Peds FA Davis ch 7, 8, 10, 11
The nurse is caring for an adolescent who weighs 110 pounds (50 kilograms). Which assessment findings should the nurse report as abnormal? Select all that apply. A. Heart rate is 50 beats per minute. B. Blood pressure is 130/60. C. Daily fluid intake is 1,800 milliliters (mL). D. Hourly urine output is 30 mL. E. Cholesterol level is 150 mg/dL (3.88 mmol/L).
A, B, C
The nurse is assessing a 6-year-old child. According to Piaget, what should the nurse expect to observe in the child at this stage? Select all that apply. A. The child's thinking is influenced by fantasy. B. The child understands the concept of time. C. The child is able to think abstractly. D. The child is able to think about things that are not in the present. E. The child's language skills are fully developed
A, D
The nurse is caring for a client in the pediatrician's office. Which statement by the nurse should be included in the client's education? Select all that apply. Client Data History and Assessment Notes02/25/XX09:158-year-old female brought to pediatrician's office for annual well visit. Doing well in school. Making friends. No past medical or surgical history. Immunizations up to date. Vital Signs02/25/XX0 9:15 Temp. 98.6°F (37°C) HR 74 beats/minute RR 20 breaths/minute BP 102/68 mm HgSpO2 99% on room air A. "It is important to wear a helmet while bike riding." B. "Always walk along the flow of traffic." C. "Before you begin babysitting, review basic first aid and cardiopulmonary resuscitation." D. "Because of the risk of choking, avoid nuts and grapes." E. "A seatbelt over your lap and shoulder should be worn while in your booster seat."
A, E
The nurse is working with an infant as the infant takes the first breath. What infant systems undergo the most transitions to extrauterine life? Select all that apply. A. Respiratory system B. Metabolic system C. Hepatic system D. Thermoregulatory system E. Circulatory system
A, E
A 3-year-old who is hospitalized following surgery cries every time his mother leaves the room. The mother expresses concern, as this is not normal behavior at home. Which is the most appropriate response from the nurse? A. "This is normal behavior for toddlers who are hospitalized." B. "This is separation anxiety and typically disappears by 9 months. Possibly the child is showing signs of pain." C. "This crying will cause unnecessary stress during recovery, so you will need to stay with the child unless they are asleep." D. "Perhaps the child is getting spoiled from all of the attention you provided right after surgery."
A.
The nurse asks the nursing student to provide an example of proximodistal development. Which would be an appropriate response by the student? A. A child is able to sit unsupported before being able to grasp objects with the fingers. B. An infant is able to hold the head up steadily before standing. C. A child learns to crawl before walking. D. A child is able to sit unsupported before pulling to stand.
A.
The nurse assesses developmental milestones of a 4-month-old infant. What is a normally expected developmental milestone? A. Rolls from abdomen to back B. Begins to lift the head when lying on the abdomen C. Transfers objects from one hand to the other D. Has taste preferences
A.
The nurse identifies that a child who consistently measures below the fifth percentile for height and weight charts is demonstrating signs of this diagnosis: A. Failure to thrive B. Failure to develop C. Developmental delay D. Organic growth deficiency
A.
The nurse is completing an infant's skin assessment. The nurse observes a cheesy substance found in the armpits and groin. What does the nurse do with this finding? A. Leave the substance intact. B. Scrub the substance off. C. Alert the healthcare provider. D. Continue to observe for further spread.
A.
Upon assessment of a hospitalized 15-month-old, the nurse notices he does not pull to a standing position. The mother states that he will stand if she holds him upright. How should the nurse interpret this finding? A. The child has not yet met the appropriate developmental milestone for age. B. The child is meeting appropriate developmental milestones. C. It is not anticipated that the child will pull up to a standing position until the end of 1 year. D. Regression is normal in a hospitalized child, so the nurse would not expect him to stand at this time.
A.
Which information is most important for the nurse to include regarding anticipatory guidance for health promotion in the school-age child? A. A balanced diet and 1 hour of exercise per day is recommended. B. School-age children should attend a basic first aid class. C. Allow for unsupervised activities. D. Limit screen time (TV, cell phones) to 4 hours per day
A.
Which statement would the nurse identify as an example of medical abuse of a child? A. An ill child is not allowed to be taken for care due to parents' religious objections. B. Parents choose not to provide a hearing aid for a school-aged child due to the stigma of wearing it. C. A child is alone at home after school for several hours every day. D. A child is left alone prior to school in the morning and is expected to take their own medications.
A.
The nurse is starting phototherapy with an infant with hyperbilirubinemia. Which nursing intervention would be appropriate to include with the start of therapy? A. Discourage breastfeeding. B. Cover the infant's eyes with eye patches during therapy. C. Place the infant in a blanket under the light for warmth. D. Allow the parents to hold the infant to promote bonding throughout the day.
B.
The nurse is suctioning an infant after delivery. Which statement reflects the correct procedure for clearing the infant's airway? A. The nurse should routinely use a bulb syringe immediately after delivery to clear the infant's oral secretions. B. The nurse will use a bulb syringe in the corner of the mouth and then suction the nose. C. The nurse will use a bulb syringe in the center of the mouth and then suction the nose. D. The nurse will use a bulb syringe in the nose and then suction the mouth.
B.
What is an important concept for a school nurse to consider when planning a class on injury prevention for adolescents? A. The topic should be general and brief because adolescents usually do not take a lot of risks. B. Present the material in a way that allows the adolescent to imagine long-term consequences of not protecting oneself from injury. C. Have the teens discuss the topic with their primary care provider D. Have the teens watch an education video
B.
What is the priority nursing intervention to ensure accurate pain assessments in a school-age child? A. Use a developmentally appropriate pain scale. B. Teach the child how to use the scale. C. Ask the child specifically about the pain level. D. Instruct the parents how to interpret facial expressions to determine pain level.
B.
Which nursing intervention should be included in the plan of care to decrease the stress for a hospitalized, chronically ill school-age child? A. Allow 24-hour visitation from peers. B. Offer the child some choices around daily activities. C. Have tutoring postponed until discharge. D. Maintain a strict daily routine.
B.
Which of these statements made by an adolescent best describes Erik Erikson's identity vs. role confusion stage of development? A. "I am glad that the whole family is going on vacation together." B. "I would rather stay home and hang out with my friends over vacation." C. "I think that my coach would like it if I practiced soccer when I am on vacation." D. "I am going to miss my friends while I am on vacation."
B.
A 13-year-old adolescent client is seen in the outpatient clinic and expresses concern that she is gaining weight. Her measurements indicate that she is in the 40th percentile for weight for her age. What is the most appropriate response by the nurse? A. "You should be seen by our nutritionist to make sure you are eating the correct foods." B. "Gaining weight is not something you need to concern yourself with." C. "Let's discuss further your concerns about your body and also review some of the normal changes your body will be going through during puberty." D. "I will have you discuss this further with the physician to make sure your questions are answered."
C.
The parents of a school-age child report that their child appears withdrawn, disinterested in school, and refuses to ride the bus to school. The nurse suspects that the child is being bullied. Which nursing assessment is the priority? A. Determine the child's sexual orientation. B. Assess the child's socioeconomic class. C. Assess for psychological effects of bullying. D. Determine what community resources are available to assist with bullying.
C.
Which anticipatory guideline does the nurse identify as appropriate for a preschool-aged child? A. A child this age will be learning to run. B. A child this age will be learning how to draw a circle with a pencil. C. A child this age will be learning dress themselves. D. A child this age will be learning to go up and down stairs independently.
C.
Which initial indication of puberty in males is identified correctly by the nurse? A. Testicular enlargement B. Adam's apple C. Pubic hair D. Adipose tissue increases
A.
Which data will the nurse collect when completing a Pediatric Early Warning System (PEWS) assessment on a postoperative school-age child? Select all that apply. A. Behavior B. Cardiovascular C. Sleep habits D. Respiratory E. Pain scale
A, B, D
The nurse is assessing pain with an infant. What is a common category with pain scales used with infants? A. Cry B. Blood pressure C. Pupil size D. Heart rate
A.
The nurse is teaching parents about child abuse. What statement indicates that the parents need more education? A. "We will use a car seat each time we take the infant out." B. "I cannot get out of bed every time the infant cries during the night." C. "My mother is the best babysitter we have today." D. "I know we need to get a babysitter when we leave the house."
B.
The nurse measures the infant's head circumference at 35 centimeters and a chest circumference at 33 centimeters. How would the nurse interpret these measurements? A. The infant has microcephaly. B. The infant has caput succedaneum. C. The infant has macrocephaly. D. The infant has normal measurements.
D.
The nurse is seeing an adolescent who has just admitted to smoking cigarettes. What should the nurse do next? A. Ask the client about their use of other substances. B. Educate the client on the dangers of tobacco. C. Offer the client information on electronic cigarettes. D. Tell the client's parents about their cigarette use.
A.
To decrease the school-age child's anxiety about a surgical procedure, the nurse will enlist the services of which member of the health-care team? A. Child-life specialist B. Surgical nurse practitioner C. Anesthesiologist D. Social worker
A.
What is the best method nurses may provide for educating adolescents about managing obesity? A. Providing teens with healthy options for planning meals and strategizing with them about making healthier choices will help them be healthier. B. Fad diets have very quick results and should be considered. C. Referring adolescents with a weight problem to a nutritionist is best. D. Talking to the adolescent's physician is the best approach, as they need to hear options from the doctor.
A.
When assessing a 9-month-old, the nurse asks the mother if the child likes to play peek-a-boo. The nurse is determining if the child has achieved which milestone? A. Object permanence B. Use of symbols to represent objects C. Coordination of reflexes D. Coordination of secondary schema
A.
Which teaching intervention by the nurse would be the most appropriate method to prepare a school-age child for a medical procedure? A. The nurse provides a simple explanation of the procedure. B. The nurse shows a video detailing the entire procedure. C. The nurse explains the procedure to the parents so that they may explain it to the child. D. School-age children should not be told what is happening before the procedure.
A.
Which term does the nurse understand to describe the process of development in which simple to more complex progression of developmental milestones is achieved? A. Differentiation B. Cephalocaudal C. Proximodistal D. Interdependent
A.
Which screenings do school nurses perform annually in the adolescent population? Select all that apply. A. Diabetes B. Cholesterol C. Body mass index (BMI) D. Hearing E. Tuberculosis
C, D
The parents of a school-age child tell the nurse that according to the measurements taken today, their child has gained 2½ pounds and grown 1 inch in the last year. What is the nurse's best response? A. "Don't worry, your child just hasn't had a growth spurt yet." B. "Okay, let's take a look at his growth chart and see how your child has been growing over the last year." C. "This is an unexpected pattern of growth in a school-age child." D. "Why don't we weigh and measure him one more time to be sure we have the correct measurements."
D.
Which of the following does the nurse correctly identify as the leading cause of mortality in adolescents? A. Homicide B. Suicide C. Cardiac disease D. Motor vehicle accidents
D.
The nurse is assessing a newborn reflex by brushing the side of the cheek near the corner of the mouth. What reflex is being assessed? A. Moro B. Startle C. Rooting D. Sucking
C.
Which statement would the nurse identify as an example of emotional abuse of a child? A. An ill child is not allowed to be taken for care due to parents' religious objections. B. Parents choose not to provide a hearing aid for a school-aged child due to the stigma of wearing it. C. A child is alone at home after school for several hours every day. D. A child is left alone prior to school in the morning and is expected to take their own medications.
C.
The nurse is caring for a 7-year-old client and obtains these vital signs: temperature 98.2°F (36.7°C), pulse 90, respirations 22, and blood pressure 93/60. What will the nurse do next? A. Cover the client with a warm blanket. B. Document these normal vital signs. C. Contact the health-care provider regarding the low blood pressure. D. Repeat the vital signs for accuracy.
B.
The nurse is discharging an infant after circumcision. What is an important teaching guide for a caregiver to care for the circumcised infant at home? A. Take the gauze off the penis when you get home. B. Report bleeding after 3 days to the pediatrician. C. Administer sugar for pain control. D. Notify the pediatrician when the infant voids
B.
The nurse is using the CRAFFT screening tool. Which adolescent should the nurse assess with this tool? A. One who vomits and fasts after overeating B. A teenager who needs health promotion activities C. A teenager who is being cyberbullied D. One who drinks beer every other weekend
D.
The nurse is discussing immunity with parents. Which statement supports the parent's decision to breastfeed the infant? A. The infant's immune system is fully developed by birth. B. Passive immunity is provided by breast milk. C. The breastfed infant has exposure to proteins and can develop allergies. D. The five immunoglobulins are found in breast milk.
B.
The nurse is explaining hyperbilirubinemia interventions to a mother who is having difficulty breastfeeding her infant. What intervention can the nurse try with the mother? A. Supplement the infant's feedings with glucose water. B. Consult a lactation specialist. C. Encourage the mother to use formula. D. Support the use of daily formula feedings and breast milk at night.
B.
A 2.5-year-old child does not search for an object when it is removed from the field of vision. The nurse correctly interprets this finding as: A. Normal cognitive development B. Delayed cognitive development C. Delayed psychosocial development D. Normal psychosocial development
B.
The school nurse is requesting written permission from the parents of older school-age students to provide information regarding risky behaviors. The mother of one student calls the nurse stating she is upset that this topic is being addressed and does not want to sign the consent form. What is the nurse's best initial response? A. "Well, you know that risky behavior starts in middle school, so it would be best if you just gave us permission to teach your child about them." B. "I understand that you are worried. We feel it is important to teach our students about risky behaviors. We know that sexting, for instance, has been linked to an increased likelihood of risky sexual behaviors in middle school students." C. "Okay, that's fine. We will make sure your child goes to the library for study time when her classmates are receiving the information on risky behaviors." D. "You absolutely have a right to be concerned. Do you have some specific questions I can answer for you to help you understand why we are addressing these issues in class?"
D.
When assessing risky behavior during a visit with a 14-year-old, what should the nurse be alerted to? Select the best answer. A. Forgetting to study for a test B. Going to a party with friends C. Joining a swimming league D. Riding in a car without a seatbelt
D.
A 15-year-old male client is seen in an outpatient clinic accompanied by his mother. Which topic is a priority health promotion topic to discuss with this client? A. Hand washing B. Hygiene C. Enforcing safe driving rules D. Encouraging use of protective gear while playing sports
D.
A nurse is caring for a toddler on an inpatient unit. Which developmental milestones should be expected at this stage by the nurse? Select all that apply. A. Gross motor development milestones include learning to ride a bike. B. Psychosocial development milestones include deciding where elimination will occur. C. Fine motor development milestones include learning to use a fine pincer grasp. D. Fine motor development milestones include drawing a circle. E. Cognitive development milestones include understanding the concept of object permanence.
B, D
A 4-year-old is exhibiting signs of anxiety due to an upcoming invasive procedure. Which is the appropriate action by the nurse to alleviate anxiety and improve compliance for this child? A. Explain the procedure in concrete terminology and allow the child to ask questions. B. Demonstrate the procedure on a doll and allow the child to manipulate the equipment. C. Reassure the child that there is no reason to be fearful. D. Explain to parents that this is normal and to ignore the behavior so that it does not become reinforced.
B.
A new mother is concerned about sudden infant death syndrome. What education would be appropriate for the nurse to provide to the mother regarding the prevention of this syndrome? A. Buy a soft, giving mattress for comfort. B. Have the infant sleep supine. C. Keep the infant in the parent's bed. D. Prop the infant to a side-lying position for sleeping.
B.
A school nurse notes that three females who are close friends each lost nearly 20 pounds recently. What is the priority nursing action in this situation? A. Tell the girls that they will need to have their weights monitored weekly from now on B. Interview and assess each of the girls privately and obtain a nutritional history C. Notify each of the girl's pediatricians of the situation D. Inform each of their parents of the situation
B.
A school-age child reports that the liquid medication "tastes bad." Which nursing intervention might the nurse try to hide the taste of the medication? A. Instruct the child to breathe in and out through his nose while taking the medication. B. Mix the medication with grape jelly. C. Request that the medication be provided as an IV medication. D. Numb the child's tongue with a Popsicle.
D.
The nurse is applying EMLA cream to a patient before a painful procedure. Which action is not safe and effective nursing care for EMLA cream application? A. Assess for allergic reaction B. Apply 5 hours before procedure C. Apply a large "glob" D. Apply dressing over medication
B.
What is the required daily fluid intake for a school-age child who weighs 36.8 kg? Record your answer in mL/day using a whole number. Enter the number only. Answer Correct Answer: 1836 Rationale: Fluid requirements for children are based on the child's weight. Using the accepted calculation of 1500 mL for the first 20 kg of body weight, the remaining fluid is calculated by multiplying 16.8 × 20mL/kg = 336 mL. Therefore, this child requires 1836 mL of fluid per day (1500 + 336).
Correct Answer: 1836 Rationale: Fluid requirements for children are based on the child's weight. Using the accepted calculation of 1500 mL for the first 20 kg of body weight, the remaining fluid is calculated by multiplying 16.8 × 20mL/kg = 336 mL. Therefore, this child requires 1836 mL of fluid per day (1500 + 336).
According to Kohlberg's theory of moral development, the nurse knows that adolescents tend to engage in which behavior? A. Depend on friends in times of crisis B. Base their value system on that of their family C. Socialize in co-ed cliques D. Explore gender roles
D.
In completing a physical assessment on a school-age child, the nurse will need to complete which step first? A. Gain permission from the child to complete the physical assessment. B. Ask the child to change into a patient gown. C. Ask the parents to leave the room. D. Develop a therapeutic relationship with the child.
D.
The mother of a 2-year-old asks the nurse advice on what toys are appropriate for this age. Which toy selection by the mother would be concerning for the nurse? A. Building blocks B. Tricycle C. Play-Doh D. Bead stringing toys
D.
The nurse is caring for a client prior to discharge on a pediatric unit. Which medication side effect does the nurse anticipate the client will be most concerned about? Client Data History and Assessment Notes 08/23/XX 12:15 14-year-old female with new-onset Crohn's disease. Past medical history unremarkable. Immunizations up to date. Stool regaining normal color, amount, consistency, and frequency. Skin appears pink and intact. Tolerating diet well. Begin home medication regimen of prednisone, mesalamine, and metronidazole. A. Constipation B. Hypertension C. Loss of appetite D. Weight gain, particularly abdominal
D.
When performing a physical assessment on a hospitalized adolescent, how should the nurse best protect their privacy? A. Perform the physical assessment on the client over their clothes B. Wait until there is no one else in the room to perform the physical assessment C. Ask the physician to perform the physical assessment D. Ask pertinent questions, making sure to address the adolescent first, then, politely ask parents and visitors to step out of the room momentarily in order to complete the physical assessment
D.