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A nurse is providing education for the family of a 6-month-old infant about ways to stimulate language development. Which of the following instructions should the nurse include? A. "Explain what you are doing to the infant while providing care." B. "Promote fine-motor development of the tongue by offering a pacifier several times each day." C. "Exercise jaw muscles with foods that require chewing, such as hot dogs and carrots." D. "Leave a television playing in the child's room during nap time."
Correct Answer: A. "Explain what you are doing to the infant while providing care." The nurse should instruct the family that exposing the infant to expressive speech is the foundation for the development of expressive skills (the ability to make others understand needs and thoughts) and receptive skills (the ability to understand spoken words).
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will lock my medications in the medicine cabinet." B. "I will keep my child's crib mattress at the highest level." C. "I will turn pot handles to the side of my stove while cooking." D. "I will give my child syrup of ipecac if she swallows something poisonous."
Correct Answer: A. "I will lock my medications in the medicine cabinet." Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow further exploration of the environment and possible access to hazardous substances.
A nurse is providing teaching to the parents of a school-aged child who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following responses by a parent indicates an understanding of the teaching? A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." B. "I will give my child 2 units of regular insulin." C. "I will insist that my child lie down to rest for 30 min." D. "I will check my child's urine for glucose twice daily."
Correct Answer: A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." Giving the child 10 to 15 g of simple carbohydrates such as 240 mL (8 oz) of milk will elevate the blood glucose level and alleviate hypoglycemia.
A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints D. Withhold live virus immunizations
Correct Answer: A. Administer ibuprofen The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic.
A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the client's bathroom to strain the client's urine D. Administer folic acid with meals
Correct Answer: A. Attach a latex allergy alert identification band Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk of latex allergy; therefore, the nurse should avoid the use of common medical products containing latex such as latex gloves for this client.
A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DTaP) B. Pneumococcal (PCV) C. Haemophilus influenzae type B (Hib) D. Hepatitis B (Hep B)
Correct Answer: A. Diphtheria, tetanus, and pertussis (DTaP) Children should receive booster doses of the DTaP immunization between the ages of 4 and 6. Around this age, blood titers drop due to decreasing antibodies.
A nurse is planning preoperative teaching for a preschooler who is scheduled for a tonsillectomy. Which of the following interventions should the nurse plan to include? A. Encourage the preschooler to bring a favorite toy to the hospital B. Spend 30 minutes teaching the preschooler about what to expect C. Schedule the teaching session for the morning of the preschooler's procedure D. Reassure the preschooler that medicine will prevent pain after the procedure
Correct Answer: A. Encourage the preschooler to bring a favorite toy to the hospital The nurse should encourage the preschooler to bring a favorite toy or blanket to the hospital on the day of the procedure. A familiar object provides comfort and relieves fear.
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A. Measure the client's weight daily B. Check for tears C. Palpate the fontanel D. Assess skin turgor
Correct Answer: A. Measure the client's weight daily When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weight.
A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? A. Monitor the child's oxygen saturation level B. Administer prescribed antibiotics to the child C. Increase the child's fluid intake D. Apply warm compresses to the child's affected joints
Correct Answer: A. Monitor the child's oxygen saturation level When using the airway, breathing, and circulation (ABC) approach to client care, the priority intervention is to monitor the child's oxygen saturation level. Promoting oxygen utilization prevents further sickling of the child's red blood cells and allows adequate oxygenation of the surrounding tissue.
A nurse is caring for a 2-day-old infant who has myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference B. Position the infant supine C. Place the infant under a radiant warmer D. Tape a piece of plastic over the protruding membranes
Correct Answer: A. Monitor the infant's head circumference Infants with myelomeningocele have an increased risk of hydrocephalus. Measuring the infant's head circumference helps determine any increase of fluid.
A nurse is caring for an infant who has tetralogy of Fallot and is experiencing a hypercyanotic episode. Which of the following actions should the nurse take? A. Place the infant in a knee-chest position B. Initiate a fluid restriction C. Provide oxygen by nasal cannula D. Administer acetaminophen
Correct Answer: A. Place the infant in a knee-chest position The nurse should place the infant in a knee-chest position during a hypercyanotic episode. This position reduces the return of desaturated blood from the legs through the venous system and promotes the diversion of blood into the pulmonary artery.
A nurse is caring for a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse perform first? A. Position the child on his side B. Measure the child's vital signs C. Loosen any restrictive clothing D. Check the child for head injuries
Correct Answer: A. Position the child on his side Using evidence-based practice, the nurse should first position the child on his side. Salivation increases and the swallowing reflex is lost during a tonic-clonic seizure, placing the child at risk for aspiration. It is essential to maintain the airway during a seizure.
A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse plan to take to help decrease the risk of a vaso-occlusive crisis? A. Provide adequate fluid intake throughout the day B. Provide oxygen at 2 L/min via nasal cannula C. Administer a blood transfusion D. Give ibuprofen to manage pain
Correct Answer: A. Provide adequate fluid intake throughout the day Adequate hydration is an effective strategy to help prevent sickle cell crises. Maintaining adequate hydration can reduce the risk of sickle cell formation.
A nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately? A. Slurred speech B. Hemoglobin level of 9 g/dL C. Hematuria D. Pain level of 7 on FACES scale
Correct Answer: A. Slurred speech The nurse should identify that slurred speech in a child who has sickle cell anemia is an indication of a stroke. The nurse should report this finding to the provider immediately.
A nurse is assessing a 3-year-old preschooler. Which of the following developmental milestones should the nurse expect the preschooler to demonstrate? A. Stacking 10 blocks B. Printing 1 letter C. Tying shoelaces D. Using 7-word sentences
Correct Answer: A. Stacking 10 blocks The nurse should expect a 3-year-old preschooler to have the fine motor ability to stack 10 blocks.
A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first? A. Tell the guardian that a repeat dose of medication should not be given B. Verify the prescribed medication regimen C. Determine if the infant has been exposed to others who are ill D. Ask the guardian about the infant's urinary output
Correct Answer: A. Tell the guardian that a repeat dose of medication should not be given The greatest risk to this infant is an injury from digoxin toxicity. Therefore, the priority action for the nurse to take is to instruct the guardian not to administer another dose of medication. The nurse should follow-up with the guardian frequently to determine if the child has further episodes of vomiting. If so, the nurse should notify the provider immediately because vomiting is a possible indication of digoxin toxicity.
A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age
Correct Answer: A. The child prefers to sit on the parent's lap during the examination Toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the examination.
A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching? A. Toddlers will react to the parents' anxiety and sadness. B. Toddlers view death as punishment for bad behavior. C. Toddlers view death as permanent and irreversible. D. Toddlers have a realistic concept of death.
Correct Answer: A. Toddlers will react to the parents' anxiety and sadness. The nurse should identify that toddlers have little understanding of death. Their reaction is related to changes in routine and the parents' emotions.
A nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? A. Withhold the medication if the infant's heart rate is less than 110/min B. Mix the medication in 120 mL (4 oz) of infant formula C. Expect the infant to vomit frequently while taking this medication D. Double the dose if the infant has increased edema
Correct Answer: A. Withhold the medication if the infant's heart rate is less than 110/min The parent should withhold the medication and notify the provider if the infant's heart rate is less than 110/min.
A nurse is teaching the family of a child about hospice care. Which of the following statements should the nurse include in the teaching? A. "The hospice staff will be the primary caregivers for the child." B. "Hospice staff members consider the family's needs to be just as important as those of the child." C. "Hospice care will end with the death of your child." D. "The priority of hospice care is to provide curative treatment for the child."
Correct Answer: B. "Hospice staff members consider the family's needs to be just as important as those of the child." The nurse should inform the family that part of the philosophy of hospice care is to provide care for the family's needs as well as those of the child. Assisting with respite care, counseling, spiritual needs, and care of the family following the child's death are all part of hospice care.
A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will use my peak flow meter whenever I feel short of breath." B. "I will continue to take my medication when my peak flow rate is in the green zone." C. "I need to use the average of 3 readings when I measure my flow rate." D. "My asthma is being controlled if my flow rate is in the yellow zone."
Correct Answer: B. "I will continue to take my medication when my peak flow rate is in the green zone." This statement by the adolescent indicates an understanding of the teaching. A peak flow rate in the green zone indicates the current treatment has been effective; therefore, the adolescent should continue with their current medication regimen.
A nurse is providing teaching about disease management to the parent of a preschooler who has a new diagnosis of asthma. Which of the following parent statements indicates an understanding of the teaching? A. "My child should not receive live virus vaccines." B. "I will encourage my child to participate in sports." C. "I will give my child aspirin when she has a fever." D. "My child will outgrow asthma by adulthood."
Correct Answer: B. "I will encourage my child to participate in sports." The parent should encourage the child to remain physically active because this promotes lung expansion and air exchange.
A nurse is teaching an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching? A. "You should drink 8 oz of a regular soft drink if you experience hypoglycemia." B. "You should drink 4 oz of orange juice if you experience hypoglycemia." C. "You should take 2 glucose tablets if you experience hypoglycemia." D. "You should take 3 tsp of sugar if you experience hypoglycemia."
Correct Answer: B. "You should drink 4 oz of orange juice if you experience hypoglycemia." The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs.
A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella vaccine at 6 months of age." B. "Your baby can start the pneumococcal vaccine now." C. "Your baby should receive the flu vaccine before 6 months of age." D. "You baby can start the measles, mumps, and rubella vaccine now."
Correct Answer: B. "Your baby can start the pneumococcal vaccine now." The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age.
A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor? A. Preeclampsia B. Alcohol consumption C. Placenta previa D. Late prenatal care
Correct Answer: B. Alcohol consumption Alcohol consumption is a maternal risk factor for the development of congenital heart disease.
A nurse is caring for a child who received penicillin IM 15 minutes ago. The child is now irritable and restless. Which of the following actions should the nurse take first? A. Administer diphenhydramine B. Assess for laryngeal edema C. Initiate hourly urine output monitoring D. Give epinephrine IV push
Correct Answer: B. Assess for laryngeal edema The greatest risk to this child is bronchoconstriction due to an anaphylactic reaction to penicillin. Therefore, the first action the nurse should take is to assess the child for laryngeal edema and implement interventions to maintain a patent airway.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. Maintain the child on strict bed rest B. Check the child's blood pressure every 4 hr C. Administer albumin to the child every 8 hr D. Provide the child with a low-carbohydrate diet
Correct Answer: B. Check the child's blood pressure every 4 hr The nurse should check the child's blood pressure every 4 to 6 hours to monitor for hypertension.
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing B. Check the child's respiratory status C. Administer an antidote to the child D. Establish IV access for the child
Correct Answer: B. Check the child's respiratory status The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. This child's lips are edematous and inflamed, and he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway.
A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child? A. Jump rope B. Coloring book and crayons C. Checkers game D. Jack-in-the-box
Correct Answer: B. Coloring book and crayons Preschoolers have increasing fine motor control and imagination. They enjoy toys that allow creativity and self-expression.
A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. Obtain a portable suction machine and suction tubing B. Ease the child to the floor in Sims' position C. Time the length of the seizure D. Notify the child's parents
Correct Answer: B. Ease the child to the floor in Sims' position The greatest risk to the child is an injury resulting from a fall; therefore, the nurse should first gently ease the child to the floor to decrease the chance of injury and turn the child on the left side to prevent aspiration.
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child B. Explain the sounds the child is hearing C. Have the child use a cane when ambulating D. Rotate nurses caring for the child
Correct Answer: B. Explain the sounds the child is hearing The noises in a facility can be frightening to a child who is experiencing a sensory loss. Explaining these noises can allay the child's fears.
A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. Dullness with chest percussion B. Heart rate 118/min C. Conjunctival discharge D. Respiratory rate 28/min
Correct Answer: B. Heart rate 118/min The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia.
A nurse is planning to teach a 9-year-old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-age children are attempting to master which of the following developmental tasks? A. Initiative vs. guilt B. Industry vs. inferiority C. Trust vs. mistrust D. Identity vs. role confusion
Correct Answer: B. Industry vs. inferiority When planning to teach, the nurse should identify that school-age children are attempting to master the developmental task of industry vs. inferiority. During this stage, children enjoy learning new skills and experiencing the sense of accomplishment that comes with mastery of the skill.
A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take? A. Measure the infant's intake and output B. Measure the infant's head circumference C. Check the infant's lower-extremity function D. Monitor the infant's blood pressure
Correct Answer: B. Measure the infant's head circumference Increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements.
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should recommend which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster
Correct Answer: B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis (which affects the brain) and meningococcemia (which affects the blood). Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention issued a recommendation that all incoming college students receive the meningococcal immunization.
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head-to-toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical terminology D. Stop the assessment if the child becomes uncooperative
Correct Answer: B. Minimize physical contact with the child initially The nurse should initially minimize physical contact with the toddler and progress from the least traumatic to the most traumatic procedures.
A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure
Correct Answer: B. Murmur at the left sternal border A ventricular septal defect (a hole in the septal wall between the ventricles) is an acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal border. The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area.
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? A. Brightly colored mobile B. Plastic stethoscope C. Small-piece jigsaw puzzle D. Book of short stories
Correct Answer: B. Plastic stethoscope Preschool play centers on imitative activities. Providing a stethoscope allows the child to engage in therapeutic play. Imitating health care personnel may ease the child's fear of unfamiliar equipment.
A nurse is discussing play activities with a group of parents of toddlers. Which of the following activities should the nurse recommend for this age group? A. Jumping rope B. Pushing a toy lawn mower C. Sorting colored marbles D. Playing a board game
Correct Answer: B. Pushing a toy lawn mower The nurse should recommend pushing a toy lawn mower as a play activity for a toddler. Toddlers are developmentally ready for push-pull toys, and they enjoy play activities that allow imitation of adults.
A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy? A. Insert the catheter to 2 cm (0.79 in) beyond the end of the tracheostomy tube B. Remove the catheter while applying intermittent suction C. Instill 0.9% sodium chloride irrigation to loosen secretions while suctioning D. Continue suctioning until the secretions are removed
Correct Answer: B. Remove the catheter while applying intermittent suction The nurse should insert the catheter without suction and then withdraw the catheter while applying intermittent suction.
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. Perform nasotracheal suctioning B. Test the nasal secretions for glucose C. Maintain direct lighting on the child D. Lower the head of the bed
Correct Answer: B. Test the nasal secretions for glucose The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are a leakage of cerebrospinal fluid (CSF). The leakage of CSF is positive for glucose and occurs if the child has a skull fracture.
A nurse is taking the history of and performing a physical on a school-age child who has attention deficit hyperactivity disorder (ADHD). Which of the following findings in the child's medical record should the nurse identify as a risk factor for ADHD? A. The child's family has a middle-class socioeconomic background. B. The child had prenatal exposure to alcohol on a regular basis. C. Both siblings of the child show moderate activity levels in school and play activities. D. The child's mother currently has diabetes mellitus.
Correct Answer: B. The child had prenatal exposure to alcohol on a regular basis. Prenatal exposure to alcohol on a regular basis is a contributing factor to ADHD, along with prenatal nicotine exposure and exposure to lead or mercury.
A nurse is assessing the dynamics of a family in which child maltreatment is suspected. Which of the following findings should the nurse report to the provider? A. The parents provide emotional support to the child during the assessment process. B. The child has several unexplained scars and bruises. C. The child cries and appears afraid of the health care provider. D. The parents offer consistent, detailed stories about the child's injuries.
Correct Answer: B. The child has several unexplained scars and bruises. The nurse should suspect child maltreatment when the child has multiple unexplained scars and bruises. The nurse should report this finding to the provider.
A nurse in a provider's office is observing children playing in the waiting room. The nurse should expect to identify parallel behavior in which of the following age groups? A. Infants B. Toddlers C. Preschoolers D. School-age children
Correct Answer: B. Toddlers Toddlers demonstrate parallel play.
A nurse is providing education for a group of parents about toddler language development during a well-child visit. Which of the following findings should the parent expect in an 18-month-old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Following simple directional commands D. Naming a single color
Correct Answer: B. Vocabulary of 10 or more words At 18 months, children typically have a vocabulary of 10 or more words.
A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A. "Children commonly begin having imaginary friends when they reach school age." B. "Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." D. "Set limits by not allowing your child to have the imaginary friend present during family meals."
Correct Answer: C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions.
A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop-side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons." D. "I should ensure the crib slats are no more than 3 inches apart."
Correct Answer: C. "I should make sure my baby's clothing does not have buttons." The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration.
A nurse is providing education to the parent of a toddler who is about to receive an MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should not play with other children for 2 days." B. "I will need to return in 2 weeks for my child to receive the varicella immunization." C. "I will help my child to blow bubbles during the injection." D. "My child may have some drainage from the injection site."
Correct Answer: C. "I will help my child to blow bubbles during the injection." Providing distraction, such as helping or allowing a child to blow bubbles while receiving an injection, is a technique that can minimize pain and discomfort for the child.
A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." B. "Your child will be unable to participate in recreational activities." C. "Your child will need a botulinum toxin A injection to reduce muscle spasticity." D. "Your child will need throw rugs placed over non-carpeted areas."
Correct Answer: C. "Your child will need a botulinum toxin A injection to reduce muscle spasticity." Children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which reduce spasticity.
A nurse is providing teaching about disease-management strategies to a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? A. "Thorough and effective pulmonary clearance can help prevent the need for a lung transplant when you get older." B. "You should eat these kinds of foods because they will help you grow big and strong." C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." D. "Your medication follows a certain schedule to help you sleep better."
Correct Answer: C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." A 9-year-old child should understand that the production of thick mucus is a part of the disease process.
A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL
Correct Answer: C. A child who has sickle cell anemia and a urine specific gravity of 1.030 The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A child who has sickle cell anemia must maintain adequate hydration because dehydration could cause sickle cell crisis that can occlude the child's circulation.
A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL. C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32%
Correct Answer: C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL The initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report this result so that the provider can adjust the client's insulin dosage.
A nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take? A. Offer the infant water before feedings B. Discontinue amoxicillin C. Administer an antifungal medication after feedings D. Give the infant formula instead of breast milk
Correct Answer: C. Administer an antifungal medication after feedings The nurse should administer an antifungal medication to the infant after feedings to ensure adequate contact time with the oral mucosa and tongue to enhance treatment of the oral candidiasis.
A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider immediately? A. A school-age child with a urine specific gravity of 1.035 B. A toddler with a BUN of 25 mg/dL and a creatinine of 0.5 mg/dL C. An infant with a WBC count of 24,000/mm3 D. An adolescent with a positive beta human chorionic gonadotropin test
Correct Answer: C. An infant with a WBC count of 24,000/mm3 The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. This WBC count is high and indicates infection and possibly sepsis, which poses the greatest risk. The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy.
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production
Correct Answer: C. Deep, rapid respirations This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia.
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? A. Lethargy B. Spontaneous coughing C. Drooling D. Hoarseness
Correct Answer: C. Drooling Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is an expected finding due to the toddler's inability to swallow saliva.
A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale B. Color tool C. FACES pain rating scale D. Numeric scale
Correct Answer: C. FACES pain rating scale The FACES scale includes various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels.
A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP
Correct Answer: C. FLACC The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age.
A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area B. Initiate contact isolation precautions C. Give the child flavored popsicles D. Administer phytonadione
Correct Answer: C. Give the child flavored popsicles Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children often accept flavored popsicles as a source of fluid.
A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. Human papillomavirus (HPV) and hepatitis A B. Measles, mumps, and rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAIV)
Correct Answer: C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) The recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization series consists of 3 to 4 doses, depending on the immunization used. At minimum, it is administered at 2 months, 4 months, and 12 to 15 months of age. The IPV immunization series consists of 4 doses and is administered at 2 months, 4 months, 6 to 18 months, and 4 to 6 years of age.
A nurse is planning care for a preschooler who is scheduled for a surgical procedure. The nurse should identify that the preschooler is in which of the following of Erikson's psychosocial stages of development? A. Industry vs. inferiority B. Trust vs. mistrust C. Initiative vs. guilt D. Identity vs. role confusion
Correct Answer: C. Initiative vs. guilt A preschooler is in the developmental stage of initiative versus guilt. Preschoolers initiate play activities and experience a feeling of guilt if their efforts at independence receive a negative reaction from caregivers.
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities B. Administer meperidine every 4 hr until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for 8 hr
Correct Answer: C. Maintain the child on bed rest The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs.
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should reply that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism
Correct Answer: C. Object permanence Object permanence refers to the cognitive skill of knowing an object still exists even when out of sight. By discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.
A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing
Correct Answer: C. Palpate the abdomen for bladder distension A neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess for bladder distension due to the possibility of incomplete emptying of the bladder.
A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? A. Side-lying B. Supine C. Prone D. Semi-Fowler's
Correct Answer: C. Prone When providing preoperative care for an infant who has a myelomeningocele, the nurse should maintain the infant in a prone position. This position reduces pressure and the risk of trauma to the sac.
A nurse is assessing a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggests a possible delay in development? A. Inability to tie shoes B. Adding 3 parts to a stick figure C. Speaking using 2- or 3-word sentences D. Inability to walk backward
Correct Answer: C. Speaking using 2- or 3-word sentences A 4-year-old child should be speaking in 4- to 5-word sentences. Speaking in 2- to 3-word sentences is typical of a 2-year-old child.
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.
Correct Answer: C. The child complains daily about going to school. Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children at this stage want to learn and master new concepts. If the child complains daily about going to school, further evaluation is warranted.
A nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing. Which of the following findings is the priority for the nurse to report to the provider? A. The child's temperature is 39°C (102°F) B. The child's skin is sallow C. The child is drooling D. The child's voice is hoarse
Correct Answer: C. The child is drooling When using the urgent versus nonurgent approach to client care, the nurse should determine that the presence of drooling is the priority finding because it can indicate the child might have developed epiglottitis, a medical emergency. Left untreated, the child can develop a complete respiratory obstruction.
A nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. Which of the following interventions should the nurse include? A. Use a mobile walker for the toddler B. Discourage activities involving repetitive joint movement C. Use manual jaw control when feeding the toddler D. Discourage the use of wrist splints
Correct Answer: C. Use manual jaw control when feeding the toddler The nurse should encourage the parent to include the use of manual jaw control during feedings. Children diagnosed with cerebral palsy can lose jaw control, and more effective control can be achieved by providing stability to the jaws during feeding.
A nurse is planning preoperative teaching for a school-age child who is scheduled for cardiac surgery. Which of the following actions should the nurse plan to take when teaching the child? A. Limit teaching sessions to 10 min B. Use simple, concrete terms when giving explanations C. Use photographs to help explain the procedure D. Conduct the teaching session 2 days before the procedure
Correct Answer: C. Use photographs to help explain the procedure The nurse should recognize the school-age child's increased language ability and desire for knowledge. The nurse should use photographs and simple diagrams to explain the procedure in an interesting and concrete way that the child can understand.
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I will breathe in through the mouthpiece, hold my breath for 5 sec, and then exhale." B. "If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10 sec interval." D. "I will record the highest reading of three attempts."
Correct Answer: D. "I will record the highest reading of three attempts." After establishing a personal best, the client should routinely check the PEFM by performing 3 attempts and recording the highest reading of the 3.
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse provide? A. "The test determines the level of antibiotics in your child's blood." B. "The test tells us if your child ever had measles." C. "The test verifies the amount of albumin in your child's blood." D. "The test shows us if your child had a recent strep infection."
Correct Answer: D. "The test shows us if your child had a recent strep infection." An ASO titer indicates the child had a recent strep infection. When determining a definitive diagnosis for acute glomerulonephritis, this must be documented because the condition is usually the result of this type of infection.
A nurse on a pediatric unit has just received reports for 4 newly admitted clients. For which of the following children should the nurse plan to initiate droplet precautions? A. A child who has Rocky Mountain spotted fever B. A child who has roseola C. A child who has Molluscum contagiosum D. A child who has pertussis
Correct Answer: D. A child who has pertussis The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to others on the unit. Pertussis, or whooping cough, is a bacterial infection that is transmitted via exposure or direct contact with the respiratory secretions from an infected person. Manifestations of pertussis include a fever, sneezing, and a severe productive cough that generally becomes worse before getting better.
A nurse in the emergency department is caring for a child who accidentally ingested an overdose of acetaminophen. Which of the following medications should the nurse expect to administer? A. Naloxone B. Diphenhydramine C. Glucagon D. Acetylcysteine
Correct Answer: D. Acetylcysteine The nurse should expect to administer acetylcysteine to the child because it is an antidote to acetaminophen
A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer to the child? A. Zafirlukast B. Budesonide C. Montelukast D. Albuterol
Correct Answer: D. Albuterol The nurse should plan to administer albuterol to a child who is experiencing an acute exacerbation of asthma. This is considered a rescue medication due to its rapid onset of action. Albuterol is a beta-adrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs.
A nurse is providing teaching to the guardians of a 4-month-old infant on how to play with the infant. Which of the following play activities should the nurse suggest for this infant? A. Show the infant a board book with large pictures B. Imitate the sounds of different farm animals for the infant C. Give the infant a large push-pull toy D. Allow the infant to splash in the bathtub
Correct Answer: D. Allow the infant to splash in the bathtub The nurse should suggest allowing this 4-month-old infant to splash in the bathtub as a play activity. Splashing is appropriate for the developmental age of the infant and provides tactile stimulation. However, the nurse should emphasize and teach bath safety to prevent injury
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers with blocks
Correct Answer: D. Building towers with blocks Building towers with blocks is an appropriate activity for a 2-year-old child. and promotes fine-motor development. Also, knocking blocks down provides a means of dealing with the stress of hospitalization.
A nurse is caring for a 7-year-old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books
Correct Answer: D. Chapter books The nurse should offer chapter books as an appropriate diversional activity for a school-age child who has limited movement due to skeletal traction
A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hr B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the skin before attaching the sensor D. Cover the oximetry sensor with clothing
Correct Answer: D. Cover the oximetry sensor with clothing The nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading.
A nurse is planning care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. Airborne precautions B. Contact precautions C. Protective environment D. Droplet precautions
Correct Answer: D. Droplet precautions The nurse should maintain droplet precautions for a client who has meningococcal meningitis for 24 to 72 hours after the initiation of antibiotic therapy. Disease transmission can occur through large-droplet particles when the client is talking. There is no drainage of infected body fluids with meningitis, so contact precautions are not necessary.
A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss >10% C. Lethargy D. Dry mucous membranes
Correct Answer: D. Dry mucous membranes Dry mucous membranes are an expected finding of moderate dehydration.
A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short
Correct Answer: D. Ensure that staff visits with the child are kept short Children who have autism spectrum disorders have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible.
A nurse is planning preoperative teaching for a 5-year-old child. Which of the following interventions should the nurse include? A. Explain the long-term benefits of the procedure. B. Provide diagrams and pictures while explaining the procedure. C. Use correct medical terminology during the teaching session. D. Explain the procedure in terms of what the child will feel, see, hear, and taste.
Correct Answer: D. Explain the procedure in terms of what the child will feel, see, hear, and taste. Teaching for a preschooler should focus on the child's sensory experience. The teaching can also include what the child can do during the procedure.
A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level? A. Word-Graphic Rating Scale B. Color Tool C. Poker Chip Tool D. FACES Rating Scale
Correct Answer: D. FACES Rating Scale The nurse should use the FACES rating scale to assess this child's pain level. This scale is appropriate for a 3-year-old and provides a series of facial expressions representing amounts of pain.
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A. Restrict the child's potassium intake B. Administer acetaminophen to the child twice daily C. Weigh the child once each week D. Keep the child away from people who have an infection
Correct Answer: D. Keep the child away from people who have an infection Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections.
A nurse is providing teaching about home care to the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? A. Dry the affected area with a hair dryer on the low setting twice per day B. Use cloth diapers washed in a low-residue detergent C. Wash the genital area vigorously with each diaper change D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes
Correct Answer: D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes Zinc oxide can be applied as a barrier ointment to areas that are reddened or open and moist. While removing the waste material, zinc oxide should be left in place as much as possible during a diaper change. More ointment can be applied as needed. The ointment can be removed, if necessary, by applying mineral oil to the area and gently wiping.
A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? A. Assess for edema of the extremities B. Apply warm compresses to the neck area C. Initiate airborne precautions D. Maintain a cardiorespiratory monitor
Correct Answer: D. Maintain a cardiorespiratory monitor Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidified oxygen and suction equipment should be used as needed.
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? A. Hypotension B. Stomatitis C. Bloody diarrhea D. Periorbital edema
Correct Answer: D. Periorbital edema Periorbital edema is an expected finding in a child who has glomerulonephritis.
A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL
Correct Answer: D. RBC 6.8 million/uL A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.
A nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse. Which of the following actions should the nurse take? A. Ask the child if his parents are responsible for the abuse B. Notify the facility's risk manager C. Interview the child with his parents present D. Report the suspected abuse to local authorities
Correct Answer: D. Report the suspected abuse to local authorities The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement.
A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot
Correct Answer: D. Standing on 1 foot The nurse should expect a 3-year-old child to have the gross motor ability to stand on 1 foot for a few seconds.
A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room? A. Pulse oximeter B. Oxygen therapy C. Bag valve mask D. Suction equipment
Correct Answer: D. Suction equipment When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority item to have in the child's room is suction equipment. If the child experiences a tonic-clonic seizure, the child is at risk for aspiration and airway occlusion due to secretions, food, or fluids. The nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bag valve mask if needed.
A nurse is assessing the fine motor skills of a 3-year-old preschooler. Which of the following findings should the nurse expect? A. The preschooler can draw a stick figure that has 7 parts B. The preschooler can print her first name C. The preschooler can cut out a picture using scissors D. The preschooler builds a tower of 9 cubes
Correct Answer: D. The preschooler builds a tower of 9 cubes The nurse should expect a 3-year-old preschooler to have the fine motors skills needed to build a tower of 9 to 10 blocks.
A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved? A. Sitting alone B. Attempting to stack objects C. Picking up small objects with a crude pincer grasp D. Turning from back to stomach
Correct Answer: D. Turning from back to stomach A 6-month-old infant should be able to turn over completely, sit momentarily without support, and reach to be picked up
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake C. Follow the child's cues to time food and fluids D. Sit beside the child's high chair for feedings E. Play music videos during scheduled meal times
Correct Answers: A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. A nutritional goal for this child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake.
A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (Select all that apply.) A. "I should eat extra food on busy days when I am more active." B. "I should wait for 2 hr after eating before going swimming with my friends." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." E. "I should have a 16 oz sports drink if I start feeling weak or shaky."
Correct Answers: A. "I should eat extra food on busy days when I am more active." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." The nurse should instruct the adolescent to increase the intake of allowable foods when the level of activity is increased. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. Additionally, the nurse should instruct the adolescent to increase the intake of sugar-free fluids when sick because fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids such as water, broth, and tea. The adolescent should continue with the usual intake at mealtimes and follow the recommended meal plan as much as possible. Finally, the nurse should instruct the adolescent to eat a recommended snack 30 minutes prior to a planned activity such as playing in a baseball game. If the game is prolonged, a snack should be consumed every 45 minutes to 1 hour. If, for some reason, the extra food cannot be tolerated, the next intervention is to decrease the adolescent's insulin dose before baseball games.
A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child's parent about the illness? (Select all that apply.) A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water C. Administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area
Correct Answers: A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water E. Wash hands before and after contact with the affected area Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on teaching the child's parents about topical application of an antibacterial ointment. The parents should wash their hands before and after contact with the affected area and wash the child's bed linens daily in hot water to decrease the risk of reinfection or transmission.
A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment
Correct Answers: A. Enlarged heart B. Enuresis C. Leg ulcers E. Retinal detachment Chronic vaso-occlusive phenomena result from the obstruction of organs by red blood cells, leading to stasis and enlargement of the organs, infarction due to ischemia, and scarring. An enlarged heart, enuresis, leg ulcers, and retinal detachment are manifestations of chronic vaso-occlusive phenomena.
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to the body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.
Correct Answers: A. The child views death as similar to sleep. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. Preschool-age children may think of death like sleep. Preschool-age children also believe that their thoughts and wishes can make things happen since they are egocentric. This is part of why the death of a family member can be difficult for a child at this age. Finally, preschool-age children sometimes believe that death is the result of guilt or a punishment for something they did, said, or thought.
A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (Select all that apply.) A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min
Correct Answers: B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea. The nurse should plan to hold the infant in a semi-upright position during feedings to promote maximum chest expansion and decrease the risk of respiratory distress. The nurse should plan to withhold oral feedings and provide gavage feedings if the infant shows indications of stress or fatigue. An infant who has a respiratory rate of 80/min to 100/min has tachypnea, which is an indicator of infant stress.