ATI Nursing care of Children Practice Tests
A nurse is providing discharge teaching to the parent of a school-age child who has undergone a tonsillectomy. Which of the following statements by the parent should the nurse identify as understanding the teaching A. My child may resume usual activities since this was just an outpatient surgery." B. "My child will be able to drink the chocolate milkshake I promised to get for her tonight." C. "I will notify the doctor if I notice that my child is swallowing frequently." D. "I will have my child gargle with warm salt water to relieve her sore throat."
C. "I will notify the doctor if I notice that my child is swallowing frequently: The nurse should instruct the parent that frequent swallowing is a sign of bleeding and, if it is observed, to notify the primary care provider immediately.
A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following findings should the nurse expect A. Koplik spots B. Hoarseness C. Facial rash D. Splenomegaly
C. Facial rash: Erythema on the face, predominantly on the child's cheeks, is a manifestation of erythema infectiosum (fifth disease). The erythema causes the child to have the appearance of a "slapped face." The rash lasts from 1 to 4 days.
A nurse is reinforcing teaching about vital signs with the guardian of a 1-year-old toddler. Which of the following statements by the guardian indicates an understanding of the teaching?
"My child's pulse could increase to 150 beats a minute with activity." A pulse rate of 150/min is within the expected reference range for a toddler during physical activity.
A nurse is reinforcing teaching about interventions for mild hypoglycemia with the parent of a child who has diabetes mellitus. Which of the following statements by the parent indicates that the teaching has been effective?
"I should give my child 4 ounces of orange juice followed by cheese and crackers." The parent should treat mild hypoglycemia with 10 to 15 g of a simple carbohydrate, such as 4 oz of orange juice, and follow it with a starch-protein snack.
A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching?
"I will allow my baby to have a pacifier while sleeping." The nurse should reinforce with the parent that allowing the infant to fall asleep with a pacifier in his mouth decreases the risk for SIDS.
A nurse is reinforcing teaching about liquid oral supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching?
"I will give this medication to my child with a straw." The nurse should reinforce with the guardian to administer this medication with a straw to prevent staining the child's teeth.
A nurse is reinforcing teaching about home care with the guardian of a 14-month-old toddler who has spastic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching?
"I will perform daily stretching exercises to my toddler's affected muscles." The nurse should reinforce that performing stretching exercises of the toddler's affected muscles will prevent muscle contractures.
A nurse in a pediatric clinic is caring for an infant who has heart failure and a prescription for digoxin. Which of the following statement by the parent indicates the desired therapeutic effect of the medication?
"My baby is breathing easier than she used to." The nurse should identify that the desired effect of digoxin is to increase cardiac output and decrease venous pressure and pulmonary edema, which will reduce respiratory demands.
A nurse is reinforcing teaching regarding the immunization schedule with the parent of a 6-month-old infant during a well-baby visit. Which of the following statements by the parent indicates an understanding of the teaching?
"My baby will receive his third DTaP vaccine today." The nurse should reinforce with the parent that the infant should receive his third diphtheria, tetanus, and pertussis (DTaP) immunization at 6 months of age.
A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the following statements by the parent requires immediate intervention by the nurse?
"My child has refused to drink any fluids for the past 8 hours." An inadequate fluid intake indicates the child is at greatest risk for dehydration and electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention by the nurse.
A nurse is reinforcing teaching with the guardian of a child who has a new prescription for levalbuterol solution for use in a nebulizer. Which of the following statements by the guardian indicates an understanding of the teaching?
"My child might experience palpitations after taking this medication." Palpitations are an adverse effect of levalbuterol. If this occurs, the guardian should discontinue the medication and notify the provider.
A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching?
"My child might have a period of irregular movement of the extremities." The nurse should instruct the guardian that the child might experience chorea weeks or months after the initial diagnosis. Chorea is a temporary lack of coordination and the presence of sudden, irregular movements or periods of clumsiness.
A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when his child will no longer be contagious. Which of the following responses should the nurse make?
"Six days after lesions appear if they are crusted." The nurse should inform the guardian that a child will stop being contagious around 6 days after the lesions appeared, as long as they are crusted over.
A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse, "I'm a bad parent, and I can't deal with this." Which of the following responses should the nurse make?
"Tell me more about what you are feeling." The nurse should use open-ended statements that will allow the parent to share his feelings and emotions. During times of grief, the parent needs to express his emotions. The use of an open-ended statement relays the message that it is safe to do so with the nurse.
A nurse is assessing a toddler who has leukemia and is receiving his first round of chemotherapy. Which of the following findings is the priority for the nurse to report to the provide A. Urticaria B. Fatigue C. Vomiting D. Anorexia
A. urticaria
A nurse is caring for a toddler who has otitis media and a temperature of 39.1 C (102.4 F). Which of the following actions should the nurse take first?
Administer an antipyretic When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature.
A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate?
Apical The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line.
A nurse is caring for a 3-year-old female child who is prescribed an indwelling urinary catheter. Which of the following actions should the nurse take when performing this procedure?
Apply 2% lidocaine lubricant into the urethral meatus. The nurse should apply 2% lidocaine lubricant into the urethral meatus to assist in decreasing the discomfort the child might experience during catheterization.
A nurse is reinforcing teaching with the guardians of a school-age child who has frequent nosebleeds. Which of the following instructions should the nurse include?
Apply pressure to the child's nose. The nurse should instruct the guardians to apply pressure to the child's nose for at least 10 min to decrease bleeding. The nurse should also instruct the guardians to tilt the child's head forward, because this position prevents aspiration of the blood.
A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler?
Ask the guardian to verify the child's name. Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should ask the guardian to verify the identity of the child and use the identification band as the second identifier.
A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next A. Insert an indwelling urinary catheter. B. Measure weight and height. C. Initiate IV access. D. Maintain ECG monitoring.
C. Initiate IV access
A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis Decreased cerebrospinal fluid pressure Decreased WBC count Increased protein concentration Increased glucose level
C. increased protein concentration: The nurse should recognize that an increased protein concentration in the spinal fluid is a finding associated with bacterial meningitis.
A nurse is assisting with the care of a child who is postoperative and received a transfusion during a surgical procedure. Which of the following findings indicates the child is having a hemolytic reaction?
Chills and flank pain Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify this finding as an indication that the child is having a hemolytic reaction.
A nurse is preparing to suction an infant who has a tracheostomy. Which of the following actions should the nurse take A. Routinely suction every 30 min. B. Instill 0.9% sodium chloride prior to suctioning. C. Limit suctioning pressure to 40 mm Hg. D. Suction for 5 seconds or less.
D. Suction for 5 seconds or less
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect A. Increase in anterior convexity of the lumbar spine B. Increased curvature of the thoracic spine C. Lateral flexion of the neck D. A unilateral rib hump
D. a unilateral rib hump: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.
A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate?
Droplet precautions The nurse should plan to initiate droplet precautions for this child, because bacterial meningitis caused by Haemophilus influenzae type B is transmitted through the air via large-particle droplets.
A nurse is reinforcing teaching with the parent of a child who is being treated with diphenhydramine for allergic rhinitis. The nurse should tell the parent to monitor the child for which of the following?
Drowsiness Diphenhydramine can cause drowsiness due to CNS depression. The nurse should reinforce with the parent to administer the medication at bedtime to avoid daytime sedation.
A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant
Great toe: he nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for pulses, temperature, and color.
A nurse is preparing to obtain a peak expiratory flow rate from an adolescent. Which of the following actions should the nurse take?
Have the client stand during the procedure. To obtain the peak expiratory flow rate, the nurse should have the client stand during the procedure, which will allow the nurse to get an accurate reading.
A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect?
Hgb 9.0 g/dL The nurse should expect a child who has iron deficiency anemia to have an Hgb level below the expected reference range of 9.5 to 15.5 g/dL. An Hgb of 9.0 g/dL is below the expected reference range.
A nurse is administering an injection of epinephrine to a child who is experiencing manifestations of anaphylaxis. The nurse should monitor for which of the following adverse effects?
Increased systolic blood pressure Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should expect the child to have an increased systolic blood pressure following administration of epinephrine.
A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints?
Mummy restraint The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the toddler that involves the head and neck. The nurse should always use the least amount of restraint necessary.
A nurse is caring for a 1-month-old infant who has a nasogastric tube in place for intermittent feedings. Which of the following actions should the nurse take?
Position the head of the crib at a 30° angle between feedings. The nurse should place the infant with the head of the crib elevated 30° to 45° to prevent aspiration.
A nurse is reviewing the plan of care for a child who has cystic fibrosis. Which of the following is the priority goal for this child?
The child will maintain an effective breathing pattern. Manifestations of cystic fibrosis, such as chronic cough, pulmonary infection, and bronchiolar obstruction lead to severely impaired ventilation and gas exchange, which causes long-term pulmonary complications. Therefore, when utilizing the airway, breathing, circulation approach to client care, maintaining an effective breathing pattern is the priority goal for the child who has cystic fibrosis.
A nurse is collecting physical data from a 4-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child's skin turgor?
The child's abdomen. The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. To check skin turgor, the nurse should grasp the skin on the child's abdomen, pull it taut, and release it quickly. The child who is dehydrated will have a prolonged period of tenting.
A nurse is collecting data from an 18-month-old toddler. Which of the following is a deviation from expected growth and development that the nurse should report to the provider?
The toddler is unable to recognize familiar objects by name. The nurse should report that the toddler is unable to recognize familiar objects by name, because this is a deviation from expected growth and development. The toddler should be able to accomplish this task by 12 months of age.
A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss
The toddler received tobramycin during a hospitalization 2 weeks ago: The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
A nurse is teaching a school-age child who has a severe allergy to bee venom and his parent about epinephrine. Which of the following instructions should the nurse include in the teaching
Use a second dose if the first dose of epinephrine does not completely reverse the symptom: A biphasic response, in which the child will appear to recover and then experience a recurrence of symptoms, is possible with some allergic reactions. The nurse should instruct the parent and child to use a second dose if the first dose does not resolve all the symptoms.
A nurse is caring for a toddler who has acute otitis media and a temperature of 40º C (104º F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature A. Apply a cooling blanket to the toddler. B. Dress the toddler in minimal clothing. C. Give the toddler a tepid bath. D. Administer diphenhydramine to the toddler.
B. Dress the toddler in minimal clothing
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates his abdominal pain at 7 on a 0 to 10 scale. Which of the following actions should the nurse take A. Instill a 500 mL tap water enema. B. Give morphine 0.05mg/kg IV. C. Administer polyethylene glycol 1g/kg PO. D. Apply a heating pad to the child's abdomen.
B. Give morphine 0.05mg/kg IV
A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycling accident. Which of the following actions should the nurse take first
Explore the parents' feelings and wishes regarding organ donation
A nurse is preparing to leave the room after performing nasal suctioning for an infant who has respiratory syncytial virus (RSV). Identify the sequence in which the nurse should remove the following personal protective equipment (PPE).
Gloves Goggles Gown Mask The infant is on droplet and contact precautions due to the RSV. First, the nurse should remove his gloves, because these are the most contaminated. Second, the nurse should remove goggles, so they do not interfere with removing the other PPE. The nurse should then remove the gown, and finally the mask, to decrease exposure to the disease.
A nurse is caring for a child who has type 1 diabetes mellitus and has been receiving insulin via subcutaneous infusion pump. Which of the following laboratory tests would verify the average blood glucose level over the past 2 months?
Glycosylated hemoglobin Glycosylated hemoglobin provides an accurate average of the client's blood glucose level over the past 120 days. This test can be used to determine the effectiveness of, or compliance with, a treatment plan. It can also be used to diagnose diabetes mellitus.
A nurse is reinforcing dietary teaching with the parent of a 2-year-old toddler. Which of the following should the nurse include in the teaching?
"An appropriate serving size is 1 tablespoon of food per year of age." The nurse should include that an appropriate serving size for a 2-year-old toddler is 1 tbsp of food per year of age.
A nurse is reinforcing teaching with the parent of an infant who has a new diagnosis of human immunodeficiency virus (HIV). Which of the following statements made by the parent indicates an understanding of the teaching?
"I should bring my child in for immunizations on schedule." Immunizations provide protection from communicable diseases and should be administered on schedule.
A nurse in a pediatric clinic is talking on the telephone with the parent of a 6-month-old infant who has a UTI and started taking an oral antibiotic the day before. Listen to the (audio clip) and determine which of the following responses the nurse should make?
"Mix the medicine with 1 teaspoon of applesauce before giving it to your baby." To enhance acceptance of an oral medication, the parent can mix the medication with a small amount of a sweet, nonessential food item.
A nurse is reinforcing teaching with an adolescent who has an inflamed, nonperforated appendix and is scheduled for a laparoscopic assisted appendectomy. Which of the following instructions should the nurse include in the teaching?
"You will sit in your chair at least twice a day after surgery." The nurse should instruct the client that she will sit in a bedside chair at least twice a day and will be encouraged to ambulate as soon as possible following surgery. This activity will enhance lung function and help prevent postoperative complications.
A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take A. Place the infant in a knee-chest position. B. Administer a dose of meperidine IV. C. Discontinue administration of IV fluids. D. Apply oxygen at 2 L/min via nasal cannula.
A. Place the infant in a knee-chest position: The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.
A nurse is assisting with the care for a 7-month-old infant who has a cleft palate. Which of the following actions should the nurse take to decrease the infant's risk for aspiration?
Burp the infant frequently during feedings. Infants with a cleft palate have difficulty creating a seal around a bottle. Burping the infant frequently, following every ounce of fluid consumed, dissipates swallowed air and helps to prevent aspiration.
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero
1
A nurse is reinforcing dietary teaching with an adolescent who is a lacto-vegetarian and has iron deficiency anemia. The nurse should recommend which of the following as the best source of iron?
1 cup (8 oz) shredded wheat cereal The nurse should determine that shredded wheat cereal is an iron-fortified food. Therefore, it is the best option to recommend because it contains 1 g of iron per serving.
A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22 lb). The prescription reads phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer with each dose?
6.25 mL
A nurse in the emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply A. Increased temperature B. Gingival hyperplasia C. Xerophthalmia D. Bradycardia E. Cervical lymphadenopathy
A, C, E increased temperature is correct. Kawasaki disease is an acute illness associated with a fever lasting more than 4 days that is unresponsive to antipyretics or antibiotics. Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction. Cervical lymphadenopathy is correct. The child who has Kawasaki disease may develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.
A nurse is teaching the mother of a 6-month-old infant about teething. Which of the following statements should the nurse make A. Your baby may pull at her ears when she is teething." B. "Rub your baby's gums with an aspirin to decrease her discomfort." C. "Place a beaded teething necklace around your baby's neck." D. "Your baby's upper middle teeth will erupt first."
A. "Your baby may pull at her ears when she is teething
A nurse is providing anticipatory guidance to the parents of a 2-week-old infant about risk factors for sudden infant death syndrome (SIDS). Which of the following risk factors should the nurse include in the teaching A. Covering the sleeping infant with a blanket B. Supine sleeping C. Maternal history of milk allergy D. Pacifier use during sleep
A. Covering the sleeping infant with a blanket
A nurse is reviewing laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following values should the nurse identify as an indication of a potential complication A. Erythrocyte sedimentation rate 18 mm/hr B. WBC 6,200/mm3 C. C-reactive protein 1.4 mg/L D. RBC 4.7 106/µL
A. Erythrocyte sedimentation rate 18 mm/hr: An erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range and is an indication of osteomyelitis.
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect A. Loud, harsh murmur B. Dysrhythmias C. Weak femoral pulses D. High blood pressure
A. Loud, harsh murmur
A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent should the nurse identify as understanding the teaching A. Mononucleosis is caused by an infection with the Epstein-Barr virus." B. Mononucleosis is a bacterial infection requiring 14 days of antibiotics." C. "A Monospot is a throat culture used to diagnosis mononucleosis." D. "Children who get mononucleosis will need to refrain from sports for 6 months."
A. Mononucleosis is caused by an infection with the Epstein-Barr virus
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period A. Place the child in a lateral position. B. Delay documentation until the child is fully alert. C. Give the child a high-carbohydrate snack. D. Administer an oral sedative to the child.
A. Place the child in a lateral position
A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse's priority when making a room assignment A. Length of stay B. Treatment schedule C. Disease process D. Self-care ability
C. Disease procesS
A nurse in an emergency department suspects that a toddler has epiglottitis. Which of the following actions should the nurse take A. Obtain a culture from the toddler's throat. B. Prepare the toddler for nasotracheal intubation. C. Visually inspect the epiglottis using a tongue depressor. D. Administer the Haemophilus influenzae type B conjugate vaccine.
B. Prepare the toddler for nasotracheal intubation: When epiglottitis is suspected the nurse should prepare for nasotracheal intubation or a tracheostomy, which might be required if the toddler begins to experience severe respiratory distress.
A nurse is providing anticipatory guidance to the parents of an 8-month-old infant during a well-child visit. Which of the following statements should the nurse make A. Your baby should be able to stand while holding on to furniture." B. "Your baby should be able to say one to two words." C. Your baby should be able to sit unsupported." D. "Your baby should be able roll a ball to you."
C. "Your baby should be able to sit unsupported
A nurse is caring for a 2-week-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain A. Instruct the mother not to breastfeed for 1 hr after the procedure. B. Undress the infant and place him under a radiant warmer prior to the procedure. C. Administer sucrose to the infant prior to the procedure. D. Recommend the mother avoid placing the infant in the kangaroo hold after the procedure.
C. Administer sucrose to the infant prior to the procedure
A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe A. Identifies right from left hand B. Uses a utensil to spread butter C. Cuts a shape using scissors D. Draws a stick figure with seven body parts
C. Cuts a shape using scissor
A nurse is reinforcing teaching with the parent of a 4-month-old infant who has a new prescription for nystatin to treat oral candidiasis and is breastfeeding. Which of the following instructions should the nurse include in the teaching?
Continue nystatin for 2 weeks after the symptoms disappear. To prevent relapse, nystatin therapy should continue for at least 2 weeks after the lesions disappear.
A nurse is caring for a toddler following a tonsillectomy. Which of the following is the priority finding that the nurse should report to the provider?
Continuous swallowing When using the urgent vs. nonurgent approach to client care, the nurse should identify that continuous swallowing is a manifestation of hemorrhage. Therefore, this is the priority finding for the nurse to report to the provider.
A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make A. I think it is important that you provide emotional support for your family at this time." B. "I agree that you have to do what you feel is best for yourself during this stressful time." C. "You can't mean that; I'm sure you want to be there for your family." D. "Let's talk about some of the ways you have handled previous stressors in your life."
D. "Let's talk about some of the ways you have handled previous stressors in your life
A nurse is planning care for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan A. Administer pancreatic enzymes 2 hr after meals. B. Decrease pancreatic enzymes if steatorrhea develops. C. Limit fluid intake to 750 mL per day. D. Increase fat content in the child's diet to 40% of total calories.
D. Increase fat content in the child's diet to 40% of total calories :A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to equal 40% of total caloric intake.
A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take A. Place the child in a room with positive-pressure airflow. B. Place the child in a room with negative-pressure airflow. C. Initiate contact precautions for the child. D. Initiate droplet precautions for the child.
D. Initiate droplet precautions for the child
A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect A. Resists having an axillary temperature taken B. Exhibits withdrawal behaviors when her parent leaves C. Has multiple bruises on her knees D. Poor personal hygiene
D. Poor personal hygiene
A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For which of the following adverse effects should the nurse monitor?
Depression Clients taking isotretinoin can experience mental status changes, such as suicidal thoughts, aggression, emotional lability, and depression. The nurse should monitor the adolescent's mental status while taking isotretinoin.
A nurse is assisting with the care of a 4-year-old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure? (Select all that apply.)
Discuss the benefits of the procedure. The nurse should discuss the benefits of the procedure with the child, because this action is an age-appropriate activity that will decrease the child's anxiety about the procedure. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Give the child needleless IV supplies to play with. The nurse should allow the child to see, hold, and collect the supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. Allow the child to perform the procedure with a doll. The nurse should allow the child to mimic the procedure with a doll to alleviate anxiety. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure.
A nurse is reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetaminde. Which of the following instructions should the nurse include?
Instill medication immediately after cleansing the eye. The nurse should instruct the guardian to place the medication in the eye immediately after cleansing.
A nurse is collecting data from a 12-month-old infant during a well-child visit. At birth, the infant's weight was 3.6 kg (8 lb) and his length was 50.8 cm (20 in). Based on this data, which of the following findings should the nurse expect?
The infant is 76.2 cm (30 in) long The nurse should expect a length of 76.2 cm (30 in), because the infant's length should increase by about 50% by 12 months of age.
A nurse is assisting with the development of a health promotion program for the guardians of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program?
The leading cause of death in adolescents is physical injury. The nurse should recommend including this information, because injuries from motor-vehicle crashes are the leading cause of death in the adolescent population.
A nurse is preparing to administer levabuterol via nebulizer to a child with asthma. Which of the following data should the nurse collect prior to administering the medication?
Lung sounds Levalbuterol is a bronchodilator used to increase air exchange. The nurse should evaluate lung sounds prior to and after the administration of the medication to determine changes in respiratory status.
A nurse is contributing to the plan of care for a child who is in Buck's traction. Which of the following interventions should the nurse include in the plan?
Maintain the leg in an extended position. The nurse should have the child maintain her affected leg in an extended position while in Buck's traction. This position decreases the risk for further injury to the extremity and minimizes the occurrence of muscle spasms.
During a well-child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make?
Provide the toddler with a favorite toy at bedtime. The nurse should recommend to the parent that providing the toddler with a favorite toy at bedtime will help the toddler to feel more secure and facilitate sleep.
A nurse is reinforcing teaching with the parents of a 2-year-old toddler at a well-child visit. Which of the following should the nurse recommend as an age-appropriate activity for the toddler?
Putting together a large-piece puzzle The nurse should recommend putting together a large-piece puzzle as an age-appropriate activity for a 2-year-old toddler. Puzzles provide the child an opportunity to develop fine motor skills. Other fine motor skill activities include finger painting and coloring with thick crayons.
A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take
Screen the child's visitors for indications of infection
A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats in a motor vehicle. Which of the following instructions should the nurse include in the teaching?
Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt. The nurse should instruct the parents to secure both the child and the booster seat with the shoulder-lap seat belt inside the motor vehicle, because booster seats do not have built-in straps.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney
Serum creatinine 3.0 mg/dt: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the normal reference range and may indicate rejection of the kidney.
A nurse is collecting data from a 10-month-old infant. Which of the following findings should the nurse report to the provider?
Sits with support by leaning on hands The nurse should identify that sitting with support can indicate a developmental delay, because an infant should be able to sit unsupported by 8 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is collecting data from a child during a well-child visit. The nurse should recognize that which of the following findings places the child at a higher risk for abuse?
The child was born at 30 weeks of gestation. The nurse should identify that children who are born prematurely are at greater risk for abuse because of the potential for impaired bonding during early infancy.
A nurse is preparing to administer an IM injection to an 11-month-old infant. In which of the following areas should the nurse administer the injection?
Vastus lateralis The nurse should administer an IM injection in the vastus lateralis muscle of an 11-month-old infant. The vastus lateralis is a well-developed muscle that is safe to use for infants and small children.
A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance. Which of the following supplements should the nurse instruct the parent to include in the child's diet?
Vitamin D Lactose intolerance is managed by eliminating dairy products from the diet. However, this can result in a decrease in bone density because of the lack of calcium and vitamin D in the diet. The nurse should instruct the parent to administer a vitamin D supplement to the child to enhance the absorption of calcium from foods other than those containing lactose.
A nurse is reinforcing discharge teaching with the guardians of a 6-month-old infant following a surgical procedure to repair a hypospadias. Which of the following instructions should the nurse include?
Wait 1 week before giving the infant a tub bath. The nurse should instruct the guardians to keep the infant's penis as dry as possible until the stent or catheter is removed. The parent should provide sponge-baths to the child until the stent or catheter is removed.
A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend?
Yellow corn A client who has celiac disease is unable to process gluten, a protein found in wheat, barley, rye, and oats. The nurse should instruct the family that the client's diet is restricted to foods that are free of gluten, such as corn, rice, and millet.
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction
flank pain
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first
tachypnea: When using the airway, breathing, circulation approach to client care, the first finding the nurse should address is the toddler's tachypnea, which results when the kidneys are unable to excrete hydrogen ions and produce bicarbonate leading to metabolic acidosis.
A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include A. The child should be able to stand on the balls of her feet when sitting on the bike. B. The child should ride her bike 2 feet to the side of other bike riders. C. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. D. The child should ride the bike facing traffic when it is necessary to ride in the street.
A. The child should be able to stand on the balls of her feet when sitting on the bike
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should teach the parent to apply which of the following to the affected area A. Zinc oxide B. Antibiotic ointment C. Talcum powder D. Antiseptic solution
A. Zinc oxide: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.
A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. The nurse should identify which of the following statements by the child as understanding the teaching A. "I will puncture the pad of my finger when I am testing my blood glucose." B. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." C. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." D. I will decrease the amount of fluids I drink when I am sick."
B. I will give myself a shot of regular insulin 30 minutes before I eat breakfast
A nurse is assessing a school-age child who has appendicitis with possible perforation. The nurse should identify which of the following as a manifestation of peritonitis A. Hyperactive bowel sounds B. Abdominal distention C. Bradycardia D. Polyuria
B. abd distention
A nurse is reinforcing anticipatory guidance to the parents of an adolescent. Which of the following recommendations should the nurse include?
Be open to the adolescent's point of view. During this stage of development, adolescents are developing autonomy and self-identity. The nurse should recommend that the parents actively listen and be open to the adolescent's point of view, even if the parents disagree with his viewpoint.
A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further?
Blood pressure 120/80 mm Hg A blood pressure of 120/80 mm Hg is outside the expected reference range for an 18-month-old toddler and requires further investigation by the nurse.
A nurse is collecting data from a school-aged child. The nurse should identify that which of the following findings is a manifestation of physical abuse?
Bruises at various stages of healing The nurse should recognize that bruises at various stages of healing are a clinical manifestation of physical abuse.
A nurse is preparing to assist a provider with a lumbar puncture for a school-aged child. Which of the following actions is the nurse's priority?
Maintaining the child's position The greatest risk to the child is injury to the spinal nerves or the major vessels. Therefore, the priority action is for the nurse to maintain the child's position to prevent trauma.
A nurse is teaching a school-age child and his parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include A. Stay home from school for 1 week following the procedure." B. Follow a diet that is low in fiber for 1 week." C. Wait 3 days before taking a tub bath." D. Apply a pressure dressing to the site for 3 days."
C. Wait 3 days before taking a tub bath: The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. He should not take a tub bath for 3 days to avoid immersion of the incision in water.
A nurse is contributing to the plan of care for a 10-month-old infant who is postoperative following a cleft palate repair. Which of the following actions should the nurse include in the plan of care?
Place the infant in side-lying position. The nurse should place the infant in side-lying position to promote healing and prevent injury to the surgical site.
