PN VATI NURSING CARE OF CHILDREN 2020 completed
A nurse is reinforcing teaching with an adolescent client who has a prescription for lisinopril. Which of the following foods should the nurse instruct the client to avoid? A. Foods high in fiber B. High-potassium foods C. Foods high in Vitamin K D. Dairy products
ANSWER: B. High-potassium foods. Rationale: The nurse should identify that lisinopril, an ACE inhibitor, can result in hyperKalemia. Therefore, the nurse should instruct the client to avoid foods high in potassium, which can increase the risk of hyperKalemia and lead to cardiac dysrhythmias.
A nurse is collecting data from a toddler who has heart failure. Which of the following findings should the nurse expect? A. Weight loss of 0.9 kg ( 2 lb.) B. Heart rate 65/min C. Bounding peripheral pulses D. Decreased urine output
ANSWER: D. Decreased Urine Output. Rationale: The nurse should expect a toddler who has heart failure to exhibit decreased urine output due to decreased renal perfusion.
A nurse is caring for an adolescent client who has a terminal illness. Which of the following statements should the nurse make to the parent? A. "I will administer pain medication on a schedule." B. "I will limit visits from siblings who are under the age of 18." C. "You should go home when your child needs to rest." D. "You should allow your child to die at home."
ANSWER: A. "I will administer pain medication on a schedule." Rationale: The nurse should inform the parents that pain medication will be administered on a schedule to promote pain control.
A nurse is caring for a 13-month-old toddler who has a prescription for a urinary catheter. Which of the following catheters should the nurse use? A. 5 French B. 12 French C. 10 French D. 14 French
ANSWER: A. 5 French. Rationale: The nurse should use this urinary catheter size for a 13-month-old toddler. Things to know: A size 10 French is used for an 8-year old child to a preadolescent client. A size 12 French and 14 French are used for Adolescent clients.
A nurse is assisting with the care of a child who is in status asthmaticus. Which of the following medications should the nurse administer first? A. Heliox via inhalation B. Albuterol via nebulizer C. Prednisone by mouth D. 0.9% sodium chloride via IV bolus
ANSWER: B. Albuterol via nebulizer. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should first administer albuterol, a short-acting-beta-adrenergic agonist, to relax the child's smooth muscles and promote bronchodilation. Status asthmaticus is a medical emergency and can result in respiratory failure; therefore, the priority action is to improve ventilation and decrease airway resistance.
A nurse is caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority? A. Monitor capillary refill of the casted extremity B. Use the palms of the hands when supporting the cast C. Examine the skin at the cast edges D. Instruct the child not to put anything inside the cast
ANSWER: A. Monitor capillary refill of the casted extremity. Rationale: The first action the nurse should take when using the airway, breathing, circulation method of client care is to monitor the circulatory status of the casted extremity. The extremity can continue to swell following application of the cast, increasing the risk for compartment syndrome.
A nurse is contributing to the plan of care for a child who has nephrotic syndrome and a prescription for corticosteroids. Which of the following interventions should the nurse recommend? A. Provide a low-sodium diet B. Encourage increased fluid intake C. Obtain urine ketone levels weekly D. Administer pancreatic enzymes with meal
ANSWER: A. Provide a low-sodium diet. Rationale: The nurse should recommend providing the child with a low-sodium diet to decrease edema associated with nephrotic syndrome.
A nurse is caring for an infant who has a cleft palate and is having trouble bottle feeding. Which of the following actions should the nurse take? A. Select a bottle with a one-way valve B. Choose a bottle with a narrow nipple C. Burp the infant every 90 mL (3 oz.) D. Use the football hold when feeding the child
ANSWER: A. Select a bottle with a one-way valve. Rationale: The nurse should use a bottle with a one-way valve to prevent reflux of liquid back into the infant's mouth.
A nurse is reviewing the medical record of a school-age child who is current on recommended immunizations. Which of the following immunizations should the nurse plan to administer at the 11-year-old well-child visit? A. Tetanus, diphtheria, acellular pertussis (Tdap) B. Haemophilus influenzae type b (Hib) C. Inactivated poliovirus (IPV) D. Rotavirus (RV)
ANSWER: A. Tetanus, diphtheria, acellular pertussis (Tdap). Rationale: The nurse should plan to administer the Tdap booster. The booster is administered to a school-aged child between 11 and 12 years of age when the child has previously received recommended immunizations.
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take? A. Use an automated lancet device to puncture the heel. B. Apply limb restraints to the infant C. Puncture the heel at the inner aspect of the heel D. Cleanse the area with povidone iodine.
ANSWER: A. Use an automated lancet device to puncture the heel. Rationale: The nurse should use an automated lancet device to puncture the heel to obtain a more precise puncture depth and to cause less pain.
A nurse is reinforcing teaching with an adolescent client who has oral candidiasis and new prescription for clotrimazole troche. Which of the following instructions should the nurse include in the teaching? A. "Place the medication in the refrigerator after each use." B. "Be sure to let the troche dissolve in your mouth for 15 minutes." C. "Crush the troche before mixing it with applesauce." D. "Stop the medication if white patches appear in your mouth."
ANSWER: B. "Be sure to let the troche dissolve in your mouth for 15 minutes." Rationale: The nurse should instruct the client to allow the troche to dissolve in the mouth over 15 to 30 min, which allows it to be absorbed through the oral mucosa.
A nurse is reinforcing preoperative teaching with an adolescent client who is scheduled for a surgical repair of scoliosis. Which of the following statements by the client indicates effectiveness of the teaching? A. "I will not be able to walk before I go home." B. "I will begin range-of-motion exercises on the first postoperative day." C. "I will be discharged in 3 days." D. "I will be fitted for my brace the day of discharge."
ANSWER: B. "I will begin range-of-motion exercises on the first postoperative day." Rationale: The nurse should reinforce the adolescent that it is important to begin range-of-motion exercises within 1 day of surgery. This promotes mobility and reduces the risk of complications.
A nurse is reinforcing teaching with the parent of a child who has diabetes mellitus. The parent asks the nurse how to minimize the child's pain when monitoring blood glucose levels. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should use their index finger to obtain blood samples." B. "My child should hold their finger under warm water before obtaining a sample." C. "My child should puncture the center of their finger pad when obtaining a sample." D. "My child should hold their finger against a table when obtaining a sample."
ANSWER: B. "My child should hold their finger under warm water before obtaining a sample." Rationale: Holding the finger under warm water will promote blood flow to the finger, making the puncture less painful.
A nurse is assisting with the care of a hospitalized toddler who has congenital heart disease. The parent calls the nurse to the room to ask for fresh linens and states. "My child never wets the bed at home. I am not sure why this is happening now." Which of the following responses should the nurse make to the parent? A. "I know this must be embarrassing for you. I have kids myself, and I would be concerned too." B. "Regression is a common reaction to stress when toddlers are hospitalized. This is temporary." C. "Your child appears to be just fine. If they aren't worried about it, then you shouldn't be either." D. "I will talk to the provider about this. It could indicate worsening of your child's condition."
ANSWER: B. "Regression is a common reaction to stress when toddlers are hospitalized. This is temporary." Rationale: Stressful situations, such as hospitalization or illness, can result in regressive behaviors, such as bed-wetting in a toddler who has been previously toilet trained. The nurse should provide reassurance to the parent of the child that the child will regain control of their bladder once they are feeling better and the stress of hospitalization is decreased.
A nurse is reinforcing teaching about introducing solid foods with the parents of a 6-month-old infant who is bottle-fed. Which of the following information should the nurse include? A. "You should use canned fruits and vegetables to introduce your baby to solid foods." B. "You should introduce one new food to your baby every 5 to 7 days." C. You should introduce a new food by giving your baby 3 to 4 tablespoons. D. "You should add rice cereal to a bottle before introducing your baby to solid foods."
ANSWER: B. "You should introduce one new food to your baby every 5 to 7 days." Rationale: The parents should introduce one new food, in plain and simple forms, over 5 to 7 days to monitor the infant for allergies or food reactions.
A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has a cleft lip and is bottle fed. Which of the following statements by the guardian indicates that the teaching was effective? A. "I will wait to burp my baby until after the feeding is finished." B. "I will used a narrow-based nipple to feed my baby." C. "I will hold my baby in an upright position during feedings." D. "I will allow my baby's cheeks to remain relaxed during feeding."
ANSWER: C. "I will hold my baby in an upright position during feedings." Rationale: The guardian should position the infant upright to improve the flow of the liquid with gravity. This method reduces the amount of fluid entering the nasal cavity.
A nurse is reinforcing teaching with the parent of a child who has a bacterial upper respiratory infection. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will force my child to drink fluids when they have a fever." B. "I will use a dehumidifier in my child's room." C. "I will keep my child's towels separate from those of the rest of the family." D. "I will make sure my child eats three meals a day, even though their appetite is not good right now."
ANSWER: C. "I will keep my child's towels separate from those of the rest of the family." Rationale: The nurse should identify that a child who has an upper respiratory infection should use separate towels, utensils, and cups to prevent the infection from spreading.
A nurse is collecting data from a toddler who has mild dehydration. Which of the following findings should the nurse expect? A. Weight loss of 8% B. Intense Thirst C. Moist mucus membranes D. Anuria
ANSWER: C. Moist Mucus Membranes. Rationale: The nurse should expect a toddler who has mild dehydration to exhibit moist mucus membranes. Other manifestations include a slight thirst, decreased urine output, and the presence of tears when crying.
A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take? A. Record the diastolic value as the first Korotkoff sound (K1). B. Release the cuff pressure at a rate of about 5 min Hg/second. C. Position the child's arm at the level of the heart. D. Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference.
ANSWER: C. Position the child's arm at the level of the heart. Rationale: The nurse should position the child's arm at the level of the heart because this will help ensure an accurate blood pressure reading. Lowering the arm below heart level will cause a false high reading. Elevating the arm above heart level will cause a false low reading.
A nurse is collecting data from an 8-month-old infant. Which of the following findings indicates expected growth and development? A. Inability to hold a bottle B. Uses palmar grasp C. Sits unsupported D. Forces tongue outward when it is touched
ANSWER: C. Sits unsupported. Rationale: The nurse should identify that by 8 months of age, the infant is expected to sit unsupported on the floor for up to 10 min.
A nurse is making a home visit to a 5-year-old child who has cerebral palsy and uses the wheelchair. Which of the following observations made by the nurse indicates that the family needs support and resources to cope with the child's condition? A. A grandparent is assisting the child in performing ADLs. B. The child is playing a game with their siblings. C. The parent is withdrawn and rarely interacts with the child. D. The step-parent is helping the child prepare to transition into school.
ANSWER: C. The parent is withdrawn and rarely interacts with the child. Rationale: The parent is exhibiting avoidance behavior in response to the child's condition. This is an unexpected finding that requires intervention by the nurse.
A nurse is assisting with the care of an infant who is post-operative following a surgical repair of a cleft lip and palate. Which of the following actions should the nurse plan to take? A. Gently rub betadine on the infant's incisions to prevent infection. B. Place the infant in a prone position for 1 hr to facilitate drainage of secretions. C. Weigh the infant once each day using the same scale. D. Suction the infant's nose and mouth using an in-line device on the lowest setting.
ANSWER: C. Weigh the infant once each day using the same scale. Rationale: The nurse should weight the infant once each day at the same time and on the same scale, wearing only a dry diaper each time. This practice maintains consistency in the results. The nurse should check the weight daily to ensure the infant's nutritional status is retained.
A nurse is reinforcing teaching with the parent of a child who is newly diagnosed with diabetes mellitus. Which of the following guidelines should the nurse include? A. "Your child should increase carbohydrate intake when sick." B. "You should omit your child's bedtime snack." C. "Your child's meal plan should consist mainly of proteins." D. "Your child's meal plan should include a snack before physical activity."
ANSWER: D. "Your child's meal plan should include a snack before physical activity." Rationale: The nurse should instruct the parent that a child who has diabetes should consume a snack before an increase in physical activity to prevent hypoglycemia.
A nurse is collecting data from a child who recently experienced a psychomotor seizure. Which of the following findings should the nurse expect? A. Hyperactivity B. Nystagmus C. Apnea D. Amnesia
ANSWER: D. Amnesia. Rationale: The nurse should identify that amnesia is an expected manifestation after a seizure. Children often do not remember the seizure activity.
A nurse in a clinic is caring for group of infants. Which of the following findings should the nurse report as a possible indication of physical maltreatment? A. A hemangioma on the infant's torso B. A burn with splash marks on the lower right leg C. A large, irregular, brownish-blue area on the infant's buttocks D. An abrasion on the back of the infant's arm
ANSWER: D. An abrasion on the back of the infant's arm. Rationale: The nurse should identify that an abrasion on the back of an infant's arm is a possible finding of maltreatment and should be reported to the provider.
A nurse is collecting data from a 1-month-old infant who has just undergone a hernia repair. Which of the following findings should the nurse report to the provider? A. Axillary temperature 37.4°C (99.3°F) B. Apical pulse 155/min C. Respiratory rate 40/min D. Blood pressure 64/40 mmHg
ANSWER: D. Blood pressure 64/40 mmHg. Rationale: The nurse should identify that this blood pressure is below the expected systolic pressure of 80 mmHg for a 1-month-old infant. The nurse should report this finding to the provider. Expected Reference Range For: 1 Month Old Infant Axillary Temperature: 36.5-38°C or 97.7-100.4°F Apical Rate: 110-160/min Respiratory Rate: 30-60/min
A nurse is contributing to the plan of care for a preschooler who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse recommend? A. Maintain clean technique during the child's dressing change B. Provide low-calorie snacks for the child three to four times each day between meals C. Allow the child to set their own daily schedule for wound care D. Ensure the child receives pain medication 30 to 45 min prior to therapy.-
ANSWER: D. Ensure the child receives pain medication 30 to 45 min prior to therapy. Rationale: The nurse should ensure that the preschooler receives pain medication 30 to 45 min prior to physical therapy sessions. The nurse should monitor the child's pain levels and treat them as needed. This will minimize or eliminate pain from moving tight skin at joints, which will encourage the child to participate in physical therapy. If the child is in pain during therapy, it will be a challenge to get the child to participate in future sessions.
A nurse is contributing to a plan of care for a 24-month-old toddler. Which of the following actions should the nurse take? A. Allowing the toddler to button up their own shirt B. Asking the toddler questions that have "yes" or "no" answers C. Providing the toddler with opportunities to share toys with others D. Making sure the toddler has at least one nap during the day
ANSWER: D. Making sure the toddler has at least one nap during the day. Rationale: Toddlers generally require at least one nap per day because of their high activity levels. At approximately 3 years of age, children have established a sleep pattern similar to that of an adult.
A nurse is reviewing the medical records of several children in an outpatient clinic. The nurse should identify that which of the following infections is included on the list of nationally notifiable conditions? A. Scarlet fever B. Rotavirus C. Erythema infectiosum (fifth disease) D. Pertussis
ANSWER: D. Pertussis. Rationale: Pertussis, aka whooping cough, is an infection that causes paroxysmal coughing, fever, and shortness of breath. It is transmitted by direct contact or respiratory droplets. Pertussis is on the list of nationally notifiable conditions. Therefore, the nurse should report this to the local health department upon identification.
A nurse is collecting data from a 7-year-old child. Which of the following findings indicates a developmental delay? A. Unable to verbalize the date B. Unable to count backwards from 20 to 1 C. Unable to make change out of a quarter D. Unable to tell the difference between right and left
ANSWER: D. Unable to tell the difference between right and left. Rationale: The nurse should recognize that a child should know the difference between right and left by 6 years of age.
A nurse is reinforcing teaching about injury prevention with the parents of a toddler. Which of the following instructions should the nurse include in the teaching? (SATA) A. Install window guards on windows B. Place scatter rugs over hardwood floors C. Keep doors locked D. Supervise at playgrounds E. Turn pot handles toward the front of the stove
Answer & Rationale: A. Install window guards on windows is correct because the nurse should instruct the parents that installing window guards on the windows is necessary to prevent falls. C. Keep doors locked is correct because the nurse should instruct the parents to keep the doors locked or use child-proof door knob covers at the entry of stairs, high porches, or other elevated areas to prevent injuries. D. Supervise at playgrounds is correct because the nurse should instruct the parents to supervise their child at playgrounds and select play areas with soft grounds and safe equipment to prevent injury.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? (SATA) A. Loosen restrictive clothing B. Hyperextend the child's neck C. Time the seizure episode D. Place the child in a side-lying position E. Restrain the child
Answer & Rationale: A. Loosen restrictive clothing is correct because the nurse should loosen restrictive clothing during a seizure to facilitate breathing. C. Time the seizure episode is correct because the nurse should observe and document the length of time of the seizure episode, including the postictal period. D. Place the child in a side-lying position is correct because the nurse should place the child in a side-lying position to facilitate drainage of secretions and prevent aspiration.
A nurse is assisting in preparing a preschooler for a diagnostic procedure. Which of the following strategies should the nurse use? (SATA) A. Review the child's present understanding B. Use abstract terms to describe the procedure C. Prepare the child shortly before the procedure D. Describe any expected sensations experienced during the procedure E. Plan for a 20 min teaching session
Answer and Rationale: A. Review the child's present understanding is correct because the nurse should review the child's present understanding of the procedure. This is a general guideline for preparing a child for a diagnostic procedure. C. Prepare the child shortly before the procedure is correct because a preschooler has a limited concept of time therefore, the nurse should prepare the child shortly before the procedure. D. Describe any expected sensations experienced during the procedure is correct because the nurse should emphasize sensory aspects of the procedure because it will minimize the child's anxiety.
A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has colic. Which of the following instructions should the nurse include in the teaching? A. "Offer a pacifier when your baby is fussy." B. "You should offer water in between feedings." C. "You should place a warm heating pad on your baby's abdomen." D. "Allow your baby to cry for 5 minutes before responding."
Answer: A. "Offer a pacifier when your baby is fussy." Rationale: The nurse should instruct the guardian to offer a pacifier to soothe and comfort the infant.
A nurse is reinforcing teaching with a school-age child who has mild persistent asthma and has a new prescription for therapy with montelukast. Which of the following information should the nurse include? A. "This medication helps prevent bronchospasms." B. "This medication is a corticosteriod." C. "You should take this medication for an acute asthma attack." D. "You should take this medication first thing in the morning."
Answer: A. "This medication helps prevent bronchospasms." Rationale: The nurse should reinforce that montelukast is a leukotriene modifier that helps treat mild persistent asthma by blocking inflammation and preventing bronchospams.
A nurse in a pediatric unit is assisting with providing care for multiple children. Which of the following physical findings and parental reports should cause the nurse to suspect child maltreatment? A. A toddler has a spiral fracture, and the parent reports a fall from a swing. B. A preschooler has bruises on the shins, and the parent reports a collision with furniture. C. An adolescent has a head injury, and the parent reports a fall from a bike. D. A school-age child has a black eye, and the parent reports a fight with a classmate.
Answer: A. A toddler has a spiral fracture, and the parent reports a fall from a swing. Rationale: The nurse should recognize the incompatibility between the parent's report and the presence of a spiral fracture, which is caused by the twisting of an extremity. This incompatibility should cause the nurse to suspect child maltreatment.
A nurse is obtaining a sputum sample from a school-age child. Which of the following actions should the nurse take? A. Ask the child to cough deeply B. Ask the child to clear their throat C. Use wall suction to obtain the sample from the child's throat D. Use a bulb syringe to obtain sputum from the child's mouth
Answer: A. Ask the child to cough deeply. Rationale: The nurse should have the child cough deeply to produce sputum that is from the lower respiratory tract.
A nurse is caring for a child who has pertussis. Which of the following precautions should the nurse initiate? A. Droplet B. Contact C. Airborne D. Protective
Answer: A. Droplet. Rationale: The nurse should initiate droplet precautions for a child who has a disease that is transmitted through droplets larger than 5 microns, such as pertussis. Individuals providing care for the child should wear a mask and the child should be placed in a private room.
A nurse is collecting data from a 5-month-old infant who is postoperative following umbilical hernia repair. Which of the following measures should the nurse use to evaluate the infant's pain level? A. FLACC pain rating scale B. COMFORT pain rating scale C. FACES pain rating scale D. CRIES pain rating scale
Answer: A. FLACC pain rating scale. Rationale: The nurse should use the FLACC pain rating scale to evaluate the infant's pain level following outpatient surgery to repair an umbilical hernia. The FLACC scale is a postoperative pain rating tool used for children ranging from 2 months old to 7 years old. The acronym stands for FACE, LEGS, ACTIVITY, CRY, and CONSOLABILITY. The scoring ranges from 0, indicating "no pain behaviors" to 10, indicating "most possible pain behaviors."
A nurse is assisting with the care of a child following a tonsillectomy. Which of the following actions is the nurse's priority? A. Monitor the child for frequent swallowing B. Offer the child crushed ice C. Administer an analgesic D. Apply an ice collar
Answer: A. Monitor the child for frequent swallowing. Rationale: The greatest risk to this child is hemorrhage following the tonsillectomy. Frequent swallowing is an early and obvious manifestation of postoperative bleeding. Therefore, the nurse's priority action is to monitor the child for frequent swallowing.
A nurse is caring for an adolescent who reports manifestations of an STI. Which of the following actions should the nurse take? A. Request that the adolescent sign a consent for treatment form prior to performing STI screening. B. Instruct the adolescent that a guardian must be present to provide consent for STI screening. C. Plan to notify the adolescent's guardian if the STI screening comes back positive. D. Obtain phone consent from the guardian of the adolescent prior to performing STI screening.
Answer: A. Request that the adolescent sign a consent for treatment form prior to performing STI screening. Rationale: All client must sign a consent for treatment form. Adolescents have the legal right to receive screening and treatment for an STI, Contraception, and Pregnancy without the consent of a guardian.
A nurse is reinforcing teaching with the guardian of an adolescent who has ADHD and a prescription for methylphenidate. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will expect my child to gain weight while taking the medication." B. "I will use charts to assist my child with organizing their day." C. "I will alternate my child's study area weekly." D. "I will give my child the medicine when they need it."
Answer: B. "I will use charts to assist my child with organizing their day." Rationale: The use of charts to assist with organization is a recommended modification of the environment to help the adolescent be more successful.
A nurse is reinforcing teaching with the parent of a 15-month-old toddler about nutritional guidelines. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child will be constipated if they drink more than 6 ounces of juice a day." B. "My child's intake of calcium should average 500 milligrams every day." C. "My child should consume 1,500 to 1,800 calories each day by the time they turn 2." D. "My child's appetite will increase suddenly when they turn 18 months old."
Answer: B. "My child's intake of calcium should average 500 milligrams every day." Rationale: The nurse should advise the parent that the toddler should receive approximately 500 mg of calcium daily to support adequate bone development . Milk, yogurt, cheese, and green leafy vegetables are all foods high in calcium, and the nurse should recommend increasing these in the toddler's diet.
A nurse is assisting with care for an adolescent client who has asthma and a new prescription for albuterol by metered-dose inhaler. Which of the following statements by the client indicates that they might be experiencing an adverse effect of albuterol? A. "My body feels relaxed after taking my medication." B. "My heart feels like it's fluttering after taking my medication." C. "I experience forgetfulness after taking my medication." D. "I become constipated after taking my medication."
Answer: B. "My heart feels like it's fluttering after taking my medication." Rationale: The nurse should identify that the client might be experiencing palpitations or tachycardia, common adverse effects of albuterol. Adverse Reactions of Albuterol Include: Restlessness, Tremors, Nausea, and Vomiting.
A nurse is assisting with providing care for an adolescent client who has neuropathic pain. Which of the following medications should the nurse anticipate administering? A. Oxycodone B. Gabapentin C. Acetaminophen D. Duloxetine
Answer: B. Gabapentin. Rationale: The nurse should identify that neuropathic pain results from injury to peripheral nerves and does not respond to opioids. However, gabapentin, an anticonvulsant medication, is effective for treatment of neuropathic pain.
A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations? A. Insomnia B. Irritability C. Diarrhea D. Hypothermia
Answer: B. Irritability. Rationale: The nurse should instruct the parents to monitor for irritability, which can indicate increased intracranial pressure following a head injury.
A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority? (Click on the exhibit tabs for additional information about the client.) A. Skin turgor B. Potassium level C. Capillary refill D. Heart Rate Exhibit 1 Graphic Record Blood pressure 68/46 mm Hg Heart rate 182/min Respiratory rate 32/min Temperature 38.8°C (101.9°F) SaO₂ 95% on room air Exhibit 2 Diagnostic Results Potassium 3.2 mEq/L Sodium 135 mEq/L Calcium 9.4 mg/dL Exhibit 3 Nurse's Notes Infant has minimal tearing when crying and a capillary refill of 3 sec. Skin turgor is poor. Infant is irritable and fussing intermittently. Father is holding infant in the rocking chair.
Answer: B. Potassium level. Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should identify that the priority finding is a potassium level of 3.2 mEq/L because this is below the expected reference range of 4.1 to 5.3 mEq/L for a 9-month-old infant. Hypokalemia, or a decreased potassium level, impacts the ability of smooth muscles to contract and can lead to cardiac arrythmias. Therefore, the nurse should identify this as the priority finding and notify the provider.
A nurse is assisting with the care of an infant who requires emergency surgery and whose parent is an emancipated adolescent. Which of the following people can sign the informed consent form for the procedure? A. The parent of the adolescent parent B. The adolescent parent C. The infant's provider D. The adult sibling of the adolescent parent
Answer: B. The adolescent parent. Rationale: An emancipated adolescent has the legal right to provide consent for themselves and their children.
A nurse is collecting data about sleep patterns from the parent of a preschooler during a well-child visit. The parent states, "My child has nightmares three to four times each week." I hope they grow out of this soon." Which of the following findings indicates to the nurse that the child is experiencing sleep terrors rather than nightmares? A. The child can describe what they were frightened of. B. The child usually goes back to sleep immediately. C. The child becomes fully awake and is in a panic. D. The child is easily comforted by the presence of the parent.
Answer: B. The child usually goes back to sleep immediately. Rationale: The nurse should identify that going back to sleep quickly is an indication of sleep terrors, rather than nightmares. A child who has sleep terrors is hard to keep awake. However, a child who is experiencing nightmares is still frightened and returning to sleep is slow.
A nurse is reinforcing teaching with the parents of a preschooler who has recently started to stutter. Which of the following instructions should the nurse include? A. "Critique your child's speech." B. "Look away from your child when they start to stutter." C. "Avoid completing your child's sentences." D. "Tell your child to take a deep breath when they are stuttering."
Answer: C. "Avoid completing your child's sentences." Rationale: The parent should avoid completing the child's sentences because it can make the child feel that the parent is frustrated. Frustration makes it harder for the child to communicate their thoughts and ideas.
A nurse in a provider's office is collecting data from an adolescent who has juvenile idiopathic arthritis and has been taking ibuprofen daily for the last 6 months. Which of the following client statements should the nurse report to the provider? A. "I have morning stiffness in my joints." B. "I have been taking a multivitamin that contains iron." C. "I noticed some blood in my stool this morning." D. "I skipped taking my ibuprofen last week after I went swimming."
Answer: C. "I noticed some blood in my stool this morning." Rationale: The nurse should identify that bloody stools are an adverse effect of long-term therapy with ibuprofen. The nurse should question the adolescent regarding a new onset of abdominal pain and should report the client's statement to the provider.
A nurse is reinforcing teaching with the parent of a toddler about promoting effective sleep patterns. Which of the following statements by the parent indicates an understanding of the teaching/ A. "My child and I will watch TV for 30 minutes before we go to bed." B. "After my child falls asleep in my bed. I will move them to their bed." C. "I will allow my child to have a drink of water each night prior to bedtime." D. "I will allow my child to eat dinner 1 hour before bedtime."
Answer: C. "I will allow my child to have a drink of water each night prior to bedtime." Rationale: The nurse should reinforce to the parent to follow routine behavior such as allowing the child to have a drink of water at bedtime. A consistent routine is a helpful strategy in promoting successful sleep patterns.
A nurse is caring for a preschooler who has diabetes mellitus and is pale, diaphoretic, and irritable. The child's blood glucose level is 52 mg/dL. Which of the following actions should the nurse take first? A. Give 1 tsp of peanut butter to the child B. Recheck the child's blood glucose level C. Administer 1 tbsp of sugar to the child D. Document the incident in the child's record
Answer: C. Administer 1 tbsp of sugar to the child. Rationale: When following evidence-based practice, the nurse should administer 15 g of simple carbohydrates. Foods, such as 1 tbsp of table sugar, will quickly bring the glucose level up and resolve the manifestations of hypoglycemia. This should be followed up by a complex carbohydrate to prevent rebound hypoglycemia.
A nurse is reinforcing teaching with the parent of a school-age child who is undergoing testing for acute lymphoid leukemia (ALL). The nurse should inform the parent that the child will undergo which of the following tests to confirm the diagnosis? A. Spinal fluid analysis B. Complete blood count C. Bone marrow biopsy D. Bleeding time
Answer: C. Bone marrow biopsy. Rationale: The nurse should inform the parent that the child will undergo a bone marrow biopsy to confirm the diagnosis of ALL.
A nurse is reinforcing teaching with the parent of a preschooler who has amblyopia. Which of the following instructions should the nurse include in the teaching? A. Instill two drops of antibiotic eye solution into both eyes for 14 days B. Irrigate both eyes with sterile water twice daily C. Patch the unaffected eye during the day D. Apply a warm pack to the affected eye three to four times per day.
Answer: C. Patch the unaffected eye during the day. Rationale: The nurse should instruct the parent to patch the unaffected eye during the day to strengthen the affected eye.
A nurse is caring for a toddler who has a respiratory illness and a temperature of 39.3°C (102.7°F). Which of the following actions should the nurse take to reduce the toddler's temperature? A. Give the toddler a tepid bath B. Administer an aspirin suppository C. Remove the toddler's extra clothing D. Apply a cooling blanket
Answer: C. Remove the toddler's extra clothing. Rationale: The nurse should remove the toddler's extra clothing after administering an antipyretic to reduce the toddler's temperature.
A nurse is reinforcing car seat safety instructions with the parent of a 15-month-old toddler. Which of the following statements by the parents indicates an understanding of the teaching? A. " I should place my child in a forward-facing car seat to ensure safety." B. "I should place my child in the front seat in a rear-facing car seat." C. "I should continue to use a booster seat until my child is 5 years old." D. "I should place my child in a rear-facing car seat until age 2."
Answer: D. "I should place my child in a rear-facing car seat until age 2." Rationale: The nurse should instruct the parents to use a rear-facing car seat until age 2. The American Academy of Pediatrics (AAP) recommends that toddlers ride in a rear-facing car seat up to 2 years of age or until they reach the highest weight or height allowed by the car seat's manufacturer.
A nurse is reinforcing discharge teaching about preventing infections with the parent of a child who is receiving chemotherapy and has a platelet count of 100,000/mm³. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will take my child's rectal temperature daily to ensure the most accurate reading." B. "I will make sure my child receives the MMR vaccine by the end of the week." C. "I will take my child to the park to ride her new bike." D. "I will inspect the inside of my child's mouth for sores every day."
Answer: D. "I will inspect the inside of my child's mouth for sores every day." Rationale: The nurse should instruct the parent to inspect the child's mouth daily for lesions, sores, or ulcerations. Conscientious mouth care is crucial to prevent infection of ulcerated areas because gingival bleeding can lead to mucositis.
A nurse is caring for a 4-year-old child who has pneumonia due to varicella zoster. The parent asks the nurse what types of activities are available for the child. Which of the following play activities should the nurse recommend? A. Watching cartoons in the unit activity room with peers. B. Pulling a wagon of stuffed animals in the hallway. C. Writing a short letter to send to a friend. D. Playing an alphabet flash card game with the parent.
Answer: D. Playing an alphabet flash card game with the parent. Rationale: The nurse should recommend playing an alphabet flash card game with the parent in the child's room. A child who requires airborne and contact precautions must remain in the assigned isolation room to prevent the spread of the infection to other children on the unit. Also, any toys brought into the room will require disinfection before and after each use.
A nurse is preparing to percuss an adolescent's chest and abdomen. Which of the following areas should the nurse expect to hear a dull sound? (Select only the Hot Spot that corresponds to your answer.)
B is correct! =) When percussing over dense tissue, such as the liver, the nurse should hear dullness, which is a thud-like sound. A is incorrect because- The nurse will hear resonance, which is a hollow sound when percussing over tissue filled with air, such as the lungs. C. is incorrect because- The nurse will hear tympany, which is a loud, musical sound when percussing over an air-filled organ, such as the stomach.
