Nursing Care of Children Final Study Guide

A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschoolers parents tells the nurse they cannot cope anymore and are thinking about moving out of the house. Which of 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 ways you have handled previous stressors in your life"

d. "Let's talk about some ways you have handled previous stressors in your life"; This statement offers a general lead to allow the parent to express their feelings in previous actions when face with stressful situation's. It also helps a parent to focus on ways they can cope with the current situation

A nurse is planning care for a school age child who is the all the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan? a. Administer ibuprofen to the child for a temperature greater than 38°C (100.4ºF) b. Assess the child's blood pressure every eight hours c. Where the child weekly at various times of the day d. Initiate seizure precautions for the child

d. Initiate seizure precautions for the child; A sodium level of 129 mEq/L indicates hyponatremia in place as a child at an increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child safety

A nurse is caring for a 15 year old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion? a. Sodium 148 mEq/L b. Urine specific gravity 1.020 c. Mental confusion d. Weak peripheral pulses

c. Mental confusion; A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an over secretion of antidiuretic hormone. Over secretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoomolarity due to over hydration. As hyponatremia becomes more severe, mental confusion and other neurological manifestations such as seizures may occur

A nurse is reviewing a 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? Thanks a. Decreased cerebrospinal fluid pressure b. Decrease WBC count c. Increase protein concentration d. Increase glucose level

c. Increase protein concentration; The nurse should identify that increase protein concentration in the spinal fluid is finding that can indicate bacterial meningitis

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

b. "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.

A nurse is caring for a school age child who is receiving chemotherapy and a severely immuno compromised. Which of the following actions should the nurse take? a. Use surgical a sepsis when providing routine care for the child b. Administer the 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 child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should scream the child's visitors for indications of infection

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? a. Reports an absence of nausea and vomiting b. Reports experiencing an onset of loose stools within 15 minutes of administration c. Serum potassium level 4.1 mEq/L d. Blood pressure 82/52 mmHg

c. Serum potassium level 4.1 mEq/L; The 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.

A nurse in an emergency department is assessing a three 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? a. Heart rate 124 bpm b. Increased tear production c. Sunken anterior fontanel d. Capillary refill 2 seconds

c. Sunken anterior fontanel; 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 nurse is providing discharge teaching to the parents of a six month old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instruction should the nurse include in the teaching? a. "You may bathe with your infant in an infant bathtub when you go home" b. "Apply hydrocortisone cream to your infants penis daily" c. "You should clamp your infants stent twice daily" d. "Allow the stent to drain directly into your infants diaper"

d. "Allow the stent to drain directly into your infants diaper"; 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 is reviewing the laboratory report of a school age child who is experiencing fatigue. Which of the following findings should the 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 2500,000/mm^3

a. Hematocrit 28%; The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity

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? a. Length of stay b. Treatment schedule c. Disease process d. Self-care ability

c. Disease process; The 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.

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

d. 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 dietary teaching to the guardians of a school age child who has cystic fibrosis. Which of the following statements should the nurse make? a. "You should offer your child high-protein meals and snacks throughout the day" b. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake" c. "You should restrict your child's calorie intake to 1200 per day" d. "You should give your child a multivitamin once weekly"

a. "You should offer your child high-protein meals and snacks throughout the day"; 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 assessing the pain of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use? a. Faces b. Numeric c. CRIES d. 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.

A nurse is caring for an infant who has RSV. Which of the following action should the nurse implement for infection control? a. Have a designated stethoscope for the infant's room b. Play the infant in a room equipped with negative airflow c. Administer palivizumab as prescribed for the infant d. Remove gloves after leaving the infants room

a. Have a designated stethoscope for the infant's room; The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant room

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 to the affected area? a. Zinc oxide b. Antibiotic ointment c. Talcum powder d. Anti-septic 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, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allow the skin to heal

A nurse is teaching the parents of a school age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by the parent indicates an understanding of the teaching? a. "My child will have a cast until healing is complete" b. "My child will receive antibiotics for several weeks" c. "My child can return to playing sports once they have been discharged" d. "My child needs to be in contact isolation"

b. "My child will receive antibiotics for several weeks"; The nurse should instruct the parent that the child will receive antibiotic therapy for at least four weeks. Surgery might be indicated if the antibiotics are not successful

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. And elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescence's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.

A nurse is preparing to collect a sample from a toddler for sickle-turbidity test. Which of the following action should the nurse plan to take? a. Obtain a sputum specimen b. Perform in Allen test c. Perform a finger stick d. Obtain a stool specimen

c. Perform a finger stick; The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease

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

a. A school age child who has sickle cell anemia and reports decreased vision in the left eye; When using the urgent versus non-urgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore the nurse should see this child first

A nurse is assessing an infant who has ventricular septal defect. Which of the following findings should the nurse expect? a. Loud, harsh murmur b. Dysrhythmias c. Weak femoral pulses d. High blood pressure

a. Loud, harsh murmur; The nurse should expect to hear a loud, heart murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to the hypertrophy of the infants heart muscle

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 and droplet precautions? a. Until the adolescent is afebrile b. For seven days following admission to the facility c. Until the adolescent has a negative blood culture d. For 24 hours following initiation of antimicrobial therapy

d. For 24 hours 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 creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following intervention should the nurse include in the plan? a. Position the infant side-lying with their head at a 0° to 5° angle b. Perform a neurological assessment every four hours c. Suction the infant snares to remove secretions d. Implement seizure precautions for the infant

d. Implement seizure precautions for the infant; An infant who has an epidural hematoma is at a great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child

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? a. "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." b. "Choose a waterproof sunscreen with a minimum SPF of 15" c. "Dress your child in loose weave polyester fabric prior to sun exposure" d. "Reapply sunscreen every 4 hours"

b. "Choose a waterproof sunscreen with a minimum SPF of 15"; 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 teaching to the family of a school age child who has juvenile idiopathic arthritis. Which of the following instructions for the nurse include in the teaching? a. "Limit movement of the child's large joints" b. "Encourage the child to perform independent self-care" c. "Provide the child with a soft mattress for sleeping" d. "Schedule a two hour daily nap for the child in the afternoon"

b. "Encourage the child to perform independent self-care"; The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem.

A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? a. "I should buy plastic shoes to wear at the swimming pool" b. "I should wear sandals as much as possible" c. "I should place the permethrin cream between my toes twice daily" d. "I should seal my non-washable shoes in plastic bags for a couple of weeks"

b. "I should wear sandals as much as possible"; Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection.

A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? a. Place a cardiac monitor on the adolescent prior to the procedure b. Apply topical analgesic cream to the site one hour prior to the procedure c. Keep the adolescent in semi Fowler's position for four hours following the procedure d. Restrict fluids for two hours following the procedure

b. Apply topical analgesic cream to the site one hour prior to the procedure; The nurse should apply topical analgesic to the lumbar site one hour prior to the procedure to decrease the adolescence's pain while the lumbar needle is inserted

A nurse is caring for a toddler who has acute otitis media and a temperature of 40°C (104ºF). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddlers temperature? a. Apply a cooling blanket to the toddler b. Dress to toddler and minimal clothing c. Give the toddler a tepid bath d. Administer diphenhydramine to the toddler

b. Dress to toddler and minimal clothing; The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature.

The nurse is caring for a school age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medication sure the nurse administer first? a. Prednisone b. Epinephrine c. Diphenhydramine d. Albuterol

b. Epinephrine; This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic antagonist that stimulates the heart, causes vasoconstriction of the blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs

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 of the infant? a. Wrist b. Great toe c. Index finger d. Heel

b. Great toe; The 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.

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

b. Presence of strabismus; 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 caring for a one month old infant who is breast-feeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain? a. Use a manual lancet to obtain the heel blood sample b. Applying ice back to the infant's heel prior to obtaining the sample c. Allow the mother to breastfeed while the sample is being obtained d. Apply a topical lidocaine cream prior to obtaining the sample

c. Allow the mother to breastfeed while the sample is being obtained; The 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 caring for a school-age child who is in Buck's traction follow and a leg fracture 24 hours ago. Which of the follow and actions are the nurse take? a. Change the child's position every two hours b. Clean the peripheral pin sites with chlorhexidine solution every four hours c. Assess peripheral pulses once every four hours d. Ensure that the head of the bed is elevated to a 90° angle

c. Assess peripheral pulses once every four hours; Bucks traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every four hours after the first 24 hours of placement in Buck's traction. The nurse should monitor and report signs of neurovascular apartment in the extremity such as diagnosis, a dime, pain, absent pulses, and tingling

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

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

The school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behavior should the nurse identify as a possible indication of physical abuse? a. Expect 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 relationship with peers

c. Denies discomfort during assessment of injuries; The nurse should suspect child maltreatment in the form of physical abuse of the adolescent has a blended response to painful stimuli or injury

A nurse is in an urgent care clinic assessing an adolescent who has an upper upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis? a. Inflamed throat with exudate b. Purulent eye drainage c. Dry, hacking cough d. Koplik spots on buccal mucosa

c. Dry, hacking cough; The nurse should identify that are dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night

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

a. Avoid palpating the abdomen when bathing the child before surgery; The 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.

A nurse is assessing an eight-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? a. Insert an indwelling urinary catheter b. Measure weight and height c. Initiate IV access d. Maintain ECG monitoring

c. Initiate IV access; 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 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 supine 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 with hip flexion. This results from a lateral S- or C- shaped curvature to the thoracic spine resulting in a symmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connected tissue disorder, or it can be congenital in nature

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority? a. Skin breakdown b. Hypotension c. Hyperpyrexia d. Tachpnea

d. Tachpnea; When using the airway, breathing, and circulation approach to client care, the nurses priority finding is the toddler is tachypnea. The tachpnea is a result of the kidneys being unable to excrete hydrogen ions in produced bicarbonate, which leads 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 toddlers Moro reflex is absent d. The toddler received tobramyosin during a hospitalization two weeks ago

d. The toddler received tobramyosin during a hospitalization two weeks ago; The nurse should identify that this medication as an aminoglycoside, which is an otoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment

A nurse is providing dietary teaching to the parent of a school-age 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; The nurse should recommend that the parent offer white rice to the child because it is a gluten free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be a secondary to this disease

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the 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 nurse should include that symmetric burns to the lower extremities and indicate physical abuse. The patterns are usually characteristics of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron

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? a. "I will offer my child small amount of fruit juice frequently" b. "I will avoid giving my child solid foods until the diarrhea has stopped" c. "I will monitor my child's number of wet diapers" d. "I will give my child polyethylene glycol daily for seven days"

c. "I will monitor my child's number of wet diapers"; 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 school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weights 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules for the nurse administer per day?

1 capsule

A nurse is preparing to administer ibuprofen 5 mg/kg every six hours PRN for a temperature above 38°C (100.5ºF) to an infant who weighs 17.6 lbs. Available is ibuprofen oral suspension 100 mg/5 mL. How many mL should the nurse administer to the infant per dose?

2 mL

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

a. Decreased edema; 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 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? a. Deep respirations of 32/min b. Shallow respirations of 10/min c. Paradoxic respirations of 26/min d. Periods of apnea lasting for 20 seconds

a. Deep respirations of 32/min; The 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.

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

a. "Mononucleosis is caused by an infection with the Epstein-Barr virus"; 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 teaching the guardian of a six month old infant about teething. Which of the following statements should the nurse make? a. "Your baby might pull at their ears when they are teething" b. "Rub your baby's gums with an aspirin to decrease discomfort" c. "Place a beaded teething necklace around your babies neck" d. "Your baby's upper middle teeth will erupt first"

a. "Your baby might pull at their ears when they are teething"; 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 in an emergency department is assessing a toddler who is Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply) a. Increased temperature b. Gingival hyperplasia c. Xerophthalmia d. Bradycardia e. Cervical lymphadenopathy

a. Increased temperature; c. Xerophthalmia; e. Cervical lymphadenopathy; Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. 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 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 action should the nurse take? a. Place the infant and a knee-chest position b. Administer a dose of meperidine IV c. Discontinue administration of IV fluids d. Apply oxygen at 2 L/min via nasal cannula

a. Place the infant and a knee-chest position; The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.

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

a. Provide the child with a book about adventure; The 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.

A nurse in an emergency department is caring for a school age child who is sustained a minor superficial burn from fireworks on the forearm. Which of the following actions should the nurse take? a. Administer the tetanus toxoid vaccine if more than one year since prior dose b. Apply an anti-microbial ointment to the affected area c. Leave the burn area open to air d. Place an ice pack on the affected area

b. Apply an anti-microbial ointment to the affected area; The nurse should apply an antimicrobial ointment to the burned area to prevent infection.

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? a. "Scold your child when they have a toileting accident" b. "Award your child with a sticker when they sit on the potty chair" c. "Play your child's favorite song while teaching them to use the body chair" d. "Teach multiple steps of the scale at the same time"

b. "Award your child with a sticker when they sit on the potty chair"; 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 providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hours ago. The nurse should instruct the guardians to report which of the following findings to the provider? a. Capillary refill time less than two seconds b. Restricted ability to move the toes c. Swelling of the casted foot when the leg is dependent d. Pedal pulse +3 bilateral

b. Restricted ability to move the toes; The 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.

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? a. Hypotension b. Reports insomnia c. Difficulty concentrating d. Tachycardia

c. Difficulty concentrating; 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.

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? a. Ensure that a padded tongue blade is at the child's bedside b. Allow the child to play video games on a tablet computer c. Allow the child to take a tub bath independently d. Ensure the oxygen source is functioning in the child's room

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

d. 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.

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

d. Potassium chloride; The 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 is teaching the parent of an infant about ways to prevent sudden infant death syndrome. Which of the following instruction 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 infants crib" d. "Give the infant a pacifier a bedtime"

d. "Give the infant a pacifier a bedtime"; The nurse should inform the parent that protective factors against SIDS include breast-feeding and the use of pacifiers when the infant is sleeping

A nurse is assessing a three year old toddler at a well child visit. Which of the following manifestations should the nurse report to the provider? a. Blood pressure 90/50 mmHg b. Respiratory rate 45/min c. weight 14.5 kg (32 lbs) d. Heart rate 110 bpm

b. Respiratory rate 45/min; The nurse should identify that the respiratory rate of 45 is above the expected reference range of 20 to 25 for a three-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report the findings to the provider

A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding of the teaching? a. "My child can resume usual activities since this is just an outpatient surgery" b. "My child will be able to drink the chocolate milkshake I promised to get for them tonight" c. "I will notify the doctor if I notice that my child is swallowing frequently" d. "I will have my child gargle with warm salt water to relieve their sore throat"

c. "I will notify the doctor if I notice that my child is swallowing frequently"; The nurse should instruct the parent that frequent swallowing is an indication of bleeding and, if it is observed, to notify the provider immediately.

A nurse is admitting a school age child who has pertussis. Which of the following action should the nurse take? a. Place a child in a room with positive pressure airflow b. Place a 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; The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks

A nurse is planning care for a toddler who has serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? a. Instruct the parents to decrease the calcium in their toddlers diet b. Prepare the toddler for chelation therapy c. Refer the family to child protective services d. Schedule the toddler for a yearly re-screening

d. Schedule the toddler for a yearly re-screening; The nurse should schedule the toddler for a lead level rescreening in one year and educate the family on ways to prevent exposure

A nurse is in an emergency department 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 versus non-urgent approach to client care, the nurse should determine that the priority action is administering up enough for an 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 caring for a school age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? a. Laryngeal edema b. Flank pain c. Distended neck veins d. Muscular weakness

b. Flank pain; The nurse should recognize that flank pain is caused by a breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion

A nurse is assessing a four-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 in outlined shape using scissors d. Draw a stick figure with seven body parts

c. Cuts in outlined shape using scissors; The nurse should recognize that an expected developmental milestone of a four-year-old is using scissors to cut out a shape

A nurse in an emergency department is caring for a school age child who has appendicitis and rates their abdominal pain is a seven on a scale of 0 to 10. Which of the following action should the nurse take? a. Instill a 500 mL tap water enema b. Give morphine 0.05 mg/kg IV c. Administer polythylene glycol 1 g/kg PO d. Apply heating pad to the child's abdomen

b. Give morphine 0.05 mg/kg IV; A pain level of seven on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief

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 playroom 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 is providing teaching to the parent of a school-age child who it has a new prescription for oral nice Staten for the treatment of oral candidiasis. Which of the following instruction should the nurse include? a. "Shake the medication prior to administration" b. "Provide the medication through a straw" c. "When's 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"; The nurse should instruct the parent to take the medication prior to the 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 asked, "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 parents 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 adolescence the right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age

A nurse is receiving change of shift report for for children. Which of the following children should the nurse assess first? a. A toddler who has a concussion and an episode of forceful vomiting b. And adolescent who has ineffective endocarditis and reports having a headache c. And adolescent who is placed into halo traction one hour ago and reports pain as a six on a scale from 0 to 10 d. A school age child who has acute glomerulonephritis and brown colored urine

a. A toddler who has a concussion and an episode of forceful vomiting; 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 reviewing the laboratory results of a school age child who has one week post operative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? a. Erythrocyte sedimentation rate 18 mm/hr b. WBC count 6,200/mm63 c. C-reactive protein 1.4 mg/L d. RBC count 4.7 million/mm^3

a. Erythrocyte sedimentation rate 18 mm/hr; The nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis.

A nurse and 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? a. Have the adolescent sign a consent form for treatment b. Instruct the adolescent to return with a guardian c. Obtain consent from the adolescence guardian over the phone d. Treat the adolescent without a consent form

a. Have the adolescent sign a consent form for treatment; The 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 is providing discharge teaching to a parent of a school age child who has moderate persistent asthma. Which of the following instruction should the nurse include? a. "You should give your child their salmeterol inhaler every four hours when they are having an acute episode of wheezing" b. "You should monitor your child's weight weekly when they are receiving inhaled corticosteroid therapy" c. "Pulmonary function test will be performed every 12 to 24 months to evaluate how your child is responding to therapy" d. "When using the peak expiratory flow meter, record your child average of three readings"

c. "Pulmonary function test will be performed every 12 to 24 months to evaluate how your child is responding to therapy"; The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly.

A nurse is teaching a school age child and their parent about post operative care follow any cardiac catheterization. Which of the following instruction should the nurse include? a. "Stay home from school for one week following the procedure" b. "Follow a diet that is low in fiber for one week" c. "Wait three days before taking a tub bath" d. "Apply pressure dressing to the site for three days"

c. "Wait three 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.

A nurse in a providers office is caring for a school age child who has varicella. The parents ask the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a. "When your child no longer has an increased temperature" b. "Three days after you first noticed the rash on your child" c. "When your child's lesions are crusted, usually six days after they appear" d. "2 to 3 weeks, when your child lesions completely disappear"

c. "When your child's lesions are crusted, usually six days after they appear"; The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.

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

c. Check the child's respiratory rate; 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 caring for a newly admitted school age child who has hypopituitarism. Which of the following medication should the nurse expect the provider to prescribe? a. Desmopressin b. Luteinizing hormone-releasing hormone c. Recombinant growth hormone d. Levothyroxine

c. Recombinant growth hormone; Recombinant 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.

A nurse is teaching the parents of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify which of the following statements by the parent indicates an understanding of 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 skin twice daily" d. "I will place my infant's diapers under the harness straps"

d. "I will place my infants diapers under the harness straps"; To prevent soiling of the harness, the parent should apply the infant's diapers under the straps

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? a. Obtain a throat culture from the child b. Monitor the child's oxygen saturation c. Put a warm mist humidifier in the child's room d. Place the child in a supine position

b. Monitor the child's oxygen saturation; 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 reviewing the laboratory report of a seven-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? a. Hgb g/dL b. WBC count 9,500/mm^3 c. Prealbumin 18 mg/dL d. Platelets 300,000/mm^3

a. Hgb 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 the anemia is diagnosed through laboratory testing of hemoglobin and 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 seven-year-old child and should be reported to the provider

A nurse is assessing an infant who has pneumonia. Which of the findings is the priority for the nurse to report to the provider? a. Nasal flaring b. WBC count 11,300/mm^3 c. Diarrhea d. Abdominal distention

a. Nasal flaring; When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress.

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

A nurse is caring for a school age child who has experienced a tonic clonic seizure. Which of the following action should the nurse take during the immediate postictal period? a. Place the child in a sideline position b. Delay documentation until the child is fully alert c. Give the child a high carbohydrate snack d. Administer an oral sedative to the child

a. Place the child in a side-lying position; The nurse should place the child and a side-lying position to prevent aspiration

'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? a. The child should be able to stand on the balls of their feet when sitting on the bike b. The child should ride their bike 2 feet to the side of other bike riders c. The child should wear a dark colored clothing with a fluorescent stripe on riding at night d. The child should ride a bike facing traffic when it is necessary to ride in the street

a. The child should be able to stand on the balls of their feet when sitting on the bike; 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 teaching a school age child who has a new diagnosis of type one diabetes Molite us. 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 g of carbohydrates if my blood glucose is low" d. "I will decrease the amount of fluids I drink when I'm sick"

b. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast"; The child should administer regular insulin 30 minutes before meals so the onset coincides with food intake

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

d. 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 toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items for the nurse offered to 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 in water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration

A nurse is providing discharge teaching to the parent of a child who has one week post operative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral? a. Occupational therapist b. Speech therapist c. Respiratory therapist d. Physical therapist

b. Speech therapist; A nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation

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

b. Vomiting; c. Lethargy; 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. 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.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory 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; The nurse should identify that a sodium level of 140 is within the expected reference range of 134 to 150 and indicates the current treatment regimen the infant is receiving for dehydration is effective

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify which of the following menu items as the highest amount of nonheme iron? a. 1/2 cup of whole milk b. 1 cup orange juice c. 1/2 cup raisins d. 1 cup raw carrots

c. 1/2 cup raisins; The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron.

A nurse is preparing to administer an immunization to a four-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 three seconds

c. Administer the immunization using a 24 gauge needle; The nurse should administer an immunization for a four-year-old child using a 22 to 25 gauge needle to minimize the amount of pain the child experiences

A nurse is assessing a school age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? a. Report a headache as six on a 0 to 10 pain scale b. Petechiae on the lower extremities c. Nuchal rigidity d. Positive Kernig's sign

b. Petechiae on the lower extremities; The presence of petechial 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 from sepsis and should be reported immediately to the provider

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 as an indication of early septic shock? a. Blood pressure 130/90 mmHg b. Heart rate 60 bpm c. Temperature 39.1°C (102.4ºF) d. Urinary output 100 mL/hr

c. Temperature 39.1°C (102.4ºF); The nurse should identify that a temperature of 39.1°C is above the expected reference range of 37° to 37.5°C for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills

A nurse is assessing a school age child who has peritonitis. Which of the following findings should the nurse expect? a. Hyperactive bowel sounds b. Abdominal distention c. Bradycardia d. Bloody stool

b. Abdominal distention; The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This information in the alderman, along with the alias that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness

A nurse is assessing a school age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? a. Purulent nasogastric drainage b. Absence of peristalsis c. Passage of dark red stool with mucus d. WBC count 6000 /mm^3

b. Absence of peristalsis; The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning

A nurse is caring for a toddler who has spastic cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply) a. Negative Babinski reflex b. Ankle clonus c. Exaggerated stretch reflexes d. Uncontrollable movements of the face e. Contractures

b. Ankle clonus; c. Exaggerated stretch reflexes; e. Contractures; The nurse should expect a child who has spastic cerebral palsy to exhibit a positive Babinski reflex. The nurse should expect a child who is spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflects tremor when the foot is dorsiflexed. The nurse should expect a child who has spastic cerebral palsy to exhibit specificity or exaggerates stretch reflexes. The nurse should expect a child who has non-spastic cerebral palsy, rather than spastic cerebral palsy to exhibit uncontrollable movement of the face and extremities. The nurse should expect a child who is spastic cerebral palsy to exhibit contractures due to the tightening of the muscles.

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? a. Urine specific gravity 1.045 b. Sodium 155 mEq/L c. Blood glucose 45 mg/dL d. Urine output 35 mL/hr

b. Sodium 155 mEq/L; A 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.

A nurse is caring for a preschooler who is scheduled for Hydro therapy treatment for wound debridement following a burn injury. Which of the following action should the nurse take prior to the procedure? a. Apply topical anti-microbial ointment to the child's wound b. Place a mesh guys dressing over the child's wound c. Administer an analgesic to the child d. Initiate prophylactic antibiotic therapy for the child

c. Administer an analgesic to the child; Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduce psychological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder

A nurse is teaching the parents of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will use a humidifier in my child's room at night" b. "I will give my child cough suppressant every six hours if he has a cough" c. "I should avoid using a wet mop on my floors when I'm cleaning" d. "I should keep my child indoors when I mow the yard"

d. "I should keep my child indoors when I mow the yard"; The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, trees, and weed pollen, will decrease the frequency of the preschooler's asthma attacks

A nurse is teaching the guardian of a six 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 seatbelt" 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° 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 seatbelt"' Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure the infant's car seat in the vehicle. The system provides anchors between the front cushion and the back rest of the car seat. Therefore, if the system is available, the seatbelt does not have to be used

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

d. "Apply a thin layer of antibiotic ointment on your babies suture line daily for the next three 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 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? a. "I will plan to increase the amount of homework I assign students who have ADHD" b. "I will give students who have ADHD the same amount of time as other students to complete tests" c. "I will allow students who have ADHD one rest break throughout the day" d. "I will teach challenging academic subjects to students who have ADHD in the morning"

d. "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 whose father is going home for a few hours while another relative stays with a 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 explain to them in relation to an event they are familiar with, such as eating

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? a. An 18-month-old toddler who has unintelligible speech b. A 3-month-old infant who has an exaggerated startle response c. A 4-month-old infant who prefers playing with others rather than alone d. An 8-month-old who is not yet making babbling sounds

d. An 8-month-old who is not yet making babbling sounds; The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing.

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

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

d. 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 providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activation 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, and physical development. Therefore, playing dress up as a recommended play activity for this child

A community health nurse is assessing an 18 month old toddler in a community daycare. Which of the following findings should the nurse identify as a potential indication of physical neglect? a. Resist having an axillary temperature taken b. Exhibit with drawl behaviors when their parents leave c. Has multiple bruises on their knees d. Poor personal hygiene

d. 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 in an emergency department is performing a physical assessment on a two week old male newborn. Which of the following findings is the priority for the nurse to report to the provider? a. Excoriated scrotal area b. Multiple capillary hemangiomas c. Depressed posterior fontanel d. Substernal retractions

d. Substernal retractions; When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is the substernal retractions. This finding indicates the newborn is experienced increased respiratory effort, which could quickly progressed to respiratory failure