Pediatric HESI Questions (3)
The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child?
"My husband and our daughter are both lactose-intolerant." Rationale: Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis because milk allergies can contribute to the child's outbreaks.
A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse?
"My son often chokes while I am feeding him." Rationale: Airway obstruction is always a priority when caring for any client
The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse?
"Tell me what you know about birth control." Rationale: Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception
Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains 250 mg/5 mL. How many milliliters should the nurse administer in one dose?
15 Rationale: Take 22lbs / 2.2 = 10kg 10kg X 75mg/kg = 750mg 750/250 mg = 3mg X 5mL = 15
Which intervention(s) should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.)
Administer mineral oil daily. Eliminate dairy products. Initiate consistent toileting routine. Rationale: Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet and increased daily fluids are components of care for a child with encopresis.
The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs?
Allow the child to assume a knee-chest position, with the head and chest slightly elevated. Rationale: Assuming a knee-chest position with the head and chest slightly elevated will help restore hemodynamic equilibrium.
Which nursing intervention(s) is (are) therapeutic when caring for a hospitalized toddler? (Select all that apply.)
Allow the toddler to choose a colored Band-Aid after an injection & Give brief but simple explanations to the child before procedures. Rationale: Giving the toddler a choice may increase autonomy in the hospitalized setting. Brief but simple explanations are beneficial with the toddler. Separation from the parent can cause emotional distress. Regression is expected, and bedwetting is not an indication for a urinary catheter. The nurse should encourage age-appropriate toys to be brought in from home.
Which nursing diagnosis has the highest priority when planning care for an infant with eczema?
Altered comfort (pruritus) related to vesicular skin eruptions Rationale: Altered comfort (pruritus) has the highest priority because itching will cause the infant to scratch, creating complications such as scarring or infection.
The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease?
Baked chicken, coleslaw, soda, and frozen fruit dessert Rationale: A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats, wheat, rye, or barley
The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this child to exhibit?
Boasts aggressively when telling a story Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales
A nurse is preparing to end the shift and receives a lab report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take?
Communicate the result to the oncoming nurse and document. Rationale: The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report.
The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child's crying during the recovery period?
Crying stresses the suture line. Rationale: Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair.
In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect?
Diminished femoral pulses Rationale: Diminished femoral pulses (D) could indicate coarctation of the aorta.
The nurse expects a 2-year-old child to exhibit which behavior?
Display possessiveness with toys. Rationale: Two-year-old children are egocentric and unable to share with other children.
A burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. When calculating the percentage of burn, which parts of the child's body is proportionally larger than an adult's?
Head and neck Rationale: The standard rule of nines is inaccurate for determining burned body surface areas with children because a child's head and neck are proportionately larger than an adult's. Specially designed charts are commonly used to measure the percentage of burn in children.
A 4-year-old child has cystic fibrosis. Which stage of Erikson's theory of psychosocial development is the nurse addressing when teaching inhalation therapy?
Initiative Rationale: Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson's theory of psychosocial development
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first?
Insert an intravenous (IV) line and begin IV fluids. Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids
At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions?
Inspiration Rationale: Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring
The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is the most likely cause of the child's impaired mobility?
Joint inflammation Rationale: Joint inflammation and pain are the typical manifestations of an exacerbation of JRA
When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority?
Maintaining adequate hydration Rationale: The key word in this question is polycythemia. Hydration decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia.
When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement?
Monitor the infant's heart rate
An infant is receiving digoxin (Lanoxin) for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement?
Obtain a therapeutic drug level. Rationale: Sinus bradycardia (heart rate < 90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority.
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome?
Presence of a systolic murmur Rationale: Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly.
The nurse is preparing a child with an intussusception for a prescribed barium enema. What is the main purpose of conducting this procedure prior to surgical intervention?
Reduce the invaginated bowel segment. Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception, thereby negating the need for surgical intervention.
Which assessment finding(s) should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.)
Steatorrhea Foul-smelling stools Delayed growth Pulmonary congestion
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about the prevention of accidental poisonings. It is most important for the nurse to include which instruction?
Store all toxic agents and medicines in locked cabinets. Rationale: The only reliable way to prevent poisonings in young children is to make the items inaccessible
A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally. Which intervention has the highest priority?
Tell the parent to take the child to the emergency department. Rationale: The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation
Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence?
Urinary catheterization Rationale: Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage.
The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP?
Use designated isolation precautions.
Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed?
"I will give her a baby aspirin every 4 hours as needed for fever." Rationale: Although fever may occur, non-aspirin-containing medications should be used because of the risk of Reye's syndrome
A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman?
"The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?" Rationale: The most effective way to provide emotional support is to acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions
A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need?
600 calories/day Rationale:An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to 10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1° F temperature elevation. Ten percent of 540 (calories/day) is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take?
Ask if the child has had a cold, runny nose, or any ear pain lately. Rationale: The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Because these findings are not completely normal, further assessment of history and related signs and symptoms are needed to interpret the findings accurately.
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement?
Assess the child's mucous membranes and skin turgor Rationale: An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit
A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit?
Bone pain, pallor Rationale: Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor.
A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical examination. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors commonly associated with DDH. Which response is accurate?
Breech presentation
A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother?
Bring the child to the clinic today for an examination related to the cough. Rationale: The child should be evaluated as soon as possible for pneumonia. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production
The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider?
Exhibits a sudden and unexplained weight gain Rationale: Sudden and unexplained weight gain (B) can indicate fluid retention and is a sign of congestive heart failure.
The nurse admits a child to the intensive care unit with a diagnosis of acquired aplastic anemia. What is the most common cause of this type of anemia?
Exposure to certain drugs Rationale: Aplastic anemia often follows exposure to certain drugs such as chloramphenicol, sulfonamides, and phenylbutazone (Butazolidin), insecticides such as DDT, and chemicals, especially, benzene.
Which preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?
Observe for projectile vomiting. Rationale: Projectile vomiting (D), the classic sign of pyloric stenosis, contributes to metabolic alkalosis.
A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit?
Persistent cold Rationale: Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection
A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the first time tomorrow. During the school day, which intervention should be implemented for this child?
Place suctioning supplies on the back of the wheelchair when transporting. Rationale: Suctioning supplies should always be readily available for use with any client who has a tracheostomy.
A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which intervention should the nurse implement first?
Place the child in strict isolation to prevent an outbreak on the unit. Rationale: The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only personnel assigned to care for this client
A 3-month-old infant returns from surgery with elbow restraints and a Logan's bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period?
Place the infant upright in an infant seat position. Rationale: The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan's bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.
Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery?
Presence of an inguinal bulge after gentle palpation Rationale: The parents should notify the health care provider if the hernia remains irreducible after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release.
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. Which nursing intervention should be included in this child's plan of care?
Remove restraints one at a time and provide range-of-motion exercises. Rationale: Removing restraints one at a time is safer than simultaneously. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously. Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in the medical record.
The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client?
Remove the brace 1 hour each day for bathing only. Rationale: The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis.
A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take?
Send the child home with the parents to see the health care provider before returning to school. Rationale: Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition
An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement?
Show the parents how to hold the child with the extremity extended. Rationale: The extremity should be extended to prevent trauma to the femoral catheterization site
The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further assessment reveals that he is concerned about his edematous facial features. Based on these assessment findings, the nurse should plan interventions related to which nursing diagnosis?
Social isolation Rationale: Peer acceptance and body image are significant issues in the growth and development of adolescents. The answer addresses the problem of a lack of contact with peers stemming from his desire to protect his ego.