ped exam 4

A child is receiving chemotherapy for the treatment of osteosarcoma. Which morning laboratory result must a nurse report immediately to the physician? A) Absolute neutrophil count of 1200. B) Platelet count of 150,000. C) Urine dipstick positive for heme. D) WBC count of 4500.

C) Urine dipstick positive for heme. Rationale - A positive urine dipstick for the presence of red blood cells could indicate hemorrhagic cystitis, a com- plication of chemotherapy agents, including cyclophosphamide and ifosfamide. This finding should be communicated immediately to the physician.

At what age should boys be taught how to do a monthly testicular self-examination? 1. 8 years old 2. 12 years old 3. 16 years old 4. When they become sexually active

2. 12 years old Testicular cancer occurs most frequently between the ages of 15 and 34; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures.

A child is admitted with a tentative diagnosis of clinical depression. Which assessment finding is most significant in confirming this diagnosis? 1. Irritability 2. Sadness 3. Weight gain 4. Fatigue

2. Sadness RATIONALE: Clinical depression is diagnosed if the child exhibits a depressed mood (sadness) or loss of interest. Irritability isn't diagnostic for depression. Although a depressed child may gain weight and report fatigue, these findings aren't essential to the diagnosis.

When assessing a child with muscular dystrophy, the nurse expects which finding? 1. Pain 2. Waddling gait 3. Joint swelling 4. Limited range of motion (ROM)

2. Waddling gait A waddling, wide-based gait is a sign of muscular dystrophy. Pain, joint swelling, and limited ROM are rare with this disease.

A child, age 3, with lead poisoning is admitted to the facility for chelation therapy. The nurse must stay alert for which adverse effect? 1. Anaphylaxis 2. Fever and chills 3. Seizures 4. Heart failure

3. Seizures Chelation therapy removes lead by combining it with another substance to form a soluble compound that the kidneys can excrete. As lead is mobilized from bone and other tissues, the serum lead level rises rapidly, increasing the client's risk of seizures. Chelation therapy doesn't cause anaphylaxis, fever, chills, or heart failure.

A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include: 1. a depressed fontanel. 2. slurred speech. 3. tachycardia. 4. an altered level of consciousness.

4. an altered level of consciousness. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge — not depress — if he had increased ICP. Slurred speech isn't a sign of increased ICP in an infant because the child isn't able to speak at this age. However, a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.

To establish a good interview relationship with an adolescent, which strategy is most appropriate? 1. Asking personal questions unrelated to the situation 2. Writing down everything the teen says 3. Asking open-ended questions 4. Discussing the nurse's own thoughts and feelings about the situation

3. Asking open-ended questions RATIONALE: Open-ended questions allow the adolescent to share information and feelings. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though he's being interrogated with unnecessary questions. Writing everything down during the interview can be a distraction and doesn't allow the nurse to observe how the adolescent behaves. Discussing the nurse's thoughts and feelings may bias the assessment and is inappropriate when interviewing any client.

An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurses response should be based on which knowledge? a.Most activities such as Girl Scouts cannot be adapted for children with CP. b.After-school activities usually result in extreme fatigue for children with CP. c.Trying to participate in activities such as Girl Scouts leads to lowered self-esteem in children with CP. d.Recreational activities often provide children with CP with opportunities for socialization and recreation.

ANS: D After-school and recreational activities serve to stimulate childrens interest and curiosity. They help the children adjust to their disability, improve their functional ability, and build self-esteem. Increasing numbers of programs are adapted for children with physical limitations. Almost all activities can be adapted. The child should participate to her level of energy. Self-esteem increases as a result of the positive feedback the child receives from participation.

A 14-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the child's room, the nurse anticipates using which traction system? 1. Bryant's traction 2. Buck's extension traction 3. Overhead suspension traction 4. 90-90 traction

1. Bryant's traction RATIONALE: Anticipating Bryant's traction is correct because this type of traction is used to treat femoral fractures or congenital hip dislocation in children younger than age 2 who weigh less than 30 lb (13.6 kg). Buck's extension traction is skin traction used for short-term immobilization or to correct bone deformities or contractures. Overhead suspension traction is used to treat fractures of the humerus; and 90-90 traction is used to treat femoral fractures in children older than age 2.

A 3-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? 1. Instituting droplet precautions 2. Administering acetaminophen (Tylenol) 3. Obtaining history information from the parents 4. Orienting the parents to the pediatric unit

1. Instituting droplet precautions Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn't take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don't take priority.

When developing a care plan for an adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on: 1. becoming industrious. 2. establishing an identity. 3. achieving intimacy. 4. developing initiative.

2. establishing an identity. RATIONALE: According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers, and strives to attain a personal identity by becoming more independent from his family. Becoming industrious is the developmental task of the school-age child; achieving intimacy is the task of the young adult; and developing initiative is the task of the preschooler.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: 1. reintroduce the tube and attach it to water seal drainage. 2. call a physician and obtain a chest tray. 3. cover the opening with petroleum gauze. 4. clean the wound with povidone-iodine and apply a gauze dressing.

3. cover the opening with petroleum gauze. RATIONALE: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.

A nurse teaches a child with spina bifida how to perform urinary self-catheterization. Which steps should the nurse include in the teaching? Place each correct step in sequential order. A) Wash hands. B) Open latex catheter package. C) Lubricate tip of catheter. D) Wash catheter with soap and water. E) Cleanse perineum with Betadine swabs.

A) Wash hands. C) Lubricate tip of catheter. D) Wash catheter with soap and water. Rationale - The first step because the child should wash hands prior to the procedure to prevent infection. The second step because lubricating jelly should be applied. After insertion and removal of the catheter, the third (and last) step is to cleanse the catheter for storage

7. The parents of a child with spastic cerebral palsy (CP) state that their child seems to have significant pain. In addition to systemic pharmacologic management, the nurse includes which teaching? a.Patterning b.Positions to reduce spasticity c.Stretching exercises after meals d.Topical analgesics for muscle spasms

ANS: B Parents and children are taught positions to assume while sitting and recumbent that reduce spasticity. The American Academy of Pediatrics has stated that patterning should not be used for neurologically disabled children. Patterning attempts to alter abnormal tone and posture and elicit desired movements through positional manipulation or other means of modifying or augmenting sensory output. Stretching should be done after appropriate analgesic medication has been given and is effective. Topical analgesia is not effective for the muscle spasms of spastic CP.

A nurse is caring for a child with meningococcemia who is on a ventilator. This morning, the nurse finds the child's mother sitting at the bedside, crying. The mother tells the nurse, "I thought it was the flu. This is my fault because I should have come to the hospital earlier." What is the best action by the nurse in response to the mother's statements? A) Tell the mother not to worry since many parents and even physicians frequently mistake meningitis symptoms for other infectious conditions. B) Make a referral to social services. C) Call the child's father and explain that the mother needs emotional support from him. D) Remind the mother that she did seek proper treatment as soon as she became concerned, and review the special care the child is receiving now.

D) Remind the mother that she did seek proper treatment as soon as she became concerned, and review the special care the child is receiving now. Rationale - The mother's statement expresses guilt feelings about the child's condition. A nurse needs to validate that the mother did seek treatment appropriately, and assist the mother to focus on what is happening now to help her child recover.

A 14-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the client's room, the nurse anticipates using which traction system? 1. Bryant's traction 2. Buck's extension traction 3. Overhead suspension traction 4. 90-90 traction

1. Bryant's traction Bryant's traction is used to treat femoral fractures or congenital hip dislocation in children younger than age 2 who weigh less than 30 lb (13.6 kg). Buck's extension traction is skin traction used for short-term immobilization or to correct bone deformities or contractures; overhead suspension traction is used to treat fractures of the humerus; and 90-90 traction is used to treat femoral fractures in children older than age 2.

A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? 1. Instituting droplet precautions 2. Administering acetaminophen (Tylenol) 3. Obtaining history information from the parents 4. Orienting the parents to the pediatric unit

1. Instituting droplet precautions RATIONALE: Instituting droplet precautions is the priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be ordered but administering it doesn't take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don't take priority.

When teaching school-age children important injury prevention strategies, the nurse must use creativity to gain cooperation because children tend not to comply with which of the following? 1. Wearing safety apparel (helmets, knee pads, elbow pads) 2. Learning to swim 3. Saying "no" when offered illegal or dangerous drugs 4. Learning "stranger danger"

1. Wearing safety apparel (helmets, knee pads, elbow pads) School-age children are subject to peer pressure, and they would rather not participate in a sport if they must wear safety apparel that provokes taunts from peers. Therefore, the nurse should discuss stylishness, comfort, and social acceptance because these are major determinants of compliance. School-age children like to swim and may work hard to perfect that skill. This age-group will usually listen to reasons for not taking illegal drugs and will adhere to group rules for not tolerating drug use. Regarding stranger danger, this age-group simply needs to be reminded of potential dangers.

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is: 1. skin traction applied to a lower extremity, with the extremity suspended above the bed. 2. skeletal traction applied to a lower extremity. 3. skin traction applied to an extended lower extremity. 4. skin traction applied bilaterally to the lower extremities.

1. skin traction applied to a lower extremity, with the extremity suspended above the bed. Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction.

The mother of a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons and that recently she had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to which of the following? 1. Bananas 2. Latex 3. Kiwifruit 4. Color dyes

2. Latex Children with spina bifida often develop an allergy to latex and shouldn't be exposed to it. If a child is sensitive to bananas, kiwifruit, and chestnuts, she's likely to be allergic to latex. Some children are allergic to dyes in foods and other products, but dyes aren't a factor in a latex allergy.

The parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment? 1. Stuttering 2. Using gestures to express desires 3. Babbling continuously 4. Playing alongside rather than interacting with peers

2. Using gestures to express desires Using gestures instead of verbal communication to express desires — especially in a child older than age 15 months — may indicate a hearing or communication impairment. Stuttering is normal in children ages 2 to 4, especially boys. Continuous babbling is a normal phase of speech development in young children; its absence, not presence, would be cause for concern. Parallel play — playing alongside peers without interacting — is typical of toddlers. However, in an older child, difficulty interacting with peers or avoiding social situations may indicate a hearing deficit.

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which of the following denotes the child's level of consciousness? 1. No motor or verbal response to noxious (painful) stimuli 2. Remains in a deep sleep; responsive only to vigorous and repeated stimulation 3. Can be aroused with stimulation 4. Limited spontaneous movement; sluggish speech

3. Can be aroused with stimulation The child is obtunded if he can be aroused with stimulation. If the child shows no motor or verbal response to noxious stimuli, he's comatose. If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation, he's stuporous. If the child has limited spontaneous movement and sluggish speech, he's lethargic.

A child is suspected of having amblyopia ("lazy eye"). To help diagnose this disorder, the child will undergo which test? 1. Snellen's test 2. Near vision test 3. Cover-uncover test 4. Peripheral vision test

3. Cover-uncover test The cover-uncover test assesses the fusion reflex, which makes binocular vision possible. During this test, the "lazy eye" exhibits wandering. Snellen's test assesses visual acuity, the near vision test evaluates near vision, and the peripheral vision test evaluates peripheral vision.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate? 1. Applying ice to the foot 2. Massaging the toes 3. Elevating the foot of the bed 4. Placing the child on the right side

3. Elevating the foot of the bed To relieve edema of the toes, the nurse should raise the affected extremity above heart level such as by elevating the foot of the bed. The other options wouldn't reduce swelling.

Craniocerebral injury in a child differs substantially from craniocerebral trauma in an adult. Which of the following identifies a negative difference between children and adults that could produce a life-threatening complication for a child? 1. Cerebral tissues in children are softer, thinner, and more flexible. 2. A child's skull can expand more than an adult's can. 3. Greater portions of a child's blood volume flows to the head. 4. Hematomas in children can include subdural, epidural, and intracerebral. .

3. Greater portions of a child's blood volume flows to the head. If hemorrhage is associated with a head injury and it goes undetected, a child may experience hypovolemic shock because a large portion of a child's blood volume goes to the head. In children, cerebral tissues are softer, thinner, and more flexible — conditions that permit diffusion of the impact. Because a child's skull can expand more than an adult's can, a greater amount of posttraumatic edema can occur without evidence of neurologic deficits. Subdural, epidural, and intracerebral hematomas are the different types of head injury that can occur in children and adults

A child, age 4, fell and broke his arm. After assisting the physician in applying a cast, the nurse should include which intervention in the immediate cast care? 1. Rest the cast on the nearest table 2. Dispose of the water containing plaster in the sink 3. Support the cast with the palms of her hands 4. Allow the cast to dry before cleaning surrounding skin

3. Support the cast with the palms of her hands After a cast is applied, the nurse should support it with the palms of her hands. Later, the nurse should dispose of the water in a garbage bag, clean the surrounding skin before the cast dries, and make sure that the cast isn't resting on a hard or sharp surface.

The development of disaster plans should take into consideration that children are more susceptible to the effects of a chemical attack than adults because children: 1. have smaller body surface areas than adults. 2. breathe at a slower rate than adults. 3. have thinner skin than adults. 4. have a low risk of developing rapid dehydration.

3. have thinner skin than adults. Because of anatomical and physiological differences, children are more susceptible to the effects of chemical and biological attacks. Children have thinner skin than adults, increasing their risk of absorbing a chemical. They also have a larger, not smaller, body surface area in relation to their weight than do adults, which increases the chance of chemical absorption. Children breathe at a faster, not slower, rate than adults, allowing them to inhale greater amounts of a toxic agent. Additionally, some chemical agents are heavier than air and accumulate close to the ground, which is closer to a child's breathing zone than an adult's. Because they have less fluid reserve than adults, children are at greater risk of developing rapid dehydration from agents that cause vomiting or diarrhea.

A child with a full-thickness burn is scheduled for debridement using hydrotherapy. Before hydrotherapy begins, the nurse should: 1. administer fluids as prescribed. 2. administer antibiotics as prescribed. 3. implement pain control measures. 4. provide nutritional supplements.

3. implement pain control measures. Because hydrotherapy is painful, the nurse should implement pain control measures before this treatment begins. Fluids and nutritional supplements can be given at any time and aren't required specifically before hydrotherapy. Antibiotics should be administered according to a specified schedule without regard to any treatment.

The nurse is providing care to a 5-year-old child with a fractured femur whose nursing diagnosis is Imbalanced nutrition: Less than body requirements. Which of the following is most likely to occur with this condition? 1. Decreased protein catabolism 2. Increased calorie intake 3. Increased digestive enzymes 4. Increased carbohydrate need

4. Increased carbohydrate need Carbohydrate need increases because healing and repair of tissue requires more carbohydrates. Increased — not decreased — protein catabolism is present. Decreased appetite — not increased — is a problem. Digestive enzymes are decreased — not increased.

A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior most strongly suggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved

4. Not crying when moved Not crying when moved most strongly suggests child abuse. A victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical client response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills.

A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? 1. Reverse isolation 2. Strict hand washing 3. Standard precautions 4. Respiratory isolation

4. Respiratory isolation Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This includes wearing a gown and gloves during direct client care and ensuring that everyone who enters the child's room wears a mask. Reverse isolation is unnecessary; it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.

According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. A nurse can best promote the development of a hospitalized adolescent by: 1. emphasizing the need to follow the facility regimen. 2. allowing parents and siblings to visit frequently. 3. arranging for tutoring in school work. 4. encouraging peer visitation.

4. encouraging peer visitation. RATIONALE: Peer visitation gives the adolescent an opportunity to continue along his path toward independence and identity. Knowledge of the facility regimen prepares the adolescent for upcoming procedures but doesn't affect his development. To achieve a sense of identity, the adolescent must gain independence from his family. Tutoring may help him maintain a positive self-image relative to his schoolwork but doesn't affect his development.

A child hospitalized with hydrocephalus is being treated with an externalized ventricular drain (EVD). A nurse begins the afternoon assessment and discovers that the drain is positioned several inches below the child's ear level. What should be the nurse's priority action? A) Raise the drain to the child's ear level. B) Leave the drain as is and monitor the CSF drainage hourly. C) Quickly elevate the head of the bed. D) Clamp the drain and complete a neurological assessment.

D) Clamp the drain and complete a neurological assessment. Rationale - The external ventricular drain (EVD) should be at the level of the ventricles, or at the child's ear level. When the EVD is too low, CSF can drain quickly and lead to neurologic complications. A nurse should prevent the CSF from draining any further and assess the child.

A chronically ill school-age child is most vulnerable to which stressor? 1. Mutilation anxiety 2. Anticipatory grief 3. Anxiety over school absences 4. Fear of hospital procedures

3. Anxiety over school absences RATIONALE: The school-age child is becoming industrious and attempts to master school-related activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child who's chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children.

A 3-year-old child is hospitalized with multiple fractures as a result of a car accident. What is the best way for a nurse to assess this child's pain level? A) Ask the child to rate pain using a numeric pain rating scale. B) Rely on vital sign measurements as a way to verify pain ratings. C) Employ the FACES pain scale with every nursing assessment. D) Try to have the child describe the pain's intensity and quality.

C) Employ the FACES pain scale with every nursing assessment. Rationale - The FACES pain rating scale can be used with children as young as 3 years of age, and pain should be investigated with every nursing assessment.

Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery? 1. Risk for infection 2. Impaired physical mobility 3. Disturbed body image 4. Constipation

1. Risk for infection RATIONALE: Because infection is a serious risk for a client in the early stages of burn recovery, a diagnosis of Risk for infection takes highest priority. Diagnoses of Impaired physical mobility, Disturbed body image, and Constipation may be relevant but take lower priority at this time.

What is the recommended treatment for scabies in a child who's under age 1? 1. lindane (Kwell) 2. tolnaftate (Tinactin) 3. thiabendazole (Mintezol) 4. permethrin (Elimite)

4. permethrin (Elimite) Permethrin is supplied in a cream. It should be massaged into the skin from the head to the soles. Although permethrin is the treatment of choice for children younger than age 1, its safety hasn't been established for clients younger than 2 months. Lindane, a treatment for scabies, isn't recommended for children younger than age 1, and it shouldn't be used on children older than age 1 if they won't be supervised. The hands and feet of a child should be covered during treatment to prevent the child from sucking the cream or lotion. Young children may be more sensitive to central nervous system toxicity from the drug. Tolnaftate is used to treat ringworm. Thiabendazole is used to treat hookworm, roundworm, threadworm, and whipworm.

Which would be an abnormal finding when doing a well-child checkup on a 1-week-old infant? A) An audible "clunk" during the Ortolani test. B) Symmetrical gluteal folds when the infant is held upright. C) Negative Barlow test. D) Symmetrical knee height when the infant is supine.

A) An audible "clunk" during the Ortolani test. Rationale - An audible, low-pitched, "clunk" during the Ortolani test is caused by the sound of the femur head exiting or entering the acetabulum, indicating hip dislocation.

Which child would be the best roommate for a 9-year- old child with myelodysplasia who is hospitalized for a foot infection? A) A 13-year-old with juvenile idiopathic arthritis. B) A 10-year-old with a fractured femur. C) An 8-year-old status post-appendectomy. D) A 6-year-old with bacterial meningitis.

B) A 10-year-old with a fractured femur. Rationale - This child is close in age and development and is likely to be immobilized in the injured leg due to a cast and/or traction. Since the child with myelodysplasia is likely to have impaired mobility in the infected foot or even complete paralysis of both lower extremities, these children share similar limitations and the nursing staff can encourage them to play video games or participate in suitable activities.

A child with status post-Harrington rod placement for the correction of scoliosis is being cared for on the pediatric unit. The child suddenly experiences facial sweating and complains of a headache. A nurse notes also a slower heart rate on the monitor. What action should the nurse take first? A) Call the surgeon immediately. B) Assess patency of the urinary catheter. C) Administer pain medication as ordered. D) Complete a neurological assessment.

B) Assess patency of the urinary catheter. Rationale - The child is experiencing symptoms of autonomic dysreflexia, an excessive stimulation of the sympathetic nervous system that is a potential complication of spinal cord surgery. Since bladder distention can lead to this problem, the nurse should first assess the urinary catheter for obstruction or malfunction.

A school nurse is preparing to teach a group of teenagers how to prevent meningitis. What aspect of meningitis prevention should the nurse be certain to include in the presentation? A) Getting a meningitis vaccine is the only way to guarantee prevention. B) Refraining from sharing food and drinks is a good way to prevent meningitis infection. C) Avoiding team sports is one way to stop the spread of meningitis infection. D) Meningitis prevention methods should be employed whenever children are in crowds.

B) Refraining from sharing food and drinks is a good way to prevent meningitis infection. Rationale - Meningitis is primarily spread through contact with droplets that arise from the nasopharynx of a person who is infected. Teenagers should be taught to not share food, drinks, or any other item that touches the nose or mouth of another person.

A nurse and nursing student are caring for a child who sustained a head injury as a result of a fall from a play structure. The nurse knows the nursing student is pre- pared to care for the child when the student states: A) "I will be sure to let you know if the child's pupils become fixed and dilated." B) "I will keep the child straight in the supine position." C) "I will look for any changes in the child's respirations, pulse, or blood pressure." D) "I will notify the physician if the child becomes sleepy."

C) "I will look for any changes in the child's respirations, pulse, or blood pressure." Rationale - This statement is evidence that the student understands that alterations in any of these vital signs could be an indication of worsening condition and should be promptly noted.

A newborn arrives in a neonatal intensive care unit with a myelomeningocele. A physician writes orders to keep the infant in the prone position. A nurse should know that the most important rationale behind this order is to: A) Prevent infection. B) Promote circulation in the lower extremities. C) Prevent trauma to the meningeal sac. D) Promote comfort.

C) Prevent trauma to the meningeal sac. Rationale - The most important rationale for the prone position is to prevent damage to the meningeal sac, which could result in damage to the nerves and infection.

A nurse performs a scoliosis screening at a local school. Which assessment finding by the nurse would least likely result in a scoliosis referral? A) Unilateral rib hump noted when the child is bent forward. B) Asymmetrical hip height noted when the child is standing erect. C) Uneven wear noted on the bottom of the child's pant legs. D) Rounded shoulders noted when the child is standing erect.

D) Rounded shoulders noted when the child is standing erect. Rationale - The nurse is least likely to refer a child for scoliosis follow-up based on an assessment finding of rounded shoulders. This finding may simply reflect the child's poor posture or in severe cases may indicate the condition of kyphosis, not scoliosis.

A 13-year-old girl visits the school nurse because she's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the girl may have scoliosis. The nurse should first: 1. send the girl home to recover. 2. inspect the girl for uneven shoulder height or uneven hip height. 3. arrange for the girl to have spinal X-rays as soon as possible. 4. ask the girl's parents to take her to a physician immediately

2. inspect the girl for uneven shoulder height or uneven hip height. RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the girl's parents.

A mother tells the nurse that her preschool-age daughter with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently she had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to: 1. bananas. 2. latex. 3. kiwifruit. 4. color dyes.

2. latex. RATIONALE: If a child is sensitive to bananas, kiwifruit, and chestnuts, she's likely to be allergic to latex. Children with spina bifida commonly develop an allergy to latex and shouldn't be exposed to it. Some children are allergic to dyes in foods and other products, but dyes aren't a factor in a latex allergy.

An 8-month-old infant is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: 1. increased myelination. 2. intracranial hypotension. 3. cerebral hyperemia. 4. a slightly thicker cranium.

3. cerebral hyperemia. RATIONALE: Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension — not hypotension — places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable than an adult's, causing the child to receive a more severe injury.

An 8-month-old is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: 1. increased myelination. 2. intracranial hypotension. 3. cerebral hyperemia. 4. a slightly thicker cranium

3. cerebral hyperemia. Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension — not hypotension — places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable, causing the child to receive a more severe injury.

A child, age 8, is immobilized with a hip spica cast. The nurse enters the room and notices the child is withdrawn and avoiding eye contact. The child's mother states, "He's just bored. He's tired of watching television." The nurse should perform which action? 1. Let the child visit the playroom daily. 2. Sit with the child for an hour in the room. 3. Place a telephone in the child's room. 4. Arrange a visit by a cooperative child from the same unit.

1. Let the child visit the playroom daily. RATIONALE: School-age children need peer interaction and thrive on peer approval and acceptance. Allowing the child to visit the playroom daily provides a nonthreatening atmosphere for peer interaction and helps the child feel less isolated. Sitting with the child for an hour wouldn't foster the necessary peer interaction. Placing a telephone in the child's room would allow the child to communicate with family and friends, but could reinforce feelings of isolation. Having another child visit would be appropriate only if the child is of the same age-group.

A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal? 1. Preventing infection 2. Ensuring adequate hydration 3. Providing adequate nutrition 4. Preventing contracture deformity

1. Preventing infection Preventing infection is the nurse's primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they're secondary to preventing infection.

A nurse is caring for an 18-month-old infant 24 hours after surgery to repair a fractured tibia. Which comfort interventions are appropriate? Select all that apply. 1. Reposition the infant as often as needed. 2. Let the infant play with his favorite toy. 3. Allow the infant's family to participate in his care as much possible. 4. Explain to the infant what she's going to do before she does it. 5. Be sure the infant gets at least 14 hours of sleep each night. 6. Give the infant his favorite foods.

1. Reposition the infant as often as needed. 2. Let the infant play with his favorite toy. 3. Allow the infant's family to participate in his care as much possible. 4. Explain to the infant what she's going to do before she does it. RATIONALE: Frequent repositioning helps decrease discomfort and gives the nurse an opportunity to assess for changes in status. Infants and children derive comfort and security from playing with a favorite toy or animal. Such play should be encouraged as long as it's permitted. Familiarity is a positive force with children, and parents should be encouraged to participate in their child's care. The nurse should explain her actions to the infant. Although the infant may not understand each event, it's better for the nurse to provide an explanation rather than leave the infant fearful of what might happen. It isn't necessary for an infant who has undergone surgery to get at least 14 hours of sleep per night. Pain, comfort level, and general anxiety may prevent him from receiving much sleep in the acute-care setting. Giving the infant favorite foods in the first 24 to 48 postoperative hours may not be an option; physicians order postoperative diet regimens.

A 12-month-old child fell down the stairs. A basilar skull fracture is suspected. The nurse should look for: 1. cerebrospinal fluid otorrhea. 2. deafness. 3. raccoon eyes. 4. Battle sign.

1. cerebrospinal fluid otorrhea. RATIONALE: Basilar skull fracture is a fracture in any bone of the base of the skull — frontal, ethmoid, sphenoid, temporal, or occipital. Therefore, cerebrospinal fluid otorrhea would be observed. Deafness doesn't commonly occur as a result of skull fracture. Battle sign and raccoon eyes occur primarily in orbital, not basilar, fractures.

A 13-year-old with anorexia nervosa is admitted to the facility for I.V. fluid therapy and nutritional management. She says she's worried that the I.V. fluids will make her gain weight. Which nursing diagnosis is most appropriate? 1. Noncompliance (dietary regimen) 2. Disturbed body image 3. Complicated grieving 4. Grieving

2. Disturbed body image RATIONALE: A client with anorexia nervosa has a body image disturbance and views herself as fat despite physical evidence to the contrary. One goal of nursing care is to help her develop realistic perceptions of her body. Although this adolescent has expressed concern about weight gain from I.V. fluids, no information suggests she'll refuse treatment; therefore, a nursing diagnosis of Noncompliance isn't warranted. Likewise, no evidence supports the nursing diagnoses of Complicated grieving and Grieving.

A child, age 4, fell and broke his arm and had a cast applied. Which of these statements by the child indicates an immediate risk for compartment syndrome? 1. "My arm hurts." 2. "I can't wiggle my fingers." 3. "I need to go home." 4. "Don't touch me."

2. "I can't wiggle my fingers." RATIONALE: Signs and symptoms of compartment syndrome, such as motor weakness, reflect a deficit or deterioration of neuromuscular status in the involved area. Inability to wiggle fingers indicates an immediate risk for compartment syndrome because it could suggest neurovascular pressure or damage caused by edema following the injury. The other statements don't indicate risk for compartment syndrome.

The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents? 1. The cast will be removed in 6 weeks. 2. A new cast is needed every 1 to 2 weeks. 3. A short leg cast is applied when the baby is ready to walk. 4. The cast will be removed when the baby begins to crawl.

2. A new cast is needed every 1 to 2 weeks. Because a neonate grows so quickly, the cast may need to be changed as often as every 1 to 2 weeks. A cast for congenital clubfoot isn't left on for 6 weeks because of the rapid rate of the infant's growth. By the time a baby is crawling or ready to walk, the final cast has long since been removed. After the cast is permanently removed, the baby may wear a Denis Browne splint until he's 1 year old.

An infant is having his 2-month checkup at the pediatrician's office. The physician tells the parents that she's assessing for Ortolani's sign. The nurse explains that the presence of Ortolani's sign indicates dislocation of what joint? 1. Shoulder 2. Elbow 3. Knee 4. Hip

4. Hip To assess for Ortolani's sign, the nurse abducts the infant's hips while flexing the legs at the knees. This is performed on all infants to assess for congenital hip dislocation. The examiner listens and feels for a "click" as the femoral head enters the acetabulum during the examination. This finding indicates a congenitally dislocated hip.

The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the appropriate nursing response is which of the following? 1. "You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "At this age, the child is developing his own personality." 4. "You need to provide more praise to the child to stop this behavior."

3. "At this age, the child is developing his own personality." According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents. Therefore options 1, 2, and 4 are incorrect responses.

Which item in the care plan for a toddler with a seizure disorder should a nurse revise? 1. Padded side rails 2. Oxygen mask and bag system at bedside 3. Arm restraints while asleep 4. Cardiorespiratory monitoring

3. Arm restraints while asleep RATIONALE: The nurse should revise a care plan that includes restraints. Restraints should never be used on a child with a seizure disorder because they could harm him if a seizure occurs. Padded side rails will prevent the child from injuring himself during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure.

A child, age 14, is diagnosed with scoliosis and scheduled for brace application. The mother asks the nurse how long her child will have to wear the brace. What is the nurse's best response? 1. "About 6 to 8 weeks." 2. "About 6 months." 3. "About 2 to 4 years." 4. "About 4 to 7 years."

4. "About 4 to 7 years." Most children with scoliosis must wear a brace until the spine matures — typically between ages 18 and 21. Therefore, this 14-year-old child will need to wear the brace for 4 to 7 years.

A nurse is assessing a severely depressed adolescent. Which finding indicates a risk of suicide? 1. Excessive talking 2. Excessive sleepiness 3. A history of cocaine use 4. A preoccupation with death

4. A preoccupation with death RATIONALE: An adolescent who demonstrates a preoccupation with death (such as by talking frequently about death) should be considered at high risk for suicide. Although depression, excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents, they also occur in adolescents who aren't suicidal. Verbal and emotional withdrawal, not excessive talking, are signs of possible depression and suicide risk in an adolescent.

A nurse is planning to teach a group of 10-year-old children about drug and alcohol prevention. Which characteristics of this age group are important for the nurse to consider when developing the teaching plan? Select all that apply. A) These children are achievement-oriented. B) They expect good behavior to be rewarded. C) Their problem-solving approach tends to be concrete and systematic. D) The central persons in their lives tend to be friends. E) These children are nearing puberty.

A) These children are achievement-oriented. B) They expect good behavior to be rewarded. C) Their problem-solving approach tends to be concrete and systematic. D) The central persons in their lives tend to be friends. E) These children are nearing puberty. Rationale - This is a developmental characteristic of the school-age child. The teaching plan should include activities that allow the children to succeed, such as games with a drug-free focus. This is a developmental characteristic of the school-age child. The teaching plan should provide for rewards (e.g., giving children pencils with fun slogans in exchange for signing a no-drug pledge form). This is a developmental characteristic of the school-age child. The teaching plan should include basic steps for avoiding substance abuse, such as ways to refuse substances when offered by peers. This is a developmental characteristic of the school-age child. The teaching plan should remind children that the majority of their peers do not abuse illicit substances. This is a developmental characteristic of the school-age child. The teaching plan should include discussions regarding physical and emotional consequences of substance abuse in boys and girls.

1. What is the most common cause of cerebral palsy (CP)? a.Central nervous system (CNS) diseases b.Birth asphyxia c.Cerebral trauma d.Neonatal encephalopath

ANS: D Approximately 80% of CP is caused by unknown prenatal causes. Neonatal encephalopathy in term and preterm infants is believed to play a significant role in the development of CP. CNS diseases such as meningitis or encephalitis can result in CP. Birth asphyxia does contribute to some cases of CP. Cerebral trauma, including shaken baby syndrome, can result in CP.

6. What is a major goal of therapy for children with cerebral palsy (CP)? a.Cure the underlying defect causing the disorder. b.Reverse the degenerative processes that have occurred. c.Prevent the spread to individuals in close contact with the child. d.Recognize the disorder early and promote optimum development.

ANS: D The goals of therapy include early recognition and promotion of an optimum developmental course to enable affected children to attain their potential within the limits of their dysfunction. The disorder is permanent, and therapy is chiefly symptomatic and preventive. It is not possible at this time to reverse the degenerative processes. CP is not contagious.

An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note: 1. symmetrical thigh and gluteal folds. 2. Ortolani's sign. 3. increased hip abduction. 4. femoral lengthening.

2. Ortolani's sign. RATIONALE: In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

When teaching a parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which description should the nurse include? 1. Burning or pain with urination 2. Complaints of a stiff neck 3. Fever disappearing for longer than 24 hours, then returning 4. History of febrile seizures

2. Complaints of a stiff neck RATIONALE: The nurse should discuss complaints of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, fever that disappears for 24 hours then returns, and a history of febrile seizures should be addressed by the physician but can wait until office hours.

When caring for a child, age 12, who's diagnosed with osteomyelitis of the left femur, the nurse should take which action first? 1. Administer I.V. antibiotics as ordered. 2. Draw blood for cultures as ordered. 3. Monitor hepatic and renal studies. 4. Prepare the child for immediate surgery.

2. Draw blood for cultures as ordered. RATIONALE: Osteomyelitis, an infectious bone disease, typically results from Staphylococcus aureus or Haemophilus influenzae. Blood cultures must be obtained to identify the causative organism and determine its sensitivity to antimicrobial agents. Although treatment may include high doses of antibiotics, blood cultures must be obtained before antibiotic therapy begins. Hepatic and renal studies are obtained during the course of antibiotic therapy to monitor the child for adverse effects. Later, surgery may be necessary to drain abscesses.

An infant undergoes surgery to remove a myelomeningocele. To detect increased intracranial pressure (ICP) as early as possible, the nurse should stay alert for which postoperative finding? 1. Decreased urine output 2. Increased heart rate 3. Bulging fontanels 4. Sunken eyeballs

3. Bulging fontanels Because an infant's fontanels remain open, the skull may expand in response to increased ICP. Therefore, bulging fontanels are a cardinal sign of increased ICP in an infant. Decreased urine output and sunken eyeballs indicate dehydration, not increased ICP. With increased ICP, the heart rate decreases.

A 15-year-old client confides in the nurse that he has been contemplating suicide. He says he has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response? 1. "We can keep this between you and me, but promise me you won't try anything." 2. "I need to protect you. I will tell your physician, but we don't need to involve your parents. We want you to be safe." 3. "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." 4. "I will need to notify the local authorities of your intentions."

3. "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." In situations in which the client is a threat to himself, the nurse can't honor confidentiality. Because this client has expressed a specific plan to commit suicide, the nurse must take immediate action to ensure his safety. The physician and mental health professionals should be notified as well as the client's family. The nurse should inform the client that she must do this, while at the same time convey a sense of caring and understanding. The local authorities don't need to be notified in this situation.

When developing a care plan for a toddler with a seizure disorder, which of the following would be inappropriate? 1. Padded side rails 2. Oxygen mask and bag system at bedside 3. Arm restraints while asleep 4. Cardiorespiratory monitoring

3. Arm restraints while asleep Restraints should never be used on a child with a seizure disorder because they could harm him if a seizure occurs. Padded side rails will prevent the child from injuring himself during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure.

A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms would the nurse expect to find during the initial assessment? 1. Bulging anterior fontanel 2. Fever 3. Nuchal rigidity 4. Petechiae 5. Irritability 6. Photophobia 7. Hypothermia

2. Fever 3. Nuchal rigidity 5. Irritability 6. Photophobia Common signs and symptoms of viral meningitis include fever, nuchal rigidity, irritability, and photophobia. A bulging anterior fontanel is a sign of hydrocephalus, which isn't likely to occur in a toddler because the anterior fontanel typically closes by age 24 months. A petechial, purpuric rash may be seen with bacterial meningitis. Hypothermia is a common sign of bacterial meningitis in an infant younger than age 3 months.

A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms does the nurse expect to find during the initial assessment? Select all that apply. 1. Bulging anterior fontanel 2. Fever 3. Nuchal rigidity 4. Petechiae 5. Irritability 6. Photophobia

2. Fever 3. Nuchal rigidity 5. Irritability 6. Photophobia RATIONALE: Common signs and symptoms of viral meningitis include fever, nuchal rigidity, irritability, and photophobia. A bulging anterior fontanel is a sign of hydrocephalus, which isn't likely to occur in a toddler because the anterior fontanel typically closes by age 24 months. A petechial, purpuric rash may be seen with bacterial meningitis.

When assessing a family suspected of abusing its 4-year-old child, which behavior is the most important criterion that would suggest abuse? 1. Attempts by the child to defend or verify what the parent states 2. Incompatibility between the history (mechanism) and the injury 3. Responsibility taken by the child for the act 4. A complaint other than the one associated with the signs of abuse

2. Incompatibility between the history (mechanism) and the injury RATIONALE: The most important criterion on which to base a decision for reporting suspected abuse is an incompatibility between the history and the injury. A maltreated child will rarely betray his parents by saying he has been abused and will, instead, attempt to defend the parent's action and verify the story. The child may even take responsibility for the act in attempt to vindicate them. However, these factors aren't as important as an incompatibility between the history and the injury. A complaint other than the one associated with the signs of abuse (for example, a complaint of being cold when second-degree burns are visible) is a warning sign of abuse but isn't the most important criterion.

An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? 1. Hypoglycemia 2. Metabolic alkalosis 3. Metabolic acidosis 4. Hyperkalemia

2. Metabolic alkalosis RATIONALE: In a client with bulimia nervosa, metabolic alkalosis may occur secondary to hydrogen loss caused by frequent, self-induced vomiting. Typically, the blood glucose level is within normal limits, making hypoglycemia unlikely. In bulimia nervosa, hypokalemia is more common than hyperkalemia and typically results from potassium loss related to frequent vomiting.

When attempting to reduce the risk for impaired skin integrity related to immobility in a toddler, which action should be avoided? 1. Gently massaging the skin with a lubricating substance 2. Spreading a thin layer of lotion over pressure points 3. Changing the toddler's position frequently 4. Cleaning the skin as often as necessary

2. Spreading a thin layer of lotion over pressure points Using a lotion on the pressure points will soften the skin and promote its breakdown. Gently massaging the skin with a lubricating substance will stimulate circulation and help prevent breakdown. Changing the toddler's position frequently will help minimize pressure, prevent edema, and stimulate circulation. Keeping the skin clean will lessen the chances of irritation and breakdown.

An adolescent, age 16, is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on the child's nutritional intake, the nurse should ask: 1. "What activities do you engage in during the day?" 2. "Do you have any allergies to foods?" 3. "Do you like yourself physically?" 4. "What kinds of foods do you like to eat?"

3. "Do you like yourself physically?" Role and relationship patterns focus on body image and the client's relationship with others, which commonly interrelate with food intake. Questions about activities and food preferences elicit information about health promotion and health protection behaviors. Questions about food allergies elicit information about health and illness patterns.

After a head injury, a child experiences enuresis, polydipsia, and weight loss. Based on these findings, the nurse should monitor closely for signs and symptoms of: 1. hypercalcemia. 2. hyperglycemia. 3. hyponatremia. 4. hypokalemia.

4. hypokalemia. RATIONALE: Enuresis, polydipsia, and weight loss suggest diabetes insipidus, a disorder that may result from a head injury that damages the neurohypophyseal structures. Diabetes insipidus places the child at risk for fluid volume depletion and hypokalemia. Diabetes insipidus doesn't cause hypercalcemia, hyperglycemia, or hyponatremia.

The nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent? 1. Anxiety related to separation from parents 2. Fear related to the unknown 3. Fear related to altered body image 4. Ineffective coping related to activity restrictions

3. Fear related to altered body image Fear related to altered body image is the most appropriate nursing diagnosis for a hospitalized adolescent because of the adolescent's developmental level and concern for physical appearance. An adolescent may fear disfigurement resulting from procedures and treatments. Separation is rarely a major stressor for the adolescent, eliminating a diagnosis of Anxiety related to separation from parents. Adolescents may have Fear related to the unknown but typically ask questions if they want information. A diagnosis of Ineffective coping related to activity restrictions may be appropriate for a toddler who has difficulty tolerating activity restrictions but is an unlikely nursing diagnosis for an adolescent.

For a child with a circumferential chest burn, what is the most important factor for the nurse to assess? 1. Wound characteristics 2. Body temperature 3. Breathing pattern 4. Heart rate

3. Breathing pattern All of the options are important. However, breathing pattern is the most important factor to assess because eschar impedes chest expansion in a child with a circumferential chest burn, causing breathing difficult

An infant undergoes surgery to remove a myelomeningocele. To detect complications as early as possible, the nurse should stay alert for which postoperative finding? 1. Decreased urine output 2. Increased heart rate 3. Bulging fontanels 4. Sunken eyeballs

3. Bulging fontanels RATIONALE: Because an infant's fontanels remain open, the skull may expand in response to increased intracranial pressure, a possible postoperative complication. Decreased urine output and sunken eyeballs (signs of dehydration) and a decrease in heart rate are rarely seen as postoperative complications of myelomenigocele removal.

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness? 1. No motor or verbal response to noxious (painful) stimuli 2. Remains in a deep sleep; responsive only to vigorous and repeated stimulation 3. Can be roused with stimulation 4. Limited spontaneous movement; sluggish speech

3. Can be roused with stimulation RATIONALE: The child is obtunded if he can be aroused with stimulation. If the child shows no motor or verbal response to noxious stimuli, he's comatose. If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation, he's stuporous. If the child has limited spontaneous movement and sluggish speech, he's lethargic.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate? 1. Applying ice to the foot 2. Massaging the toes 3. Elevating the foot of the bed 4. Placing the child on his right side

3. Elevating the foot of the bed RATIONALE: To relieve edema of the toes, the most appropriate reaction is to raise the affected extremity above heart level such as by elevating the foot of the bed. Applying ice, massaging the toes, and placing the child on his right side wouldn't reduce swelling.

When assessing a toddler, age 18 months, the nurse should interpret which reflex as a sign of a neurologic dysfunction? 1. Positive gag reflex 2. Positive tonic neck reflex 3. Positive Babinski's reflex 4. Positive corneal reflex

3. Positive Babinski's reflex Babinski's reflex should disappear by age 12 months; its presence after this age indicates neurologic dysfunction. The gag reflex, tonic neck reflex, and corneal reflex are normal findings for a toddler.

A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the child, what is the nurse's highest priority? 1. Administering platelets as ordered 2. Taking measures to prevent infection 3. Frequently assessing the child's level of consciousness (LOC) 4. Discussing a safe play environment with the parents

3. Frequently assessing the child's level of consciousness (LOC) RATIONALE: In hemophilia, one of the factors required for blood clotting is absent, significantly increasing the risk of hemorrhage after injury. Therefore, the nurse must assess the child frequently for signs and symptoms of intracranial bleeding, such as an altered LOC, slurred speech, vomiting, and headache. To manage hemophilia, the absent blood clotting factor is replaced via I.V. infusion of factor, cryoprecipitate, or fresh frozen plasma; this may be done prophylactically or after a traumatic injury. Platelet transfusions aren't necessary. Clients with hemophilia aren't at increased risk for infection. Discussing a safe play environment with the parents is important but isn't the highest priority.

An 8-year-old child is suspected of having meningitis. Signs of meningitis include: 1. Cullen's sign. 2. Koplik's spots. 3. Kernig's sign. 4. Chvostek's sign.

3. Kernig's sign. RATIONALE: Signs and symptoms of meningitis include Kernig's sign, stiff neck, headache, and fever. To test for Kernig's sign, the client is in the supine position with knees flexed; a leg is then flexed at the hip so that the thigh is brought to a position perpendicular to the trunk. An attempt is then made to extend the knee. If meningeal irritation is present, the knee can't be extended and attempts to extend the knee result in pain. Cullen's sign is the bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. Koplik's spots are reddened areas with grayish blue centers that are found on the buccal mucosa of a client with measles. Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. A calcium deficit is suggested if the facial muscles twitch.

A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which emotional response is typical during early adolescence? 1. Frequent anger 2. Cooperativeness 3. Moodiness 4. Combativeness

3. Moodiness RATIONALE: Moodiness may occur often during early adolescence. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.

A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? 1. Registered dietitian 2. Physical therapist 3. Occupational therapist 4. Nursing assistant

3. Occupational therapist RATIONALE: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy but isn't trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nursing assistant can help a child eat; however, the nursing assistant isn't trained in modifying utensils.

A toddler is having a tonic-clonic seizure. What should the nurse do first? 1. Restrain the child. 2. Place a tongue blade in the child's mouth. 3. Remove objects from the child's surroundings. 4. Check the child's breathing.

3. Remove objects from the child's surroundings. RATIONALE: During a seizure, the nurse's first priority is to protect the child from injury caused by uncontrolled movements. Therefore, the nurse must first remove objects from the child's surroundings and pad objects that can't be removed. Restraining the child or placing an object in the child's mouth during a seizure isn't appropriate because it may cause injury. When the seizure stops, the nurse should then check for breathing and, if indicated, initiate rescue breathing.

A 2-year-old child is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: 1. question the mother about the child's allergies. 2. initiate standard precautions. 3. evaluate the child's neurologic status. 4. examine the child's throat and ears.

3. evaluate the child's neurologic status. RATIONALE: Petechiae across the child's chest, abdomen, and back are signs of meningitis. The priority is to evaluate neurologic status. Petechiae aren't allergic reactions, so the nurse shouldn't ask about allergies. Standard precautions should be used when there is risk of contacting body fluids. Contact precautions should be instituted for the client diagnosed with meningitis. Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis.

A child with a full-thickness burn is scheduled for debridement using hydrotherapy. Before hydrotherapy begins, the nurse should: 1. administer fluids as ordered. 2. administer antibiotics as ordered. 3. implement pain control measures. 4. provide nutritional supplements.

3. implement pain control measures. RATIONALE: Because hydrotherapy is painful, the nurse should implement pain control measures before this treatment begins. Fluids and nutritional supplements can be given at any time and aren't required specifically before hydrotherapy. Antibiotics should be administered according to a specified schedule without regard to any treatment.

A nurse is providing care to a 5-year-old child with a fractured femur whose nursing diagnosis is Imbalanced nutrition: Less than body requirements. Which change is most likely to occur with this condition? 1. Decreased protein catabolism 2. Increased calorie intake 3. Increased digestive enzymes 4. Increased carbohydrate need

4. Increased carbohydrate need RATIONALE: Increased carbohydrate need is most likely because healing and repair of tissue requires more carbohydrates. Increased — not decreased — protein catabolism is present and decreased appetite — not increased — is a problem. Digestive enzymes are decreased — not increased.

A nurse suspects that a toddler, who is admitted to the pediatric unit, has been physically abused by his mother. What is the nurse required to do? 1. Talk with the child about she suspects. 2. Confront the mother with her suspicions. 3. Discuss the case with another nurse during lunch break. 4. Report the case to local authorities.

4. Report the case to local authorities. RATIONALE: The nurse is required to report the case to local authorities because every state in the United States has laws for mandatory reporting of suspected child abuse and neglect. These cases are then referred to local agencies, such as Child Protective Services, for investigation. Social workers should be consulted before approaching a child and discussing child abuse. Confronting the mother could increase the risk of harm to the child and to the nurse. Discussing the case with another nurse breaches the client's confidentiality.

A female adolescent client refuses to allow male nurses to care for her while she's hospitalized. Which of these health care rights is this adolescent exerting? 1. Right to competent care 2. Right to have an advance directive on file 3. Right to confidentiality of her medical record 4. Right to privacy

4. Right to privacy RATIONALE: This adolescent is exhibiting her right to privacy when she requests that she doesn't want a male nurse to care for her. She also has a right to competent care, the right to have an advance directive on file, and a right to confidentiality. However, she isn't exercising these rights in this scenario.

The nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs would include: 1. a depressed fontanel. 2. slurred speech. 3. tachycardia. 4. an altered level of consciousness.

4. an altered level of consciousness. One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge if he had increased ICP. The child isn't able to speak at this age, but a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.

A nurse enters the room of a child following the placement of a ventriculoperitoneal shunt. The child is sitting up in bed, crying, and has vomited a small amount on the bed linens. What are the priority nursing actions? Select all that apply. A) Complete a neurological assessment. B) Place the child in the supine position. C) Administer the antiemetic as ordered. D) Complete a pain assessment. E) Increase the child's IV rate.

A) Complete a neurological assessment. C) Administer the antiemetic as ordered. D) Complete a pain assessment. Rationale - The nurse should assess the child thoroughly to determine whether the child's neurological status has changed since the last assessment. Nausea and vomiting are common following neurosurgery. The antiemetic should be administered because vomiting needs to be prevented since it increases intracranial pressure (ICP). Determining the child's pain level should be part of the physical assessment. It is expected that the child may have pain from this surgery.

When assessing a child for impetigo, the nurse expects which assessment findings? 1. Small, brown, benign lesions 2. Honey-colored, crusted lesions 3. Linear, threadlike burrows 4. Circular lesions that clear centrally

2. Honey-colored, crusted lesions RATIONALE: In impetigo, honey-colored, crusted lesions develop once the pustules rupture. Small, brown, benign lesions are common in children with warts. Linear, threadlike burrows are typical in a child with scabies. Circular lesions that clear centrally characterize tinea corporis.

When caring for an adolescent who's at risk for injury related to intracranial pathology, which action would maintain stable intracranial pressure (ICP)? 1. Turning the adolescent's head from side to side frequently 2. Keeping the adolescent's head in midline position while raising the head of the bed 15 to 30 degrees 3. Hyperextending the adolescent's head with a blanket roll 4. Suctioning frequently to maintain a clear airway

2. Keeping the adolescent's head in midline position while raising the head of the bed 15 to 30 degrees RATIONALE: Elevating the head of the bed while keeping the adolescent's head in midline position will facilitate venous drainage and avoid jugular compression. Turning the head, hyperextending the neck, and suctioning will increase ICP.

A neonate was admitted to the pediatric unit with an unexpected congenital defect. What is the best way to involve the parents in the neonate's care? 1. Assume the parents have already been told how to care for their neonate. 2. Offer the parents opportunities to be involved with the neonate's care while they adjust to his unexpected condition. 3. Tell the parents that they'll be shown how to do everything for the neonate once before they take him home. 4. Don't show the parents how to care for the neonate at this time.

2. Offer the parents opportunities to be involved with the neonate's care while they adjust to his unexpected condition. Many new parents need to grieve over the loss of a "normal" child. Adequate time and support should be given for the parents to adjust to the unexpected condition of their child. Never assume that the parents have already been educated about the neonate's care, or that they'll be able to learn everything they need to know after receiving instructions only once. The parents should be involved in the neonate's care during hospitalization; this will help them learn and will instill confidence.

The nurse is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen? 1. Occupational therapist 2. Physical therapist 3. Recreational therapist 4. Nurse

2. Physical therapist After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability. An occupational therapist, who helps the chronically ill or disabled to perform activities of daily living and adapt to limitations, isn't necessary at this time. A recreational therapist, who uses games and group activities to redirect maladaptive energy into appropriate behavior, also isn't required. The nurse hasn't been trained to design an exercise regimen for a child with congenital clubfoot.

When performing a physical examination on an infant, the nurse notes abnormally low-set ears. This finding is associated with: 1. otogenous tetanus. 2. tracheoesophageal fistula. 3. congenital heart defects. 4. renal anomalies.

4. renal anomalies. Normally, the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation. Low-set ears don't accompany otogenous tetanus, tracheoesophageal fistula, or congenital heart defects.

An 18-month-old child immobilized with traction to the legs has a nursing diagnosis of Deficient diversional activity related to immobility. Which diversional activity is most appropriate for the nurse to include in the care plan? 1. Playing with Tinker toys 2. Playing with a pounding board 3. Playing with a pull toy 4. Playing board games

2. Playing with a pounding board RATIONALE: Playing with a pounding board is a developmentally appropriate diversional activity for a toddler because it not only promotes physical development but also provides an acceptable energy outlet during immobilization. A child younger than age 3 accidentally may swallow Tinker toys and other toys with small parts. Whereas a pull toy is appropriate for a toddler, it isn't appropriate for one who's immobilized. Playing board games is too advanced for a toddler's developmental stage.

A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior suggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved

4. Not crying when moved RATIONALE: Not crying when moved most strongly suggests child abuse because a victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills.

For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in: 1. an arched, side-lying position, with the neck flexed onto the chest. 2. an arched, side-lying position, avoiding flexion of the neck onto the chest. 3. a mummy restraint. 4. a prone position, with the head over the edge of the bed.

2. an arched, side-lying position, avoiding flexion of the neck onto the chest. RATIONALE: For a lumbar puncture, the nurse should place the infant in an arched, side-lying position to maximize the space between the third and fifth lumbar vertebrae. The nurse's hands should rest on the back of the infant's shoulders to prevent neck flexion, which could block the airway and cause respiratory arrest. The infant should be placed at the edge of the bed or table during the procedure, and the nurse should speak quietly to calm the infant. A mummy restraint would limit access to the lumbar area because it involves wrapping the child's trunk and extremities snugly in a blanket or towel. A prone position isn't appropriate because it wouldn't cause separation of the vertebral spaces.

A nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent? 1. Anxiety related to separation from parents 2. Fear related to the unknown 3. Fear related to altered body image 4. Ineffective coping related to activity restrictions

3. Fear related to altered body image RATIONALE: Fear related to altered body image is the most appropriate nursing diagnosis for a hospitalized adolescent because of the adolescent's developmental level and concern for physical appearance. An adolescent may fear disfigurement resulting from procedures and treatments. Separation is rarely a major stressor for the adolescent, eliminating a diagnosis of Anxiety related to separation from parents. Adolescents may have Fear related to the unknown, but they typically ask questions if they want information. A diagnosis of Ineffective coping related to activity restrictions may be appropriate for a toddler who has difficulty tolerating activity restrictions but is an unlikely nursing diagnosis for an adolescent.

According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Identity versus role confusion

3. Industry versus inferiority RATIONALE: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence.

Which of the following is the least effective strategy for interviewing an adolescent? 1. Maintaining objectivity by avoiding assumptions, judgments, and lectures 2. Beginning with less sensitive issues and proceed to more sensitive ones 3. Interviewing adolescents with the parents present 4. Asking open-ended questions and moving to more directive questions when possible

3. Interviewing adolescents with the parents present When possible, adolescents should be interviewed without their parents present to ensure confidentiality and privacy. Avoid assumptions, judgments, and lectures to increase the adolescent's comfort in disclosing sensitive information. Begin with less sensitive questions so the adolescent won't feel threatened and uncomfortable and become uncooperative during the interview. Ask open-ended questions to give adolescents opportunities to share their psychosocial context.

A 10-year-old boy falls, injures his left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first? 1. Apply a warm compress to the injured shoulder. 2. Ask him to demonstrate full range of motion of his left arm. 3. Keep him in a comfortable position and apply ice to the injured shoulder. 4. Give him a nonopioid analgesic for pain.

3. Keep him in a comfortable position and apply ice to the injured shoulder. RATIONALE: Ice should be applied first to reduce swelling and pain. The client should also be helped into a comfortable position. The nurse shouldn't apply warm compresses because it may increase swelling and cause bleeding into the injured tissue. Demonstrating full range of motion of the left arm may cause further damage to the injured area. In the emergency department, the nurse must have a physician's order to administer an analgesic.

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching? 1. "I hope this cast will cure his feet in the next several weeks." 2. "I know I will have to be careful when changing his diapers." 3. "We will have to be careful how we hold our baby." 4. "Immunizations will have to be delayed until the casts come off."

4. "Immunizations will have to be delayed until the casts come off." The father's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements.

A 14-year-old girl in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the girl's need to achieve what developmental milestone? 1. Autonomy 2. Initiative 3. Industry 4. Identity

4. Identity RATIONALE: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. When an adolescent is hospitalized, she is separated from her peer group and her body image may be altered. This alteration in body image may interfere with the ongoing development of her identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

The nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant? 1. Vomiting 2. Papilledema 3. Headache 4. Increased head circumference

4. Increased head circumference Increased head circumference is the first sign of increased ICP in an infant. Vomiting occurs later. Papilledema is a late sign of increased ICP and may not be evident. Because the infant can't speak, the nurse would have trouble determining whether the infant has a headache.

An 18-month-old child immobilized with traction to the legs has a nursing diagnosis of Deficient diversional activity related to immobility. The nurse should include which diversional activity in the care plan? 1. Playing with tinker toys 2. Playing with a pounding board 3. Playing with a pull toy 4. Playing games

2. Playing with a pounding board Playing with a pounding board is a developmentally appropriate diversional activity for a toddler. Besides promoting physical development, it provides an acceptable energy outlet during immobilization. A child younger than age 3 accidentally may swallow tinker toys and other toys with small parts. A pull toy is appropriate for a toddler but not for one who's immobilized. Playing games is too advanced for a toddler's developmental stage.

A 13-year-old boy visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first: 1. send the child home to recover. 2. inspect the child for uneven shoulder height or uneven hip height. 3. arrange for the child to have spinal X-rays as soon as possible. 4. ask the child's mother to take him to a physician immediately.

2. inspect the child for uneven shoulder height or uneven hip height. Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the parent.

Which relaxation strategy would be effective for a school-age child to use during a painful procedure? 1. Having the child keep his eyes shut at all times 2. Having the child hold his breath and not yell 3. Having the child take a deep breath and blow it out until told to stop 4. Being honest with the child and telling him the procedure will hurt a lot

3. Having the child take a deep breath and blow it out until told to stop RATIONALE: Having the child take a deep breath and blow it out is a form of distraction and will help the child cope better with the procedure. A child may prefer to keep his eyes open, not shut, during a procedure so he can see what is going on and can anticipate what is going to happen. Letting a child yell during a procedure is a form of helpful distraction. In addition, holding the breath isn't beneficial and could have adverse effects (such as feeling dizzy or faint). The nurse should prepare a child for a procedure by using nonpain descriptors and not suggesting pain. For example, the nurse might say, "Sometimes this feels like pushing or sticking, and sometimes it doesn't bother children at all."

A 4-year-old child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect: 1. subdural hematoma. 2. epidural hematoma. 3. subarachnoid hemorrhage. 4. concussion.

2. epidural hematoma. RATIONALE: An epidural hematoma is characterized by an initial loss of consciousness followed by transient consciousness leading to unconsciousness. Subdural hematoma results in rapid deterioration in level of consciousness. Subarachnoid hemorrhage causes irritability rather than loss of consciousness. As for a concussion, it may result in a brief loss of consciousness.

A 17-year-old adolescent with a history of muscular dystrophy is admitted with aspiration pneumonia. The nurse asks the parents if the client has an advance directive. Which response by the parents leads the nurse to believe that the parents don't understand the severity of the client's medical condition? 1. "He has pneumonia; I shouldn't have let him go to that party last week." 2. "This is the third time he's had pneumonia in the past 6 months. I'm afraid he needs a feeding tube." 3. "Yes, he has an advance directive." 4. "He is only 17. He doesn't need an advance directive."

4. "He is only 17. He doesn't need an advance directive." RATIONALE: The parents stating that their son is too young for an advanced directive suggests that the parents don't fully understand the seriousness of their son's medical condition. Advance directives can be used for any client who has an irreversible condition. Stating that they shouldn't have allowed their son to go to a party shows a lack of knowledge about acquiring aspiration pneumonia. Being concerned about the need for a feeding tube and having an advance directive show an understanding of their son's condition.