6500 Exam #2 Self Assessment Quiz's

The nurse is assessing a 2-month-old for signs and symptoms of increased intracranial pressure. Which of the following would the nurse expect to assess? Select all that apply.

Bulging fontanel Resistance to being held

The nurse is preparing to use biobehavioral interventions to control a child's pain. Which statement by the nurse would be most appropriate?

"Does your child have a favorite movie? We can play it in the room so he can focus on something other than the pain."

The nurse is caring for an adolescent who says, "I'm sick of this. I wish I weren't alive anymore." What is the best response by the nurse?

"Have you thought about hurting yourself?"

The nurse is caring for a child with cystic fibrosis who receives pancreatic enzymes. Which statement by the child's mother indicates an understanding of how to administer the supplemental enzymes?

"The enzymes should be given at the beginning of each meal and snack."

The nurse is caring for a 15-year-old patient who was involved in a motor vehicle accident (MVA.. The patient is receiving patient-controlled analgesia via an epidural route for pain in the extremities caused by bilateral compound leg fractures. When teaching the adolescent about pain control, which statement by the nurse would be most appropriate?

"You may notice decreased sensation and ability to move your legs with this type of pain control."

The nurse caring for a 28-week preterm infant prepares to obtain a capillary blood specimen for a routine bilirubin test via heel stick. The parents are at the bedside and ask the nurse if their infant will feel pain when he is stuck. Which response by the nurse would be most appropriate?

"Your son will experience pain for a brief moment when his heel is stuck."

The nurse is caring for a child with acute otitis media. The child weighs 22 lb. The medication order reads: amoxicillin 160 mg PO every 8 hours. Amoxicillin is supplied as 200 mg/5 mL. How many milliliters will the nurse administer with each dose? Round to the nearest whole number.

4

At a well-child visit, hydrocephalus may be suspected in an infant if upon assessment the nurse finds:

A rapid increase in head circumference

A toddler has moderate respiratory distress, is mildly cyanotic, and has increased work of breathing, with a respiratory rate of 40. What is the priority nursing intervention?

Airway maintenance and 100% oxygen by mask.

A nurse is providing care for a child who will be undergoing a painful procedure. When developing the child's plan of care, which of the following be most appropriate?

Allow the child to participate when possible. Emphasize that pain is not a punishment. Tell the child if pain is anticipated with a procedure.

When performing a PEFR (peak expiratory flow rate) with a peak flow meter, put the following steps in correct order. A. Stand up straight. B. Blow out hard and fast C. Slide the arrow down to "zero." D. Take a deep breath and close the lips tightly around the mouthpiece. E. Note the number the arrow moves to.

C, A, D, B, E

The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. Which of the following would the nurse include as characteristic of a seizure? Select all that apply.

Convulsive activity occurs. Crying is not typically noted.

A child is diagnosed with bacterial meningitis. When reviewing the results of the cerebrospinal fluid evaluation, which of the following would the nurse expect to find? Select all that apply.

Elevated CSF pressure Cloudy appearance

The nurse is caring for a 12-year-old child with cerebral palsy who is unable to communicate verbally. When assessing this child's pain, which assessment tool would the nurse most likely use?

Face, legs, activity, cry, and consolability (FLACC. descriptors)

A 6-month-old infant is admitted to the hospital with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. The priority nursing intervention would be:

Initiate appropriate isolation precautions and begin intravenous antibiotics.

A nurse is obtaining the history from a parent of a child who experiences absence seizures. Which of the following would the nurse expect the mother to describe?

Loss of motor activity accompanied by a blank stare

Which of the following are warning signs of autism? Select all that apply.

Not babbling by 12 months Not pointing or using gestures by 12 months No single words by 16 months Losing language or social skills at any age

A 4-year old complains of extreme pain when the tragus is touched. Though not diagnostic, this sign is most indicative of which disorder?

Otitis externa

A 10-year-old child is admitted to the hospital due to history of seizure activity. As his nurse, you are called into the room by his mother, who states he is having a seizure. What would be the priority nursing intervention?

Prevention of injury by placing the child on his side and opening his airway

A 5-month-old infant with RSV bronchiolitis is in respiratory distress. The baby has copious secretions, increased work of breathing, cyanosis, and a respiratory rate of 78. What is the most appropriate initial nursing intervention?

Suction secretions, provide 100% oxygen via mask, and anticipate respiratory failure.

The nurse is conducting an assessment of a 5-year-old boy. During the assessment, the nurse notes that the child does not maintain eye contract or speak. The nurse suspects an autism spectrum disorder. Which additional finding would help support the nurse's suspicion?

The child constantly opens and closes his hands.

When compared with adults, why are infants and children at an increased risk of head trauma?

The head of the infant and young child is large in proportion to the body and the neck muscles are not well developed.

The nurse is providing care to an infant experiencing pain. Which of the following would be most appropriate for the nurse to implement?

Tightly wrapping in a blanket with extremities flexed and hands uncovered Coating a pacifier with an oral sucrose solution for sucking Using rhythmic, continuous horizontal motions while holding

The nurse is caring for a 2-year-old child who has had surgery. When assessing this child's pain, which of the following development characteristics would the nurse need to keep in mind?

Uses words for pain such as owie, boo-boo, or hurt

Which is the most appropriate treatment for epistaxis?

With the child sitting up and leaning forward, pinch the lower third of the nose closed.

Which of the following is a sign of Down's syndrome?

oblique palpebral fissures

Which of the following is a late sign of respiratory distress and impending respiratory failure?

slow irregular breathing

Which of the following would be included in the therapeutic management of a child with autism?

write a goal that the child will reach optimal functioning possible Individualize care Keep a highly structured environment Allow the use of music therapy and sensory integration techniques