretic hormones. Luteinizing hormone-releasing hormoneLuteinizing hormone-releasing hormone is used in the treatment of precocious puberty to slow prepubertal growth in children and in the treatment of advanced prostate cancer in adult clients. Recombinant growth hormoneMY ANSWERRecombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment. LevothyroxineLevothyroxine is used to treat various hypothyroid conditions.

A nurse on a pediatric unit is caring for a school-age child. Exhibit 1 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. Exhibit 2 0830: Temperature 37.1° C (98.8° F)Heart rate 100/minRespiratory rate 22/minBlood pressure 90/60 mm HgPulse oximetry 97% on 2 L of oxygen via nasal cannula1100:Temperature 37.1° C (98.8° F)Heart rate 110/minRespiratory rate 30/minPulse oximetry 94% on 2 L of oxygen via nasal cannula Exhibit 3 Diagnostic Results 1200: CBC: Hemoglobin 10 g/dL (10 to 15.5 g/dL)Hematocrit 32% (32% to 44%)WBC count 11,000/mm3 (5,000 to 10,000/mm3)Arterial Blood Gases (ABGs): pH 7.49 (7.35 to 7.45)PCO

Arterial blood gases is correct. The child's arterial blood gases (ABGs) indicate respiratory alkalosis, which is associated with complications of asthma, such as hyperventilation and hypoxia. Therefore, the nurse should report these findings to the provider. Cardiovascular assessment is incorrect. The child's cardiovascular assessment reflects expected findings for a school-age child. Therefore, there is no indication that the nurse should report these findings to the provider. WBC count is correct. The child's WBC count is above the expected reference range, which could be an indication of infection or inflammation. Therefore, the nurse should report this finding to the provider. Hemoglobin is incorrect. The child's hemoglobin is within the expected reference range. Therefore, there is no indication that the nurse should report this finding to the provider. Oxygen saturation level is correct. The child's oxygen saturation level has decreased below the expected reference range despite the use of supplemental oxygen. Therefore, the nurse should report this finding to the provider. Respiratory assessment is correct. The child's respiratory assessment indicates increased respiratory distress, as evidenced by the presence of tachypnea, retractions, and increased wheezing. Therefore, the nurse should report these findings to the provider.

A nurse is caring for an 8-month-old infant. Exhibit 2 Vital Signs Day of admission 0515: Weight 7.1 kg (15.65 lb)Temperature 38.7° C (101.7° F)Heart rate 184/minRespiratory rate 78/minBlood pressure 86/52 mm Hg0630: ​Temperature 37° C (98.6° F)Heart rate 180/minRespiratory rate 68/minBlood pressure 84/51 mm Hg Exhibit 1 Nurses' Notes Day of admission 0515: Infant is admitted for moderate acute laryngotracheobronchitis (LTB) and decreased fluid intake. The infant's parent reports it has been more than 12 hr since the infant last voided. The infant is restless, irritable, has a hoarse cry, and is not easily consoled by the parent. Audible inspiratory stridor is evident with a barky sounding occasional non-productive cough. Respiratory rate is 78/min with moderate suprasternal and intercostal retractions and nasal flaring. SpO2 is 89%. Color of mucous membranes is consistent with the client's genetic background. Capillary refill is 2 seconds, mucus membranes are slightly dry, and skin turgor is good. IV of dextrose 5% in 0.45% sodium chloride is infusing at 30 mL/hr. 100% cool mist oxygen is being given via blow-by tubing that the parent is holding.0600:SpO2 is 92%. Breath sounds are dimin

Audible inspiratory stridor noted is incorrect. The continued presence of audible inspiratory stridor is an indication that the infant has a narrowing of the upper airway due to inflammation from a viral infection. Therefore, this is not an indication that the infant's condition has improved. Infant is sleeping in parent's arms is correct. Restlessness and irritability are potential indications of hypoxia and impending airway obstruction. The infant was restless and irritable on admission, even when the parent was holding them. Therefore, this finding is an indication that the infant's condition has improved. SpO2 is 96% with 100% cool mist oxygen via blow-by is correct. A low SpO2 is an indication of hypoxia. The infant's SpO2 has increased from 89% to 96%, which is within the expected reference range. Therefore, this finding is an indication that the infant's condition has improved. Respiratory rate is 68/min with moderate suprasternal and intercostal retractions and nasal flaring is incorrect. This finding indicates the infant is experiencing continued respiratory distress. Therefore, this is not an indication that the infant's condition has improved. Has occasional barky cough with a hoarse cry is incorrect. The continued presence of occasional barky cough is characteristic of LTB. Therefore, this is not an indication that the infant's condition has improved. Breath sounds are present and equal bilaterally in the bases is correct. This finding indicates increased air movement compared to the 0600 assessment. Therefore, this finding is an indication that the infant's condition has improved. Infant voided 34 mL is correct. The infant's parent reported upon admission that the infant had not voided in over 12 hr. The infant's mucous membranes were noted on admission to be slightly dry, which is an indication of dehydration. Therefore, the infant voiding 34 mL is an indication that their hydration status has improved.

A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? Avoid palpating the abdomen when bathing the child before surgery. Refrain from auscultating the child's bowel sounds during the postoperative assessment. Encourage the child to play with other children on the unit prior to surgery. Explain to the child that their pain will be managed after the surgery.

Avoid palpating the abdomen when bathing the child before surgery.MY ANSWERThe nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site. Refrain from auscultating the child's bowel sounds during the postoperative assessment.Auscultation of the child's bowel sounds to monitor for an obstruction is an important part of the postoperative assessment. Therefore, the nurse should auscultate bowel sounds following the surgery. Encourage the child to play with other children on the unit prior to surgery.The child's risk for injury increases with physical activity. Therefore, the nurse should not encourage the child to play with other children on the unit. Explain to the child that their pain will be managed after the surgery.Telling the child about pain prior to surgery will likely increase their fear and anxiety level. Therefore, the nurse should not explain to the child that pain will be managed after surgery.

A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? "Use a kitchen teaspoon to measure the medication." "Brush the child's teeth after giving the medication." "Double the next dose if the child misses a dose." "Repeat the dose if the child vomits."

B. "Use a kitchen teaspoon to measure the medication."The nurse should instruct the parents to use the calibrated device that comes with the medication when measuring the medication to avoid accidental overdose. "Brush the child's teeth after giving the medication."The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste. "Double the next dose if the child misses a dose."The parent should administer digoxin at regular intervals, usually twice daily, or every 12 hr. The nurse should instruct the parents not to double the medication amount if they miss a dose because this can result in digoxin toxicity. "Repeat the dose if the child vomits."

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? Reports an absence of nausea and vomiting Reports experiencing an onset of loose stools within 15 min of administration Serum potassium level 4.1 mEq/L Blood pressure 86/52 mm Hg

C. Reports an absence of nausea and vomitingAbsence of nausea and vomiting indicates effectiveness of an antiemetic medication. Sodium polystyrene sulfonate is an antidote, which exchanges sodium ions in the intestine. Therefore, absence of nausea and vomiting is not an indicator of the medication's effectiveness. Reports experiencing an onset of loose stools within 15 min of administrationMY ANSWERThe nurse should monitor the adolescent for diarrhea because it is an adverse effect of sodium polystyrene sulfonate. Serum potassium level 4.1 mEq/LThe nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication. Blood pressure 86/52 mm HgA blood pressure of 86/52 mm Hg is below the expected reference range of 90 to 110 mm Hg systolic and 60 to 80 mm Hg diastolic for an adolescent and does not indicate effectiveness of the medication. The nurse should continue to monitor blood pressure as an indicator of fluid and electrolyte imbalance.

A nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? "Stay home from school for 1 week following the procedure." "Follow a diet that is low in fiber for 1 week." "Wait 3 days before taking a tub bath." "Apply a pressure dressing to the site for 3 days."

C. "Stay home from school for 1 week following the procedure."The child can attend school the next day but they should avoid strenuous activities to prevent bleeding at the insertion site. "Follow a diet that is low in fiber for 1 week."The child can resume their regular diet after the procedure. "Wait 3 days before taking a tub bath."The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. "Apply a pressure dressing to the site for 3 days."MY ANSWERThe parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? ½ cup whole milk 1 cup orange juice ½ cup raisins 1 cup raw carrots

C. ½ cup whole milkWhole milk does not contain the highest amount of nonheme iron. However, it does contain high amounts of calcium. 1 cup orange juiceOrange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body. ½ cup raisinsMY ANSWERThe nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. 1 cup raw carrotsRaw carrots do not contain the highest amount of nonheme iron.

A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following findings to the provider? Capillary refill time less than 2 seconds Restricted ability to move the toes Swelling of the casted foot when the leg is dependent Pedal pulse +3 bilateral

Capillary refill time less than 2 secondsCapillary refill time is assessed to determine circulatory status by pressing lightly on the tips of the toes until the skin has blanched. A capillary refill time that is greater than 2 seconds indicates circulatory compromise and should be reported to the provider immediately. Restricted ability to move the toesThe nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours. Swelling of the casted foot when the leg is dependentSwelling of the casted foot when the leg is dependent is an expected finding. The nurse should instruct the guardians that frequent rest is needed for the next several days, and that the casted foot should not be in a dependent position for more than 30 min. When the toddler is resting, the casted extremity should be elevated on a pillow at chest level to minimize swelling. Pedal pulse +3 bilateralMY ANSWERA pulse that is not easily obliterated with pressure is graded as a +3 and is an expected finding that indicates adequate circulation of the extremity. An absent pulse indicates circulatory compromise and should be reported to the provider immediately.

Exhibit 1 Graphic Record Temperature 37.5° C (99.5° F) Heart rate 70/min Respiratory rate 30/min Birth weight 3.2 kg (7 lb) Current weight 5.9 (13 lb) Exhibit 2 Nurses' Notes 3 episodes of vomiting 6 wet diapers in 24 hr Consumed 3 oz concentrated formula every 3 hr Exhibit 3 Medication Administration Record Digoxin 0.5 mcg PO Q12H Furosemide 20 mg PO Q12H A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? Episodes of vomiting Formula consumption Weight Temperature

Episodes of vomitingMY ANSWERWhen using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. Formula consumptionA 4-month-old infant who has heart failure requires 3 to 4 oz of formula every 3 hr to adequately address caloric needs. A feeding schedule of every 2 hr does not allow sufficient rest time between feedings, and a feeding schedule of every 4 hr requires consumption of a higher volume, which is often not tolerated by the infant. An intake of 3 to 4 oz of formula every 3 hr indicates that the infant is tolerating the current feeding schedule. Therefore, there is another finding that is the nurse's priority. The infant who has heart failure is at risk for inadequate nutrition; therefore, the nurse should closely monitor the infant's intake. WeightA weight of 5.9 kg (13 lb) is an expected finding for a 4-month-old infant who weighed 3.2 kg (7 lb) at birth. Therefore, there is another finding that is the nurse's priority. The infant should gain 680 g (1.5 lb) per month until the age of 5 months. TemperatureA temperature of 37.5º C (99.5º C) is within the expected reference range of 37º to 37.5º C (98.6º to 99.5º F) for a 4-month-old infant. Therefore, there is another finding that is the nurse's priority.

A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? "I will plan to increase the amount of homework I assign to students who have ADHD." "I will give students who have ADHD the same amount of time as other students to complete tests." "I will allow students who have ADHD one rest break throughout the day." "I will teach challenging academic subjects to students who have ADHD in the morning."

Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective

A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? Furosemide Captopril Regular insulin Potassium chloride

FurosemideA child who has congestive heart failure might need a diuretic to prevent fluid overload from heart failure. Furosemide is a loop diuretic that excretes potassium. Since the child is exhibiting manifestations of hyperkalemia, this medication is safe to administer. CaptoprilA child who has congestive heart failure will require medications that cause vasodilation, such as ACE inhibitors, to reduce cardiac afterload. Regular insulinA child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and that insulin should be administered to facilitate the movement of potassium into the cells. Potassium chlorideMY ANSWERThe nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia.

A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? Have the adolescent sign a consent form for treatment. Instruct the adolescent to return with a guardian. Obtain consent from the adolescent's guardian over the phone. Treat the adolescent without a consent form.

Have the adolescent sign a consent form for treatment.MY ANSWERThe nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent.

A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? Heart rate 124/min Increased tear production Sunken anterior fontanel Capillary refill 2 seconds

Sunken anterior fontanel MY ANSWER The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. A heart rate of 124/min is within the expected reference range of 106 to 186/min for a 3- to 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia.

A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? "You may bathe your infant in an infant bathtub when you go home." "Apply hydrocortisone cream to your infant's penis daily." "You should clamp your infant's stent twice daily." "Allow the stent to drain directly into your infant's diaper."

Hypospadias repair is a surgical procedure performed to correct a congenital condition in males where the opening of the urethra is not located at the tip of the penis but on the underside. Instead of the typical location at the tip of the penis, the urethral opening may be along the shaft or near the scrotum. This condition can vary in severity, and hypospadias repair aims to reposition the urethral opening to the tip of the penis for proper urinary function and a more typical appearance. The surgeon makes an incision on the underside of the penis. The urethra is repositioned to the tip of the penis. Tissues may be used to create a tube for the urethra. D. The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow.

A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply.) Increased temperature Gingival hyperplasia Xerophthalmia Bradycardia Cervical lymphadenopathy

Increased temperature is correct. Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics.Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia.Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia.Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction.Cervical lymphadenopathy is correct. A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.

A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse's priority? Length of stay Treatment schedule Disease process Self-care ability

Length of stayIt is important for the nurse to consider the child's anticipated length of stay because some client rooms might be larger, and thus more comfortable for families during long hospitalizations. However, this is not the nurse's priority consideration. Treatment scheduleMY ANSWERIt is important for the nurse to consider the child's treatment schedule when making room assignments because children requiring frequent monitoring and treatment should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration. Disease processThe transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration. Self-care abilityIt is important for the nurse to consider the child's self-care ability when making room assignments because children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration.

A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take? Place the infant in a knee-chest position. Administer a dose of meperidine IV. Discontinue administration of IV fluids. Apply oxygen at 2 L/min via nasal cannula.

Management of a hypercyanotic spell typically involves calming the child, providing supplemental oxygen, and increasing blood flow to the lungs, often by positioning the child with their knees to their chest (known as the knee-chest position) to reduce the pressure on the heart. Tetralogy of Fallot is a congenital heart defect that involves four different heart abnormalities occurring in the same individual. These four defects include: Ventricular Septal Defect (VSD): A hole in the wall (septum) that separates the two lower chambers (ventricles) of the heart, allowing oxygen-poor blood from the right ventricle to mix with oxygen-rich blood from the left ventricle. Pulmonary Stenosis: Narrowing of the pulmonary valve or the blood vessel that carries oxygen-poor blood from the heart to the lungs. Right Ventricular Hypertrophy: Enlargement of the right ventricle, the chamber responsible for pumping oxygen-poor blood to the lungs. Overriding Aorta: The aorta, the main artery that carries oxygenated blood to the body, is shifted slightly to the right and lies directly above the ventricular septal defect. Tetralogy of Fallot results in reduced blood flow to the lungs and a mixture of oxygen-poor and oxygen-rich blood in the body, leading to cyanosis (bluish discoloration of the skin and mucous membranes) in affected individuals.

A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect? Resists having an axillary temperature taken Exhibits withdrawal behaviors when their parent leaves Has multiple bruises on their knees Poor personal hygiene

Poor personal hygiene A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision.

A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take? Provide the child with a book about adventure. Arrange frequent visits from family members and peers. Give the child a large-piece puzzle. Use puppets to entertain the child.

Provide the child with a book about adventure.MY ANSWERThe nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read. Arrange frequent visits from family members and peers.The nurse should limit visitors for a child who has neutropenia because this places the child at an increased risk for infection. Give the child a large-piece puzzle.The nurse should provide a large-piece puzzle to a preschooler. School-age children tend to be challenged mentally with complex board and video games. Use puppets to entertain the child.The nurse should use puppets to entertain toddlers. School-age children are not typically entertained for very long or challenged mentally with puppets. Instead, they tend to prefer complex board and video games.

A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.) Steatorrhea Vomiting Lethargy Constipation Weight gain

Steatorrhea is incorrect. The nurse should expect an infant who has intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis.Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel.Lethargy is correct. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake.Constipation is incorrect. The nurse should expect an infant who has intussusception to have mucus-filled and red jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen.Weight gain is incorrect. The nurse should expect an infant who has intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.

A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? Presence of a central incisor tooth Presence of strabismus Presence of an open anterior fontanel Presence of external cerumen

Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider.

A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? Hypotension Reports insomnia Difficulty concentrating Tachycardia

The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem. The nurse should identify that hypertension is a late manifestation of increased intracranial pressure due to compression of the brain vessels. Reports insomniaThe nurse should identify that somnolence and lethargy are manifestations of increased intracranial pressure. Difficulty concentratingThe nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem. TachycardiaMY ANSWERThe nurse should identify that bradycardia is a late manifestation of increased intracranial pressure.

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching? "Mononucleosis is caused by an infection with the Epstein-Barr virus." "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." "A Monospot is a throat culture used to diagnosis mononucleosis." "Children who get mononucleosis will need to refrain from sports for 6 months."

The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus.

A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? Controls impulsive feelings Understands right from wrong Easily separates from parents for long periods of time Expresses likes and dislikes

The nurse should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions.

A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make?

The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness.

A nurse is creating a plan of care for a child who has varicella. Which of the following interventions should the nurse include? Maintain the child's room temperature at 80° F. Prepare the child for a lumbar puncture. Administer aspirin to the child for a temperature greater than 38.3° C (101° F). Initiate airborne precautions for the child.

The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear.

A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." "Choose a waterproof sunscreen with a minimum SPF of 15." "Dress your child in loose weave polyester fabric prior to sun exposure." "Reapply sunscreen every 4 hours."

The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn.

A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? "You should offer your child high-protein meals and snacks throughout the day." "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." "You should restrict your child's calorie intake to 1,200 per day." "You should give your child a multivitamin once weekly."

The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection.

A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? Urine specific gravity 1.045 Sodium 155 mEq/L Blood glucose 45 mg/dL Urine output 35 mL/hr

Urine specific gravity 1.045MY ANSWERUrine specific gravity of 1.045 is above the expected reference range of 1.005 to 1.030. A child who has diabetes insipidus is more likely to have diluted urine and a urine specific gravity below the expected reference range. Sodium 155 mEq/LA child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. Blood glucose 45 mg/dLBlood glucose of 45 mg/dL is below the expected reference range of 70 to 110 mg/dL. A child who has diabetes insipidus is expected to have a blood glucose level within the expected reference range. Urine output 35 mL/hrUrinary output of 35 mL/hr is within the expected reference range of 33 to 58 mL/hr for a 10-year-old child. A child who has diabetes insipidus is expected to have polyuria.

A nurse is caring for a school-age child following an appendectomy. Exhibit 1 Vital Signs Day of admission: Temperature 37.1° C (98.8° F)Heart rate 100/minRespiratory rate 20/minBlood pressure 94/60 mm HgPulse oximetry 97%24 hr following the procedure: Temperature 38.6° C (101.5° F)Heart rate 110/minRespiratory rate 24/minBlood pressure 100/60 mm HgPulse oximetry 95% Exhibit 2 Day of admission:Child is drowsy but easily aroused and responsive to verbal stimuli. Child rates pain as 4 on a scale of 0 to 10. Lungs clear to auscultation. Abdomen is soft, flat, and non-distended. Bowel sounds hypoactive in all four quadrants. Extremities are warm and dry to touch. Gauze pads with clear transparent dressings noted to the umbilicus, left lower quadrant, and suprapubic area.24 hr following the procedure:Child is alert and responsive to verbal stimuli. Appears irritable and restless. Child rates pain as 8 on a scale of 0 to 10. Respirations are shallow. No accessory muscle use noted. Lungs clear to auscultation. Abdomen is rigid and distended. Bowel sounds hypoactive in all four quadrants. Gauze pads with clear transparent dressings noted to the umbilicus, left lower quadrant, and suprapubic area

WBC count is correct. The child's WBC count has increased significantly following the procedure. The nurse should identify that this is a potential indication of a postoperative infection. Oxygen saturation level is incorrect. The child's oxygen saturation level is within the expected reference range. Therefore, this finding does not indicate a potential complication. Platelets is incorrect. The child's platelet count is within the expected reference range. Therefore, this finding does not indicate a potential complication. Abdomen assessment is correct. The child's abdomen is rigid and distended and they are reporting increased pain. The nurse should identify that this is a potential indication of a postoperative infection. Temperature is correct. One day following surgery, the child's temperature has increased and is above the expected reference range. The nurse should identify that this is a potential indication of a postoperative infection. Abdominal dressings assessment is incorrect. The child's abdominal dressings have scant serous drainage present, which is an expected finding following surgery. Therefore, this finding does not indicate a potential complication.

nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip.) Wheezes Crackles Pleural friction rub Rhonchi

WheezesThe nurse should identify the sound during auscultation as wheezes, which are high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. CracklesThe nurse should identify crackles as high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted. Pleural friction rubMY ANSWERThe nurse should identify a pleural friction rub as a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together. RhonchiThe nurse should identify rhonchi as low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed.

A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? Check the child for a head injury. Observe for oral bleeding. Check the child's respiratory rate. Observe for extremity weakness.

When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths.

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first?

When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? Wrist Great toe Index finger Heel

WristIt is important for the sensor to be positioned in the correct area to obtain an accurate reading. The nurse should avoid placing the sensor on the wrist because this placement will result in an inaccurate reading. B. Great toeThe nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse. Index fingerMY ANSWERThe nurse should secure the sensor to the index finger of a child and then use a self-adhering bandage to hold the sensor in place; however, this site is not recommended for pulse oximetry of an infant. HeelIt is important for the sensor to be positioned in the correct area to obtain an accurate reading. The nurse should avoid placing the sensor on the heel of the infant's foot because this placement will result in an inaccurate reading.