Block 9: Peds Module 1-5 practice questions
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate? A. "As a nurse, I am required by law to report suspected child abuse." B. "I am unable to discuss this, but I can contact my supervisor to speak with you." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities."
A. "As a nurse, I am required by law to report suspected child abuse." Rationale:A nurse is required by law to report suspected child abuse. Therefore, this is a truthful, non-accusatory response.
A nurse is educating new parents about risk factors for sudden infant death syndrome (SIDS). Which of the following statements should indicate to the nurse the need for additional teaching? A. "Our baby will sleep in our bed because I am breastfeeding." B. "We will give my baby a pacifier during naps and at bedtime." C. "We will place my baby on her back when sleeping." D. "We will remove blankets and toys from the crib."
A. "Our baby will sleep in our bed because I am breastfeeding. Rationale: Allowing an infant to sleep in the same bed as an adult can lead to suffocation and falls. The parent should place the infant back in her crib after breastfeeding
A nurse is teaching a parent of a 6-month-old infant about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "Our car seat is an infant model and is anchored in the car." B. "Our car seat is front-facing in the back seat." C. "I can fit my hand between the baby and the car seat harness." D. "The car seat is rear-facing in the front passenger seat."
A. "Our car seat is an infant model and is anchored in the car."
A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother? A. "Placing your child on her back when sleeping will decrease the risk of SIDS." B. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." C. "SIDS rates have been rising over the last 10 years." D. "Sleep apnea is the main cause of SIDS."
A. "Placing your child on her back when sleeping will decrease the risk of SIDS."
A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? A. "The teacher says my child has to squint to see the board." B. "My child has recently lost both front top teeth." C. "My child often cheats when we play board games." D. "Sometimes my child acts bossy with his friends."
A. "The teacher says my child has to squint to see the board." Rationale:Squinting to see the board can indicate a vision problem. It is essential to assess children for hearing a
A nurse is administering ear drops to a toddler and pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following explanations should the nurse provide? A. "This technique opens the ear canal, allowing medication to reach the inner ear region." B. "When this technique is used, the toddler experiences less pain." C. "This is the safest and easiest way to administer this medication." D. "When this technique is used, the medication will not run out of the ear."
A. "This technique opens the ear canal, allowing medication to reach the inner ear region."
A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? A. A needleless syringe and a doll B. A video game C. A story book about a child who has diabetes D. A period of play in the playroom
A. A needleless syringe and a doll Rationale:Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child, because they will allow the child to act out feelings of anger and helplessness. Playing a video game is a distraction and is useful for a child who is bored. Reading does not provide an outlet for working out the feelings that the child is unable to verbalize at the age of 4. Playing in the playroom is not a therapeutic activity in this situation.
A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions? A. An anxiety reaction B. Regression C. Resentment toward the mother D. Developing autonomy
A. An anxiety reaction Rationale : separation anxiety is an added stress along with the stress of hospitalization the toddler maybe demonstrate emotions of despair by remaining sad and quiet.
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel B. Uses thumb and index fingers in a pincer grasp C. Lateral incisors D. Sitting steadily without support
A. Closed posterior fontanel posterior fontanel should close by about 8 weeks of age. (A 9-month-old infant should be able to use his thumb and index fingers in a crude pincer grasp; develop upper lateral incisors between 9 and 13 months of age and lower lateral incisors at 10 to 16 months; 8-month-old infant should be able to sit without support)
A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs? A. "Can I listen to your lungs?" B. "I am going to listen to your heart." C. "I am going to take your blood pressure now." D. "Can you stand very still while I feel how warm you are?"
B. "I am going to listen to your heart." inform the toddler of the procedure prior(don't ask yes/no questions. Negativism is a way for toddlers to assert self-control & gain independence. Therefore, toddlers tend to answer questions with a negative response and are likely to initially resist. If the nurse asks, the toddler responds "no," the nurse proceeds anyway, creates an environment of mistrust; avoid using the word "take" when measuring bc toddler might interpret the words literally)
A nurse is providing teaching about dental care and teething to the caregiver of a 9 month old infant. Which of the following statements by the caregiver indicates an understanding of the teaching? A. "I can give my baby a warm teething ring to relieve discomfort." B. "I should clean my baby's teeth with a cool, wet washcloth." C. "I can give advil for up to 5 days while my baby is teething." D. "I should place diluted juice in the bottle my baby drinks while falling asleep."
B. "I should clean my baby's teeth with a cool, wet washcloth." This is the most appropriate answer. You would use a frozen teething ring or ice cube for discomfort not a warm on. You should never use ibuprofen longer than 3 days. To prevent childhood caries, infants should not be given bottles while falling asleep.
A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? A. "Newborns are abdominal breathers." B. "Newborns do not expand their lungs fully with each respiration." C. "Activity will increase the respiratory rate." D. "The rate and rhythm of breath are irregular in newborns."
D. "The rate and rhythm of breath are irregular in newborns" Rationale: Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate Other options are correct, however have no impact on obtaining a respiratory rate
A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Autonomy vs. shame and doubt B. Industry vs. inferiority C. Identity vs. role confusion D. Initiative vs. guilt E. Trust vs. mistrust
E. Trust vs. mistrust =infancy A. Autonomy vs. shame and doubt= early childhood D. Initiative vs. guilt =preschool B. Industry vs. inferiority =school age C. Identity vs. role confusion= adolescent The correct order
Parents tell the nurse that their toddler eats little at mealtimes, only sits at the table with the family briefly, and wants snacks "all the time." The nurse should recommend that the parents: a. Give her planned, frequent, and nutritious snacks. b. Offer rewards for eating at mealtimes. c. Avoid snacks so she is hungry at mealtimes. d. Explain to her in a firm manner what is expected of her.
a. Give her planned, frequent, and nutritious snacks. Most toddlers exhibit a physiological anorexia in response to the decreased nutritional requirements associated with the slower growth rate. Parents should assist the child in developing health eating habits. Toddlers are often unable Ch 11 hockenberry 11th
What is the leading cause of death during the toddler period? a. Injuries b. Infectious diseases c. Childhood diseases d. Congenital disorders
a. Injuries Injuries are the most common cause of death in children ages 1-4 years. Congenital disorders are 2nd. Ch 11 hockenberry 11th
A nurse is providing education about age-appropriate activities for the caregivers of a 6 year old child. Which of the following activities should the nurse include in the teaching? a. Jumping rope b. Playing card games c. Solving a jigsaw puzzle d. Joining competitive sports
a. Jumping rope Recommended activities (playing hopscotch, jumping rope, riding bicycles, and joining organized sports.) Competitive sports are more appropriate for 9-12 year olds
Parents of an 18-month-old boy tells the nurse that he says "no" to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. What is the nurse's best interpretation of this behavior? a. This is normal behavior for his age. b. This is unusual behavior for his age. c. He is not effectively coping with stress. d. He is showing he needs more attention.
a. This is normal behavior for his age. Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and us of the word no. Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18 month old. Ch 11 hockenberry 11th
According to Piaget, magical thinking is the belief of which? a. Thoughts are all powerful b. God is an imaginary friend c. Events have cause and effect d. If the skin is broken, the insides will come out
a. Thoughts are all powerful Because of their egocentrism and transductive reasoning, preschoolers believe that thoughts are all powerful. Believing God is an imaginary friend is an example of concrete thinking in preschoolers spiritual development. Cause and effect implies logical thought, not magical thinking. Believing that if the skin is broken, the insides will come out is an example of concrete thinking in development of body image. Ch 12 hockenberry 11th
A hospitalized two year old child is crying because his mother is leaving. The most appropriate nursing action is to: a. Give the child some stuffed animals for play. b. Ask the child life specialist to play with him. c. Ask the mother what time she will be back. d. Allow the child two minutes to stop crying.
b. Ask the child life specialist to play with him. The most appropriate nursing action is to ask the child life specialist to play with the toddler. The child life specialist is specially trained and educated to play with hospitalized children within their developmental levels and with the appropriate play therapies. Separation anxiety is a significant stressor in the hospitalized toddlers and infants (James et al.)
Which type of play is most typical of the preschool period? a. Solitary b. Associative c. Parallel d. Team
b. Associative Associative play is a group play in similar or identical activities but without rigid organization or rules. School age children play in teams. Parallel play is that of toddlers. Solitary play is that of infants. Ch 12 hockenberry 11th
What is descriptive of the social development of school-age children? a. Identification with peers in minimum b. Children frequently have best friends c. Boys and girls play equally with each other d. Peer approval is not yet an influence for the child to conform
b. Children frequently have best friends Identification with peers is a strong influence in children gaining independence from parents. They also learn how to relate to people in positions of leadership and authority and how to explore ideas and the physical environment. A child's concept of appropriate sex roles is influenced by relationships with peers.
Which finding in a newborn is suggestive of tracheoesophageal fistula? a. Failure to pass meconium in 24 hours b. Choking on the first feeding c. Palpable mass in the sternal area d. Visible peristalsis across abdomen
b. Choking on the first feeding Newborns with with tracheoesophageal fistula cannot swallow, including their own oral secretions, which can also result in excessive drooling.
During hospitalization, a school-age child sucks his thumb and wets his bed every day. Which of the following nursing actions is most appropriate? a. Place the child in "time out". b. Clean the patient's bed and give him emotional support. c. Call the patient's parents so the child can be disciplined. d. Notify the pediatrician and request medication.
b. Clean the patient's bed and give him emotional support. In a stressful situation such as hospitalization, a child with undue anxiety can regress and reactivate a behavior more appropriate to an earlier stage of development.
A nurse is assessing a 3-year-old child with a tentative diagnosis of lead poisoning. What clinical finding supports this diagnosis? a. Epistaxis b. Clumsiness c. Excessive salivation d. Decreased pulse rate
b. Clumsiness Behavioral disturbances such as clumsiness are important clues to early identification of lead poisoning. The other options are incorrect because: Nosebleeds (epistaxis), Excessive salivation, & Bradycardia are clinical signs of lead poisoning.
A 4-year-old bot is hospitalized with a serious bacterial infection. He tells the nurse that he is sick because he was bad. What is the nurses best interpretation of this comment? a. Sign of stress b. Common at this age c. Suggestive of maladaptation d. Suggestive of excessive discipline at home
b. Common at this age Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them think they are directly responsible for events, making them feel guilt for things outside their control. Children of this age react to stress by regressing developmentally or acting out. Maladaptation is unlikely. This comment does not imply excessive discipline at home.
A nurse is caring for a child who has enuresis. Which of the following is a complication of enuresis? a. Urinary tract infections b. Emotional problems c. Urosepsis d. Progressive kidney disease
b. Emotional problems Emotional problems are a complication of enuresis. Urinary tract infections CAN happen but are not a complication of enuresis. Urosepsis and progressive kidney disease are are complications of UTIs.
exophthalmos (protruding eyes) may occur in children with which condition? a. Hypothyroidism b. Hyperthyroidism c. Hypoparathyroidism d. Hyperparathyroidism
b. Hyperthyroidism Exophthalmos is associated with hyperthyroidism. Hypothyroidism, hypoparathyroidism, and hyperparathyroidism are not associated with exophthalmos.
A nurse is assessing a 9-month old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? a. Creeps on hands and knees b. Inability to vocalize vowel sounds c. Uses crude pincer grasp d. Stands by holding onto support
b. Inability to vocalize vowel sounds The infant should begin vocalizing vowels at the age of 7 months and the age of 10 months, able to say at least one word. The infant should creep on her hands and knees at age 9 month, and begin to stand holding onto furniture at 10 mos. Most infants demonstrate a crude pincer grasp at 9 mos and the use of the dominant hand is evident at this time too.
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? a. Perform the assessment in a head to toe sequence b. Minimize physical contact with child initially c. Explain procedures in medical terms d. Stop the assessment if the child becomes uncooperative
b. Minimize physical contact with child initially Correct because start with least invasive then progress. Head to toe is more appropriate for preschool and school age. Nurse should use age appropriate language not medical terms. If child becomes uncooperative nurse would perform procedures more quickly.
A nurse is caring for an infant who just returned from PACU following cleft lip and palate repair. Which of the following actions should the nurse take? a. Remove the packing in the mouth b. Place the infant in an upright position c. Offer pacifier with sucrose d. Assess the mouth with a tongue blade
b. Place the infant in an upright position Placing the client upright with facilitate drainage and prevent aspiration. Packing should stay in the mouth for 2-3 days. Objects in mouth could injure the surgical site.
A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take? a. Encourage a high fiber, low protein, low calorie diet. b. Prepare the family for surgery c. Place an NG tube for decompression d. Initiate bed rest
b. Prepare the family for surgery Hirschsprung disease will require surgery to remove the affected segment of the intestine. They also are encouraged to eat a LOW fiber, HIGH protein, HIGH calorie diet. Placing a NG tube isn't the appropriate action. Bed rest is an intervention for a client with Meckel's diverticulum to prevent further bleeding.
A nurse is feeding an infant with a recent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding? a. Burp several times b. Rinse the suture line c. Place on the abdomen d. Hold for several minutes
b. Rinse the suture line Meticulous care of the suture line is necessary because inflammation and sloughing of tissue disrupt healing. The other options are incorrect because: a-Burping should be done throughout the feeding. b-Placing on the abdomen is contraindicated not only because the infant may rub the face on the sheet and irritate the suture line, but because of its relationship to SIDS. c-The infant can be held at any time.
A nurse is teaching a course about safety during the school-age. Which of the following information should the nurse include in the course? (SATA) a. Gating stairs at top and bottom b. Wearing helmets when riding bicycles or skateboarding c. Riding safely in bed of pickup trucks d. Implementing firearm safety e. Wearing seatbelts
b. Wearing helmets when riding bicycles or skateboarding d. Implementing firearm safety e. Wearing seatbelts Gating stairs at top and bottom is a good safety precaution for toddlers not school age. It is never safe to ride in a pickup bed.
When appropriately assessing an infant's heart rate, it is important for the nurse to: (Select all that apply) a. count for 15 seconds and multiply by 4. b. count the heart rate for one full minute . c. count the brachial pulse with one finger. d. ask the parent to look at her watch while counting the pulse. e. assess the apical pulse using a stethoscope.
b. count the heart rate for one full minute . e. assess the apical pulse using a stethoscope. The HR is most accurate when it is assessed with a stethoscope, for one full minute by the nurse, especially for children less than 2 years old. (James et al.-chapter 9-physical assessment)
When checking a toddler's vital signs, the nurse initially assesses the: a. heart rate. b. respiratory rate. c. blood pressure. d. temperature.
b. respiratory rate. The nurse assesses the least invasive VS first and then progresses to the most invasive. Thus, RR, HR, temperature, and then BP. (James et al., chapter 9-physical assessment)
A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of a toddler? A. Explains the difference between right and wrong B. Prints letters and numbers C. Separates easily from primary caregiver for short periods of time D. Cooperates in doing simple chores
c) Separates easily from primary care giver for short periods of time By 3 years, a toddler's psychosocial development should include the ability to accept separating from a primary care giver for short periods of time, should also be able to express likes/dislikes and begin to play with children and others outside the family. (diff btwn right & wrong is school-age, ability to write letters and numbers and simple chores is 5 years)
At which age do most infants begin to fear strangers? a. 2 months b. 4 months c. 6 months d. 12 months
c. 6 months Between ages 6-8 months, fear of strangers and stranger anxiety become prominent and are related to infants ability to discriminate between familiar and unfamiliar people. At 2 months, infants are just beginning to respond to differentially to their mothers. The infant at age 4 months is beginning the process of separation-individuation, which involves recognizing the self and mother as separate beings. 12 months is too late; the infant requires referral for evaluation if he or she does not fear strangers by this age.
At which age can most infants sit steadily unsupported? a. 4 months b. 6 months c. 8 months d. 10 months
c. 8 months Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 6 months, the infant will maintain a sitting positions if propped. By 10 months , the infant can usually move from a prone to a sitting position.
The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation? a. Place in the Trendelenburg position b. Apply moist heat to the abdomen c. Allow the child to assume a position of comfort d. Administer a saline enema to cleanse the bowel
c. Allow the child to assume a position of comfort The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with discomfort. If appendicitis is a possibility, administering laxative or enemas or applying heat to area is dangerous. Such measures stimulate bowel motility and increase the risk of perforation.
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? a. Feed the infant in supine position b. Encourage the mother to breastfeed the infant exclusively c. Burp the infant frequently during feedings d. Perform nasotracheal suctioning if coughing occurs
c. Burp the infant frequently during feedings Rationale: Infants with a cleft palate have difficulty creating a seal around a bottle. Burping the infants frequently during feedings
A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? a. Give the toddler milk b. Go to the emergency department c. Call the poison control center d. Induce vomiting
c. Call the poison control center According to evidence based practice, the nurse should instruct parents to first call poison control center, which will then identify further actions the parents can take. The other answers answers are right for some interventions for ingestion of certain toxic substances but poison control is the first step.
During administration of an intravenous fluid to a child, the nurse assesses redness and swelling at the IV catheter insertion site. Which of the following is the most appropriate course of action for the nurse? a. Continue the infusion until it is complete. b. Discontinue the infusion after calling the doctor. c. Discontinue the IV fluid infusion. d. Ask another RN to assess the IV site.
c. Discontinue the IV fluid infusion. If signs and symptoms of complications or infiltration are noted, the IV infusion is discontinued and the physician should be notified.
A nurse is caring for a 1-month-old infant who had surgery to repair a cleft lip. What should the nurse use to facilitate feeding during the immediate postoperative period? a. Soft nipple b. Plastic spoon c. Feeding syringe d. Nasogastric tube
c. Feeding syringe Feeding with a syringe provides nutrition without placing stress on the suture line. The other options are incorrect because: a-Sucking stresses the suture line. b-A spoon may injure the suture line. d-Nasogastric feedings are unnecessary because fluid can be ingested orally.
Which characteristic best describes the fine motor skills of an infant at age 5 months? a. Neat pincer grasp b. Strong grasp reflex c. Builds a tower of two cubes d. Able to grasp object voluntarily
d. Able to grasp object voluntarily At age 5 months, the infant should be able to voluntarily grasp an object. The grasp reflex is present in the first 2 to 3 months of life. Gradually, the reflex becomes voluntary. The neat pincer grasp is not achieved until age 11 months. At age 12 months, an infant will attempt to build a tower of two cubes but will most likely be unsuccessful.
The developmental task with which the child of 15-30 months is likely to be struggling is a sense of which? a. Trust b. Initiative c. Intimacy d. Autonomy
d. Autonomy Autonomy versus shame and doubt is the developmental task of toddlers. Trust versus mistrust is the developmental stage of infancy. Initiative versus guilt is the developmental stage of early childhood. Intimacy and solidarity versus isolation is the developmental stage of early adulthood. Ch 11 hockenberry 11th
During assessment, the nurse notes an infant's head circumference has increased almost 6 centimeters since the last hospitalization six months ago. The nurse understands the increase in head circumference in this infant indicates which of the following? a. Higher IQ b. Increased hearing acuity c. Increased sense of sight d. Brain growth
d. Brain growth One parameter of the growth of the developing child is the head circumference; this indicates brain growth. The average head growth occurs in the pattern of 12 cm during the first year.
What clinical manifestation should be the most suggestive of acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Colicky, cramping, abdominal pain around the umbilicus
d. Colicky, cramping, abdominal pain around the umbilicus Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain becomes constant and may to the RLQ. Rebound tenderness is not a reliable sign and relieved by eating are not signs of appendicitis.
In terms of fine motor development, what could the 3-year-old child be expected to do? a. Tie shoelaces. b. Use scissors or a pencil very well. c. Draw a person with seven to nine parts. d. Copy (draw) a circle.
d. Copy (draw) a circle. 3 year children are able to accomplish the fine motor skill of copying (drawing) a circle. Shoelaces, using scissors or a pencil very well, and drawing a person with 7-9 parts are fine motor skills for a 5 year old. Ch 12 hockenberry 11th
To obtain an appropriate pain assessment of a preschool aged child, the nurse uses which of the following tools? a. Numeric Rating Scale b. FLACC c. CRIES Pain Scale d. FACES Pain Rating Scale
d. FACES Pain Rating Scale Most appropriate-FACES Pain Rating Scale is for 3 y.o. and older. Numeric-Child 9 y.o. and older. FLACC-infants, preverbal or nonverbal child. CRIES-neonates, 0-6 months old. (James et al., p. 323)
What clinical manifestation is considered a cardinal sign of diabetes mellitus? a. Nausea b. Seizures c. Impaired vision d. Frequent urination
d. Frequent urination Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia. Nausea and seizures are not clinical manifestations of DM. Impaired vision is a long term complication of DM.
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. Which of the following is the most essential part of the nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness
d. Level of consciousness The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal neurologic signs. The other options are incorrect because: A-Neurologic posturing is indicative of neurologic damage. B and C --Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.
A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication? a. Hyperkalemia b. Hyperchloremia c. Metabolic acidosis d. Metabolic alkalosis
d. Metabolic alkalosis Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis is likely.
A parent asks the nurse about negativism in toddlers. What is the most appropriate recommendation? a. Punish the child b. Provide more attention c. Ask child not to always say no d. Reduce the opportunities for a no answer
d. Reduce the opportunities for a no answer The nurse should suggest to the parent that questions should be phrased with realistics choices rather than yes or no answers. This provides a sense of control for the toddler and reduces the opportunity for negativism. Negativism is not an indication of stubborness or insolence and shouldn't be punished nor a function of attention. The child is testing limits to gain an understanding of the world. The toddler is too young to comply with requests not say no. Ch 11 hockenberry 11th
While an adolescent is hospitalized, a source of anxiety for him is the: a. Separation from his computer. b. Separation from his siblings. c. Separation from his parents. d. Separation from his friends.
d. Separation from his friends. While the adolescent is hospitalized, separation from his friends is a source of anxiety as he feels his peer group is important (James et al.).
Which of the following are appropriate and safe toys for infants? (Select all that apply) a. Latex balloon with ribbons b. Car keys with plastic ring c. Cell phone with Elmo case d. Soft bright teething toy e. Plastic nesting containers
d. Soft bright teething toy e. Plastic nesting containers For infants, provide bright rattles, tactile toys, a mirror, bath toys, large ball, plastic stacking or nesting containers, and/or cloth, cardboard, or plastic books (James et al., Chapter 5). Always provide supervision during play time with infants.
Which characteristic best describes the gross motor skills of a 24 month old child? a. Skips b. Broad jumps c. Rides tricycle d. Walks up and down stairs
d. Walks up and down stairs A 24 month old child can go up and down stairs alone with two feet on each step. Skipping and broad jumping are skills acquired at age 3 years. Tricycle riding is achieved at age 4. Ch 11 hockenberry 11th
Which of the following questions would be most important to include in the initial assessment of a near-drowning victim? a. Does the child know how to swim? b. Did the child fall or dive into the water? c. Is the child able to talk about the accident? d. Was the water fresh or salt water?
d. Was the water fresh or salt water? The physiologic responses are different with near-drowning depending on whether the water inhaled was fresh or salt water. The other options will not influence how you treat the patient or meet their immediate needs.
The nurse understands caring for a child means the nurse is caring for the: a. family dog and the child. b. child and his siblings. c. child only. d. whole family as the client.
d. whole family as the client. In 2003, family-centered care was adopted as a philosophy of care for pediatric nursing by the Society of Pediatric Nurses.
4.A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson? A. Encourage the client to complete school work. B. Vary the child's schedule each day. C. Discourage visits from the client's friends. D. Provide a daily session with a play therapist.
A. Encourage the client to complete school work. A. Encourage the client to complete school work. Rationale:Erikson's stage of psychosocial development for a 10-year-old child is industry vs. inferiority. By providing school-age children the opportunity to keep up with their school work, they can continue to develop skills and knowledge and maintain a sense of accomplishment. Maintaining a consistent daily schedule can help make the child feel more secure, decrease stress, and feel less isolated from their peers. Encouraging visits from friends can help the school-age child adjust emotionally to the stress of prolonged hospitalization. The school-age child needs to play, and a daily therapeutic session with the play therapist will help the child adjust to the stress of prolonged hospitalization. However, this action does not address the child's psychosocial development according to Erikson.
A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) A. Have a parent stay with the child during procedures. B. Cluster invasive procedures whenever possible. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. E. Use mummy restraints during painful procedures.
A. Have a parent stay with the child during procedures C. Perform procedures as quickly as possible D. Allow the child to keep a toy from home with her
A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) A. Have a parent stay with the child during procedures. B. Cluster invasive procedures whenever possible. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. E. Use mummy restraints during painful procedures
A. Have a parent stay with the child during procedures. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. Rationale: Have a parent stay with the child during procedures is correct. Maintaining parent-child contact is one of the most supportive interventions for toddlers and preschoolers undergoing painful procedures. Cluster invasive procedures when possible is incorrect. Clustering creates an unnecessarily lengthy and painful period for the client, which is likely to increase her fear. Perform procedures as quickly as possible is correct. Moving quickly through the steps of a painful procedure is a supportive intervention for children undergoing painful procedures. Allow the child to keep a toy from home with her is correct. Having familiar and cherished objects nearby is therapeutic for children during their hospitalization. Use mummy restraints during painful procedures is incorrect. Mummy restraints help to immobilize very young children and keep them safe during procedures, but it is likely to increase fear in toddlers and preschoolers.
A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider? A. Inability to raise head when in prone position B. Inability to sit without support C. Inability to pick up an object with her fingers D. Inability to bring an object to her mouth
A. Inability to raise head when in prone position A 3-month-old infant should be able to raise her head and shoulders from prone position. (should be able to sit without support at 8 months; should be able to grasp objects w fingers at 6 months; should be able to bring objects to her mouth at 4 months)
A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Management of tantrums B. How to establish trust C. How to encourage cooperative play D. Dental care E. Need for increased caloric intake
A. Management of tantrums D. Dental care
A nurse is teaching car seat safety to a parent of an infant who weighs 4.5 kg (10 lb). Which of the following car seat positions should the nurse include in the teaching? A. Rear-facing in the middle of the back seat B. Forward-facing in the back seat C. Forward-facing in the front passenger seat D. Rear-facing in the back seat next to a window
A. Rear-facing in the middle of the back seat The safest position for infants is rear facing in the center of the back seat. Infants should ride rear-facing until age 2 or until the child outgrows the height or weight limits of a rear-facing seat. Studies have shown that children who ride properly restrained in the middle of the back seat have a 43% decreased risk for injury compared to children who are placed near a window.
A nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. C. Install accordion style gates. D. Set the water heater at 65.6° C (150° F). E. Fit the mattress so that it is snug against the sides of the crib.
A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. E. Fit the mattress so that it is snug against the sides of the crib. Rationale:Serve food in small, non-circular pieces is correct. Infants have small airways. Food items are a common cause of aspiration. The foods most associated with choking and aspiration are hot dogs, candy, nuts, and grapes.Tie plastic bags in knots before discarding them is correct. Tying the bags in knots prevents the child from placing the plastic over her head.Install accordion style gates is incorrect. This type of gate can cause the child to pinch herself or to become entangled in the openings.Set the water heater at 65.6° C (150° F) is incorrect. Water heaters should be set to a temperature of 48.9° C (120° F) or lower to prevent burns.Fit the mattress so that it is snug against the sides of the crib is correct. The mattress should be fit snugly to prevent the child from being caught between the slats of the crib and the mattress.
The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make? A. "Let your child sleep in your bed with you." B. "Keep a night light on in your child's room." C. "Tell your child that monsters are not real." D. "Stay with your child until the child is asleep."
B. "Keep a night light on in your child's room." Rationale: Fears of the dark and "monsters" are common in preschool-age children who are imaginative thinkers and have difficulty distinguishing between real and make-believe. After the parent reassures the child that there are no monsters, the night light provides enough illumination for the child to see that there is nothing hiding in the closet. This is not an appropriate suggestion for a preschool-age child who has difficulty distinguishing between real and make-believe. This behavior can develop into a habit that can be difficult to break. 6.A nurse is developing a health program for the parents of school-age boys. Co-sleeping can develop into a habit that can be difficult to break.
A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? A. 3 months B. 6 months C. 9 months D. 12 months
B. 6 months
A nurse is assessing a 2.5 year old (30 months) toddler at a well-child visit. Which of the following findings should the nurse report to the provider? A. Height increased by 7.5 cm (3 in) in the past year. B. Head circumference exceeds chest circumference. C. Anterior and posterior fontanels are closed. D. Current weight equals four times the birth weight
B. Head circumference exceeds chest circumference. The head and chest circumference should be equal by age 1 to 2, with the chest circumference continuing to increase in size until it exceeds the head circumference. So by this age 2.5 you would report this finding to the provider. Everything else is WNL for toddler physical development. ATI RN NURSING CARE OF CHILDREN pg 21
A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take? A. Report the suspected abuse to the authorities. B. Obtain a detailed history. C. Ask a psychiatrist to talk with the parents. D. Separate the child from the parents.
B. Obtain a detailed history. Rationale: The nurse should obtain a detailed history in order to assess for other indicators of abuse. Determining abuse requires more than one indicator.
A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant is unable to imitate animal sounds. B. The infant does not sit steadily without support. C. The infant cannot turn pages in a book. D. The infant cannot build a tower of three or four cubes
B. The infant does not sit steadily without support Rationale: An 8-month old should be able to sit steadily without support. A 10-month-old infant should be able to change from a prone to sitting position, stand while holding onto furniture, and life one foot while standing. A 12-month-old should be able to imitate animal sounds and turn pages in a book. A 18-month-old should be able to build a tower of three or four cubes
A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot build a tower of six to seven cubes. B. The toddler cannot stand upright without support. C. The toddler cannot jump with both feet. D. The toddler cannot turn a doorknob.
B. The toddler cannot stand upright without support Rationale this is to be expected by 15 months if not achieved it can be indicative of a developmental delay. (build a tower of 6-7 cubes at 24 months; jump with both feet at 30 months; turn a doorknob at 24 months)
A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress? A. Set of building blocks B. Toy hammer and pounding board C. Picture book about hospitals D. Stuffed animal
B. Toy hammer and pounding board All toys are age appropriate, but a toy hammer and pounding board helps the child to express the anger and frustration he feels about the parent leaving but lacks the verbal ability to express.
A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching? A. "Share piercing needles only with close friends you trust." B. "Limit your caloric intake to avoid becoming overweight." C. "Your need for sleep will increase during periods of growth." D. "Tanning beds are much safer then lying in the sun."
C. "Your need for sleep will increase during periods of growth." Rationale: The nurse should inform the adolescent that sleep needs increase during growth spurts. Adequate sleep and rest during the adolescent period is important for optimal health. According to Erickson, the developmental goal of adolescence is the need to establish an identity. Some choose methods of body modification, such as piercing and tattooing. The goal for the nurse is not to prevent these practices, but to educate the adolescent and care givers about engaging in safe practices if they choose these activities. Adolescents have more independence and often make nutrition decisions on their own. Caloric intake should be based on the level of activity and the nurse should educate the adolescent regarding dietary guidelines for all nutrients. Tanning beds pose serious long-term risks. The long-term effects of tanning beds include premature aging of the skin as well as an increased risk of skin cancer.
A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions should the nurse take to promote sleep? A. Explain the source of the toddler's fears. B. Turn off the room light. C. Provide bedtime rituals. D. Encourage play exercises in the evening.
C. Provide bedtime rituals.
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse? A. A child who has frequent visitors B. A child who has a BMI indicating obesity C. A child who uses the call light frequently D. A child whose parents answer questions for the child
D. A child whose parents answer questions for the child Rationale: Often the perpetrator of abuse is controlling and will talk for the child to avoid the risk of the child saying something that could expose the abuse. A school-age child should be able to answer most questions. Parents of abused children often control interactions with peers and try to seclude children. Abused children often do not have many friends or frequently change friends. A child who is abused is often numb or emotionless. The child does not talk much or show signs of curiosity. The child often tries to disappear to avoid notice and decrease the risk of additional abuse. This child is not likely to use the call light frequently. :An abused child is likely to show failure to thrive and a low body weight.
A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation? A. Uses a unidextrous grasp B. Has a fear of strangers C. Shows preferences towards foods D. Babbles one-syllable sounds
D. Babbles one-syllable sounds Rationale: A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds, therefore, this finding indicates a need for further evaluation
A nurse is developing a health program for the parents of school-age boys. Which of the following information about pubescent changes should the nurse include in the program? A. Changes in the voice signal the beginning of puberty. B. Gynecomastia commonly occurs during late puberty. C. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years. D. Growth spurts in height occur toward the end of midpuberty.
D. Growth spurts in height occur toward the end of midpuberty. Rationale: Growth spurts in height occur toward the end of midpuberty. Boys grow an average of 10 to 30 cm (4 to 12 inches) during this period. Enlargement of the testicles signals the beginning of puberty. Gynecomastia typically occurs during midpuberty. Puberty changes might be delayed if scrotal changes have not occurred by 13½ to 14 years of age.
.A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse include as being expected of a preschooler? A. Controls impulsive feelings B. Builds a collection of cards C. Expresses need for privacy D. Participates in imaginary play
D. Participates in imaginary play Rationale:By 5 years of age, a preschooler should participate in imaginary and creative play, play cooperatively with peers, and speak in complete sentences. By 12 years of age, a school-age child usually expresses a need for privacy when performing personal hygiene, such as bathing or showering. By 12 years of age, a school-age child's psychosocial development should include the ability to collect small items, such as cards, stamps, rocks, and buttons. By 12 years of age, a school-age child's psychosocial development should include the ability to control impulsive feelings.
A toddler, age 16 months, falls down a few stairs. He gets up and scolds the stairs as if they caused him to fall. What is this an example of? a. Animism b. Ritualism c. Delayed cognitive development d. Irreversibility
a. Animism Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the toddler is attributing human characteristics to them. Ritualism is the need to maintain sameness and reliability. It provides a sense of comfort to toddlers. Irreversibility is the inability to reverse or undo actions initiated physically. The toddler is acting in an age appropriate.
A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? a. At the end b. At the beginning c. before examining the head and neck d. Before auscultating the chest and abdomen
a. At the end Rational:Save invasive procedure for last- part of modified Head-to-toe approach
A nurse is planning care for a 10 month old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (SATA) a. Observe the parents' actions when feeding the child b. Maintain a detailed record of food and fluid intake c. Follow the child's cues as to when fluids are provided d. Sits besides the child's high chair when feeding the child e. Play music videos during scheduled meal times
a. Observe the parents' actions when feeding the child b. Maintain a detailed record of food and fluid intake. Inappropriate feeding techniques and meal patterns provided by parents can contribute to a childs failure to grow. A nutritional goal for the child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake. A child with FTT may not have feeding cues. Should sit directly in front of child when feeding and promote eye contact. A quiet stimulate free environment should be provided at meal times to avoid distractions and focus attention on food intake.
What is an important nursing intervention for a full-term infant receiving phototherapy? a. Observing for signs of dehydration b. Using sunscreen to protect the infants skin c. Keeping the infant diapered to collect frequent stools d. Informing the mother why breastfeeding must be discontinued
a. Observing for signs of dehydration Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions shouldn't be used, breastfeeding is encouraged.
A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? (SATA) a. Projectile vomiting b. Dry mucous membranes c. Currant jelly stools d. Sausage shaped abdominal mass e. Constant hunger
a. Projectile vomiting b. Dry mucous membranes e. Constant hunger A client with pyloric stricture has thickening of the pyloric sphincter,resulting in projectile vomiting and they are unable to consume food and fluid resulting in dehydration (dry mucous membranes) and hunger. Sausage shaped abdominal mass and currant jelly stools are manifestations of intussusception.
A nurse is caring for a preschool age child who is dying. Which of the following findings is an age appropriate reaction to death by the child? (SATA) a. The child views death similar to sleep b. The child is interested in what happens to his body after death c. The child recognizes that death is permanent d. The child believes his thoughts can cause death e. The child thinks death is a punishment
a. The child views death similar to sleep d. The child believes his thoughts can cause death e. The child thinks death is a punishment School age child would be more interested in what happens after death and to the body than preschool age. Preschool age have difficulty understanding what is permanent and a concept of time. They perceive death as reversible.
What statement best describes Hirschsprung disease? a. The colon has an aganglionic segment b. It results in frequent evacuation of solids, liquid, and gas c. The neonate passes excessive amounts of meconium d. It results in excessive peristaltic movements within the gastrointestinal tract
a. The colon has an aganglionic segment Mechanical obstruction in the colon results from a lack of innervation. In most cases, the aganglionic segment includes the rectum and some portion of the distal colon. There is decreased evacuation of the large secondary to the aganglionic segment. Liquid stool may ooze around the blockage. The obstruction does not affect meconium production. The infant may not be able to pass the meconium stool. There is decreased movement in the colon.
What is descriptive of nutritional requirements of preschool children? a. The quality of the food consumed is more important than the quantity b. The average daily intake of preschoolers should be about 3000 calories c. Nutritional requirements for preschoolers are very different from requirments for toddlers. d. Requirements for calories per unit of body weight increases slightly during the preschool period
a. The quality of the food consumed is more important than the quantity Parents need to be reassured that the quality of food eaten is more important than the quantity. Children are able to self regulate their intake when offered foods high in nutritional value. The average daily caloric intake should be approx 1800 cals. Toddlers and preschoolers have similar nutritional requirements. There is an overall slight decrease in needed calories and fluids during the preschool period.
For which of the following reasons are infants and children at greater risk for infection? (Select all that apply) a. Their immune systems are not as robust as adults' immune systems. b. Their parents do not give them chewable multi-vitamins every day. c. They have a proportionately greater body surface area in relation to mass. d. They do not drink enough Gatorade, Powerade, and energy drinks. e. They have increased exposure to infections in daycares and schools.
a. Their immune systems are not as robust as adults' immune systems. c. They have a proportionately greater body surface area in relation to mass. e. They have increased exposure to infections in daycares and schools. In comparison to adults, infants and children have a proportionately greater body surface in relation to body mass, resulting in a greater potential for fluid loss through the skin and gastrointestinal tract. Their immune systems are not as robust as adults, rendering young children more susceptible to infectious diseases, fever, gastroenteritis, & respiratory infections, all of which result in fluid & electrolyte disturbances and fluid-volume deficit. They are also at higher risk because of increased exposure to infections in a daycare, nursery, and school settings. (James et al., p. 337)
The parents of a 3 month old infant report that their infant sleeps supine (Face up) but is often prone (face down) while awake. The nurses response should be based on remembering what? a. This is acceptable to encourage head control and turning over b. This is acceptable to encourage fine motor development c. This is unacceptable because of the risk of SIDS d. This is unacceptable because it does not encourage achievement of developmental milestones
a. This is acceptable to encourage head control and turning over These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs to reduce the risk of SIDS and then be placed on their abdomens when awake to enhance achievement of milestones such as head control. These position changes encourage gross motor, not fine motor, development.
What is descriptive of the play of school age children? a. They like to invent games, making up the rules as they go b. Individuality in play is better tolerated than at earlier ages c. Knowing the rules of a game gives an important sense of belonging d. Team play helps children learn the universal importance of competition and winning
c. Knowing the rules of a game gives an important sense of belonging Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and cliques and develop a sense of belonging to a team or club. At this age, children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, attribute highly valued in the U.S. but not all cultures.
What statement best describes the relationship school-age children have with their families? a. Ready to reject parental controls b. Desire to spend equal time with family and peers c. Need and want restrictions placed on their behavior by the family d. Peer group replaces the family as the primary influence in setting standards of behavior and rules
c. Need and want restrictions placed on their behavior by the family School age children need and want restrictions placed on their behavior , and they are not prepared to cope with all the problems of their expanding environment. Although increased independence is the goal of middle childhood, they feel more secure knowing that an authority figure can implement controls and restriction. In the middle school years, children prefer peer group activities oveto family activities and want to spend more time with peers. Family value systems usually take precedence over peer value systems.
A child who is unable to verbalize his feelings may express feelings and thoughts through which of the following? a. Diet b. Clothing c. Play d. Watching television
c. Play Play can greatly facilitate communication with children. Children are less likely to be inhibited when participating in play interactions.
When safely administering otic drops to a five year old child, the appropriate nursing action(s) is to: a. Grasp pinna at lobe, pull down and back. b. Grasp ear at the center, pull backwards. c. Pull pinna at the lobe, pull up and back. d. Pull the pinna of the ear up and back.
c. Pull pinna at the lobe, pull up and back. Administering otic drops-For a child older than 3 years old, pull the pinna of the ear up and back.
When caring for a child with probably appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation? a. Anorexia b. Bradycardia c. Sudden relief from pain d. Decreased abdominal distention
c. Sudden relief from pain Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Anorexia is already a clinical manifestation of peritonitis. Abdominal distention usually increase in addition to an increase in pain (usually diffuses and accompanied by rigid guarding of the abdomen).
Although a 14-month-old girl received a shock from an electrical outlet recently, her parents find her about to place a paper clip in another outlet. The best interpretation of this behavior is: a. Her cognitive development is delayed. b. This is typical behavior because toddlers are not very developed. c. This is typical behavior because of inability to transfer knowledge to new situations. d. This is not typical behavior because toddlers should know better than to repeat an act that caused pain.
c. This is typical behavior because of inability to transfer knowledge to new situations. This is typical behavior for a toddler, who is only somewhat aware of a causal relation between events. Her cognitive development is appropriate for her age.
In terms of gross motor development, what should the nurse expect an infant age 5 months to do? a. Sit erect without support b. Roll from the back to the abdomen c. Turn from the abdomen to the back d. Move from a prone to a sitting position
c. Turn from the abdomen to the back Rolling from the abdomen to the back is developmentally appropriate for an infant at age 6 months. Sitting erect without support is a developmental milestone usually achieved by 8 months. A 10 month old infant can usually move from a prone to a sitting position.
To assess the Point of Maximum Impulse (PMI) of a child who is 10 years old, the nurse assesses the apical pulse at the: a. third intercostal space, lateral to the midclavicular line. b. fourth intercostal space, lateral to the midclavicular line. c. fifth intercostal space at the midclavicular line. d. space anywhere around the left nipple.
c. fifth intercostal space at the midclavicular line. Correct-The PMI in a child older than 7 years old is located in the fifth intercostal space in the midclavicular line.
The most appropriate communication skill the pediatric nurse should use when caring for an adolescent patient is: a. using toys and games. b. the use of smart phones for texting. c. listening nonjudgmentally. d. having family present at all times
c. listening nonjudgmentally. Nurses who work with adolescents must develop communication skills that include remaining nonjudgmental, making no assumptions, making the adolescent feel comfortable.
A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? A. Imaginary playmates B. Erikson's stage of initiative versus guilt C. Demonstrations of sexual curiosity D. Negative behaviors characterized by the need for autonomy
d) Negative behaviors characterized by the need for autonomy Assertion of autonomy is seen in toddlers as they begin their language and social development.(imaginary playmates at 4-5 yrs; initiative vs guilt & sexual curiosity is preschool-aged)
A safe volume of medication for an intramuscular injection for an infant is: a. 2 mL b. 1.5 mL c. 1.1 mL d. 0.5 mL
d. 0.5 mL The safe volume of medication for an IM injection for the infant is 0.5 mL, especially if they have smaller muscle mass. The maximum amount of volume for an IM injection for a premature infant is 0.5 mL; a neonate is 0.5-1.0 mL; an infant from 1-12 months is up to 1.0 mL. Proper assessment of the infant's muscle mass is appropriate. Incorrect: >1 mL
What blood glucose measurement is most likely associated with diabetic ketoacidosis? a. 185 mg/dl b. 220 mg/dl c. 280 mg/dl d. 330 mg/dl
d. 330 mg/dl Diabetic Ketoacidosis is a state of relative insulin insufficiency and may include the presence of hyperglycemia, a blood glucose level greater than or equal to 330 mg/dL; 18, 220, 280 mg/dL are values that are too low for the definition of ketoacidosis.
