Care Of Children youssef

Superior vena cava The superior and inferior vena cava carry

deoxygenated blood to the right atrium.

A client who has dysphagia has

difficulty swallowing.

A client who has visual receptive aphasia has

difficulty understanding written words.

adolescent is in the developmental stage of

identity versus role confusion.

A toddler experiencing severe dehydration would exhibit

absence of tears and sunken eyeballs

Autonomy is the

right to self-determination, independence, and freedom of choice

A client with dysarthria has

slurred speech. The nurse cannot determine if the client has dysarthria due to the lack of verbal response.

RIFLE classification

the RIFLE classification, R is for Risk, I is for Injury, F is for Failure, L is for Loss, and E is for End-stage kidney disease.

A client who exhibits decorticate posturing flexes

the arms with internal rotation of the forearms and extends and plantar flexes the leg

Effacement is the thinning of

the cervical tissue.

remote memory,

the nurse should ask the client for information from the distant past such as the client's city of birth or the schools he attended. It is best to ask information that the nurse can verify.

infant is in the developmental stage of

trust versus mistrust

Facial droop and an asymmetrical smile indicate damage to

CN VII. 7

Weakness of the tongue indicates damage to

CN XII. 12

A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child?

Coloring book and crayons Preschoolers have increasing fine motor control and imagination abilities. They enjoy toys that allow for creativity and self-expression.

Heberden's nodes

D. Hard lumps over the joints of the fingers, bony lumps or nodules in the joints of the fingers

Chronic diarrhea is an expected finding for a preschooler who has

HIV.

Fasting is not required for the

PSA test. The client may eat or drink up until the time of the test.

A nurse is reinforcing teaching about home safety with the parent of a 2-month-old infant. Which of the following information should the nurse include?

Remove bibs before the infant goes to sleep The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation. Incorrect Answers: B. The nurse should instruct the parent to dress the infant in a 1-piece sleep sack and avoid using blankets to decrease the risk of suffocation. C. The nurse should instruct the parent to avoid placing the infant in direct sunlight for more than 2 to 3 minutes at a time. If the infant will be exposed to sunlight for a longer period, the parent should cover any exposed areas of skin. D. The nurse should instruct the parent to set the hot water heater to no more than 49°C (120°F) to prevent burn injuries

sign of the treatment of syphilis was effective

The client reports an episode of fever for 24 hours. A sudden episode of hypotension, fever, tachycardia, and muscle aches is known as a Jarisch-Herxheimer reaction, which is caused by the sudden destruction of spirochetes after therapy

newborn who was delivered after 42 weeks of gestation.

The lack of vernix in-utero causes the dry peeling appearance of the skin

osteoarthritis

The nurse should identify unilateral joint involvement as a finding of osteoarthritis. aging is a risk factor that causes degenerative changes in osteoarthritis. The nurse should expect the joints of a client who has osteoarthritis to feel bony and cool to the touch. A client who has rheumatoid arthritis experiences red, hot, tender joints. The nurse should recognize that osteoarthritis is limited to the joints.

an expected fine motor skill for9-month-old infant should

The pincer grasp Falling to a sitting position from a standing position ability to maintain balance while leaning forward in a sitting position.

an expected age-related change in older adult

Thickening of blood vessel walls is in older adults. Decreased peripheral circulation Increased pulmonary vascular Decreased cardiac output

Recall

To test recall or recent memory, the nurse should ask the client to provide details about how he arrived at the appointment and with whom. The nurse could also ask the client to name any health care providers he saw in the past few days.

The presence of an S4 heart sound is

an expected finding in an older adult.

A widened anterior-posterior chest diameter is an expected finding for

an older adult client. This occurs as a result of a loss in skeletal muscle strength in the thorax and the diaphragm as well as age-related hyperinflation of the lungs.

Dilation is the widening of the

cervix during labor

Slander, or spoken defamation of character, refers to a

false statement by someone that can damage another person's reputation, casting a negative light on that person's character.

Preschool and school-aged children are typically interested in a demonstration of

how the examination equipment works. Toddlers might want to inspect the equipment before use but are not usually interested in how it functions.

school-aged child is in the developmental stage of

industry versus inferiority

Conversion is an

involuntary or unconscious transformation of anxiety into physical symptoms that have no physiological cause. This client is not demonstrating conversion

Corticosteroids can suppress adrenal gland function, and abruptly stopping them can

lead to adrenal insufficiency, a potentially life-threatening condition

A client who has a friction rub will manifest

loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration.

Lower back pain is common among clients who have

osteoporosis, especially when they lift, stoop, or bend. Back pain and tenderness that cause movement restriction might indicate vertebral compression fractures, which are the most common type of fracture resulting from osteoporosis.

A 3-year-old child does not have the

physical coordination to jump rope. This choice is appropriate for a 5-year-old child

The nurse should identify that decreased urinary output is a manifestation of

placenta previa

The number 4 denotes the number of

pregnancies, including the current pregnancy, not the number of living children

Abundant lanugo is a physical manifestation of

prematurity. The nurse should assign this finding a score of 3

what does biophysical profile less than or equal 4 mean

prepare the client for delivery

The nurse is reinforcing teaching for the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching?

"I should ignore the stuttering and not interrupt her." Explanation: Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become prolonged

Sublimation is the

process of unconsciously replacing an unacceptable behavior with something more acceptable. This client is not demonstrating sublimation.

The nurse should place a child who has myelomeningocele in a

prone position to minimize the risk of trauma or tension to the sac.

A nurse is reinforcing discharge teaching with the parent of a newborn who has been prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching?

"I should lightly massage my baby underneath the straps once a day." The parent should lightly massage the skin under the harness daily to promote circulation. Incorrect Answers: A.The parent should avoid using powder and lotion because they can accumulate in the skin folds and cause irritation. B. The parent should never adjust the length of the straps on the harness. The straps should only be adjusted by the health care provider to ensure prevention of hip extension and adduction. D. The diaper should be placed under the harness to maintain cleanliness.

2 month enfant

"Your baby can start the pneumococcal vaccine now." The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age.

Bright flashes of light (especially in the peripheral visual field) and floaters are associated with

retinal detachment. Retinal detachment refers to the separation of the light-sensitive membrane in the back of the eye from its supporting layers. Trauma, the aging process, severe diabetes mellitus, or an inflammatory disorder can cause retinal detachment, but this condition frequently occurs spontaneously.

Infants who are exposed to HIV should receive all

routine vaccinations that are inactivated.

uterine atony

serious condition that can occur after childbirth. It occurs when the uterus fails to contract after the delivery of the baby, and it can lead to a potentially life-threatening condition known as postpartum hemorrhage.

Decerebrate posturing indicates

severe brainstem injury and late neurological decline.

The nurse should expect a 24-month-old toddler to be able to

stack a short tower of 6 or 7 blocks. A 24-month-old toddler will have a "pot-bellied" appearance, and the client's legs should be slightly bowed in appearance to support the weight of the large trunk. have 16 teeth. have a vocabulary of about 300 words, and be able to speak in 2- to 3-word phrases. have a head circumference that is equal to or less than the chest circumference

Instill a diluted alcohol solution into the ear after

swimming External otitis is inflammation of the external auditory canal. It is often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.

Displacement is a

transfer of feelings related to a person or situation to another less threatening or neutral person or situation. This client is not demonstrating displacement.

1 year infant

varicella vaccine until 1 year

Hyperbilirubinemia The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because these mothers possess naturally occurring

A and B antibodies, which are transferred across the placenta to the fetus.

denial stage of grief

A client experiencing delayed grief is unable to accept the reality of a loss, remaining in the denial stage of grief and refusing to experience feelings of sorrow and loss.

the client should move the walker

15.24 cm (6 in) and then steps into the walker. The correct technique for using a walker is to balance on both feet; lift the walker and place it in front; walk into the walker, using it for support when standing on the affected limb; and then balance on both feet before repeating the sequence. This provides maximum support for the client. Incorrect Answers: A. The nurse should instruct the client that placing the walker at this height will increase the strain on her upper extremities. The client should have a slight bend in the elbow when her hands are on the walker grips. C. The safe manner in which to move from a sitting to a standing position is to push up from the chair, gain balance, and then move the hands to the walker individually. Pulling oneself up by using the walker causes instability and can result in a client fall. D. The use of a walker on stairs is unsafe and might result in a fall. When climbing or descending stairs, the client should hold onto the handrails; the client should use the walker only on flat surfaces.

Pregnancy-associated plasma protein is part of the screening for potential birth defects at

16 to 18 weeks and is not indicated in the presence of risk factors for gestational diabetes

The nurse should instruct the guardian to administer the ferrous sulfate in

2 or 3 divided doses throughout the day to promote adequate absorption. The goal of therapy is to promote red blood cell production.

A client who has systemic lupus erythematosus should have a

butterfly rash across the bridge of the nose.

An infant begins to localize sounds by the age of

3 months. By 9 months of age, the infant should be able to turn the head toward the location of the sound. This is an indication that the infant's sensory skills are

The expected reference range of blood glucose level for a newborn is

30 to 60 mg/dL.

A 4-year-old child should be speaking in

4- to 5-word sentences

The expected reference range for a newborn for hematocrit is

44% to 64%

tying shoelaces and Walking backward are a skill expected of atying shoelaces and Walking backward are a skill expected of a

5-year-old child. B. This is an expected finding in a 4-year-old child.

prepare the woman for delivery

biophysical profile score less than or equal 4

measles

Koplik spots

Crackles in the lung bases

Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs.

manifestation of Graves' disease, the most common type of hyperthyroidism.

Tremors A low-grade fever Diaphoresis, great fever along with heat intolerance,

A client who has rhonchi will manifest

coarse, loud, low-pitched sounds during inspiration or expiration. Coughing often clears the airway and stops the sound.

Adolescents are typically concerned about

comparing their development to the development of peers. Toddlers are just beginning to understand their existence as a separate person from their mother and are not concerned with how their development compares to other toddlers

A decrease in urine output after a TURP indicates

an obstruction to urine flow by a clot or residual prostatic tissue and should be reported to the provider.

In the GTPAL system of reporting pregnancy history, the third digit denotes

the number of preterm births the client has had. This client had no preterm births.

In the GTPAL system, the first digit refers to

the number of times the client has been pregnant.

. A spinal block eliminates all sensations from the level of the

breasts to the feet. It is commonly used for cesarean births. A local anesthetic is injected directly into the spinal fluid at the third, fourth, or fifth lumbar interspace.

Magnesium sulfate is a tocolytic medication used to treat preterm labor and decrease the risk of

eclamptic seizures

Lightening is the term used to describe

engagement of the fetal head into the pelvis. When this occurs, breathing becomes easier, but urination is more frequent.

immediate or new memory,

the nurse should give the client 3 unrelated words, ask him to repeat them, and then ask him to repeat them again 5 minutes later.

The nurse should expect a school-aged child to be

curious about what happens to a body following death

The nurse should expect a 4-year-old preschooler to

cut out a picture using scissors.

4 years child

cut out a picture using scissors. is able to hop on 1 foot gross motor ability to skip and hop on 1 foot until about

Negligence is

failure to provide the expected standard of care.

Quickening is the initial occurrence of

fetal movemen

The nurse should expect a positive corneal reflex (i.e. blink reflex) from a

15-month-old toddler because this is expected to be present at the time of birth.

Maternal serum alpha-fetoprotein is part of the screening for open neural tube defects which takes place at

16 to 18 weeks of gestation and is not related to maternal obesity or a history of macrosomia

Clients who have chronic pancreatitis should limit their fat intake to no more than

30% to 40% of their total calories. Ice cream is high in fat, with 48 g of fat in a 1-cup serving of vanilla ice cream. The client should choose healthier fat-containing options to support a balanced diet such as avocados and nuts. Incorrect Answers: A. Foods high in fiber can reduce lipase activity, making a low-fiber diet helpful for clients who have chronic pancreatitis. White rice is low in fiber, with only 1 g of fiber in a 1-cup serving. B. Clients who have chronic pancreatitis need an adequate amount of protein, about 1.5 g/kg/day. Fish is a good source of protein, with 26 g of protein in a 170 g portion of cod. D. Foods high in fiber can reduce lipase activity, making a low-fiber diet helpful for clients who have chronic pancreatitis. Canned peaches are low in fiber, with only 3 g of fiber in a 1-cup serving

Chorionic villus sampling is indicated for women older than

35 years of age at the time of pregnancy, as well as those who have a history of spontaneous abortions, previous pregnancies of infants with chromosomal defects, or an abnormal ultrasound finding. It is not indicated for women with a history of post-term delivery

A toddler experiencing severe dehydration would exhibit a capillary refill of

4 seconds or greater and skin tenting.

acute grief

A client will have both somatic and psychological manifestations of distress such as the inability to sleep well or profound sadness. This client is experiencing acute grief, and the nurse should further evaluate his support system, concurrent stressors in his life, and his ability to manage stress.

Coarse crackles

A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by the movement of air through airways partially or intermittently occluded with fluid. These sounds are associated with heart failure and frothy sputum, are heard at the end of inspiration and are not cleared by coughing.

A nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?

A client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL The initial goal of therapy for diabetic ketoacidosis (DKA) is reaching a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the client's blood glucose level hourly. The nurse should report the client's result so that the provider can adjust the insulin dosage. Incorrect Answers: A. An elevated WBC count is an expected finding with bacterial pneumonia. B. A low calcium level is an expected finding with chronic kidney disease. D. A decreased hematocrit is an expected finding with leukemia.

A nurse in a provider's office is caring for a school-aged child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer to the child?

Albuterol The nurse should plan to administer albuterol to a child who is experiencing an acute exacerbation of asthma. Albuterol is a beta-adrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs. It is considered a rescue medication due to its rapid onset of action. Incorrect Answers: A. Zafirlukast is not considered a rescue medication. It is a leukotriene modifier that is used for prophylaxis and maintenance therapy for asthma and to prevent exercise-induced bronchospasm. B. Budesonide is not considered a rescue medication. It is a glucocorticoid that is used for long-term control and prophylaxis of chronic asthma. C. Montelukast is not considered a rescue medication. It is the most commonly prescribed leukotriene modifier used for prophylaxis and maintenance therapy for asthma and to prevent exercise-induced bronchospasm

HbA1c measures

average plasma glucose concentration over the 12 weeks preceding the test. A female client whose BMI is >30 and who has a history of delivering a baby weighing over 4,082.33 grams (9 lb) is at risk for impaired glucose metabolism and should be screened at the end of the first trimester

9- to 12-month-old infant.

board book with large pictures imitating animal sounds as a play activity to provide auditory stimulation for a

The nurse should expect to find a transverse palmar crease in a toddler who has

Down syndrome. Other findings associated with Down syndrome include a flattened forehead, a small nose with a depressed nasal bridge, a protruding tongue, a protruding abdomen, short stature, hyperflexibility, muscle weakness, hypotonia, and a short, broad neck.

manifestation of hypoglycemia

Increased hunger Cold, clammy skin Tremulousness

A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following?

Speech patterns The nurse should recognize that chronic otitis media can result in hearing loss, which can affect speech development.

A nurse is caring for a 2-year-old child who has a history of frequent urinary tract infections. When reinforcing teaching with the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include?

Teach the child to wipe from front to back The child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra. Incorrect Answers: B. The child should avoid bubble baths because they can cause urethral irritation. C. The child should urinate at least every 4 hours to prevent stasis of urine in the bladder, which can cause bacteria growth. D. Oxybutynin is an antispasmodic used for clients ages 6 and older who have neurogenic bladders.

age 6 years and older.

a game of checkers to have the cognitive ability to identify left and right

Oxybutynin is an

antispasmodic used for clients ages 6 and older who have neurogenic bladders.

Paralytic poliomyelitis presents with pain and stiffness in the

back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause discomfort

A client who has Addison's disease will have a

darkening of the skin in both exposed and unexposed parts of the body due to a hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex).

The nurse should expect a 3-year-old preschooler to

have the ability to draw a circle but not print letters until age5

A sudden onset of air hunger can be related to

hemorrhage or pulmonary embolism, which are medical emergencies that can lead to a cardiopulmonary arrest if they are not managed aggressively.

School-aged children want to understand

how things work. Any explanation should include appropriate scientific and medical terminology

Increased urination (polyuria) is a manifestation of

hyperglycemia due to a deficiency of insulin, which can lead to osmotic diuresis.

A preschooler

initiative versus guilt.

The nurse should allow the infant to lie on his abdomen because the ostomy has

no nerves. Therefore, laying on the ostomy will not cause pain.

A client who has expressive aphasia understands

speech but has difficulty speaking and writing. This typically occurs as a result of a lesion at Broca's area of the frontal lobe.

the second digit In the GTPAL system denotes the number of

term births the client had

If both the meal and dessert are offered together, the child will likely fill up on

the dessert first and might choose to not eat the other options. Instead, dessert should be offered at the end of the meal.

An epidural block eliminates sensation from

the level of the umbilicus to the thighs. It also relieves the pain of contractions, pressure, fetal descent, and perineal stretching. This analgesic block consists of morphine or fentanyl and is injected into the space at the fourth or fifth lumbar vertebrae.

In the GTPAL system of reporting pregnancy history, the last digit refers to

the number of living children the client has. This client has 2 living children.

Vaginal secretions increase during pregnancy; however, they are typically

thin, white, odorless secretions. A thick, cottage-cheese-like, or malodorous discharge can indicate a yeast or a bacterial infection and should be reported to the provider.

Methylergonovine is used

to prevent and control bleeding from the uterus that can happen after childbirth but we don't give to the patient who preeclampsia

Expected PSA values increase

with age. also Ejaculation within 24 hours prior to the test can cause falsely elevated levels of PSA; however, the client can ejaculate after the PSA test

Chorionic villus sampling is indicated for

women older than 35 years of age at the time of pregnancy, as well as those who have a history of spontaneous abortions, previous pregnancies of infants with chromosomal defects, or an abnormal ultrasound finding. It is not indicated for women with a history of post-term delivery.

A nurse is talking with a parent of a preschooler. The parent reports that her child becomes upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent?

"Use a stable, relaxing routine such as a bath and story time before bed." Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime and allow parental-child interaction prior to bed. Incorrect Answers: B. Completely darkened rooms can elicit fear in preschoolers, including fear of the dark. C. Allowing the child to fall asleep routinely in a parent's lap might make the child unable to fall asleep alone. Instead, the child should learn to settle to sleep in bed with a transitional object such as a blanket or toy. D. The parent should not respond to attention-seeking behavior in order to avoid reinforcing behavior that will delay and disrupt bedtime.

The disappearance of the extrusion reflex,

not the rooting reflex, is an indicator of the infant's developmental readiness for solid foods.

Dizziness and hearing loss reflect alterations in the

vestibulocochlear area, which CN VIII innervates.

indicated for cutaneous manifestations of SLE

"Apply lotion twice per day to dry skin." The nurse should instruct the client to apply a lotion twice daily to dry the skin. to wear a hat and protective clothing when outside. However, covering SLE lesions with a sterile dressing when outdoors is unnecessary. The lesions are often dry and scaly, not open and draining. gently pat, not rub, the lesions to dry. use Topical corticosteroid creams, not antibiotic creams, are

A nurse is reinforcing teaching with a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching?

"I need to apply paste to the back of the wafer on my child's appliance." The parent should apply stoma paste to the back of the wafer on the appliance, as well as around the stoma. This will act as a sealant to prevent skin breakdown. Incorrect Answer: A. The parent should dress the infant in 1-piece outfits to restrict the infant's hands from reaching the pouch. B. The parent should use diapers that are larger than those the child usually wears to go over the stoma and help with drainage. D.

A nurse is caring for a school-aged child who has terminal cancer and is receiving palliative care. The child's family asks about possible interventions. Which of the following statements should the nurse include in the teaching?

"Nonpharmacological interventions have a place in managing your child's palliative care." Nonpharmacological interventions such as relaxation breathing are important adjunctive therapies and should be used along with pharmacological interventions. Incorrect Answers: B. Palliative chemotherapy and palliative radiation are designed to increase comfort by slowing the growth of cancer. However, these interventions do not offer the potential to be curative or to lengthen the child's life. C. For children who are receiving palliative care for a terminal illness, addiction to opioids is not a concern. They should receive an appropriate dose to manage their pain. D. Children potentially underreport their pain to avoid additional pain or discomfort as a result of how medications might be administered. Oral, sublingual, and transdermal routes should be used to provide pain relief without the trauma of injections whenever possible.

A nurse is reinforcing teaching on strategies to decrease allergen exposure with a parent whose child has asthma. Which of the following statements should the nurse include?

"You should watch closely for any signs of roaches in your home." Exposure to roaches is a known allergen that can exacerbate an asthma attack. Parents should exterminate if roaches are present and keep the kitchen counters, cabinets, and floors clean and free of food to help prevent infestation. Incorrect Answers: A. While the child's room should be cleaned and vacuumed weekly to decrease exposure to allergens, the child should not perform this task due to the increased risk of causing an asthma exacerbation. B. Exposure to particulate matter from wood burning can increase the risk of an asthma exacerbation. C. Stuffed toys that can be washed in hot water and thoroughly dried weekly are acceptable for children who have asthma.

the infant can receive the first dose of the measles, mumps, and rubella vaccine beginning at

12 months of age.

A nurse is caring for a 10-year-old child who should reduce his fat intake. Which of the following menu choices should the nurse suggest?

3 oz of baked chicken on a whole wheat roll A baked chicken sandwich on a whole wheat bun has the lowest fat content at 6.2 g. Incorrect Answers: A. A hot dog on a bun contains over 18.1 g of fat. C. Diced potatoes with scrambled eggs contain 16.5 g of fat. D. A medium blueberry muffin contains 18.2 g of fat.

he American Cancer Society recommends that all men begin annual PSA testing at the age of

50. or Men who have a family history of prostate cancer or men of African descent should discuss with their provider the possible benefits of initiating testing at age 45.

The expected reference range of WBC for a newborn is

5000 to 10000/mm^3.

A nurse is reinforcing teaching with a 17-year-old client about managing manifestations of polycystic ovary syndrome (PCOS). Which of the following client statements indicates an understanding of the teaching?

A nurse is reinforcing teaching with a 17-year-old client about managing manifestations of polycystic ovary syndrome (PCOS). Which of the following client statements indicates an understanding of the teaching?

Dupuytren's disease

A progressive flexion contracture of the palmar fascia affecting the middle, fourth, or fifth fingers

A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death?

Believes that her own thoughts can cause death The nurse should expect preschoolers to believe that their own thoughts or actions can cause death, and they might believe that death is a punishment for wrong-doing. Incorrect Answers: B. The nurse should expect a preschooler to view death as a temporary occurrence like sleeping. The preschooler might believe the person can "wake up" again. C. The nurse should expect a school-aged child to be curious about what happens to a body following death. D. The nurse should expect an adolescent to reject traditions surrounding death such as funeral services as unnecessary or unimportant.

A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority?

Capillary refill 5 seconds When using the urgent vs nonurgent approach to client care, the nurse should identify that the priority finding is a capillary refill of 5 seconds. A capillary refill above 4 seconds is an indication of severe dehydration and requires immediate intervention to prevent progression to hypovolemic shock. Incorrect Answers: A. Decreased skin turgor is nonurgent because it is a manifestation of moderate dehydration. Therefore, there is another finding that is the nurse's priority. C. A heart rate of 150/min is nonurgent because it is an expected finding for an infant. Therefore, there is another finding that is the nurse's priority. D. Dry mucous membranes are a nonurgent finding and an early manifestation of mild dehydration. Therefore, there is another finding that is the nurse's priority.

A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect?

HbA1c measures average plasma glucose concentration over the 12 weeks preceding the test. A female client whose BMI is >30 and who has a history of delivering a baby weighing over 4,082.33 grams (9 lb) is at risk for impaired glucose metabolism and should be screened at the end of the first trimester.

A nurse is collecting data from an infant who has diabetes insipidus (DI). Which of the following findings should the nurse expect?

Increased urine output Diabetes insipidus is characterized by a decreased secretion of ADH, which results in an increased production of urine. Incorrect Answers: A. An infant who has DI has unquenchable thirst due to the decreased secretion of antidiuretic hormone (ADH). Irritability that is relieved by water but not milk is an early indication of DI in an infant. B. An infant who has DI is expected to have hypernatremia due to dehydration, which causes an increased concentration of serum sodium. D. An infant who has DI is expected to have a decreased urine specific gravity.

CPM device

Line up the frame joints of the CPM device with the client's knee To avoid damage to the operative knee, the nurse should line up the joints of the CPM machine with the client's operative knee. A. The nurse should apply the CPM device while it is in the extended position for client comfort and to ensure proper placement. C. The nurse should check the settings on the CPM device every 8 hours to ensure the appropriate flexion and extension cycle is occurring. D. The nurse should initially place the client in a supine position when applying the CPM device. Following placement, the nurse should place the head of the bed at 20° if the client is able to tolerate this angle.

manifestation of right-sided heart failure.

Peripheral edema Jugular vein distention Hepatomegaly

Providing local anesthesia to the perineum during delivery The nurse should identify that a pudendal block is administered

Providing local anesthesia to the perineum during delivery The nurse should identify that a pudendal block is administered transvaginally into the space just anterior of the pudendal nerve. The local anesthetic block contains lidocaine or bupivacaine and has no serious maternal or fetal adverse effects.

A nurse is collecting data for an adult client. What is the correct sequence of steps for data collection of the abdomen? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Step 1. Inspection Step 2. Palpation Step 3. Percussion Step 4. Auscultation

Suppression is a

Suppression is a deliberate denial or blocking of an undesirable situation. By delaying his response to his feelings about dying, the client is demonstrating suppression.

A nurse is reinforcing teaching with the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to take?

Teach the parent to provide kangaroo care for the infant Studies show that premature infants who are held skin-to-skin (i.e. given kangaroo care) demonstrate improved thermostability, oxygen saturation, interest in feeding, and maintenance of an organized, relaxed state.

The eustachian tube connects the

The eustachian tube connects the middle ear to the throat and allows equalization of pressure and drainage of fluids from the middle ear into the throat.

Meperidine hydrochloride

This medication can make you sleepy." Meperidine hydrochloride is an opioid analgesic used for moderate to severe pain during labor. It binds to the brain's opioid receptors and alters the client's response to pain. The client should be informed of the possible adverse effects of this medication such as hypotension, confusion, sedation, headaches, respiratory depression, constipation, and urinary retention.

A nurse in a provider's office is observing children playing in the waiting room. The nurse should expect to identify parallel behavior in which of the following age groups?

Toddlers Toddlers demonstrate parallel play. Incorrect Answers: A. Infants demonstrate solitary play. C. Preschoolers demonstrate associative play. D. School-aged children demonstrate cooperative play.

A nurse is caring for a client who has preeclampsia and is postpartum. Which of the following actions should the nurse implement when measuring the client's blood pressure?

Use the Korotkoff phase V to record the diastolic value The nurse should use the Korotkoff phase V (the disappearance of sound) to document the diastolic value.

Speaking in 2- to 3-word sentences is typical for

a 2-year-old child

increased ICP

a bulging fontanel, a high-pitched cry, and increased sleeping. bradycardia increased sleep time

A client who exhibits decorticate posturing internally

flexes the wrists and arms and extends and plantar flexes the legs.

Infants who are HIV-positive should receive immunization against childhood illnesses, including

measles, mumps, rubella, and influenza.

The nurse should recognize that complications of otitis media include

meningitis, labyrinthitis, and various types of abscesses and thromboses.

Justice is the

obligation to be fair and to treat people in an equal manner.

Fidelity is the

obligation to be faithful to commitments made to self and others.

Loss of peripheral vision is an initial report by a client who has

open-angle glaucoma. Glaucoma is a condition characterized by increased fluid pressure inside the eye, known as intraocular pressure. This increased pressure damages the optic nerve, causing partial vision loss; blindness is a possible outcome.

Larger portions might overwhelm the child and prompt a refusal to eat. Instead, the nurse should provide

smaller, more frequent meals and offer second helpings when food is eaten.

A client who has RA experiences

symmetrical joint impairment. is an autoimmune disease in which the body's immune system attacks itself client who has rheumatoid arthritis experiences red, hot, tender joints . RA is a systemic autoimmune disease, involving other body organs.

contractions lasting longer than 2 minutes or more than 5 contractions in a 10-minute period is considered

tachysystole

A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend?

1/2 cup baked beans The nurse should recommend foods high in fiber for a child who has chronic constipation. A half cup of baked beans contains approximately 5 g of fiber. Therefore, the nurse should instruct the guardian to include this food in the child's diet. Incorrect Answers: A. A half cup of whole milk contains no fiber. C. One cup of green leaf lettuce contains no fiber. D. One cup of apple juice contains no fiber

sessions for a preschooler to

10 to 15 minutes each.

A nurse is reinforcing teaching with the guardians of a 4-month-old infant about how to play with the infant. Which of the following play activities should the nurse suggest for a 4-month-old infant?

Allow the infant to splash in the bathtub placing a toy that has bright colors in the infant's hand. placing a rattle in the infant's hand. The nurse should suggest that the guardians allow this 4-month-old infant to splash in the bathtub as a play activity. Splashing is appropriate for the developmental age of the infant and provides tactile stimulation. The nurse should emphasize and teach bath safety to prevent injury. Incorrect Answers: board book with large pictures 9- to 12-month-old infant. An example of an activity that provides visual stimulation for a 4-month-old infant would be placing a toy that has bright colors in the infant's hand. B. The nurse should suggest imitating animal sounds as a play activity to provide auditory stimulation for a 9- to 12- month-old infant. An activity that provides auditory stimulation for a 4-month-old infant is placing a rattle in the infant's hand. C.The nurse should suggest imitating animal sounds as a play activity to provide auditory stimulation for a 9- to 12- month-old infant. An activity that provides auditory stimulation for a 4-month-old infant is placing a rattle in the infant's hand.

A nurse is coordinating care for an adolescent who requires peritoneal dialysis (PD) to treat an acute kidney injury. Which of the following actions should the nurse take?

Ask if the adolescent would like to record the amount of solution infused and drained Allowing the adolescent to be involved in helping with the procedure gives the adolescent a sense of control over what is happening. Recording the amounts is an appropriate action for an adolescent. Incorrect Answers: A. check the adolescent's vital signs before and after PD to maintain a precise record of all aspects of the treatment regimen and to help identify any complications that should be reported to the provider. B. The infusion should not be stopped because this is an expected finding during the infusion process. D. This would be appropriate for a school-aged child, but the adolescent needs to be taught how the procedure will be immediately beneficial. When the information being taught only explains how it will affect symptoms at some future date, the adolescent will not remember information as easily

A nurse is reinforcing teaching with a group of parents and guardians about child development. Which of the following recommendations should the nurse make to promote the developmental task of industry in a school-aged child?

Assign the child several small chores The nurse should recommend assigning the child several small chores. The completion of each chore in a short amount of time offers the child a sense of accomplishment and promotes achievement of the developmental task of industry. Incorrect Answers: A. Providing consistent care that meets a physical need promotes trust; however, it doesn't promote industry. Trust is a developmental task that should be achieved during infancy. C. The nurse should recommend discussing career choices and plans for adulthood with an adolescent as a means of promoting achievement of the developmental task of identity. D. The nurse should recommend talking about the family's and child's value system with an adolescent as a means of promoting achievement of the developmental task of identity

A nurse working on a maternal-newborn unit is assisting with planning an in-service training session for staff about assisting new mothers with breastfeeding. Which of the following infant conditions should the nurse recommend including in the teaching as a contraindication for breastfeeding?

Galactosemia An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes. Incorrect Answers: B. An infant who has hyperbilirubinemia can develop jaundice due to the accumulation of bilirubin in the system. Breastfeeding is encouraged in the early postpartum period for infants who develop hyperbilirubinemia because the colostrum in breast milk is a natural laxative that promotes the excretion of excess bilirubin. C. Glycogen storage disease is a congenital disorder in which glycogen, which is usually stored in the liver and metabolized into glucose when needed, cannot be metabolized into glucose due to a missing or deficient enzyme. As a result, the infant develops hypoglycemia and can experience neurological damage. Treatment involves continuous nasogastric or gastrostomy feedings during the night. However, breastfeeding is not contraindicated for infants who have glycogen storage disease. D. Infants who are born with congenital hypothyroidism will require lifelong treatment with a thyroid-replacement medication. However, breastfeeding is not contraindicated for infants who have hypothyroidism.

A nurse is reinforcing teaching with an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions?

Hip Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. When participating in vigorous exercise that involves both the arms and legs, the client should use a hip as the insulin injection site. Incorrect Answers: B. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the upper arms during basketball competitions. C. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the thighs during basketball competitions. D. The lower leg is not a recommended injection site for insulin. Insulin is administered subcutaneously into adipose or fat tissue over a muscle. Recommended injection sites for insulin are the abdomen, hips, buttocks, upper arms and thighs. When participating in vigorous exercise, the nurse should instruct the client to select an injection site that is not on an extremity involved in the activity

A nurse is performing a neurological examination on a 15-month-old toddler. Which of the following findings should the nurse expect?

Negative Babinski reflex The nurse should expect a negative Babinski reflex from a 15-month-old toddler because this reflex usually disappears around 12 months of age. Incorrect Answers: B. The nurse should expect a negative Moro reflex from a 15-month-old toddler because this reflex usually disappears around 4 months of age. C. The nurse should expect a positive corneal reflex (i.e. blink reflex) from a 15-month-old toddler because this is expected to be present at the time of birth. D. The nurse should expect the palmar grasp to be absent from a 15-month-old toddler because this reflex is usually replaced by the pincer grasp around 8 to 9 months of age.

A nurse is contributing to the plan of care for a child who has aplastic anemia. Which of the following interventions is the priority for the nurse to include?

Place the child in a protective environment with positive air pressure The greatest risk to a child who has aplastic anemia is infection. The child has decreased RBCs, platelets, and WBCs, causing severe suppression of the immune system. Therefore, the priority intervention for the nurse to include is to initiate protective environment isolation. Incorrect Answers: A. The nurse should pad the side rails of the child's bed with thick towels or blankets to minimize or prevent bruising. However, another intervention is the priority. C. The nurse should inspect and remove toys that have sharp corners or edges to minimize bruising and prevent bleeding. However, another intervention is the priority. D. The nurse should hold pressure on the child's puncture site for 5 minutes when obtaining blood samples to prevent bleeding. However, another intervention is the priority.

A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take?

Prepare concentrated sucrose for oral administration The nurse should provide the newborn with oral sucrose 2 minutes prior to performing the heel puncture. This practice, along with non-nutritive sucking, has been shown to decrease the pain the newborn experiences during the heel puncture. Incorrect Answers: A. Tolmetin is an oral analgesic medication for clients 2 years of age and older. Therefore, the nurse should not administer this medication to the newborn. B. The nurse should apply EMLA cream to the puncture site about 1 hour prior to the procedure. This allows time for the EMLA cream to decrease the pain the newborn experiences during the heel puncture. D. If skin-to-skin contact with a parent is not possible, the nurse should swaddle and rock or hold the infant to decrease the pain that the newborn experiences during the heel puncture. Swaddling the newborn can reduce pain associated with procedures because it mimics the feeling of being in the womb, whereas being placed in an extended position would be uncomfortable for the newborn and would likely increase pain because it is not a natural position at this age.

A nurse working in the emergency department is caring for a 6-month-old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse, "My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take?

Prepare to administer intravenous fluids The nurse should prepare to assist with the administration of intravenous fluids for an infant who has RSV because this condition can cause dehydration as a result of the presence of a fever and the infant's inability to finish a bottle of formula. Also, fluids will help loosen congestion, which typically occurs with RSV. Incorrect Answers: A. The infant's inability to finish a bottle of formula does not indicate the need to assess the infant's sucking reflex. The sucking reflex begins to diminish at about 6 months of age. A weak or nonexistent sucking reflex would have been identified much earlier than 6 months of age because it would have impeded feeding. B. The infant might require suctioning to clear secretions; however, suctioning should only be performed when necessary and not as a prophylactic treatment because it can cause tissue damage. D. There is no indication that the nurse should place the infant in a negative-pressure isolation room. This type of isolation is used for clients who have tuberculosis.

A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse take to help decrease the child's risk of experiencing a vaso-occlusive crisis?

Provide adequate fluid intake throughout the day Adequate hydration is an effective strategy for preventing sickle cell crises. Maintaining adequate hydration can reduce the risk of sickle cell formation. Incorrect Answers: B. Oxygen might be necessary to manage a sickle cell crisis, but it is not routinely used to prevent a crisis. C. A blood transfusion might be necessary to manage a sickle cell crisis, but it is not routinely used to prevent a crisis. D. The nurse can administer ibuprofen to manage the pain of a sickle cell crisis, but it will not prevent a crisis from occurring

A nurse is collecting data from a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggest a possible delay in development?

Speaking using 2- or 3-word sentences A 4-year-old child should be speaking in 4- to 5-word sentences. Speaking in 2- to 3-word sentences is typical for a 2-year-old child.

A nurse in the outpatient setting is planning to administer the varicella vaccine to a toddler. Which of the following findings is a contraindication to the child receiving this vaccination?

The child is receiving chemotherapy Severe immunosuppression is a contraindication to receiving a live virus vaccine such as the varicella vaccine. Potentially, the live virus could reproduce in an immunocompromised host and cause a vaccine-induced illness. Incorrect Answers: A. The presence of a minor illness is not a contraindication to receiving a vaccination. Routine vaccinations should be delayed if the child displays manifestations of a serious febrile illness. B. This is not a contraindication to receiving a routine vaccination. Extensive research shows no link between routine vaccinations and autism. D. An allergy to eggs is not a contraindication to receiving the varicella vaccine.

A nurse is caring for a 4-week-old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful?

The infant has a total bilirubin level of 0.3 mg/dL. A bilirubin level of 0.3 mg/dL is within the expected reference range and indicates the surgery was successful. Incorrect Answers: A. Weight loss is an indication that the surgery was not successful. The infant should gain weight following the surgery due to improved intestinal absorption. C. An AST level of 120 units/L is above the expected reference range and indicates continued biliary obstruction. D. If the surgical correction was successful, the infant's stools should turn yellow and then brown in color. Gray stools indicate continued biliary obstruction

A nurse on a pediatric unit is assisting with the care of a preschooler who is prescribed an IV medication. Which of the following techniques should the nurse use to assist with preparing the child for the procedure?

Use role-play activities with the child The nurse should use role-play activities to decrease the child's anxiety about the procedure. This approach will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Incorrect Answers: B. The nurse should avoid giving a detailed explanation , easy words and phrases. C. sessions for a preschooler to 10 to 15 minutes each. D. The nurse should allow the child to see, hold, and ask questions about needleless IV supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. Giving the child identical IV supplies to play with is a major safety risk because the child will likely be injured by the needle.

A nurse is reinforcing teaching with a 13-year-old client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of diabetes mellitus management?

"I should check my blood glucose levels more often when I am sick." Blood glucose levels should be checked every 3 hours during illness for a client who has type 1 diabetes mellitus, even if the client consumes fewer calories than usual. Hyperglycemia often occurs with an infection, requiring additional doses of insulin. Incorrect Answers: A. The client is at risk for hypoglycemia between meals due to the release of insulin into the bloodstream. Therefore, snacks are necessary to maintain blood sugar levels. Total caloric needs and distribution of calories are based on activity patterns and should guide snack choices. C. Exercise lowers blood glucose levels and is encouraged. Restrictions on exercise are not necessary for this client. Activity level and type of exercise need to be considered when determining insulin dosing, the site of insulin injection, and carbohydrate intake. D. Shakiness, difficulty concentrating, headaches, emotional lability, and hunger are all indications of hypoglycemia. The client should let someone know about these signs and should consume 10 to 15 g of simple carbohydrates such as sugar, followed by complex carbohydrates and rest. Consuming excessive carbohydrates can lead to hyperglycemia, which requires additional insulin

A nurse is present at the time of a child's death following a terminal illness. Which of the following statements should the nurse make to the child's parent?

"I will miss your child's infectious laugh; it always made me smile." Expressing personal feelings about the loss of the child can convey empathy and support the grieving parent. Describing the positive impact that the child had, such as making others smile, is a way to share positive memories with the parent. Incorrect Answers: A. Following a traumatic event such as the loss of a child, the nurse should convey empathy and provide emotional support. The nurse should respect the emotional needs of the parent and allow the parent to determine when the funeral home should be contacted. B. The nurse should avoid using trite phrases that belittle the parent's feelings and minimize the impact of the loss. D. Giving a personal opinion such as instructing the parent at this time is nontherapeutic and judgmental and does not take into consideration the parent's grief

A nurse is reinforcing teaching about home care with the guardian of a school-aged child who has seizures. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will turn my child onto his side when a seizure begins." To reduce the risk of aspiration and to improve oxygenation, the guardian should place the child in a side-lying position. Incorrect Answers: A. The guardian should notify emergency services if the child has a seizure that lasts more than 5 minutes. B. The guardian should not offer the child anything to drink or eat during the postictal phase because the child's gag and swallow reflex might be dulled or absent. C. The guardian should not hold or attempt to restrain the child during a seizure because this could injure the child.

A nurse is reinforcing teaching about immunization schedules with the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching?

"Initial vaccines should be administered between birth and 2 weeks of age." The first dose of the hepatitis B vaccine should be administered within the first 2 weeks after birth. The dose should be given before discharge from the hospital if the mother is hepatitis B surface antigen (HBsAg) negative. Incorrect Answers: B. If a client receives an initial dose in a series but misses a subsequent dose, the client will not need to begin the series again. The client should receive the missed dose as soon as possible. C. Allergic reactions to vaccines are most often caused by the inactive parts of the vaccine, which are used to enhance the effectiveness of the vaccine. Examples of inactive ingredients that might cause an allergic reaction include purified culture medium proteins such as egg and antibiotics such as neomycin. D. A vaccination does not need to be postponed for minor illnesses such as a common cold. A rectal temperature of 37.5°C (99.5°F) is considered within the expected reference range. However, all immunizations should be postponed for a severe febrile illness.

A nurse on a pediatric unit is caring for a child who is not eating well. Which of the following suggestions should the nurse reinforce with the parents to promote the child's food intake?

"Let the child eat with others when possible." Socialization with others promotes nutrition by making the child feel more comfortable in his surroundings and enhancing his enjoyment of mealtimes. Incorrect Answers: A. The child will be more likely to eat if he has participated in the menu selection. B. Highly seasoned foods and foods with strong odors are typically unappealing to clients who are not feeling well. The parents should offer foods that are familiar and do not have strong flavors or smells. D. Forcing the child to eat can result in rebellion, and the child might begin using food refusal as a control mechanism. Parents should instead offer meals and frequent snacks, make foods attractive and appealing, and praise the child when he does eat.

A nurse is reinforcing teaching with the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching?

"My child may take aspirin for his joint pain." Children who have rheumatic fever may take salicylates (aspirin) to control the inflammatory process that occurs in the joints. Incorrect Answer: B. A child who has rheumatic fever does not require blood transfusions since there is no blood loss from this disorder. C. A child who has rheumatic fever only needs standard isolation precautions because the immune response occurs after an infection with group A β-hemolytic streptococci. D. Kawasaki disease causes peeling hands, but rheumatic fever does not.

A nurse is reinforcing teaching with the guardian of a child who has severe iron-deficiency anemia and a new prescription for ferrous sulfate oral suspension. Which of the following statements by the guardian indicates an understanding of the instructions?

"My child's blood count will be monitored regularly for the next several weeks." The nurse should inform the guardian that the child's hemoglobin and hematocrit levels should be monitored routinely for several weeks to determine the effectiveness of treatment. The nurse should also inform the guardian that treatment can take up to 3 months to be effective. Incorrect Answers: A. The nurse should instruct the guardian to administer the ferrous sulfate in 2 or 3 divided doses throughout the day to promote adequate absorption. The goal of therapy is to promote red blood cell production. B. The nurse should instruct the guardian to administer the medication with orange juice. Vitamin C will increase, not decrease, the absorption. The guardian can mix the liquid iron suspension with a small amount of juice to make it more palatable. C. The nurse should inform the guardian that administering ferrous sulfate with milk can decrease absorption. Other dietary items that should be avoided are cereal, tea, eggs, and foods that are high in fiber.

A nurse is reinforcing teaching about disease management strategies with a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include?

"Your mucus is thick because cystic fibrosis interferes with how your glands work." A 9-year-old child should cognitively understand that the production of thick mucus is part of the disease process. Incorrect Answers: A. School-aged children do not have the ability to engage in abstract thought and reasoning. They are unable to grasp the reality of long-term consequences. This statement would be appropriate for an adolescent client. B. School-aged children want to understand how things work. Any explanation should include appropriate scientific and medical terminology. D. This statement does not explain the pathophysiology of cystic fibrosis, why it interferes with sleep, or how the medicine will help.

The expected reference range for a newborn Hgb is

14 to 24 g/dL.

infant can receive an annual influenza vaccine beginning at

6 months of age.

An infant begins to vocalize chained syllables such as "dada" by the age of

7 months of age. By 10 months of age, the infant associates meaning with words such as "mama." This is an indication that the infant's vocalization skills are ahead of expected findings.

The use of a pincer grasp usually begins to appear at the age of

8 months and becomes more refined by the age of 9 months. This is an indication that the infant's fine motor skills are on track with expected findings.

imitating animal sounds as a play activity to provide auditory stimulation for a

9- to 12- month-old infant. An activity that provides auditory stimulation for a 4-month-old infant is placing a rattle in the infant's hand.

Halos when looking at lights

A cataract is a cloudy or opaque area in the lens of the client's eye. Cataracts in adults usually develop with advancing age and can be hereditary. Cataracts develop slowly and painlessly with a gradual onset of difficulty with vision. Visual problems include difficulty seeing at night, halos around lights or glare sensitivity, and decreased visual acuity, even in daylight. Cataracts are accelerated by environmental factors (e.g. cigarette smoke or other toxic substances) or in response to metabolic diseases (e.g. diabetes mellitus)

A nurse is reinforcing teaching with a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods should the nurse increases the risk of choking in toddlers? (Select all that apply.)

A. Hot dogs B. Grapes C. Bagels D. Marshmallows Foods that are tubular or circular in shape such as hot dogs and grapes increase the risk of choking because they can completely block the throat when swallowed whole due to their shape and solidity. Foods that are hard to chew such as bagels and marshmallows can block the airway if swallowed before they are adequately chewed. Incorrect Answer: E. All foods and fluids can potentially cause choking. However, graham crackers become soft quickly when mixed with saliva. Their consistency when wet is more like cooked cereal or soft cookies soaked in milk. Therefore, graham crackers do not pose an increased choking hazard for toddlers.

A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse prepare to administer

Albuterol The nurse should prepare to administer albuterol to a child who is experiencing an acute exacerbation of asthma and requires a rescue medication. Albuterol is a beta-adrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs. Incorrect Answers: A. Zafirlukast is a leukotriene modifier that is used as prophylaxis and maintenance therapy for asthma and prevention of exercise-induced bronchospasm. It is not classified as a rescue medication. B. Budesonide is a glucocorticoid that is used for long-term control and prophylaxis of chronic asthma. It is not classified as a rescue medication. C. Montelukast is the most commonly prescribed leukotriene modifier. It is used for prophylaxis and maintenance therapy for asthma and prevention of exercise-induced bronchospasm. It is not classified as a rescue medication.

A nurse is caring for a 5-year-old child who has pneumonia and is experiencing a poor appetite. Which of the following interventions should the nurse take?

Allow the child to choose foods with a lower nutritional content Allowing the child to consume non-nutritional, empty-calorie foods and liquids will still provide needed calories and fluid during periods of illness. Once the child has recovered from the illness, the child's appetite will typically improve.

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following items of data should the nurse share as a common example of a suggestive finding?

Arm cast for a spiral fracture of the forearm Spiral fractures occur from twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury. Incorrect Answers: A. Bruising of the knees and sutures are typical findings associated with accidental childhood injuries such as falling off a bicycle. Lacerations or abrasions to the backs of the legs are suggestive of physical abuse. C. Bedwetting has many causes and affects many preschoolers. In the absence of other findings, it does not usually indicate abuse. Pain with urination or recurrent urinary tract infections are suggestive of sexual abuse. D. These reports have many causes. In the absence of other findings, they are not likely to indicate abuse. However, abdominal pain and swelling accompanied by indications of punching are suggestive of physical abuse

what to do for dysphagia patient

Ask the client to think of a food that produces salivation To prevent dryness in the mouth during meals, which can be a risk factor for choking, the nurse should ask the client to think of a food that promotes salivation such as lemon slices or dill pickles. Thick liquids. drink fluids after clearing the mouth of food. They should use coughing and dry swallowing to remove food particles from their mouth. should rest before meals to avoid fatigue when focusing on swallowing safely

A nurse is caring for a preschooler who has acute leukemia and methicillin-resistant Staphylococcus aureus (MRSA). The parents are not allowed to take the client to the hospital playroom, and the child appears bored. Which of the following actions should the nurse take?

Ask the parents to bring toys from home for the preschooler The nurse can recommend that the parents bring toys from home for the preschooler. Any toys will need to be cleaned thoroughly with soap and water before the preschooler plays with them and after the preschooler is discharged to remove any MRSA. This will protect the preschooler's depressed immune system as a result of leukemia. Incorrect Answers: A. The nurse should provide play materials that are appropriate for the child's age. Plastic beads are not an appropriate item for a preschooler. B. The nurse should not encourage frequent visits from siblings due to the isolation precautions that are required for this preschooler's room. Those who do enter the preschooler's room must wear isolation garb for contact precautions. D. The nurse should encourage play time for the preschooler and should work with the parents to find suitable diversion activities. Play can assist the preschooler with releasing tension and expressing feelings.

A nurse is reinforcing teaching with the parents of an infant who is breastfeeding. When should the nurse instruct the parents to introduce solid foods into the infant's diet?

At 4 to 6 months of age The nurse should identify that infants are developmentally ready for solid foods at 4 to 6 months of age. Incorrect Answers: A. The disappearance of the extrusion reflex, not the rooting reflex, is an indicator of the infant's developmental readiness for solid foods. B. Infants between 2 and 3 months of age still have the extrusion reflex and are not developmentally ready for solid foods. C. The timing of the eruption of the infant's first tooth varies greatly and is not an appropriate indicator of when to introduce solid foods

A nurse is assisting with the care of a school-aged child who had a tonsillectomy. Which of the following interventions should the nurse take?

Avoid providing straws for use when drinking fluids Straws should be avoided because they can accidently damage the surgical site and cause excessive bleeding. Incorrect Answers: A. Suctioning should only be performed as needed and done gently to avoid damaging the surgical site. C. Brown blood is an expected finding following a tonsillectomy. Parents should be instructed to notify the physician if bright red bleeding is occurring or if the child is frequently clearing the throat, as this is a sign of increased bleeding. D. Nose blowing, coughing frequently, and throat clearing can increase bleeding from the surgical site. These actions should be avoided.

patient after mastectomy with drainage

Avoid wearing deodorant until the drains are removed and the incision heals. The nurse should instruct the client to avoid applying deodorants and talcum powder to the affected underarm until the drainage tubes are removed and the incision is healed. cloudy, malodorous drainage might indicate infection and should be reported to the provider. take baths until the provider removes the drainage tubes and stitches. normal use and nonstrenuous exercise are appropriate before the provider removes the drainage tubes. More strenuous exercise can begin following the removal of the

hypothyroidism

Bradycardia An elevated TSH level indicates hypothyroidism, which is characterized by weight gain, bradycardia, cold intolerance, paresthesia, hearing loss, depression, and many other manifestations. B.

hypermetabolism diseases

COPD,Cancer, Parkinson's Major and burns

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption?

Celiac disease The nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. Other malabsorption conditions include short-bowel syndrome, lactose intolerance, and congenital enzyme deficiency. Incorrect Answers: B. The nurse should recognize that ulcerative colitis causes chronic diarrhea because it is an inflammatory bowel disease. C. The nurse should recognize that Hirschsprung's disease causes chronic diarrhea because of motility disorders. D. The nurse should recognize that Crohn's disease causes chronic diarrhea because it is an inflammatory bowel disease

A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan?

Check the bag for stool every 4 hours The nurse should check the bag for stool every 4 hours or less to prevent the bag from overfilling and leaking. Stool from an ileostomy is acidic and can cause excoriation of the skin. Incorrect Answers: A. The nurse should allow the infant to lie on his abdomen because the ostomy has no nerves. Therefore, laying on the ostomy will not cause pain. B. The nurse should tuck the ostomy appliance into the infant's diaper to prevent accidental removal. D. The nurse should plan to replace the appliance once a week. Frequently changing the appliance increases the risk of injury to the skin surrounding the stoma

The client rigidly extends his arms. A client who exhibits a decerebrate posture rigidly extends and pronates his 4 extremities and externally rotates his wrists.

Decerebrate posturing indicates severe brainstem injury and late neurological decline.

A nurse is collecting data from a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration?

Deep, rapid respirations This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia.

A nurse is planning to reinforce education with the parents of a school-aged child who has attentiondeficit/hyperactivity disorder (ADHD). Which of the following instructions should the nurse include?

Develop a daily morning task chart for child Visual organizational charts are helpful for children with ADHD due to their high level of distractibility. Incorrect Answers: B. Children with ADHD often perform better when seated near the front of the classroom, which can decrease visual distractions. C. More academic subjects should be covered in the morning for a child with ADHD while the child is experiencing the effects of the morning dosage of medication. D. Choices can be difficult for children with ADHD due to their high level of distractibility. Limiting choices can decrease frustration in the child and family members

A nurse is reinforcing teaching with the parents of an infant who has a cleft palate. The parents ask the nurse how long they should wait before the infant should have corrective surgery. The nurse explains that the parents should wait no longer than 6 to 12 months to avoid which of the following outcomes?

Difficulty with language acquisition Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With a cleft in the palate, these infants could develop poor speech habits. Incorrect Answers: A. Infants who have a cleft palate are at an increased risk for ear infections; however, this can persist even after the repair of the palate. B. Infants who have a cleft palate are at increased risk for poor nutrition due to feeding difficulties. However, there are multiple strategies to help the parents promote nutrition and to help the infant create a seal and generate suction to feed. C. Repair of a cleft palate does not affect the child's immune system. However, repairing the palate too soon can affect the skeletal growth of the mid portion of the child's face.

how can we treat Pruritus gravidarum

Exposure to sunlight can reduce itching Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin.

born at 32 weeks of gestation has

Extended extremities is unable to maintain the flexed position seen in an infant who was born at full term. will have few creases present on the sole of the foot. testes only partially descended into the sac and only a few rugae were present.

A nurse is collecting data from an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing?

High-pitched cry The nurse should identify that an infant's high-pitched cry is an indication of increased ICP. Other indications include a bulging fontanel, a high-pitched cry, and increased sleeping. Incorrect Answers: B. The nurse should identify that a firm and bulging fontanel is an indication of increased ICP. C. The nurse should identify bradycardia as an indication of increased ICP. D. The nurse should identify increased sleep time as an indication of increased ICP

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate?

Hyperbilirubinemia

A nurse is assisting with the care of a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform?

Infuse a 500-mL bolus of 0.9% sodium chloride or lactated Ringer's 15 to 30 minutes before the procedure to offset the potential complication of hypotension. assess the fetal heart rate pattern for a minimum of 20 to 30 minutes before the procedure. position the client with her spine flexed to open the intervertebral spaces and allow the placement of the spinal needle. monitor the client's blood pressure, pulse, respirations, and fetal heart rate every 5 to 10 minutes after the introduction of the anesthetic agent

A nurse is reinforcing discharge teaching with the parents of a school-aged child who has nephrotic syndrome and a prescription for corticosteroid therapy. Which of the following home-care instructions should the nurse include?

Keep the child away from people who have an infection The nurse should instruct the parents to keep the child away from others who have or might have an infection. Children who have nephrotic syndrome are prescribed corticosteroids, which impair the immune system. Therefore, the child is at an increased risk of contracting an infection. Incorrect Answers: A. The nurse should instruct the parents to restrict the child's sodium intake rather than potassium intake. The parents should eliminate high-sodium foods from the child's diet and avoid the addition of salt to the child's food. The parents can resume a regular salt intake for the child after the acute phase of nephrotic syndrome has passed. C. The nurse should instruct the parents to weigh the child daily, at the same time of day, and with the child wearing the same clothing each time. The nurse should also remind the parents to notify the provider if the child's weight increases. D. The nurse should inform the parents that nephrotic syndrome does not cause pain. Therefore, there is no indication for administering acetaminophen on a daily basis, and doing so can cause additional stress to the child's kidneys.

A nurse is reinforcing teaching about home care with the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include?

Leave the zinc oxide ointment intact and reapply as necessary during diaper changes Zinc oxide can be applied as a barrier ointment to areas that are reddened or open and moist. While removing the waste material, zinc oxide should be left in place as much as possible during a diaper change. More ointment can be applied as needed. The ointment can be removed, if necessary, by applying mineral oil to the area and gently wiping. Incorrect Answers: A. Healthy and slightly irritated skin can be exposed to air to maximize drying and to prevent dermatitis. However, hair dryers and heat lamps have been shown to cause burns and should not be used. B. Superabsorbent disposable diapers should be used to reduce wetness on the skin when diaper dermatitis is present. These diapers prevent the mixing of urine and stool, which increases the occurrence of dermatitis. C. Over-washing of the skin, especially with perfumed soaps or wipes, can be irritating and increase the risk for the development of dermatitis

A nurse is caring for a child who is terminally ill and who is nearing death. Which of the following interventions should the nurse perform?

Limit provision of care to essential needs The nurse should only perform care needs that are essential for the client's immediate comfort. This action will decrease unnecessary pain and preserve the child's strength. Incorrect Answers: A. The nurse should encourage the family to take breaks and to stagger their vigil at the bedside in order to provide respite care for each other. C. It is an expected finding that urine output will diminish as the child approaches death. The nurse should not perform unnecessary invasive procedures on a terminal child. D. The nurse should continue to administer pain medications around the clock to a terminal client who is approaching death. This action will ensure the child's physical comfort and provide emotional comfort for the family

A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take?

Monitor the infant's head circumference Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference can help determine any increase. Incorrect Answer: B. The nurse should place a child who has myelomeningocele in a prone position to minimize the risk of trauma or tension to the sac. C. The nurse should not place a child who has myelomeningocele under a radiant warmer due to the risk of drying out the lesion and causing cracking. D. Placing a piece of plastic over the protruding membranes will exert pressure on the area. Instead, the nurse can place wet gauze over the lesion to help provide moisture.

A nurse working at a rehabilitation facility is attending an interdisciplinary team meeting for a client who had a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse recommend to assist this client? (Select all that apply.)

Nurse B. Occupational therapist C. Speech therapist D. Physical therapist The nurse should attend the interdisciplinary meeting to present the client's condition and possible needs. An occupational therapist is needed to assist the client with activities of daily living and to enhance independence through eating, dressing, bathing, grooming, and feeding. A speech therapist is needed to assist the client, who might have difficulties with speech and swallowing as a result of the stroke. The speech therapist can also conduct an initial evaluation, complete a swallowing assessment, and provide ongoing speech therapy. A physical therapist is needed to discuss and manage the physical impairments the client has related to mobility as a result of the stroke. Ongoing physical therapy is needed to help the client learn how to walk again with the use of an assistive device such as a cane or a walker.

A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately?

Oxygen saturation 85% The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should report this finding to the provider immediately. Incorrect Answers: A. A blood glucose level of 140 mg/dL is above the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately. C. An RBC of 3.2 million/uL is below the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately. D. A serum sodium level of 156 mEq/L is above the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately.

A nurse is reinforcing teaching with the guardian of a 10-year-old child whose weight is in the 95th percentile on a growth chart. Which of the following instructions should the nurse include

Plan a menu that provides the child with 1,200 calories each day The child should take in about 1,200 calories per day to help him lose weight while still providing enough calories to form new body tissue for continued growth. Incorrect Answers: A. Children are much more likely to participate in an exercise program that they have selected and enjoy. C. School-aged children perform better when setting short-term goals rather than long-term goals. The guardian should assist the child in setting a goal of losing a small amount of weight in a shorter time period such as 2.25 kg (5 lb) in 1 month as opposed to 22.5 lb (50 lb) in 1 year. D. Children should limit television and other screen time to 1 to 3 hours per day

A nurse is assisting with the plan of care for a child who has hyperthermia. Which of the following actions should the nurse take?

Position the child on a cooling blanket and cover her with a sheet A cooling blanket will lower the temperature of the blood circulating at the skin's surface. This cool blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated to the skin and dispensed to the cooler outside surface. Incorrect Answers: A. Hyperthermia is caused by external conditions that create more heat than the body can eliminate. The body temperature exceeds the set point, which differs from the elevation of the body's actual setpoint associated with hyperpyrexia. Because of this, antipyretics are not effective in treating hyperthermia. C. The child should be placed in a warm bath. The nurse should gradually add cool water until the water temperature is 1°C (33°F) less than the child's body temperature. Placing the child in water that is too cool will result in vasoconstriction of the blood vessels on the surface, which will not allow the visceral heat to dissipate to the cooler outside air. D. The nurse should assess the child's temperature every 30 to 60 minutes or continually during the cooling process to prevent hypothermia.

A nurse is planning to perform chest physiotherapy (CPT) for an infant who has cystic fibrosis. Which of the following techniques should the nurse plan to include?

Repeatedly strike the infant's chest using a cupped hand Percussion involves striking a cupped or curved palm against the infant's chest to produce an audible thumping noise. This technique loosens the mucus in the airway for expectoration and should not produce discomfort. Incorrect Answers: B. CPT is best scheduled before meals or at least 1 hour after a meal so the subsequent coughing does not cause vomiting. C. When draining the apical segment of the left upper lobe, the nurse should position the infant on the nurse's lap. D. Hyperoxygenation is not necessary prior to CPT. It should be used prior to suctioning an infant. "

A nurse is reinforcing teaching with the guardian of a school-aged child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child?

Speak at the child's eye level The nurse should instruct the guardian to speak at the child's eye level and ensure there is adequate lighting on the speaker's face to facilitate lip-reading and communication. Incorrect Answers: A. The nurse should instruct the guardian to avoid exaggerating the pronunciation of words because this can impair understanding. B. The nurse should instruct the guardian to use hand gestures to promote understanding. D. The nurse should instruct the guardian to use facial expressions when speaking to assist in conveying the message

when the nurse has to stop the infusion of oxytocin

Stop the oxytocin infusion A pattern of contractions lasting longer than 2 minutes or more than 5 contractions in a 10-minute period is considered tachysystole. This pattern can result in decreased placental perfusion of oxygen. The appropriate action is to discontinue the oxytocin infusion.

A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take?

Supplement the child's feedings with enteral feedings A child who has burns over more than 25% of the total body surface area requires enteral supplementation to consume enough calories to heal. Incorrect Answers: A. Children who have cystic fibrosis require pancrelipase, a pancreatic enzyme to aid in digestion, since they are unable to digest properly. C. Superficial partial-thickness burns affect both the outer and underlying layers of the skin, causing pain, redness, swelling, and blistering. A child who has a burn needs a high-carbohydrate and high-protein diet with adequate fat for healing. D. Dressing changes are painful, so they should not be done close to the time of feeding since appetite and digestion might be negatively affected.

A nurse is preparing to assist with the physical assessment of a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination?

The child prefers to sit on the parent's lap during the Engaging in play near other children A toddler is expected to play in parallel with other children. As socialization begins, the child plays alongside other children, not with them.

Results of enzyme-linked immunosorbent assay (ELISA) testing for an 18-month-old infant who has Pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors?

The infant's mother is likely HIV-positive. Transmission of HIV from a woman to her infant can occur during pregnancy, delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants. Incorrect Answer: B. The ELISA test is unreliable for testing for HIV in infants under 18 months of age because of false positive results due to maternal antibodies. The results are reliable, however, for clients 18 months of age and older. C. While antiretroviral medications cannot cure HIV, they do slow the progress of the infection for clients of all ages. D.

The nurse should notify the provider immediately and prepare for a tracheostomy after hearing

The laryngeal stridor is a high-pitched, harsh breathing sound that indicates respiratory distress due to swelling, tetany, or laryngeal spasms.

The nurse should plan to replace the appliance of the ostomy

The nurse should plan to replace the appliance once a week. Frequently changing the appliance increases the risk of injury to the skin surrounding the stoma

SIADH causes the body to retain too much water.

This client with SIADH will have hyponatremia decrease in urine output with increased urine osmolarity. excess antidiuretic hormone. hypothermia

A nurse is reviewing the laboratory reports of a child with acute nephrotic syndrome who has been receiving prednisone by mouth for the past week. Which of the following findings should the nurse report to the provider?

WBC count 3,000/mm^3 The nurse should understand that the use of corticosteroids suppresses the child's immune system and increases the risk of infection. The nurse should identify that a WBC count of 3,000/mm^3 is below the expected reference range for a child and should report this finding to the provider. Incorrect Answers: A. The nurse should identify that a serum sodium level of 142 mEq/L is within the expected reference range for a child. Therefore, it is not necessary for the nurse to report this finding to the provider. B. The nurse should identify that a serum potassium of 4 mEq/L is within the expected reference range for a child. Therefore, it is not necessary for the nurse to report this finding to the provider. D. The nurse should identify that a platelet count of 2980,000/mm^3 is within the expected reference range for a child. Therefore, it is not necessary for the nurse to report this finding to the provider.

A nurse in a pediatric clinic is preparing to assist with a sweat chloride test for a toddler who is suspected to have cystic fibrosis. Which of the following actions should the nurse plan to take?

Warm the temperature of the toddler's examination room The nurse should ensure that the examination room is warm. A warm environment promotes the toddler's ability to produce sweat for the sweat chloride test. To further promote sweating, the nurse should apply blankets to maintain the toddler's body heat during the test. Incorrect Answers: A. The nurse should ensure that the toddler has adequate fluid intake prior to the sweat chloride test. If the toddler is dehydrated, the test results can be inaccurate due to a decreased ability to produce sweat and an increased concentration of electrolytes. B. The nurse should review and document the toddler's food intake for 72 hours if the toddler is having a stool analysis for the diagnosis of cystic fibrosis. A 72-hour stool test analyzes the amounts of fat and enzymes in the stool samples. D. The nurse should expose the thigh of an infant and the forearm of an older child for application of electrodes during a sweat chloride test. The nurse should keep other areas of the toddler's body covered with blankets to maintain body heat during the test.

manifestation of increased intracranial pressure.

Widened pulse pressure A widening of the pulse pressure, which is the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, changes in the level of consciousness, and nausea and vomiting. Incorrect Answers: bradycardia

The expected reference range for a toddler is

a creatinine level of 0.3 to 0.7 mg/dL. BUN level of 5 to 18 mg/dL. B. The expected reference range for a toddler is a uric acid level of 2.0 to 5.5 mg/dL. urine specific gravity of 1.001 to 1.030.

A client who has wheezes will manifest

a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway.

Varcilla

a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over.

Skin with cracking and rare veins is a physical manifestation of

a term newborn. The nurse should assign this finding a score of 3.

A transcutaneous electrical nerve stimulation (TENS) is used to treat

a variety of conditions. TENS is helpful for some antepartum clients as a component of nonpharmacological pain management and cutaneous stimulation strategies.

School-aged children do not have the ability to engage in

abstract thought and reasoning. They are unable to grasp the reality of long-term consequences. This statement would be appropriate for an adolescent client.

Pruritus and flushing are findings that indicate a response to

allergens present in the transfused blood product. The nurse should identify that the child is having an allergic reaction.

Anticipatory grief is

an expected response occurring prior to an actual loss. Clients experiencing anticipatory grief might be preoccupied with the impending loss, make extensive funeral arrangements, or exhibit a change in attitude toward the lost thing or individual.

assault is an

attempt or threat to harm another person unjustifiably. Threatening to administer an IM injection to the client if she does not take her medication orally is a form of assault.

Autosomal recessive PKU is inheritable by

autosomal recessive gene patterns. In these types of disorders, neither parent might have the disorder, but both mother and father must carry and contribute a variant gene for the disorder to occur. Other autosomal recessive disorders are cystic fibrosis and sickle cell anemia.

A child who has a colostomy will need

bladder training when developmentally ready because the urinary system is still intact.

To test a newborn for the presence of HIV, a sample of the newborn's

blood must be obtained. Maternal antibodies will be present in the cord blood and can cause misinterpretation of the test results.

Rales and cyanosis are findings that indicate the

blood product might have been administered too quickly. The nurse should identify these findings as an indication the child is experiencing fluid overload.

A fetal heart rate baseline of 90 bpm is considered

bradycardia and should be reported to the provider. Fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia, and fetal viral infections

Fifth disease usually begins with

bright red cheeks, producing a "slapped-cheek" appearance. Following this, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance to the rash.

disenfranchised grief

cannot openly acknowledge the loss because of societal or religious norms

SLE is a

chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temperature and report any elevations promptly, as a fever can suggest either an exacerbation or a potentially life-threatening infection. NSAIDs are commonly used to treat the inflammation, joint discomfort, and fevers that might accompany an exacerbation of SLE. Corticosteroids are typically required, at least in minimal doses, on a chronic basis for clients who have SLE. If the client were to stop taking the corticosteroids, she would need to taper off under the provider's direction. SLE can affect any organ of the body, including the skin. Any source of ultraviolet light (e.g. exposure to the sun) can cause an exacerbation of this disease.

The nurse should expect an infant who has untreated congenital hypothyroidism to exhibit

constipation and an enlarged abdomen. hyporeflexia and decreased muscle tone. hypothermia and cool extremities.

"Before bedtime is a good time to start

counting the kicks." Clients should be instructed to perform a kick count, which is the daily fetal movement count (DFMC), before bedtime or after meals for 2 hours, or until 10 movements are counted. Alternatively, the client can count all fetal movements in a 12-hour period each day until at least 10 movements are counted.

Dysphagia (difficulty swallowing) can occur as a result of damage to

cranial nerves IX (glossopharyngeal) or X (vagus). The cranial nerves primarily innervate the face, neck, and a few organs.

Eyestrain and headaches with close work are associated with

decreased visual acuity. Both nearsightedness, which is an error of visual focusing that makes distant objects appear blurred, and farsightedness, which is an age-associated progressive loss of the focusing power of the lens that results in difficulty seeing objects close up, can cause eyestrain and headaches. Changes in visual acuity can represent primary eye disease, aging, eye trauma, or a generalized systemic illness. Whatever the cause, the nurse should not ignore visual changes, as decreased vision is a significant threat to the quality of life of older adult clients.

Nonmaleficence is the

duty to do no harm and to protect clients from harm by eliminating threats. These actions are important for promoting the safety of the client by preventing aspiration.

Oxytocin is a uterotonic medication that causes the uterus to contract and reduces

excessive uterine bleeding

The nurse should identify that a firm and bulging fontanel, bradycardia, and increased sleep time an indication of

increased ICP.

A client who has hepatic, biliary, or gallbladder disease should have

jaundice of the face and sclera

Differences in pulse strength between

lower extremities A difference in pulse strength can indicate a vascular complication. Assessment of the peripheral vascular system should also include temperature, color, sensation, edema, and skin integrity of both the upper and lower extremities. The nurse should identify any differences in symmetry of these findings and report them.

Maternal serum alpha-fetoprotein is part of the screening for

open neural tube defects which takes place at 16 to 18 weeks of gestation and is not related to maternal obesity or a history of macrosomia. B. Pregnancy-associated plasma protein is part of the screening for potential birth defects at 16 to 18 weeks and is not indicated in the presence of risk factors for gestational diabetes.

Loss of the same visual field in both eyes (hemianopsia) indicates damage to the

optic tract, which connects to CN II.2

The nurse should explain to the client that the circulatory system's ability to compensate for changes in position decreases with aging, causing

orthostatic hypotension when an older adult client moves from a sitting to a standing position. Blood vessel walls become less elastic with age. The valves of the heart thicken with age. Peripheral pulses can become weaker with age but should remain palpable

"Use a cellular phone on the opposite ear from the

pacemaker." The nurse should instruct the client to use and hold a cellular phone to the opposite ear from the pacemaker. This will avoid interference of the generator inside the pacemaker.

5 y child

physical coordination to jump rope. draw a stick figure that has 7 to 9 parts. tying shoelaces and Walking backward are a skill expected of a Play becomes associative At this age, the child attempts to follow rules but might cheat to prevent losing. ability to identify time-related words such as the days of the week. Print letters

Oxygen therapy can cause retinopathy of

prematurity, especially in preterm newborns. Retinopathy is a disorder of retinal blood vessel development in a premature newborn. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This can reduce vision or result in complete blindness.

Terbutaline is a tocolytic medication that causes uterine relaxation and is used to treat

preterm labor.

Pressuring a child to eat might cause the child to

rebel and then use food consumption as a control mechanism. The nurse should praise the child for what is eaten and avoid using any tactics to force the child to eat.

The nurse should expect an adolescent to

reject traditions surrounding death such as funeral services as unnecessary or unimportant.

An amnioinfusion is performed during labor to

relieve transient fetal hypoxia caused by umbilical cord compression.

This client who has type 2 diabetes mellitus will have

resistance to insulin and a decrease in the secretion of insulin by the pancreatic beta cells. B. A client who has type 2 diabetes mellitus does not secrete enough insulin by the pancreatic beta cells to break down enough glucose. C. A client who has type 1 diabetes mellitus does not secrete insulin because of the destruction of beta cells by the body. Although insulin is still produced, it is of insufficient quantity to maintain homeostasis. D. The client who has type 1 diabetes mellitus has the destruction of the beta cells because of the body producing blood antibodies. This is not a manifestation of type 2 diabetes mellitus.

The nurse should expect a preschooler to view death as a

temporary occurrence like sleeping. The preschooler might believe the person can "wake up" again.

An ear formed and firm with instant recoil is a physical manifestation of a

term newborn. The nurse should assign this finding a score of 3.

A plantar crease over entire sole is a physical manifestation of a

term newborn. The nurse should assign this finding a score of 4

the nurse should instruct the client to take alendronate in the

the morning must be taken whole. with a full glass of water.before eating or drinking. It is also important to reinforce that the client must remain upright for 30 to 60 minutes after taking this medication to avoid esophagitis stop taking the medication if she develops heartburn

Newborns who have neonatal abstinence syndrome can have

tremors, tachypnea, nasal flaring apnea, retractions, incessant crying, frequent yawning and sneezing, mottling of the skin, excessive sucking, vomiting, and fevers. shrill cry. exaggerated Moro reflex. diarrhea

The nurse should expect a 3-year-old preschooler to have the language ability to

use 3- to 4-word sentences. Seven-word sentences are not expected until age 5.

Methylergonovine is a

uterotonic medication that has an adverse effect of hypertension. Therefore, this medication is contraindicated for a client who has preeclampsia

Seizures are the result of

various neurological and metabolic imbalances such as hypocalcemia and hypomagnesemia;

The child by 3 years

walk on tiptoe

Battery refers to the

willful touching of another person in a manner that might or might not cause harm. An example of battery is touching a client without consent.

A nurse in an urgent care clinic is collecting data from a preschooler who has indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse?

Bruises at various stages of healing Bruises at various stages of healing are a manifestation of physical abuse. Incorrect Answers: A. Depriving a child of medical and dental care is a manifestation of physical neglect. B. Malnutrition is a manifestation of physical neglect. C. Frequent urinary tract infections are a manifestation of sexual abuse.

A nurse is reinforcing teaching with the family of a 6-month-old infant about ways to stimulate language development. Which of the following instructions should the nurse include?

"Explain what you are doing to the infant while providing care." Exposing the infant to expressive speech is the foundation for the development of expressive skills (the ability to make others understand needs and thoughts) and receptive skills (the ability to understand spoken words). Incorrect Answers: B. Pacifier use is associated with an increased incidence of otitis media and does not encourage language development. The nurse should instruct the parents to discourage pacifier use after 6 months of age. C. Chewing and jaw muscle development do not promote language development. The nurse should instruct the family that hot dogs and carrots are choking hazards and should not be given to infants. D. Leaving a television playing in the child's room can be disruptive to sleep patterns and should be avoided

A nurse is providing teaching about home care to the parent of a child who has a newly applied fiberglass leg cast. Which of the following statements should the nurse include?

"Monitor the color of your child's toes every 4 hours for 24 hours." The nurse should instruct the parent to monitor the color of the child's toes every 4 hours to check for alterations in perfusion. The nurse should instruct the parent to notify the provider if the child's toes are discolored or cool to the touch. Incorrect Answers: B. The nurse should instruct the parent not to insert anything into the cast to avoid injury to the skin, which can cause infection. The parent should blow cool air into the cast with a hair dryer or fan if the child experiences itching. C. The nurse should instruct the parent that the fiberglass cast will dry within 30 minutes. Casts made from plaster take up to 72 hours to dry. D. The nurse should instruct the parent that the cast must stay dry at all times. The parent should cover the cast with a plastic bag before the child showers or bathes and assist the child as necessary to ensure the cast stays dry when bathing

The pincer grasp is an expected fine motor skill for should have the gross motor ability to maintain balance while leaning forward in a sitting position; however, the infant does not yet have the ability to maintain balance while leaning sideways.

a 9-month-old infant. C. Falling to a sitting position from a standing position is an expected gross motor skill for a 9-month-old infant.

Bradycardia and diarrhea are findings that indicate a

complication due to the transfusion of large amounts of blood or a problem with the kidneys. The nurse should identify these findings as an indication the child is experiencing an electrolyte imbalance

A 3-year-old child might be able to

play a game with simple rules. However, build a tower of 9 to 10 blocks. to have the fine motor ability to stack 10 blocks. understand the concept of sharing until around

School-aged children are typically interested in how

the body works and are open to instructions. Toddlers can understand the names and basic actions that body parts can perform, but they do not usually ask specific questions about body functions.

A nurse is reinforcing teaching about oxycodone with an adolescent who is experiencing a vaso-occlusive crisis. Which of the following pieces of information should the nurse include?

"This medication might cause nausea." The nurse should instruct the adolescent that nausea is an adverse effect of oxycodone. Other adverse effects include dizziness, sedation, and confusion. Incorrect Answers: A. The nurse should instruct the adolescent that constipation is a common adverse effect of oxycodone. B. The nurse should instruct the adolescent that this medication can cause orthostatic hypotension. Therefore, the adolescent should change positions slowly. D. The nurse should instruct the adolescent that this medication can cause dry mouth.

A nurse is caring for a toddler in the immediate postoperative period following the placement of a ventriculoperitoneal (VP) shunt. Which of the following interventions should the nurse perform?

Check for abdominal distention Intracranial fluid draining into the abdominal cavity may cause peritonitis or an ileus. The nurse should monitor the abdomen for distention and bowel sounds. Incorrect Answers: B. The child should be positioned flat during the immediate postoperative period to prevent the intracranial fluid from draining too rapidly, which could cause complications. C. While bulging or tenseness are signs of increased intracranial pressure in an infant, a toddler's anterior fontanel is closed. The anterior fontanel typically closes by 12 to 18 months of age. D. The child should be positioned with the operative side up to keep pressure off the shunt valve

A charge nurse is reinforcing teaching about child maltreatment with a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching?

Children who were born prematurely are more likely to be maltreated. Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often has increased care needs, which increases the risk of caregiver fatigue and can lead to a higher potential for maltreatment. Incorrect Answers: A. While child maltreatment occurs in all age groups, infants from birth to 1 year of age have the highest rate of maltreatment. B. In single-parent families, the parent is more often the abuser than the nonbiological partner. D. While child maltreatment does occur across all socioeconomic groups, the most cases occur in families of lower income and education level. These families often have additional stressors and restricted access to available support systems.

A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety?

Encourage rooming-in Rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope in an unfamiliar environment. Incorrect Answers: A.Toddlers are not as concerned about privacy as school-aged children and adolescents. Instead, they prefer to be with someone during procedures. B. The nurse should provide the toddler with short, simple explanations. A long explanation might cause heightened anxiety for the child. D. When speaking to a toddler, the nurse should refrain from using the word "fix" because this will cause toddlers to assume they are broken. Instead, the nurse should say, "I will help make you feel better."

A nurse is reinforcing teaching with a parent about pinworm testing. At which of the following times should the nurse advise the parent to perform the tape test?

Immediately after the child wakes up in the morning The nurse should instruct the parent to perform the tape test as soon as the child wakes up in the morning and before the child bathes or uses the restroom. The test should be repeated for 3 mornings in a before the child has a bowel movement and before the child bathes provide the child with a usual diet.

A nurse is reinforcing teaching with the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include?

Instruct the child to walk the bike through intersections The child should walk the bike through intersections and crosswalks to decrease the risk of injury. Incorrect Answers: A. The child should ride a bike with the flow of traffic to decrease the risk of injury. C. The child should ride a bike that is the appropriate size to prevent injuries. The balls of the child's feet should be on the ground when the child sits on the bicycle seat. D. The bike helmet should not obstruct the child's eyes or ears to decrease the risk of injury

A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect?

Metabolic acidosis Metabolic acidosis is an expected finding for clients who have acute renal failure. Incorrect Answers: A. Hyperkalemia is an expected finding for clients who have acute renal failure. B. Hypocalcemia is an expected finding for clients who have acute renal failure. C. An elevated plasma creatinine level is an expected finding for clients who have acute renal failure

A nurse on a pediatric mental health unit is caring for a school-aged child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation?

"Tell me about your favorite video game." The nurse uses the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication. Incorrect Answers: A. D. The nurse should avoid using closed-ended questions when attempting to foster rapport. This type of question typically results in a yes or no answer and does not encourage further communication. C. The nurse should avoid nontherapeutic statements that shift the focus away from the client and does not reflect interest in him as an individual

A nurse is reinforcing teaching with the family of a child about hospice care. Which of the following statements should the nurse include in the teaching?

"Hospice staff members consider the family's needs to be just as important as those of the child." The nurse should inform the family that part of the philosophy of hospice care is to provide care for the family's needs as well as those of the child. Assisting with respite care, counseling, spiritual needs, and care of the family following the child's death are all part of hospice care. Incorrect Answers: A. The nurse should inform the family that the hospice staff works closely with the family to coordinate the care of the child. Family members are active participants in the child's care and attend to the child's personal and hygiene needs as well as administration of medication. C. The nurse should inform the family that hospice care continues after the death of the child. Bereavement care is provided for a year or longer, if needed, to assist the family with adjusting to life following the loss of the child. D. The nurse should inform the family that hospice care focuses on palliative care and supporting the natural process of the child's death.

A nurse is reinforcing teaching with an adolescent client who has scoliosis. When discussing how to wear the back brace, the client appears to be holding back tears. Which of the following responses should the nurse make?

"This is a lot of new information to absorb about back braces; can you tell me your thoughts on what we have discussed?" Having scoliosis and wearing a back brace can negatively impact an adolescent's body image. When communicating with an adolescent client, the nurse should show empathy and encourage expression of feelings and thoughts. This allows the nurse to identify and address the client's specific concerns and needs. Incorrect Answers: B. Using stereotypical comments or clichés block therapeutic communication and might prevent the client from sharing fears and concerns. C. While it is therapeutic for the nurse to provide guidance regarding the selection of clothing, in this scenario the nurse is offering unsolicited advice without knowing why the client is crying. D. Close-ended questions elicit yes or no answers rather than allowing the client to express emotions.

A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make

"You can use a vial of insulin for up to 30 days." The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator. Incorrect Answers: A. Sugar-free cola will not increase the client's blood sugar because it does not contain sugar. The nurse should encourage the child to drink juice or milk with a complex carbohydrate. B. Insulin requirements increase during puberty due to a decreased sensitivity to insulin resulting in an increase in the child's insulin dosage. D. Blood glucose levels rise during illness and stress; therefore, the child might need to contact the provider for an increased insulin dosage.

A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority?

A child who has sickle cell anemia and a urine specific gravity of 1.030 The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A child who has sickle cell anemia must maintain adequate hydration because dehydration might cause a sickle cell crisis that can occlude circulation. Incorrect Answers: A. A child who has asthma should have a pulse oximetry reading of 90% or greater; therefore, this is not the nurse's priority finding. B. A child who has nephrotic syndrome typically has moderate to large amounts of protein in the urine; therefore, this is not the nurse's priority finding. D. A blood glucose level of 110 mg/dL is within the expected reference range; therefore, this is not the nurse's priority

A nurse is caring for a preschooler who has a vesicular, honey-colored, crusty region around the nose and mouth and has been diagnosed with impetigo contagiosa. Which of the following instructions should the nurse plan to reinforce with the parents? (Select all that apply.)

A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water E. Wash hands before and after contact with the affected area Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on reinforcing teaching about applying an antibacterial ointment, washing the child's bed linens daily in hot water, and washing hands before and after contact with the affected area to decrease the risk of reinfection or transmission to others. Incorrect Answers: C. The nurse should reinforce teaching with the child's parents about the administration of antibacterial medications. Acyclovir is an antiviral medication used for the treatment of viral skin infections. D. The nurse should reinforce teaching with the child's parents about washing the crusts each day with water and soap to promote healing.

A nurse is collecting data from a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion 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 that the child is having a hemolytic reaction. Incorrect Answers: B. Pruritus and flushing are findings that indicate a response to allergens present in the transfused blood product. The nurse should identify that the child is having an allergic reaction. C. Rales and cyanosis are findings that indicate the blood product might have been administered too quickly. The nurse should identify these findings as an indication the child is experiencing fluid overload. D. Bradycardia and diarrhea are findings that indicate a complication due to the transfusion of large amounts of blood or a problem with the kidneys. The nurse should identify these findings as an indication the child is experiencing an electrolyte imbalance.

A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room?

Suction equipment When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority item to have in the child's room is suction equipment. If the child experiences a tonic-clonic seizure, the child is at risk for aspiration and airway occlusion due to secretions, food, or fluids. The nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bag valve mask if needed. Incorrect Answers: A. The nurse should have a pulse oximeter available in the child's room because the child is at risk for hypoxia from a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room. B. The nurse should have oxygen therapy equipment available in the child's room because the child is at risk for hypoxia from a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room. C. The nurse should have a bag valve mask available in the child's room because the child might need rescue breaths following a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room.

A nurse is reviewing the dynamics of a family in which abuse is suspected. Which of the following findings should the nurse report to the provider?

The child has several unexplained scars and bruises. The nurse should suspect child maltreatment when the child has multiple unexplained scars and bruises. The nurse should report this finding to the provider. Incorrect Answers: A. Parents providing emotional support to the child is an expected finding. An unexpected finding would be the parents showing no emotion at all toward the child. C. A fear of health care staff is an expected finding in a child. An unexpected finding would be the child showing indiscriminate friendliness toward strangers such as the health care provider. D. Parents offering consistent stories about the child's injuries is an expected finding. An unexpected finding would be the parents presenting conflicting stories about the injury.

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 to the child When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Incorrect Answers: A. Reducing the room temperature is an effective method of lowering the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take. B. Redressing the child in minimal clothing is an effective method of reducing the toddler's temperature when implemented about 1 hour following the administration of an antipyretic. Therefore, this is not the first action the nurse should take. C. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take.

A nurse is caring for an 8-year-old child in the acute care setting. Which of the following actions should the nurse take?

Assign the child the task of checking her blood sugar before meals School-aged children are in Erikson's stage of Industry versus Inferiority. They are willing to accept and thrive when assigned the responsibility to perform simple tasks. Incorrect Answers: A. This action would be appropriate for an adolescent. School-aged children should receive teaching up to 1 day before the scheduled procedure to allow adequate time to process the information but not cause undue anxiety. C. This action would be appropriate for a toddler or a preschool-aged child. Children in these age groups typically exhibit animism, which is the belief that inanimate objects can assume life-like characteristics. D. This action would be appropriate when caring for a preschooler. Preschool-aged children are fearful of being injured or losing body parts.

A nurse is reinforcing discharge teaching with the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider?

Constant clearing of the throat A manifestation of hemorrhage following a tonsillectomy is the constant clearing of blood that is draining in the back of the throat. Therefore, the provider should be notified if the adolescent begins constantly clearing her throat following a tonsillectomy. Incorrect Answers: A. Following a tonsillectomy, some secretions can contain old blood. Old blood is a dark brown color, and fresh blood is bright red. Nasal secretions containing dark brown blood should not be reported to the provider because this is an expected finding. C. Following a tonsillectomy, an unpleasant odor from the oral cavity for several days is an expected manifestation. D. Following a tonsillectomy, a low-grade fever for several days is an expected manifestation.

A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take?

Burp the infant at least 2 to 3 times during the feeding Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed. Incorrect Answers: B. Infants who have a cleft lip and palate are typically "noisy" feeders due to the increased amount of air that is swallowed during a feeding. The nurse should watch the infant carefully for signs of distress during a feeding such as a wrinkled brow, elevated eyebrows, or watering eyes. If these distress signs are noted, the nurse should remove the nipple and allow time for the infant to swallow the formula. C. Formula is expected to appear in the nose of an infant who has a cleft lip and palate due to a lack of separation between the oral and nasal cavities. D. Parents and caregivers should be encouraged to begin feeding the infant as soon as possible. This opportunity enables the caregivers to gain experience and confidence in their ability to feed the infant prior to discharge, which typically occurs before the surgical repair.

A nurse is checking the motor development of a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay?

Dropping a cube when passing it between the hands The ability to pass a cube from a hand to the other is a fine motor skill expected of a 7-month-old infant. Therefore, the nurse should identify the 9-month-old infant's inability to perform this task as a possible developmental delay and should report this finding to the provider. Incorrect Answers: A. The pincer grasp is an expected fine motor skill for a 9-month-old infant. C. Falling to a sitting position from a standing position is an expected gross motor skill for a 9-month-old infant. D. A 9-month-old infant should have the gross motor ability to maintain balance while leaning forward in a sitting position; however, the infant does not yet have the ability to maintain balance while leaning sideways.

A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use?

FACES pain rating scale The FACES pain rating scale presents the client with various images of faces that represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels. Incorrect Answers: A. A word-graphic rating scale uses a line with words identifying a scale of no pain to worst possible pain. Children ages 4 to 17 place a line on the scale that describes their pain. However, children who are 3 years old will have difficulty understanding the words. B. The color tool uses 4 markers for the child to represent pain at various levels. Children ages 4 and older can use this tool. Children who are 3 years old might have difficulty remembering what each marker represents. D. Using a numeric scale (0 to 10) to rate pain requires the child to understand numbers. This tool is helpful for children ages 5 and older.

A nurse is collecting data from a 9-month-old infant. Which of the following findings should the nurse report to the provider as a delay in development?

Requiring support to sit for prolonged periods An infant should be able to sit unsupported by the age of 8 months. The nurse should report this finding to the provider because it is an indication of a delay in gross motor development. Incorrect Answers: A. The use of a pincer grasp usually begins to appear at the age of 8 months and becomes more refined by the age of 9 months. This is an indication that the infant's fine motor skills are on track with expected findings. C. An infant begins to localize sounds by the age of 3 months. By 9 months of age, the infant should be able to turn the head toward the location of the sound. This is an indication that the infant's sensory skills are on track with expected findings. D. An infant begins to vocalize chained syllables such as "dada" by the age of 7 months of age. By 10 months of age, the infant associates meaning with words such as "mama." This is an indication that the infant's vocalization skills are ahead of expected findings.

A nurse is reviewing the laboratory values for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect?

Sodium 125 mEq/L The nurse should expect an infant with acute renal failure to have hyponatremia. A sodium level of 125 mEq/L is below the expected reference range for an infant. Incorrect Answers: A. The nurse should expect an infant with acute renal failure to have an elevated BUN level. A BUN level of 5 mg/dL is within the expected reference range for an infant. B. The nurse should expect an infant with acute renal failure to have an elevated creatinine level. A creatinine level of 0.2 mg/dL is within the expected reference range for an infant. D. The nurse should expect an infant with acute renal failure to have hyperkalemia. A potassium level of 4.2 mEq/L is within the expected reference range for an infant.