PEDS

A school nurse is assessing a school-age child's blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first?

The greatest risk to this child is aspiration, occlusion of the airway, and bodily injury from falling out of the chair. The nurse should ease the child down to floor in a side-lying position immediately. This position enables the child's secretions to drain from the mouth, preventing aspiration, and maintaining a patent airway.

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?

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

A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?

The nurse should apply a topical analgesic to the lumbar site 60 min prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted.

A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include?

The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site.

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of iron?

The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron.

A nurse is assessing the vital signs of a 10-year-old child following a burn injury. Which of the following clinical manifestations indicate early septic shock?

The nurse should expect a child who has early septic shock to have a fever and chills.

A nurse is assessing a school-age child immediately postoperative following a perforated appendix repair. Which of the following findings should the nurse expect?

The nurse should expect absence of peristalsis in the immediate postoperative period, until the bowel resumes functioning.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?

The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range and indicates the current treatment regimen the infant is receiving for dehydration is effective.

A nurse is providing teaching to the parents of a preschooler who has heart failure and who is to begin taking digoxin twice daily. Which of the following instructions should the nurse include in the teaching?

The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste.

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?

The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range indicates the effectiveness of the medication.

A nurse in the emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take?

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

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?

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

A nurse is creating a plan of care for a newly-admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?

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

A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take?

The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read.

A nurse is assessing a client who has a new diagnosis of celiac disease. Which of the following clinical manifestations should the nurse expect?

The nurse should realize that clients who have celiac disease are unable to digest gluten. This will cause damage to the cells in the bowel, leading to malabsorption, steatorrhea, and diarrhea.

A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?

The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid.

A nurse is creating a plan of care for a toddler who has minimal change nephrotic syndrome (MCNS) and 3+ pitting edema. Which of the following interventions should the nurse include in the plan?

The nurse should recognize that corticosteroids are the treatment of choice for providers caring for children who have MCNS. Therefore, the nurse should include administration of prescribed corticosteroids in the plan of care for this toddler.

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?

The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for more extensive evaluation of hearing.

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?

The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.

A nurse in an emergency department is caring for an adolescent who reports painful urination. Which of the following behaviors should the nurse identify as suggestive of possible child maltreatment?

The nurse should suspect child maltreatment if the adolescent exhibits a substance use disorder with mood-elevating drugs or alcohol.

A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching?

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

A nurse is providing anticipatory guidance to the mother of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include in the teaching?

The nurse should teach the mother that her toddler will begin to express her likes and dislikes. This is the time in life when a toddler is developing autonomy and self-concept. She will try to assert herself and frequently refuse to comply. The parent should allow the child to have some control but also set limits in order for her to learn from her behavior and learn to control her actions.

A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration as a result of acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?

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

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

The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts the current level of pain. The nurse can then determine the need for pain management.

A nurse in the emergency department is caring for a toddler who has partial-thickness burns on his right arm. Which of the following actions should the nurse take?

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

A nurse is providing dietary teaching to the parent of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?

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

A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following clinical manifestations indicates to the nurse that the medication is effective?

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

A nurse in the emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? (You will find "hot spots" to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A is correct. The nurse should identify the lower right quadrant of the abdomen between the umbilicus and the anterior iliac crest as the location of McBurney's point.

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following clinical manifestations should the nurse expect? (Select all that apply.)

Negative Babinski reflex is incorrect. A child who has spastic cerebral palsy will exhibit a positive Babinski reflex. Ankle clonus is correct. A child who has spastic cerebral palsy will exhibit ankle clonus which is a rhythmic reflex tremor when the foot is dorsiflexed. Exaggerated stretch reflexes is correct. A child who has spastic cerebral palsy will exhibit spasticity or exaggerated stretch reflexes. Uncontrollable movements of the face is incorrect. Uncontrollable movements of the face and extremities are manifestations of nonspastic (dyskinetic) cerebral palsy, rather than spastic (pyramidal) cerebral palsy. Contractures is correct. A child who has spastic cerebral palsy will exhibit contractures due to the tightening of the muscles.

A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for temperatures above 38.0º C (100.5º F) to an infant who weighs 17.6 lb. The infant has a temperature of 38.4º C (101.2º F). Available is ibuprofen liquid 100 mg/5 ml. How many mL should the nurse administer to the infant per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Reassess to determine if the amount to give makes sense. If there are 100 mg/5 mL and the prescribed amount is 40 mg, it makes sense to give 2 mL. The nurse should administer ibuprofen oral solution 2 mL PO per dose.

A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?

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

A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should the nurse include?

The nurse should inform the parent that her child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their symptoms can improve or decline and treatment needs to change accordingly.

A nurse at an urgent care clinic is assessing an adolescent client who has an upper respiratory tract infection. Which of the following findings should the nurse recognize as a manifestation of pertussis?

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

A nurse is providing teaching about car seat use to the mother of a 6-month-old infant. Which of the following statements by the mother indicates an understanding of the teaching?

Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back-rest for the car seat. Therefore, if this system is available, the seatbelt does not have to be used.

A nurse is caring for a hospitalized preschooler. The child's mother is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when her mother will return?

Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following clinical manifestations should the charge nurse include as suggestive of potential physical abuse?

The nurse should include in the teaching that symmetric burns of the lower extremities are a suggestive clinical manifestation of physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.

A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching?

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

A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

The live attenuated influenza vaccine is contraindicated in a child who has asthma.

A nurse in an emergency department is performing a physical assessment on a 2-week-old male infant. Which of the following manifestations is the priority for the nurse to report to the provider?

When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the infant is experiencing acute respiratory distress and increased respiratory effort, which could quickly progress to respiratory failure.

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?

When using the airway, breathing, circulation approach to client care, the nurse should place the priority on nasal flaring. Nasal flaring indicates that the infant is experiencing acute respiratory distress.

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

When using the urgent vs nonurgent approach to client care, the nurse determines that the priority action is administering IM epinephrine to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately it causes decreased blood return to the heart.

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

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

A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?

The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider immediately.

A nurse is providing teaching to the parents of a toddler about the administration of prescribed eye drops and eye ointment. Which of the following instructions should the nurse include?

The nurse should instruct the parents to administer the eye drops first and then wait 3 min before administering the eye ointment. This action provides adequate time and spacing for each separate medication to work.

A nurse is caring for a 15-year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration.

A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus?

A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range.

A nurse is providing discharge teaching to the parents of a 3-month-old infant following a cheiloplasty. Which of the following instructions should the nurse include?

Correct answer: The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing. The parents should clean the infant's sutures with sterile water or diluted hydrogen peroxide following each feeding. Excessive swallowing is an indication of bleeding and should be reported to the provider immediately.

A nurse is caring for a school-age child who has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?

Correct answer: The nurse should palpate the dorsum of the feet by pressing her fingertip against a bony prominence for 5 seconds to assess for peripheral edema. Assessing the child's skin turgor measures the elasticity and mobility of the skin; however, this is not an acceptable method for assessing for peripheral edema.

A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?

Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity. Hemoglobin 13.5 g/dl This hemoglobin level is within the expected reference range for a school-age child.

A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?

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

A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet. The child cannot consume oats, rye, barley or wheat, and sometimes lactose deficiency can be secondary to this disease. The nurse should recognize that rice pudding is a gluten-free food. Therefore, it is an acceptable choice for the nurse to recommend to the parent of a child who has celiac disease.

A nurse is providing teaching to the parent of a school-age child who has oral candidiasis and is to begin taking oral nystatin. Which of the following instructions should the nurse include?

The nurse should instruct the parent to shake the medication prior to administration in order to disperse the medication evenly within the suspension.

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip.)

The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.

A nurse is creating a plan of care for an infant who has an epidural hematoma with a skull fracture. Which of the following actions should the nurse include in the plan?

The nurse should implement seizure precautions for an infant who has an epidural hematoma as a safety measure.

A nurse is teaching the parent of a newborn about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?

The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.

A nurse in a provider's office is caring for a school-age child who has varicella. The parent asks the nurse when her child will no longer be contagious. Which of the following responses should the nurse make?

The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.

A nurse is creating an educational plan to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?

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

A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?

The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful.