Combo with "Evolve : Adolescents" and 5 others
The nurse provides nutritional counseling to the parents of a 6-month-old formula-fed infant who will begin eating solid foods. Which statement by a parent indicates understanding of the nurse's advice?
"I'll keep give him formula instead of regular cow's milk."
The nurse is providing instruction to a parent of a child with influenza. Which statement by the parent indicates the need for further instruction?
"I'll manage the fever with baby aspirin."
What statement by the nursing student indicates understanding of the precautions needed in the provision of care to a 7-year-old child who is HIV positive?
"I'll put on gloves if I'm going to be in contact with body fluids."
The clinic nurse is teaching an adolescent about lifestyle modifications to prevent hyperlipidemia. Which statement by the adolescent indicates a need for further teaching?
"I'll start eating more red meat."
The nurse is caring for an adolescent with hemophilia. Which statement by the client indicates a need for further teaching?
"I'll use a straight razor when I start shaving."
A nurse gives a teenager discharge instructions regarding cast care. The nurse concludes that the instructions have been understood when the teenager says:
"If I get itchy around the cast, I'll rub the itchy area gently."
An 8-year-old boy is found to have a mild concussion and is to be discharged home. The mother was instructed to check her child for responsiveness every 2 hours and to wake him up for this assessment after he goes to sleep. She telephones the nurse and says that she is afraid to allow him to go to sleep. How should the nurse respond? (Select all that apply.)
"If your son becomes difficult to awaken, bring him to the hospital." "Awakening your son throughout the night should alert you to any change."
Parents express concerns to the nurse that their 4-year-old child is spending a large amount of time playing with an imaginary friend. What is the best response by the nurse?
"Imaginary playmates are an important part of a young child's life."
The parents of a 6-month-old ask a nurse how to introduce their infant to pureed foods. How should the nurse respond?
"Introduce one food at a time every 4 to 7 days."
A 7-year-old boy with a diagnosis of attention deficit hyperactivity disorder (ADHD) is receiving methylphenidate (Concerta). His mother asks about its action and side effects. What is the nurse's initial response?
"It is a stimulant that has a calming effect on children with your son's disorder."
The parents of a 2-year-old boy are watching the nurse administer the Denver II Developmental Screening Test to their son. They ask, "Why did you make him draw on paper? We don't let him to draw at home." What is the best response by the nurse?
"It lets us test his ability to perform tasks requiring his hands."
A mother brings her 16-month-old daughter to the well-child clinic for a checkup. She is upset and reports, "My child refuses to eat at mealtimes. It's a battle between us." What is the best response by the nurse?
"It may be helpful to keep a daily diary of the food she eats."
A 15-month-old child is hospitalized after ingesting toilet bowl cleaner. The mother confides that she feels guilty about leaving the cleaner where her child could get it. What is the best response by the nurse?
"It was an accident, but you should consider special locks on your closets."
A nurse is teaching a young adolescent with type 2 diabetes about nutritional needs. Which statement demonstrates that the adolescent understands what was taught?
"It's OK for me to eat one slice of pizza at a party."
A nurse is preparing to give a 3-year-old toddler an intramuscular injection, and the child starts to cry. What is the most therapeutic approach for the nurse to take?
"It's all right to cry as loud as you want, but don't move."
A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate?
"It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby."
A 5-year-old girl is undergoing a course of chemotherapy. One day the nurse sees the child crying. The child tells the nurse, "All my hair is gone and everyone stares at me." What is the best response by the nurse?
"Let's ask your mother to bring in a hat for you to wear until your hair grows back."
A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, "Look how much weight he's gained even though he drinks only orange juice! He won't drink any milk!" What is best response by the nurse.
"Let's talk about his nutrition."
While discussing immunizations with the nurse, the father of a 7-month-old boy states, "You know, my son doesn't sit up by himself yet. Shouldn't he be able to do this by now?" How should the nurse respond?
"Many babies don't sit up until they're 8 months old. Let's watch what he does when I sit him up."
The parents of a school-aged child with recently diagnosed leukemia ask the nurse why they were told that their child has too many white blood cells. How should the nurse respond?
"The bone marrow is not controlling your child's white blood cell production as it should."
A 15-year-old high school student with hay fever has been taking a prescribed long-acting antihistamine/decongestant every 8 hours for the past 2 days. The adolescent tells the nurse, "This medicine is making me sleepy. Can you change it to something else?" How should the nurse respond?
"The drowsiness usually goes away after several days."
An anxious parent of a 6-year-old child expresses that the child looks slimmer than a year ago, although the nurse finds the child's height and weight to be age-appropriate. What is the nurse's response to the parent?
"The fat has diminished, and the fat distribution pattern has changed."
The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve site. What statement indicates that they understand the teaching?
"The flat left side-lying position is the safest position for our baby."
A 4-year-old boy with Reye syndrome is beginning to show signs of recovery. The intracranial pressure has receded, the vital signs are stable, the fever has subsided, and urine output is within the acceptable range for the child's weight and fluid intake. What should the nurse tell the parents about their son's recovery?
"The recovery is now progressing as we'd hoped."
The mother of an infant with hypertrophic pyloric stenosis states that she has never heard of this disorder and asks many questions. What should the nurse emphasize when responding?
"This disorder has an excellent prognosis."
The mother of a 2-year-old girl expresses concern that her daughter's growth rate has slowed. What should the nurse explain to the mother about the growth of toddlers?
"This growth pattern is typical at this age.
How should a nurse respond to parents who are concerned about separation anxiety in their 15-month-old toddler?
"This is an expected developmental reaction."
A 3½ -year-old child has been ill with nephrotic syndrome. The child has been toilet-trained for longer than a year but has been incontinent lately. The child's parents express concern over this behavior. What is the most therapeutic response by the nurse to the parents?
"This is an expected response to hospitalization. Ignore the regressive behavior and be supportive."
A nurse is preparing an intramuscular injection to be administered to a 2-year-old child. What approach is the most therapeutic?
"This might hurt, but it's important that you be very still."
A mother whose infant was found to have cerebral palsy at 6 months of age asks why she was not told that her baby had cerebral palsy when the infant was born. How should the nurse respond?
"Until there's control of voluntary movement a diagnosis can't be confirmed."
An intravenous line is inserted in the scalp vein of an infant. The mother asks why the IV is not placed in the hand or arm as for an adult. How should the nurse respond?
"Usually veins in the arm or hand are used, but your baby's were too small."
A nurse is teaching the parents of a 3-year-old child with a diagnosis of cystic fibrosis about their child's special needs. What statement indicates that the parents need further teaching about the issues related to cystic fibrosis?
"We'll have to move to a very warm climate."
What should a nurse say to promote a sense of control in a 6-year-old child who is about to receive an injection?
"Which arm should I use to give you the medicine?"
Ferrous fumarate (Feostat) 30 mg is prescribed for an infant. The ferrous fumarate solution contains 45 mg/0.6 mL. How much solution should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL
0.4 ml
A toddler who swallowed drain cleaner is hospitalized for observation because of the risk for vomiting and aspiration. Over the next 24 hours the child does not exhibit any respiratory distress and does not vomit. At discharge the nurse emphasizes that the parents should monitor their child for the onset of:
Gagging and vomiting
A 13-year-old girl is found to have idiopathic scoliosis. She is upset about the treatment regimen and is worried about being different from her friends. What should the nurse do to help the child maintain a positive self-image during treatment?
Help her investigate appropriate clothing to enhance her appearance
Monitoring vital signs, particularly the blood pressure and the rate and quality of the pulse, is essential in detecting physiological adaptations in a preschool child with nephrotic syndrome. Which clinical manifestation should the nurse be able to detect from these vital signs?
Hypovolemia
A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis?
Hypoxia
Discharge planning for a toddler with newly diagnosed celiac disease includes instructions regarding dietary restrictions. What foods should the nurse recommend? (Select all that apply.)
Ice cream Rice cakes Corn crisps
When assessing a 7-year-old child, which activity would the nurse anticipate the child to perform?
Identifying missing numbers and pictures
A toddler has frequent temper tantrums. The parents ask a nurse how to limit this acting-out behavior. What should the nurse recommend?
Ignore the tantrum whenever possible.
A nurse is caring for a 10-year-old boy who sustained a fractured cervical vertebra while playing football. When he is placed in cervical traction, the nurse teaches him that the traction will:
Immobilize the area to minimize injury to the spinal cord
A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action?
Immobilizing the child's spine to limit additional injury
A nurse in the pediatric clinic is counseling the parents of a school-aged child with celiac disease. The child has extensive mucosal damage and as a result the digestion of disaccharides is impaired. What substance should the nurse teach the parents to temporarily eliminate from their child's diet?
Milk
What is included in a toddler's diet if the family follows a lactovegetarian diet? Select all that apply.
Milk Fruit Vegetables
When planning discharge teaching for the parents of a child with asthma, what information should be included?
Minimize exertion and exposure to cold.
A school-aged child with a seizure disorder has been taking carbamazepine (Tegretol) for 3 years. What nursing intervention is most important at this time?
Monitoring the child's complete blood cell counts
What is the priority of nursing care for an infant with a newly applied spica cast?
Monitoring the child's peripheral circulation
A severely dehydrated infant admitted to the pediatric unit is too lethargic to receive oral rehydration therapy, and an intravenous infusion is started. What is the nurse's primary responsibility?
Monitoring the prescribed rate of flow
A 3-year-old child is scheduled for cardiac catheterization. What is the priority nursing care after this procedure?
Monitoring the site for bleeding
The mother of a 13-year-old child with sickle cell anemia tells the nurse that the family is going camping by a lake this summer. She asks what activities are appropriate for her child. Which activity should the nurse suggest?
Motorboat rides around the lake
A 15-year-old adolescent with type 1 diabetes arrives at the diabetic outpatient clinic with a parent. The adolescent sits back in the chair with arms folded, frowns, and displays a withdrawn attitude. The adolescent and parent argue in front of the nurse. What is the best approach for the nurse to use?
Speaking separately with each of them, encouraging them to recognize and vent their anger
During a well-child visit the parents tell a nurse, "Our 3-year-old doesn't listen to us when we speak—he ignores us!" An auditory screening reveals that the child has a mild hearing loss. What should the nurse explain to the parents about this degree of hearing loss?
Speech therapy in addition to hearing aids may be required.
A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse evaluate the infant?
Tachycardia
A busy work-at-home parent reports little time to interact with preschool children who become easily bored. Which activity is best for the nurse to recommend to keep the children occupied for long periods?
Teach the children games such as tag, jump rope, and hide-and-seek.
While communicating with the parents of a preschool child, the nurse finds that the parents are worried about their child's feelings of rivalry with his siblings and by the use of offensive language by their child. What other aspects should the nurse anticipate in the child? Select all that apply.
Telling exaggerated stories Asking too many questions Using 4-5 word sentences
At 7 am a nurse learns that an adolescent with diabetes had a 6:30 am fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?
Telling the adolescent that the prescribed dose of rapid-acting insulin should be administered
An 11-year-old boy who has stepped on a rusty nail is given tetanus immune globulin in the emergency department. The nurse knows that the immune globulin injection will confer:
Temporary passive acquired immunity
A nurse teaches a mother about appropriate play for an 8-month-old infant. Which of the mother's suggestions indicate that the teaching has been understood? (Select all that apply.)
Textured book Stuffed animal Hanging mobile
The nurse finds that an adolescent male's trunk is short when compared to the legs. What should the nurse infer from these findings?
The adolescent has normal growth and development.
Range-of-motion exercises are prescribed for a child with juvenile idiopathic arthritis. What criterion should the nurse use to evaluate the effectiveness of the exercises?
The affected joints can flex and extend.
A child, accompanied by a parent, visits a dentist for reimplantation of an avulsed tooth. The child holds the avulsed tooth in the socket by biting on it. After examination, the dentist concludes that the tooth cannot be reimplanted. What is the possible reason for this conclusion?
The tooth was inserted with the lip side facing back.
Why is it essential for the nurse to obtain the height and weight of a severely dehydrated toddler?
The values are used to calculate fluid replacement and medication dosages.
A nurse is preparing to take the vital signs of a 4-year-old child who was brought to the well-child clinic. What criterion should the nurse use when selecting the appropriate size of blood pressure cuff?
The width is approximately 40% of the circumference of the upper arm.
A nurse explains to the parents of a toddler why 2-year-old children are at risk for lead poisoning. What major risk factor does the nurse includes in the discussion?
They explore the environment by touching and tasting.
A nurse in the daycare center is teaching a group of assistants why toddlers are prone to lead poisoning. What factor primarily contributes to their risk for lead poisoning?
They have a high level of oral activity.
The parents of a gifted 4-year-old notice that their child has been showing signs of rebellion and acting out. One important thing to teach the parents about gifted children is:
They need boundaries like any other child
The nurse finds a 4½ -year-old hospitalized girl, who has several siblings, crying and shouting at her teddy bear, "There! You bad girl! Don't be mad at your brother! Go to the hospital!" An understanding of preschooler development leads the nurse to believe that this behavior is based on the fact that the child:
Thinks that being sick is related to bad thoughts about the brother
A nurse is preparing for a teaching session with the parents of an infant with phenylketonuria (PKU). The parents are upset and want an explanation of why the child has this disease that they have never heard of. What should the nurse consider before responding?
This autosomal recessive disorder was inherited from parents who are carriers.
A 2-year-old toddler requires close supervision to protect against potential accidents. The nurse teaches a class for parents about the learning style of toddlers. How do toddlers learn self-protection?
Through trial-and-error strategies
Which toddler behavior reflects animism?
Toddlers attribute lifelike qualities to inanimate objects.
Which age-specific cognitive characteristic increases the risk of injuries in school-age children?
Transitional cognitive processes
Which of the following signs are indications of hydration status during a sickle cell crisis? (Select all that apply.)
Turgor of tissue Texture of mucous membranes
A 14-year-old adolescent with diabetes has been self-administering insulin twice a day. This morning the parents found their child lethargic and confused. After the adolescent's admission to the emergency department, laboratory testing reveals a hemoglobin A1C level of 10% and a blood glucose level of 200 mg/dL. What does the nurse suspect as the most likely cause of this client's condition?
Uncontrolled blood glucose level
When is a toddler considered ready for toilet training? Select all that apply.
When the child is able to sit, walk, and squat When the child is capable of removing his or her own clothing When the child is able to recognize the urge to defecate or urinate
After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our son have to have restraints?" How should the nurse respond?
"Because we're keeping the arms straight your baby won't be able to touch his mouth."
A 30-month-old boy who was transferred to a regional hospital has not seen his parents for 2 weeks. He now responds to the staff with friendliness and affection. When his mother visits he turns away from her and ignores her. What should the nurse explain to the mother?
"Your little boy misses you very much; give him time and he'll reach for you."
The father of a child who is dying of cancer asks the nurse whether he should tell his 7-year-old son that his sister is dying. What is the most appropriate response by the nurse?
"Your son probably doesn't understand death as we do but fears it just the same. He should be told the truth to let him prepare for his sister's possible death."
A toddler with hemophilia A is receiving factor VIII. The mother asks the nurse, "If my son hurts himself, I'll give him 2 children's Advil. Is that right?" How should the nurse respond?
'Give him Tylenol—Advil may cause bleeding."
A neonate has irregular, slow, weak cry; well-flexed extremities; heart rate of 102 beats/min; no response to reflex irritability; and the color of the body is completely pink. What would be the Apgar score in this neonate? Record your answer using a whole number.______
-Irregular, slow, weak cry = 1, well-flexed extremities = 2, heart rate of 102 beats/min = 2, no response to reflex irritability = 0, color is completely pink = 2. Therefore, the Apgar score is 7.
Which activities should the nurse expect to see exhibited by a healthy 6-month-old infant during an evaluation of the infant's growth and development? (Select all that apply.)
1 Playing peek-a-boo 2 Turning completely over 3 Reaching to be picked up 5 Sitting for a short time without support
At which age does an infant have a strong grasp reflex?
1 month
A practitioner prescribes an initial loading dose of 75 mcg of oral digoxin (Lanoxin) for a school-aged child. The medication is supplied as an elixir, 50 mcg/mL. How many milliliters of solution should the nurse administer? Record your answer rounding to one decimal place. __________ mL
1.5 mL
To evaluate kidney function, the nurse must accurately measure the hourly urine output of a 1½-year-old toddler weighing 22 lb who has been admitted with extensive burns. What is the minimum safe output per hour for a child this age?
10 to 20 mL
A nurse provides clapping, percussion, and postural drainage every 4 hours for a 3-month-old infant with cystic fibrosis. When is the best time for the nurse to schedule chest physiotherapy?
2 hours after feedings
An infant is receiving 22 mL/hr intravenous fluid by way of an infusion pump. How much fluid will be infused between 8 am and 8 pm? Record your answer using a whole number. __________ mL
22 mL × 12 h = 264 mL
At what ages are children considered preschoolers? Select all that apply.
3 years 4 years 5 years
A nurse at the well-child clinic determines a 1-year-old infant's length to be below what is expected. The current height is 28 inches, and the birth length was 20 inches. What should this infant's current length be? Record your answer using a whole number. __________ inches
30 inches.
An IV of 800 mL/24 hr is prescribed for a 2½-year-old child. At how many milliliters per hour should the nurse set the volume control device?
33 mL
A 16-year-old adolescent with recently diagnosed type 1 diabetes will receive NPH (Novolin N) insulin subcutaneously. The nurse teaches the adolescent about peak action of the drug and the risk for hypoglycemia. How many hours after the drug does the NPH peak?
4 to 12 hours
A 4-year-old child is admitted with burns over the entire right arm and the anterior and posterior aspects of both legs. Using the percentage of total body surface area (TBSA) that was burned, the nurse estimates that the TBSA affected is approximately:
41%
An 18-month-old toddler is to receive an intravenous infusion of 1000 mL 5% dextrose and 0.45% sodium chloride over 24 hours. At what rate should the nurse set the volume-control device? Record your answer using a whole number. __________ mL/hr
42 mL/hr
A broad-spectrum oral antibiotic is prescribed for an adolescent with a bacterial infection. The prescription reads, "Take three times a day." At which times should the nurse recommend that the medication be taken to maintain a therapeutic blood level?
6 am, 2 pm, 10 pm
Oral phenobarbital 30 mg every 6 hours is prescribed for a toddler who has had a seizure. A bottle of phenobarbital liquid labeled "20 mg/4 mL" is available. How much solution should the nurse administer? Record your answer using a whole number. __________
6 mL
Which intelligence quotient (IQ) in a school-age child indicates special learning needs?
60
With which roommate should the nurse place a 4-year-old boy who has been admitted to the hospital with nephrotic syndrome?
A 5-year-old girl with acute glomerulonephritis
What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)?
A low-phenylalanine diet is required.
A gavage feeding is prescribed for an infant. How does the nurse determine the length of tube needed to reach the stomach?
A measurement is made from earlobe to nose and then to the epigastric area.
A 2-month-old infant is to have a nasogastric tube inserted. The nurse expects that:
A pacifier will be offered to lessen gagging and allow easier insertion of the tube
The parents of an infant born with a myelomeningocele are confused about what the health care provider has told them about the condition. What should the nurse consider before answering the parents' questions in language that they will understand?
A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine.
A nurse is caring for an 8-year-old child who has been admitted to the pediatric unit with a tentative diagnosis of acute poststreptococcal glomerulonephritis (APSGN). Diagnostic tests are ordered. Which tests will help confirm the diagnosis? (Select all that apply.)
ASO titer Urinalysis Blood chemistry
A nurse in the pediatric clinic determines that the pancreatic enzyme replacement being taken by a child with cystic fibrosis is inadequate. What clinical finding supports this conclusion?
Abdominal cramping
Which assessment finding in a newborn indicates impaired vision?
Absence of corneal reflex
A nurse is caring for an infant with a myelomeningocele. What does the nurse expect this infant to have that differentiates it from an infant with a meningocele?
Affected lower extremities
When does the Babinski reflex disappear?
After 12 months
The parents of a boy born with hypospadias ask the nurse at what age the repair of this congenital defect is performed. What is the most appropriate response by the nurse?
After 6 months and before 1 year of age
Methylphenidate (Ritalin SR) is ordered for a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD). The nurse teaches the father about the safe administration of the medication and concludes that the instructions have been understood when the father says that he should administer it:
After breakfast
How many deciduous teeth would be present in a 10-month-old infant? Record your answer as a whole number. ________
Age of child in months minus 6 = Number of deciduous teeth. Therefore, the number of deciduous teeth is 10 - 6 = 4.
A practitioner recommends that an adolescent with the diagnosis of osteogenic sarcoma have the affected leg amputated and then be treated with chemotherapy. The parents are concerned about what to tell their child and ask the nurse for advice. The nurse suggests that they discuss the:
Amputation and provide information about chemotherapy
A 30-month-old boy with cystic fibrosis is admitted to the pediatric unit with a severe upper respiratory infection. The toddler is small for his age. What pathological process does the nurse know is the cause of his small stature?
An absence of pancreatic enzymes
A nurse in the pediatric clinic is reviewing the chart of a 1-year-old infant before the examination. The infant's birthweight was 7 lb 8 oz. What weight should the nurse expect the infant to be at 1 year of age? Record your answer rounding to one decimal place. __________ lb
An infant's birthweight should triple by 1 year of age; therefore 7.5 lb × 3 = 22.5 lb.
Which stage is observed in a 2-year-old child according to Freud's theory?
Anal stage
Which characteristics are observed in the embryonic stage of prenatal development? Select all that apply.
Appearance of arm and leg buds Rapid development of the nervous system Beginning of development of fingers and toes
What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein?
Applying arm boards to prevent bending at the elbows
A nurse determines that a 22-month-old child uses two- or three-word phrases (telegraphic speech), has a vocabulary of about 20 words, and often uses the word "me." The nurse concludes that the child's language development is:
Appropriate
Several 3-year-old girls in the daycare center are having a tea party with their dolls. The center's nurse concludes that this behavior is:
Appropriate make-believe play
The nurse notes that a 6-month-old infant is startled by a loud noise but does not turn in the direction of the sound. How should the nurse interpret this response?
As evidence of hearing loss
An 18-month-old toddler requires an intramuscular injection. As the nurse enters the room with the medication, the child begins to scream and flail about on the bed. The father is sitting at the child's bedside and gets up to leave. What action should the nurse take to best handle this situation?
Ask the father to stay to comfort the child while the injection is being given
A parent tearfully tells a nurse, "They think our toddler is developmentally delayed. We're investigating a preschool program for cognitively impaired children." What is the most appropriate response by the nurse?
Asking for more specific information related to the developmental delays
In which type of play do children play together, share toys, and communicate with each other?
Associative play
A nurse is teaching parents about growth and development in preadolescent girls, and a mother asks at what age her daughter will have her first period. What is the most accurate response by the nurse?
At the end of the growth spurt
Which type of cerebral palsy may cause a wide-based gait in children?
Ataxic
A nurse is planning to administer albuterol (Proventil) to a 4-year-old child. The nurse should evaluate the effectiveness of this medication by:
Auscultating breath sounds
An adolescent child who has sustained full-thickness burns is to undergo skin grafting. The nurse explains to the child's parents that for permanent grafts the child must have:
Autografts
A 2½-year-old toddler arrives at the well-baby clinic for a routine physical examination. The child opens all of the cabinets in the examination room and carefully moves the tongue depressors and other items to different places. What psychosocial developmental stage does the nurse determine that this child is in?
Autonomy
A nurse who is teaching a growth and development class to a group of parents at the daycare center explains that the toddler strives for a sense of:
Autonomy
Which stage of psychosocial development should an individual successfully master to achieve self-control and willpower, according to Erikson's theory?
Autonomy versus shame and doubt
The nurse is assessing a newborn immediately after birth. Which findings indicate abnormality and need further investigation? Select all that apply.
BP is 80/70 mm Hg Body temperature is 97.0° F Head circumference is 3 cm less than chest circumference
The parents of a 3-month old infant who is breastfed ask the nurse how to prevent nutritional anemia. What is the best response by the nurse?
Baby cereal or an iron supplement should be given around 4 months of age.
A parent of a 6-month-old infant asks the nurse which foods should be introduced first. What is the best response by the nurse?
Baby cereals
Which family has at least one step-parent and step-sibling?
Blended Family
During a routine checkup, the nurse learns that an adolescent patient is planning to get a navel piercing. What should the nurse assess in the adolescent to ensure safety?
Blood glucose levels
The nurse is helping an adolescent with iron-deficiency anemia make breakfast meal choices. Which foods should the nurse suggest?
Bowl of raisin bran
Which fine motor activity can be observed in a 3-month-old infant?
Brings objects from the hand to the mouth
The gross motor skills of a 5-year-old child are being evaluated. According to the principles of developmental direction, in which order do these skills develop? Begin with the skill that is accomplished first.
Climbing up and down stairs Riding a tricycle Skipping and hopping on one foot Walking backward
Which behavior is observed in a newborn in deep sleep?
Closed eyes
Which condition is an example of a deformation that affects a child's growth and development?
Club foot
A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?
Clustering care to conserve energy
A toddler with a puncture wound to the sole is brought to the emergency department. Because of a language barrier the caregiver cannot provide a clear history of previous tetanus immunizations. Tetanus immunoglobulin (TIG) is prescribed by the practitioner. The nurse explains to the caregiver that this medication is given because it:
Confers short-term passive defense against tetanus
A nurse is caring for an infant with Down syndrome. What does the nurse recall as the most common serious anomaly associated with this disorder?
Congenital heart disease
Which condition causes failure to thrive in infants due to an increased metabolism?
Congenital heart disease
A nurse is observing hospitalized toddlers in the playroom. What does the nurse identify as their most important need?
Contact with their parents
What is the appropriate parenting implication for an infant who is sleeping with the eyes closed and has regular breathing, no movements except for an occasional sudden bodily twitch, and no eye movement?
Continue usual house noises
A 9-year-old child who has successfully completed the emergency (resuscitative) phase of treatment for a severe burn injury is started on a high protein, high calorie diet. Which snacks should the nurse encourage between meals? (Select all that apply.)
Crackers and cheese Banana pudding and whipped cream Frozen yogurt and chocolate sprinkles
Which motor response appears at 8 months of age?
Crude pincer grasp
The parent of a child who has received all of the primary immunizations asks the nurse which ones the child should receive before starting kindergarten. The nurse tells the parent that her child should receive:
DTaP, IPV, MMR
A 2-year-old boy born with cryptorchidism is to undergo orchiopexy. What should the nurse tell the parents about the anticipated outcome of this surgery?
Damage to the undescended testicle will be prevented.
The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, what is the best recommendation the nurse can make?
Decrease fast food intake.
A school-aged child with celiac disease has been eating a gluten-free diet for 2 days. What criterion should the nurse and parent use to determine the effectiveness of the diet?
Decreased irritability
Upon assessing a newborn, the nurse finds that the newborn's eyes are closed with no eye movement. Also, the newborn's breathing is regular with no body movement. What does the nurse understand about the newborn's state?
Deep sleep -The newborn with closed eyes, no eye movement, and regular breathing is in deep sleep. A newborn in light sleep may have closed eyes with irregular breathing and may smile. During a quiet alert state, a newborn may have the eyes wide open and respond to stimuli. During an active alert state, a newborn's eyes are open and may show slight body movement and irregular breathing.
What common finding can the nurse identify in most children with symptomatic cardiac malformations?
Delayed physical growth
A nurse is planning to teach the importance of handwashing to children in first grade. What is the most effective approach for this age group?
Demonstrating handwashing and asking for return demonstrations
An infant is born with exstrophy of the bladder. The parents are concerned and confused when they are told that their infant will need surgery. What nursing intervention will best help the infant's parents?
Demonstrating the same manner of care for the infant as for other infants on the unit
On the third day of a 2-year-old toddler's hospitalization the nurse notes that the child, who had been screaming and crying inconsolably, has begun to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?
Despair
A nurse is caring for a 9-month-old infant who has been admitted to the pediatric unit with a tentative diagnosis of meningitis. A lumbar puncture is performed. The nurse explains to the parents that the primary reason this procedure is performed is to:
Determine the causative agent
A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include?
Encouraging continuation of breastfeeding
What is the best way for the nurse to promote the social development of a 9-month-old infant?
Engaging in peek-a-boo
A nurse is planning care for a school-aged child after the application of a spica cast. What should the nurse include in the plan of care for the child?
Evaluating neurovascular status of the legs
A mother whose infant is born with talipes equinovarus (clubfoot) tells the nurse that she is afraid to have more children because they might have the same problem. What is the best response by the nurse?
Exploring the mother's understanding of the probable causes of this disorder
An infant has a plaster cast applied for clubfoot correction. What nursing intervention will hasten drying of the cast?
Exposing the casted extremity
A nurse is caring for a 1-month-old infant who has undergone surgery to repair a cleft lip. What should the nurse use to facilitate feeding during the immediate postoperative period?
Feeding syringe
An infant appears very fussy, cries loudly, and draws up its legs to the abdomen. What does the nurse suspect to be the cause of these behaviors?
Feeding the infant cow's milk
A 2-month-old infant is admitted to the pediatric unit for observation after an automobile collision. Family members are unable to stay. How can the nurse best provide psychological comfort for the infant?
Following a routine to which the infant is accustomed
What behavior does the nurse expect a healthy 5-month-old infant to exhibit?
Grasping objects voluntarily
A mother expresses concern that her adolescent daughter is not ingesting enough calcium because of her allergy to milk. What alternative foods or liquids should the nurse suggest? (Select all that apply.)
Green leafy vegetables Black or baked beans Oranges Salmon and sardines
A practitioner prescribes supplemental oral iron therapy for a child with iron-deficiency anemia. What side effect should the nurse tell the parents to anticipate?
Greenish-black stool
A nurse is trying to soothe a 2-month-old infant who is crying. What is the best way to soothe a young infant?
Holding and rocking the infant in a quiet room
How can a nurse best soothe a hospitalized infant who appears to be in pain?
Holding the infant
An 18-month-old child has received all required immunizations. What immunization should the nurse explain to a parent will be one of the vaccines required between 4 and 6 years of age?
Inactivated poliovirus
Which intervention, if followed by the parent, may help manage encopresis in a 9-year-old child?
Including cereals in the child's diet
An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect the health care provider to identify during the physical assessment?
Limited abduction of the affected hip
A preschool-age boy has been restricted to bedrest since being admitted to the hospital. As he begins to recover, he becomes interested in playing. In light of his developmental level and activity restriction, what should the nurse provide for him?
Little cars and a shoebox garage
A nurse is caring for a 15-year-old adolescent who was admitted to the hospital after taking an acetaminophen (Tylenol) overdose. The result of which diagnostic study is most important for the nurse to monitor at this time?
Liver function tests
Before administering the first series of immunizations to a 2-month-old infant, the nurse tells the mother that reactions may occur. What are the characteristics of these reactions?
Local or systemic and usually mild
Spinal fusion is performed in an adolescent with scoliosis. What postoperative nursing intervention is specifically related to surgery for scoliosis?
Log-rolling every 2 hours
A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care?
Maintain standard and contact precautions.
A 1-month-old infant with hydrocephalus is scheduled to have surgery for the insertion of a ventriculoperitoneal shunt. What is the primary focus of nursing interventions for this infant?
Maintaining a satisfactory comfort level to limit crying
A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. The nurse and client agree that the primary long-term goal for this teenager is:
Maintaining normoglycemia
When providing nursing care to children the nurse remembers that in the child, as in the adult, respiratory patterns are controlled by the:
Medulla
A 9-year-old child has been found to have Legg-Calvé-Perthes disease and is on bedrest. The nurse encourages the parents to look for something creative for the child to do or a hobby for the child to begin with the purpose of:
Meeting the developmental task of initiative
A male adolescent with cystic fibrosis, whose parents are both carriers of the disease, asks the nurse, "When I have children, could they have cystic fibrosis like me?" What information should the nurse consider before responding?
Men with cystic fibrosis usually are sterile, although sexual function is not affected.
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing?
Metabolic acidosis
A critically ill 5-year-old child exhibits Kussmaul respirations. The nurse suspects an increasing acid-base imbalance related to:
Metabolic acidosis cause by a concentration of cations in body fluids
A nurse is caring for a preschooler on the pediatric unit. What does the nurse identify as the child's greatest fear at this age?
Mutilation
What does a nurse recognize as the most serious complication of meningitis in young children?
Peripheral circulatory collapse
A 4-year-old child is receiving prednisone. Which immunizations are safe for the child to receive? (Select all that apply.)
Pertussis Inactivated poliovirus Tetanus immune globulin
In which stage of development can a child identify with the parent of the same sex, according to Freud's theory?
Phallic
An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. What should the nurse do when caring for the infant during the initial postoperative period?
Place the infant flat with the head on the unaffected side
Which stage of cognitive development does the nurse suspect in a child who says, "My doll is crying because it is feeling hungry"?
Preoperational
The nurse is caring for a high-risk infant who is receiving intravenous fluids through an infusion pump. Which complications may occur if the fluid rate is more than the prescribed rate? Select all that apply.
Pulmonary edema Congestive heart failure Intraventricular hemorrhage
What procedure should a nurse use when elevating the head of an infant in a spica cast?
Raising the entire mattress at the head of the crib
What is a characteristic of a slow-to-warm-up child?
Reacting negatively to new stimuli
The factor that is most significant for the nurse working with the family of an infant born with a genetic disorder is their:
Readiness to talk about problems their infant may have in the future
What nursing intervention is most effective in alleviating the fretfulness of a hospitalized 5-year-old child?
Reading a story to the child
Which enzyme is responsible for retaining milk in the stomach of infants long enough for digestion?
Rennin
After orthopedic surgery a 15-year-old adolescent reports pain and rates it a 5 on a scale of 0 to 10. A nurse administers the prescribed 5 mg of oxycodone every 3 hours as needed. Two hours after having been given this medication, the adolescent reports pain and rates it a 10 of 10. What action should the nurse take next?
Request that the health care provider evaluate the need for additional medication
A school-aged child with cystic fibrosis has been admitted with a respiratory infection. The child has been very disruptive and angry with staff and parents. The nurse suspects that the child is:
Resentful of the restriction of the hospitalizations
During a home visit, the nurse finds that a 9-year-old child is very fond of riding on a scooter. The nurse teaches the child and the family about the safety measures to be followed. Which action of the child indicates a need for additional teaching?
Riding the scooter at night when there is less traffic
A toddler undergoes cardiac catheterization as part of a diagnostic workup for pulmonic stenosis. In which part of the cardiovascular system should the nurse expect an increase in pressure?
Right ventricle
The parents of a boy with hypospadias with chordee ask a nurse why their child should undergo corrective surgery. What problem that may develop eventually should the nurse discuss with the parents?
Sexual difficulties
A nurse is caring for a child with chordee. The parents ask why corrective surgery is necessary. Before responding, the nurse considers that in adulthood, if the chordee is not surgically corrected, the child will be at increased risk for:
Sexual dysfunction
A 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. What significant adverse outcome during the first 48 hours should the nurse attempt to prevent?
Shock
A toddler who has undergone cleft palate repair is now able to tolerate fluids. What should the nurse use to offer the toddler fluids?
Small cup
The parent of a 14-month-old toddler asks the nurse how to proceed with bowel training. What is the best response by the nurse?
Start by having the child sit on a potty chair
After multiple upper respiratory infections, a school-aged child undergoes a tonsillectomy and adenoidectomy. Two weeks after surgery the nurse evaluates the child's condition. On what should the nurse focus? (Select all that apply.)
Taste Smell Hearing Breathing
The parents of a 4-year-old child call the health center and report that their child has a fever of 102.6° F (39.2° C), is complaining of a sore throat, and will not lie down, preferring to sit up and lean forward. The child is drooling and looks ill and agitated. In light of this information, what guidance should the nurse provide the family?
The child needs to be seen immediately by a health care provider.
The nurse finds that an 8-year-old girl has a large collection of dolls. What should the nurse understand from the girl's behavior?
The girl enjoys collecting the dolls.
A 10-year-old child is found to have hemophilia. The nurse is explaining how hemophilia is inherited. What is the best explanation of the genetic factor that is involved?
The mother is a carrier of the disorder but is not affected by it.
A nurse suspects that a 7-month-old infant who is brought to the well-baby clinic for the first time has a hearing deficit. What behavior leads the nurse to come to this conclusion?
The mother says the infant stopped making verbal sounds about a month ago.
What could be a cause of a stiff, tense appearance of the sutures in a newborn?
The neonate is crying.
The parents of an infant with pyloric stenosis ask a nurse many questions about the problem. What information should the nurse communicate when answering these questions?
This is a condition with an excellent prognosis.
A nurse is reviewing the laboratory report of an infant with tetralogy of Fallot that indicates an increased red blood cell (RBC) count. What does the nurse identify as the cause of the polycythemia?
Tissue oxygen needs
The mother of a school-age child asks the school nurse how her child got head lice. What should the nurse explain to the mother?
Transmission occurs through contact with contaminated children and objects.
A 3-year-old child with sickle cell anemia is admitted to the child health unit during a painful episode. Splenomegaly is identified. The nurse explains to the parents that splenomegaly is:
Triggered by a vaso-occlusive crisis
A 2-year-old child with previously diagnosed hemophilia is admitted to the pediatric unit for observation after a motor vehicle collision. The toddler has several bruises but no other apparent injuries. What is the nurse's specific concern regarding this child?
Undetected injury
The parents of an infant with newly diagnosed cystic fibrosis ask a nurse what causes the foul-smelling, frothy stool. What is the best response by the nurse?
Undigested fat
An infant child with juvenile idiopathic arthritis is seen in the clinic. Ibuprofen 90 mg by mouth every 6 hours is prescribed. Ibuprofen is available in a solution of 100 mg/2.5 mL. How many milliliters should the nurse instruct the parents to give with each dose? Record your answer rounding to two decimal places. __________ mL
Use ratio and proportion to calculate the dose. Desire 90 mg x mL ----------------- = ------ Have 100 mg 2.5 mL 100x = 225 x = 225 ÷ 100 x = 2.25 mL
A 3-year-old boy has been observed in the clinic waiting room taking toys from others, tearing pages out of books, and striking his mother. The nurse takes time when interviewing the mother to ask about television habits because:
Viewing violent programs is positively correlated with the development of aggression
After being bitten by a rabid dog a 4-year-old child is to receive a series of antirabies inoculations. The nurse who is to administer the injections should recall that rabies is a:
Viral infection characterized by seizures and difficulty swallowing
A 1-week-old infant has been in the pediatric unit for 18 hours after placement of a spica cast. The nurse obtains a respiratory rate slower than 24 breaths/min; no other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken?
Vital signs that are outside the expected parameters are significant and should be documented.
An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? (Select all that apply.)
Weak pulse Difficulty swallowing Loss of bladder control
A nurse is preparing a 10-year-old child for a tonsillectomy and adenoidectomy to be performed later in the day. What information should the nurse share with the child?
What the child will experience before and after the procedure
A nurse is planning to obtain a blood specimen from a 4-week-old high-risk infant in the neonatal intensive care unit to test for hypoglycemia. At which point, on the figure of the bottom of the infant's foot, should the automatic lancet device be placed?
c
It is suspected that a 5-week-old infant has pulmonic stenosis, and cardiac catheterization is scheduled. When the parents ask what the test involves, the nurse replies:
"A catheter will be inserted into a blood vessel in your baby's groin and then threaded to the heart to confirm an anatomic abnormality."
Which statement by the parents of an infant with Erb palsy indicates to the nurse that they have an accurate understanding of their infant's prognosis?
"Complete recovery takes a few months."
The parents of a 6-year-old child tell a nurse at the pediatric clinic that their child is weak and lethargic, has headaches, has no appetite, and has dark, cloudy urine. The nurse suspects acute poststreptococcal glomerulonephritis (APSGN). What should the nurse ask the mother?
"Did your child have a sore throat during the past 3 weeks?"
Which statement by the mother of a 5-month-old infant indicates effective learning about proper nutrition for the infant's growth and development?
"I will breastfeed my child."
The registered nurse is teaching the mother of an infant about the prevention of sudden infant death syndrome (SIDS). Which statement by the mother indicates effective learning?
"I will position my baby on the back while sleeping."
A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder states:
"I'll start to have symptoms when I drink less fluid."
The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the mother says:
"Lying on the abdomen is prohibited, so we'll keep him in an infant seat."
The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond?
"Maternal antibodies interfere with the development of active antibodies by the infant when immunized."
Which statement made by the parent of a 7-month-old infant indicates that the child has delayed fine motor development?
"My child is unable to use both hands while grasping objects."
A new father tells a nurse that his sister and her family plan to visit the new baby and that his niece and nephew have just recovered from chickenpox (varicella). Their lesions are completely healed or have scabs and are no longer draining. He asks the nurse whether it is safe for them to be near the baby. What is the best response by the nurse?
"The most contagious time is before the spots appear. It'll be safe to visit."
A 17-year-old child was recently found to have type 2 diabetes mellitus. What information will the nurse include when providing education to the family?
"The most important interventions are good nutrition and portion control."
A mother asks why her 2-year-old toddler's cleft palate was not repaired at the same time that the cleft lip was repaired. What is the best response by the nurse?
"The palate usually is repaired before a child starts to speak. Some surgeons prefer to wait up to 2 years."
The parent of an 8-year-old child is worried that the child is very thin and looks unattractive due to large teeth. What is the nurse's best response?
"The pattern of fat distribution changes in children of this age."
When a 12-year-old boy who sustained several tick bites on a camping trip becomes ill, he is told that he may have Lyme disease. He asks the nurse, "What is Lyme disease?" What is the best response by the nurse?
"The tick bites gave you an infection. There is medication that will treat it."
An infant who was in a motor vehicle collision has undergone open repair of a fractured sternum and now has a chest tube. What should the nurse explain to the infant's parents about the chest tube?
"The tube has been placed to drain the air that entered the chest cavity during surgery."
An infant is found to have communicating hydrocephalus. The parents ask for clarification of the health care provider's explanation of the problem. How should the nurse respond?
"There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately."
A mother indicates to the nurse in the pediatric clinic that she is concerned that her 20-month-old son's bedtime thumb-sucking will cause his teeth to protrude. How should the nurse respond?
"There is no reason to be concerned about the teeth protruding unless he keeps sucking his thumb after his permanent teeth have come in."
An 8-year-old child with cerebral palsy is admitted to the hospital for a tendon-lengthening procedure. After the surgery the parents ask a nurse why their child must wear braces and shoes for at least 12 hours a day, even while in bed. What is the best response by the nurse?
"They maintain body alignment and help prevent foot drop."
Phenobarbital is prescribed for an infant who has had repeated seizures. One week later, at the follow-up visit, the infant is lethargic and the mother states that the infant is sleeping excessively. The infant's mother asks the nurse what is happening to her baby. What should the nurse tell the mother?
"This is a response to the medication that will subside eventually."
A parent tells the nurse, "My 9-month-old doesn't have the same strong grasp that she had when she was born, and she's not startled by loud noises anymore." How should the nurse explain these changes in behavior?
"Those responses are replaced by voluntary activity around 5 months of age."
The parents of a neonate born with a cleft lip ask a nurse when the cleft lip will be repaired. What is the best response by the nurse?
"Usually before the baby is 12 weeks old."
The mother of a 5-month-old boy calls the nurse in the pediatric clinic to ask why her son no longer turns his head toward her breast when she touches his cheek. How should the nurse respond?
"Usually this reflex disappears around 4 months."
When a nurse brings a dinner tray to a 4-year-old child hospitalized with pneumonia, the child says, "I'm too sick to feed myself." What is the best response by the nurse?
"Wait a few minutes, and I will be back to help you."
A parent asks the nurse, "The doctor said my baby has something called pulmonic stenosis. What does that mean?" What is the best response by the nurse?
"What else did the doctor say?"
The parent of a 7-year-old child states, "My 7-year-old is the same size as my friend's 10-year-old. I get embarrassed when we are all out together, as my child is not nearly so well behaved." What is the best response from the nurse?
"Your child's behavior is age-appropriate."
A father expresses concern that his 2-year-old daughter has become a "finicky eater" and is eating less. How should the nurse respond?
"Your daughter's behavior is expected in response to her slower growth."
A nurse is teaching a mother about the immunization schedule for her baby. Between which months of age should the measles vaccine be given?
12 and 15
What is the average duration of sleep per night for a preschooler?
12 hours
A 10-year-old child has sustained partial-thickness burns of the anterior surfaces of both arms and hands and the upper half of the chest. Using the grading system of the American Burn Association, the nurse estimates the total body surface area (TBSA) involved. What is the approximate TBSA affected? Record your answer using a whole number. _________ %
17%
A nurse evaluating a 1-year-old infant's hematocrit reading compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy12-month-old infant?
29% to 41%
Acetaminophen (Tylenol) 15 mg/kg is prescribed for a preschooler who weighs 44 lb. Each 5 mL of solution contains 160 mg. How many milliliters of acetaminophen should the nurse administer? Record your answer rounding to one decimal place. __________ mL
9.4
An 8-year-old child who is experiencing a sickle cell pain episode is admitted to the child health unit. What is the most appropriate nursing care during this acute period?
Administering prescribed analgesics
A 3-year-old child with chronic lead poisoning who has not responded to succimer (Chemet) therapy must be given multiple injections of edetate calcium disodium (calcium EDTA). How should the nurse prepare the child psychologically for this treatment?
Allow the child to play with a syringe, using a doll, before treatment is initiated and after each injection is administered
A nurse encourages parents to have their toddler's eyes tested especially for monocular strabismus. What should the nurse explain may occur if the condition is not corrected early?
Amblyopia will progress in the weak eye.
The parents of a 6-week-old infant who was born without an immune system ask the nurse why their baby is still so healthy. What is the best response by the nurse?
Antibodies are passively received from the mother through the placenta and breast milk.
A nurse is teaching a group of parents about age-related issues in 5-year-old children. What should the nurse include as a major concern of children of this age?
Anxiety about body integrity
A hospitalized 3-year-old child with leukemia is undergoing chemotherapy. The mother tells the nurse that her child is asking for fried chicken. How should the nurse respond?
Any food that is requested should be given, because the child needs calories.
A hospitalized 10-year-old child is apathetic about eating. What is the best nursing intervention to support the child's nutrition?
Asking the parents to visit at mealtimes
A 13-month-old child is admitted with a tentative diagnosis of bacterial meningitis, and the practitioner schedules a lumbar puncture. What is the most important action the nurse should take in preparation for the lumbar puncture?
Asking the parents what they were told about the test
An adolescent with leukemia is to be given a chemotherapeutic agent that is known to cause nausea and vomiting. When is the best time for the nurse to administer the prescribed antiemetic?
Before each dose
A nurse is teaching a parent about the behaviors that are first evident in an infant at 8 months of age. What should the nurse include? (Select all that apply.)
Being shy with strangers Showing interest in small objects
What is the cause of athetoid cerebral palsy in infants?
Birth asphyxia
An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do?
Breathe into cupped hands
How can a nurse best meet a preschooler's developmental needs just before a physical examination?
By allowing the child to handle the examination equipment
An 8-year-old child is being prepared for surgery the next day. How should the nurse present preoperative instructions to this child?
By focusing on simple anatomical diagrams
A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt?
By palpating the anterior fontanel
A nurse is caring for a 2½-year-old child who is expressing pain. What is the most reliable indicator of this child's pain?
Changes in behavior
A 3-week-old infant has surgery for esophageal atresia. What is the immediate postoperative nursing care priority for this infant?
Checking the patency of the nasogastric tube
A 7-year-old child sustains a fractured femur in a bicycle accident. The admission x-ray films reveal evidence of fractures of other long bones in various stages of healing. What does the nurse suspect as the cause of the fracture?
Child abuse
A 3-month-old infant hospitalized with severe diarrhea has excoriated skin in the diaper area. The mother becomes concerned when she discovers that the nurse has left her infant without a diaper. What is the nurse's explanation for this action?
Cleansing of the skin followed by air-drying reduces excoriation
At the age of 3 weeks an infant undergoes surgery to repair a cleft lip. Postoperative nursing care should include:
Cleansing the suture line to prevent infection
A 12-year-old child is to be bedridden at home for several weeks after orthopedic surgery. What activity should the nurse encourage the parents to plan?
Continuing schoolwork
A nurse is caring for a 4-week-old infant with hypertrophic pyloric stenosis who has been admitted to the child health unit for corrective surgery. What is the primary objective of preoperative care for this infant?
Correcting fluid and electrolyte imbalances
A 2-year-old toddler is to have intravenous antibiotic therapy. What should the nurse plan to do to prevent the child from pulling out the IV line?
Covering the IV site with a protective device
The mother of a toddler complains that the toddler has not been acting quite right lately. She has had a fever for a couple of days and now presents with decreasing oral intake and a rash over her hands and feet. Which condition does the nurse suspect?
Coxsackievirus infection
A 5-year-old child who is newly arrived from Latin America attends a nursery school where everyone speaks English. The child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. What is the probable reason for the child's behavior?
Culture shock
A toddler is admitted to the pediatric unit with diarrhea and severe dehydration. After several days of treatment the child is evaluated. What clinical findings indicate that the child is rehydrated? (Select all that apply.)
Decreased hematocrit Increase in daily weight Decreased blood urea nitrogen level
A nurse is caring for a newborn with a diaphragmatic hernia and impaired gas exchange. What does the nurse identify as the cause of the infant's decreased gas exchange?
Decreased oxygen intake
A dehydrated 15-month-old toddler is admitted to the pediatric unit with a diagnosis of intractable diarrhea. After several days of treatment the child is reevaluated. Which finding indicates to the nurse that the child's hydration status has improved??
Decreased urine specific gravity
A community health nurse makes a home visit to a disabled 13-year-old client who has a 6-month-old infant sister. The infant lies quietly in her crib and rarely smiles or vocalizes; it appears that the infant barely has her basic needs met. What is the nurse's most appropriate intervention?
Determine if there is anyone who can help with chores and the infant's care.
Which clinical findings should cause the nurse to suspect that an adolescent child with type 1 diabetes is hypoglycemic?
Difficulty concentrating, hunger, and diaphoresis
A 4-year-old child is admitted to the pediatric unit with a diagnosis of Wilms tumor. Considering the unique needs of a child with this diagnosis, the nurse should place a sign on the child's bed that states:
Do not palpate the abdomen
One principle to be followed for children with type 1 diabetes is to provide for the variability of the child's activity. What should the nurse teach the child about how to compensate for increased physical activity?
Eat more food when planning to exercise more than usual.
An adolescent has been admitted with symptoms of fatigue, intermittent fever, weight loss, and arthralgia, and the diagnosis is systemic lupus erythematous. The nurse knows that the best intervention at this time is:
Education about diet, rest, and exercise
Which behavioral quality involves demonstrating the feelings and behaviors characterized by self-consciousness?
Egocentricity
Which could be the result if a person fails to master the intimacy vs. isolation stage of Erikson's psychosocial development?
Egocentricity
Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly?
Encouraging them to express their concerns
What behavior does a nurse expect when caring for a 15-year-old adolescent who is undergoing chemotherapy?
Exhibiting concern about being different
What should the nurse advise the parents of a child who performs manual stimulation of his genitalia in public places?
Explain that genital stimulation is acceptable in private places.
A preschooler says he wishes his sibling would die, and then the sibling falls ill with an infection. The preschooler feels guilty for wishing harm to his sibling. What is the best action for the parents to take in this scenario?
Explain to the child that wishes do not make things happen.
An 11-year-old child has gained weight. The mother tells the nurse that she is concerned that her child, who loves sports, may become obese. What is the most appropriate response by the nurse?
Explaining that this is expected during preadolescence
To confirm a tentative diagnosis of leukemia a bone marrow aspiration and biopsy are to be performed on a 4-year-old boy. The nurse gives an age-appropriate explanation of the procedure to the child. What else is involved in caring for this child?
Explaining to the child that he will sleep during the procedure
What should be included in the plan of care for a newborn with hypospadias before corrective surgery is performed?
Explaining to the parents why a circumcision is not done
A nurse is caring for a toddler who has undergone bone marrow transplantation. What clinical findings should the nurse anticipate if an infection develops?
Fever and lethargy
What play activity should the nurse provide for a 4-year-old child on bedrest?
Finger painting on blank sheets of paper
The parents of a toddler who has been admitted to the pediatric unit for surgery to correct hypospadias ask the nurse when this defect happened. The nurse responds that it usually occurs during fetal development, in the:
First 12 weeks
Which of the following clinical findings should the nurse expect to find during the care of a child with acute glomerulonephritis (AGN)? (Select all that apply.)
Flank pain Periorbital edema
A nurse is caring for an infant who is to undergo surgery for hypertrophic pyloric stenosis (HPS). The nurse explains to the parents that this type of surgery has a high success rate when the infant's physical status meets certain criteria. What specific criterion should be discussed with the parents?
Fluid and electrolyte imbalances are corrected
The mother of a 5-month-old infant with heart failure questions the necessity of weighing her baby every morning. The nurse's response is based on the fact that this daily information is important in determining:
Fluid retention
During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse?
Frequent diaper changes with cleansing are needed.
A nurse is discussing dietary guidelines with the parents of a school-aged child with irritable bowel disease (IBD) who is anorexic. What should the nurse instruct them to offer their child to ensure sufficient intake of calories?
Frequent snacks of high protein, high calorie foods
Which theory explains psychosexual development through infancy to adolescence?
Freud's theory
Children with special needs have the same needs as other children, although their means of satisfying these needs may be limited. What effect should the nurse expect that these limitations will frequently cause?
Frustration
The school health nurse is teaching a group of teachers about promoting the mental health of school-age children. Which action made by the teachers promotes a sense of industry among the children?
Giving grades and gifts for satisfactory performances
A 4½-year-old child is brought to the emergency department with a fractured tibia. Which type of fracture is most common in children of this age?
Greenstick
An 18-month-old toddler with celiac disease is to be started on a gluten-free diet. The nurse teaches the parents to identify foods that should be avoided. Which food named by the parents as one to be avoided indicates to the nurse that the teaching has been successful?
Grilled frankfurter
A 4-month-old infant is to receive the second diphtheria/tetanus/pertussis (DTaP) immunization. The nurse reviews the infant's medical history before administering the vaccine. What information in the infant's history will influence the decision whether to administer the vaccine?
High fever after the first dose
A nurse is reviewing the laboratory report of an adolescent child with nephrotic syndrome. What does the nurse expect analysis of the child's urine to reveal?
High protein level
Which immunoglobulins (Ig) are transferred from a mother to a fetus?
IgG
What does a nurse identify as the priority short-term goal for a toddler with dehydration caused by diarrhea?
Improvement of fluid balance
A newborn infant has a heart rate of 80 beats per minute and irregular respirations with a weak cry. The extremities show some flexion; however, the infant exhibits a sneezing reflex, and the body is pink. What would be this infant's Apgar score? Record your answer using a whole number._______
In Apgar scoring, each characteristic is assessed via a numerical scale. A heart rate of 80 beats per minute, irregular respiration with a weak cry, and some flexion of the extremities are each scored as 1. The presence of a sneezing reflex would be scored as 2. The body is pink and the extremities are blue, a condition known as acrocyanosis, which would be scored as 1. Therefore, the total Apgar score of the infant is 1 + 1 + 1 + 2 + 1 = 6.
At Children's Hospital, infants are usually transported to x-ray in their parent's arms. After admission to the hospital for an upper respiratory infection, a 3-month-old infant is scheduled for a chest x-ray. The baby's mother is also sick and unable to go with the infant to the x-ray department. What manner of transportation should the nurse use to transport the infant to the x-ray department?
In the child's stroller
A dehydrated infant with a several-day history of vomiting is admitted to the pediatric unit with the diagnosis of gastroenteritis. The nurse plans to monitor the infant's response to parenteral therapy. What is the best indicator of rehydration?
Increased weight
A 13-month-old child is undergoing lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. What does this finding indicate?
Increased white blood cell (WBC) count
The nurse explains to the parent of a 2-year-old child that the toddler's negativism is expected at this age. What need is this behavior meeting?
Independence
A nurse is caring for a 4-year-old child. In what stage of Erikson's psychosocial development does the nurse expect the child to be in the process of achieving?
Initiative
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? (Select all that apply.)
Instilling saline nose drops Maintaining contact precautions Suctioning mucus with a bulb syringe
Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents?
Instructions about which high-sodium foods to avoid
An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should be included in the teaching plan? (Select all that apply.)
Insulin therapy Blood glucose monitoring Adherence to the treatment regimen
A nurse is discussing insulin needs with an adolescent with recently diagnosed type 1 diabetes. What information is important for the nurse to include concerning insulin administration?
Insulin will be required throughout life.
Which attribute of temperament is related to the energy level of the child's reaction?
Intensity of reaction
A mother tells the nurse that her 7-month-old infant has just started sitting without support. The nurse teaches the mother that this:
Is expected developmental behavior at this age
A 2½-year-old child is receiving intravenous fluid. A 500 mL bag of D5 in ½NS is hung at 1 am and is to infuse at 45 mL/hr. At 6 am the nurse notes that there is 125 mL left in the bag. The nurse correctly concludes that the fluid that has infused:
Is more than the child should have received
A parent of three young children has contracted tuberculosis. Which should the nurse expect the health care provider to prescribe for members of the family who have a positive reaction to the tuberculin skin test and are candidates for treatment?
Isoniazid
A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent?
Keep the infant in an upright position after feedings.
A nurse is caring for an infant born with a myelomeningocele who is scheduled for surgery. What is the priority preoperative goal for this infant?
Keeping the infant infection free
An infant with Tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In what position should the nurse place the infant to relieve the cyanosis and dyspnea?
Knee-chest
A nurse is teaching the mother of a toddler with celiac disease the specific foods allowed on the gluten-free diet. What is the most important information for the nurse to help the mother understand?
Labels of prepared foods must be read carefully.
A 3-year-old child is hospitalized with nephrotic syndrome. The child has oliguria and generalized edema. What factor does the nurse identify that will have the greatest effect on the child's adjustment to hospitalization?
Lack of parental visits
Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early?
Laryngeal edema
A 1-year-old infant with a distended abdomen is admitted to the pediatric unit with the diagnosis of Hirschsprung disease. In which position should the nurse place the infant?
Lateral
The parents of a 3-year-old tell the nurse that their child is afraid to sleep alone because of monsters under the bed. They ask for suggestions. What should the nurse recommend?
Leave a small light on at night and state, "Monsters aren't allowed in the house."
The mother of a 17-year-old adolescent who is going to be a foreign exchange student asks the nurse why her child must have a tetanus toxoid immunization instead of the immune globulin. The nurse responds that the tetanus toxoid immunization provides:
Longer-lasting active immunity
A nurse is caring for an infant with phenylketonuria. What diet should the nurse anticipate will be prescribed by the health care provider?
Low-phenylalanine
The parents of a school-aged child with fever, headache, and a stiff neck ask that the child be tested for meningitis. Which test should the nurse tell the parents is used to confirm the diagnosis of meningitis?
Lumbar puncture
Which of the following clinical manifestations does the nurse associate with rubeola?
Macular rash
A 5-month-old infant is brought to the pediatric clinic because of exposure to an adolescent sibling with measles. The infant's mother asks the nurse whether her baby can be vaccinated against measles at this age. What should the nurse consider before replying?
Maternal diseases and immunizations
A 3-year-old child is seen in the emergency department after a fall off a swing, and a possible concussion is diagnosed. When using the Glasgow Coma Scale, the nurse should remember that most children 3 years of age:
May not respond to strangers asking questions
A newborn's immunization program is started. While discussing the immunization schedule for the first 6 months with the parents, the nurse informs them that infants usually are not immunized against:
Measles
A nurse who is caring for a 2-day-old neonate suspects that the infant has cystic fibrosis. What early sign of this disorder did the nurse identify?
Meconium ileus
The mother of a 3-month-old infant asks the nurse in the well-baby clinic what toys to give her child. What is the nurse's response? (Select all that apply.)
Metallic mirror Colorful mobile
According to Piaget, which developmental stage is characterized by logical thinking?
Middle childhood
The nurse has completed a newborn's initial assessment and finds tiny white papules on the newborn's cheeks, chin, and nose. How should the nurse document the finding?
Milia
An 8-month-old infant undergoes surgical correction for hypospadias. What is a priority nursing intervention during the postoperative period?
Minimizing pain with adequate analgesia
A nurse accompanies a 3-year-old child to the pediatric unit's playroom. The toddler seems reluctant to select a toy or activity. Which toy is most appropriate for the nurse to offer as a means of fostering creativity?
Mold and clay
The nurse is rendering preoperative care to a child with a Wilms tumor. What is the most important aspect of this care?
Monitoring blood pressure
A nurse is caring for a toddler in acute respiratory distress precipitated by laryngotracheobronchitis. The child has a temperature of 103° F (39.4° C). What is the priority nursing intervention?
Monitoring respiratory status continuously
What is the priority nursing intervention for a 6-month-old infant with bronchiolitis?
Monitoring skin color, anterior fontanel, and vital signs
After several days of bedrest, a preschool-age boy with the diagnosis of a liver laceration becomes demanding and will not listen to the nurses. The child was found in the playroom twice on the previous shift. How can the nurse best meet the needs of this child?
Move the child into a room with another preschooler with whom he can play
While in the playroom a 7-year-old child exhibits twitching of the right arm and leg that progresses to a generalized tonic-clonic seizure. What is the nurse's initial action?
Moving toys and furniture away from the child
A 4-year-old child is undergoing a diagnostic workup for pulmonic stenosis. The mother asks the nurse about the diagnosis. The nurse bases the response on the fact that pulmonic stenosis is:
Narrowing of the valve between the right ventricle and the pulmonary artery
A nurse is planning an evening snack for a child receiving Novolin N insulin. What is the reason for this nursing action?
Nourishment helps counteract late insulin activity.
A nurse is caring for several school-aged children on the pediatric unit who are on prolonged bedrest and eating regular diets. Which breakfast should the nurse recommend to the children?
Oatmeal with raisins and milk
A nurse plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed?
Obesity
A 4-month-old infant is on nothing-by-mouth status in preparation for surgery. What should the nurse do when the infant starts crying?
Offer a pacifier
The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose tolerance test. What information should the nurse consider before replying?
Pancreatic scarring predisposes the child to diabetes.
A nurse is observing two 18-month-old children playing side by side in a sandbox. Although they watch each other, neither interacts with the other. What type of play does the nurse identify?
Parallel
A nurse is teaching several aides about the play behavior of 2-year-old toddlers. What is this type of play called?
Parallel
During a parenting class a nurse is discussing infant/toddler nutrition and ways to reduce the risk of food allergies. What food item should the nurse recommend that the parents avoid until their children are 3 years old?
Peanut butter
A 3-year-old boy in respiratory distress is treated in the emergency department. A diagnosis of acute spasmodic laryngitis (spasmodic croup) is made. At the time of discharge, the mother asks how to handle another attack at home. What should the nurse recommend?
Placing him near a cool-mist humidifier
A complete blood count is ordered for a 5-month-old infant with Tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results?
Polycythemia
Which signs and symptoms would a nurse observe in a newborn in which Werdnig-Hoffmann disease is suspected? Select all that apply.
Poor suck reflex Absence of deep tendon reflexes Diaphragmatic breathing with sternal retractions
What action should the nurse suggest to help parents promote the effectiveness of their toddler's myringotomy procedure?
Positioning the child with the affected ear down
What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever?
Positive antistreptolysin titer
A child recovering from a severe asthma attack is given oral prednisone 15 mg twice daily. What is the priority nursing intervention?
Preventing exposure of the child to infection
A nurse is caring for a 13-year-old child who has an external fixation device on a leg. What is the nurse's priority goal when providing pin care?
Preventing infection
A nurse in the pediatric clinic is teaching a mother how to care for her infant who has eczema. What is most important for the nurse to teach the mother?
Preventing secondary infections
A parent tells the nurse in the emergency department, "My 3-year-old has had a fever for several days and has been vomiting." After prescribed measures to reduce the fever have been instituted, what nursing action is most important?
Preventing shivering
An infant is found to have hydrocephalus. Which finding alerts the nurse to suspect increasing intracranial pressure?
Projectile vomiting
On a visit to the well-baby clinic the parents are upset because their 9-month-old infant has severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent's question?
Prolonged contact with an irritant
What should the plan of care include to minimize the potential for a sickling episode in a child with sickle cell anemia?
Promoting adequate oxygenation
A 10-year-old child is admitted to the hospital for surgery. The parents state that the child is mentally challenged and functions on the level of a 3-year-old. What should be included in the child's preoperative teaching plan?
Providing explanations at a preschooler's level of understanding
What nursing intervention best meets the developmental needs of hospitalized preschool-age children?
Providing materials for simulating activities
What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure?
Providing small, frequent feedings.
What nursing intervention will be most effective in helping relieve the anxiety of a young school-age child during the postoperative period?
Providing the child with sterile dressing equipment and a doll
A child with β-thalassemia is receiving therapy that includes multiple blood transfusions. This child is at increased risk for which complication?
Pulmonary edema
A nurse is planning to foster independence in a group of 4-year-old children. What self-care skill does the nurse expect 4-year-olds to be capable of performing?
Putting on a shirt and buttoning it
Which clinical manifestations should the nurse look for in a newborn with suspected spina bifida cystica? Select all that apply.
Rectal prolapse Overflow incontinence Flaccid partial paralysis of the lower extremities
The nurse who is caring for a child with botulism anticipates that the child's growth and development may be hampered due to cranial nerve deficits. Which signs presented by the child support the nurse's conclusion? Select all that apply.
Reduced gag reflex Loss of head control
After surgery for repair of a myelomeningocele, the nurse places the infant in a side-lying position with the head slightly elevated. The main reason the nurse places the infant in this position after this particular surgery is that it:
Reduces intracranial pressure
An 8-year-old child admitted to the hospital 2 days ago tells the nurse, "I'm too sick to feed myself." The nurse recognizes that this statement is most likely indicative of:
Regression
Which feelings and behaviors can be observed in early preschool children in response to the divorce of parents? Select all that apply.
Regressive behavior Increased tantrums Blaming themselves for the divorce
What action should the nurse take if abuse of a 10-year-old child is suspected?
Report the suspicion to local authorities
An infant is admitted to the pediatric unit with bronchiolitis caused by the respiratory syncytial virus (RSV). What medication does the nurse anticipate that the practitioner will prescribe?
Ribavirin
A nurse is teaching the parents of a child with juvenile idiopathic arthritis how to prevent loss of joint function. Which activities should be encouraged? (Select all that apply.)
Riding a bicycle Walking to school Swimming in the community pool
The parents of an infant with tetralogy of Fallot ask the nurse to explain what is wrong with their baby's heart. Before explaining the problem in a way that they will understand, the nurse remembers that tetralogy of Fallot includes:
Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding of the aorta
A nurse is reviewing the immunization schedule of an 5-month-old infant. What immunizations does the nurse expect the infant to have already received?
Rotavirus, DTaP, Haemophilus influenzae, polio, pneumococcal
A nurse is caring for an infant after a cleft lip repair. Which item should the nurse use to feed the infant for several days after the surgery?
Rubber-tipped syringe
Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate?
Rubber-tipped syringe
A nurse in the pediatric clinic receives a call from the mother of a 12-month-old infant who has had a fever, runny nose, cough, and white spots in the mouth for 3 days. A rash started on the face and has now spread to the entire body. Which communicable infection does the nurse suspect?
Rubeola
A postpartum nurse is reviewing principles related to automobile infant restraint systems with the parents of a newborn who is to be discharged in the morning. What information should be included in the teaching session? (Select all that apply.)
Secure the infant seat so that it faces the rear. Follow the manufacturer's directions to secure the infant seat in the back seat. Be sure to follow weight guidelines set forth in the manufacturer's instructions.
What is the first activity of daily living (ADL) that the nurse should help teach a developmentally disabled 8-year-old child?
Self-feeding
An infant is receiving intermittent nasogastric tube feedings. In what position should the nurse place the infant?
Semi-Fowler
Which content type of play allows a child to experience pleasure by swinging?
Sense-pleasure play
A toddler with cystic fibrosis has been hospitalized with bacterial pneumonia. The nurse determines that the child has no known allergies. What does the nurse conclude is the reason that the health care provider selected a specific antibiotic?
Sensitivity of the bacteria
In which phase does a child develop the sense of object permanence according to Jean Piaget?
Sensorimotor
A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that should be included in the discharge teaching plan for the mother?
Signs of dehydration in infants
Which gross motor skill can be observed in a 7-month-old infant?
Sits alone without support
Which internal asset helps young people make positive choices and build relationships?
Social competencies
Which is the fifth stage of moral development according to Lawrence Kohlberg?
Social contract orientation
Children's patterns of play change as they grow from infancy through school-age. Rank the order of appearance of each type of play, starting with infant play.
Solitary Parallel Associative Cooperative
At 1 am a 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. At 3 am, after the child is settled in, the mother tells the nurse, "I have to leave now, but whenever I try to go my child gets upset and then I start to cry." What is the best action by the nurse?
Staying with the child while the mother leaves
The mother of a 5-month-old infant asks the nurse in the well-baby clinic to tell her the order in which new foods should be introduced. The nurse responds that once infant cereals have been introduced, the foods that are best for an infant of this age include:
Strained vegetables
A 5-month-old child undergoes heart surgery to repair the defects associated with tetralogy of Fallot. Prevention of what behavior is a priority for the nurse after the surgery?
Straining at stool
A nurse is teaching a class about behavioral expectations of infants and children to a group of parents. The nurse includes those behaviors expected of 8-month-old infants. (Select all that apply.)
Stranger anxiety Playing peek-a-boo Standing by holding on to furniture
A nurse in the pediatric clinic is advising the mother of a toddler who has a pinworm infestation. What should the nurse teach the mother about caring for her child during and after treatment? (Select all that apply.)
Strategies to prevent reinfestation The need for medication for the entire family The importance of handwashing before eating
A 9-year-old child is found to have acute glomerulonephritis after a recent infection. What microorganism should the nurse suspect as the cause of the child's current health problem?
Streptococcus
A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this preadolescent?
Swimming
A nurse questions the parents of a child with chickenpox about relatives or friends who are undergoing specific prolonged medication therapy. What type of medication will put a person at risk if he or she is exposed to the varicella virus?
Systemic corticosteroid
A 2-month-old infant is admitted to the pediatric unit with gastroenteritis and dehydration. Which finding should the nurse anticipate?
Tachycardia
A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?
Tachycardia
A school-aged child with a seizure disorder is to start taking divalproex (Depakote). What should the nurse teach the parents about caring for their child in regard to this medication?
Take the child for regularly scheduled blood tests
A 9-month-old infant is admitted to the pediatric unit with a possible head injury. Twelve hours later the nurse determines that the previous blood pressures were taken using a neonate-size cuff. The nurse documents the size of the cuff that was used for previous measurements. What is the best action for the nurse to take?
Taking the next measurement with both a neonate- and a child-size cuff
A major developmental milestone of a toddler is the achievement of autonomy. What should the nurse instruct the parents to do to enhance their toddler's need for autonomy?
Teach the child to accept external limits
One minute after birth a neonate's heart rate is 106 beats/min; acrycyanosis and muscle tone with flexion are observed; flicking the sole triggers crying; and the cry is strong. What is the neonate's Apgar score? Record your answer using a whole number. __________
The Apgar score is calculated from scores in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each area is given a score of 0, 1, or 2. Pulse over 100 = 2 points; good cry = 2 points; good muscle tone = 2 points; excellent reflex irritability (stimulus precipitates a cry) = 2 points; bluish extremities (acrocyanosis) = 1 point.
Which finding indicates an 8-year-old is a latchkey child?
The child is unsupervised at home after school.
A newborn who was delivered with the assistance of forceps sustains an injury that results in facial paralysis. What would the nurse state to the mother?
The condition usually subsides on its own in a few days.
A 16-year-old male asks the nurse about the use of condoms. He states, "I've used condoms in the past, but I'm not sure I'm using them correctly." What should be included as part of the teaching about condoms?
The condom must be positioned after an erection has occurred.
An infant is undergoing parenteral therapy. The health care provider has instructed that 400 mL of D5W 0.45% sodium chloride be infused over 8 hours. At how many milliliters per hour should the nurse maintain the hourly rate? Record your answer using a whole number. __________ mL
The correct rate is 50 mL/hr. Divide the total volume to be infused (400 mL) by the number of hours it is to be infused in (8): 400 ÷ 8 = 50 mL.
While assessing a newborn, the nurse finds a pink rash with papules on the thorax and abdomen. What does the nurse infer from this finding?
The neonate has erythema toxicum. -A pink rash with papules superimposed on the thorax, back, buttocks, and abdomen is called erythema toxicum. A port-wine stain is called nevus flammeus. Irregular areas of deep blue pigmentation in the sacral and gluteal regions are called Mongolian spots. Flat, deep pink localized areas usually seen on the back of the neck are called telangiectatic nevi.
A 3-year-old child sustains multiple fractures in a motor vehicle collision, and casts are applied. The child is admitted for observation to rule out internal injuries. The health care provider asks that vital signs, including blood pressure, be taken every 4 hours. The nurse decides to use the posterior tibial artery to obtain the blood pressure. Mark the extremity where the blood pressure cuff should be positioned to obtain this blood pressure.
The posterior tibial artery is posterior to the medial malleolus on the inner aspect of the ankle. The blood pressure cuff should be positioned 1 inch above the ankle.
The parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus are concerned about the prognosis. What information should the nurse give the parents?
The shunt may need to be replaced as the child grows older.
At 18 months of age a child born with a cleft lip and palate is readmitted for palate surgery. Why does the nurse teach the parents not to brush their child's teeth immediately after the surgery?
The suture line might be injured.
A preadolescent brings home a note from the school nurse informing the parents that the child should be evaluated for scoliosis. The mother calls the clinic nurse to ask for a description of scoliosis. Before responding, the nurse recalls that in scoliosis:
There is a rotary deformity of the lateral curvature of the spine
A nurse is planning to evaluate the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained?
There is an obstruction above the opening of the common bile duct.
A nurse is caring for several school-aged children with cystic fibrosis. Why does the nurse anticipate that these children will probably be small and underdeveloped for their age?
These children digest little food because pancreatic enzymes are blocked.
A nurse is planning to discuss the importance of following the prescribed course of treatment with a group of adolescent clients. What is the nurse's priority consideration regarding these clients?
They are involved more with the present than with the future.
A 6-week-old infant grasps a rattle placed in the hand. The mother is impressed with this skill. What should the nurse teach the mother about this behavior?
This is the palmar grasp reflex and is expected at this age.
An infant has been admitted for dehydration as a result of acute gastroenteritis and vomiting, and the nurse administers lactated Ringer's solution intravenously. The nurse concludes that the treatment has been effective after noting:
Three wet diapers in 24 hours
The nurse is reviewing the dietary habits of a few toddlers in a day care center. Which toddler is most at risk of calcium deficiency?
Toddler A
What is a characteristic of play among toddlers?
Toddlers play beside each other.
The parents of a 6-year-old child with celiac disease tell the nurse that their child becomes dejected because she is not able to eat snack foods like the rest of her class and friends. What snack can the nurse recommend that is safe for the child to eat?
Tortilla chips
A 30-month-old toddler is brought to the emergency department in acute respiratory distress, and a diagnosis of laryngotracheobronchitis (viral croup) is made. What is the most important equipment for the nurse to have available when the child is admitted to the pediatric unit?
Tracheotomy set
The nurse anticipates that a child born with a missing chromosome is most likely to have:
Turner syndrome
Which finding in a 5-month-old infant indicates age-appropriate gross motor development? Select all that apply
Turns over from the abdomen to the back Assumes symmetric positioning with the arms extended Puts the feet to the mouth when placed in a supine position
If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already?
Two doses of diphtheria, tetanus, and pertussis vaccine
When talking with a 4-year-old child, a nurse determines that the child is shy and stutters. What does stuttering in a 4-year-old child indicate?
Typical preschooler speech
The mother of a 5-month-old infant tells the nurse that she has started to feed her baby fortified cereal mixed with formula. She asks in which order she should introduce new foods. What foods should be selected first?
Vegetables and noncitrus fruits
A 6-year-old child is in the acute phase of nephrotic syndrome. The mother asks the nurse about play activities for her child. What should the nurse suggest? (Select all that apply.)
Video games Children's books
The nurse, caring for a 3-year-old child with meningitis, should be alert for which signs and symptoms of increased intracranial pressure? (Select all that apply.)
Vomiting Headache Irritability
The nurse teaches a parent about managing nocturnal enuresis for a 7-year-old child. Which action by the parent would be helpful in managing the child?
Waking up the child at night to use the bathroom
A nurse teaches the parents of a 1-year-old infant that the primary developmental milestone to be accomplished between 12 and 15 months of age is the ability to:
Walk erect
A nurse must administer a medication by means of injection to a 2-year-old whose parent is not present. What is the most therapeutic approach for the nurse to use?
Warning the child about the injection just before administering it, saying that it is OK to cry, and then comforting the child
An infant with diarrhea requires contact precautions. What is the most effective nursing action to control the spread of this infant's pathogens?
Washing hands before and after contact with the infant
The nurse is giving unlicensed assistive personnel (UAP) strategies to care for a 2-year-old child admitted to the hospital with severe diarrhea. Which strategies should the nurse provide?
Weighing the child at the same time every day
A 6-week-old infant is brought to the clinic by the parents. The mother states that the baby has been vomiting with increasing frequency and force after feeding. Hypertrophic pyloric stenosis (HPS) is diagnosed by the practitioner. What clinical findings of HPS does the nurse expect to identify? (Select all that apply.)
White vomitus Peristaltic waves Insatiable hunger
A 3-year-old child is admitted to the pediatric unit with a diagnosis of acute asthma. The child is short of breath, the respiratory rate is 56 breaths/min, the pulse is 102 beats/min, and there is a nonproductive cough. What does the nurse expect regarding the child's blood gas values?
pH of 7.32
A 3-year-old child is admitted to the pediatric unit with a diagnosis of acute asthma. The child is short of breath, with a respiratory rate of 56 breaths/min; the pulse is 102, and the child has a nonproductive cough. What blood gas value does the nurse expect to see?
pH of 7.32
A nurse working the 8 am-4 pm shift is caring for a 14-year-old adolescent for whom intake and output are being monitored. The health care provider orders an intravenous infusion to be administered at a rate of 50 mL/hr. The adolescent had 4 oz of milk and a muffin for breakfast at 8:30 am. At 9 am the adolescent vomited 200 mL. At 10 am the adolescent had 60 mL of water with medications. At 11 am the adolescent voided 550 mL of urine. For lunch, at 12:30 pm, the adolescent ate 3 oz of soup and 4 oz of ice cream. The adolescent voided 450 mL at 2 pm. Calculate the adolescent's total intake for the 8 am-4 pm shift. Record your answer using a whole number. __________ mL
790 mL
A nurse is planning to give a preschool child an immunization consisting of bacterial cells that have been modified. What is the substance called?
A vaccine
An adolescent who has sickle cell anemia is recovering from a painful episode. What does the nurse see as the priority issue for this adolescent?
Alteration in body image resulting from skeletal deformities
A nurse explains to the mother of a 1-year-old with a history of frequent ear infections that the primary cause of otitis media in young children is:
An obstructed eustachian tube
What does the nurse identify as an early sign of chronic lead poisoning (plumbism) in school-aged children?
Anemia
Which congenital neural tube defect is characterized by absence of both hemispheres?
Anencephaly
Which condition is more common in adolescent girls than boys?
Anorexia nervosa
Which type of play behavior does a preschooler exhibit?
Associative play
According to Piaget's theory of cognitive development, what should the nurse expect a 6-month-old infant to demonstrate?
Beginning of object permanence
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most appropriate action by the nurse?
Continuing to observe the seizure
What action should be included in the nursing care of an infant with increased intracranial pressure?
Elevating the head higher than the hips
An infant with bronchiolitis caused by the respiratory syncytial virus (RSV) is admitted to the pediatric unit. What does the nurse expect the prescribed treatment to include?
Humidified air and adequate hydration
A 6-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis (painful episode). What are the priority nursing concerns? (Select all that apply.)
Hydration Pain management
A 2½-year-old child is admitted to the hospital with deep partial-thickness burns involving the face and chest. The nurse bases a plan of care on concerns related to the child's injury. Place the following concerns in their order of importance.
Impaired gas exchange Presence of pain Disturbed fluid balance Potential for infection Compromised body image
A nurse is screening children in an elementary school for head lice (pediculosis capitis). What common secondary infection from head lice is of most concern to the nurse?
Impetigo
An infant is being admitted with bacterial meningitis. The nurse knows the priority nursing action is:
Implementing respiratory isolation precautions
A 12-month-old infant is to receive ferrous sulfate for iron-deficiency anemia. How should the nurse administer the medication?
In a syringe directed toward the back of the mouth
A 13-year-old-child with type 1 diabetes is receiving 15 units of Novolin R insulin and 20 units of Novolin N insulin at 7 am each day. At what time should the nurse anticipate a hypoglycemic reaction from the Novolin N to occur?
In the afternoon
Which factor is responsible for predisposing an infant to severe acute respiratory tract infections?
Inability to produce sufficient immunoglobulin A
Which finding supports the nurse's conclusion that a 12-month-old infant should be evaluated further for developmental dysplasia of the hip?
Inability to pull to a standing position
Which of Erikson's stages of psychosocial development occurs at the preschool age?
Initiative vs. guilt
A nurse knows that when routine oxygen therapy is being administered to a 7-year-old child, the oxygen:
Is closely monitored for the correct concentration
A nurse is caring for a child with acute lymphoid leukemia who is undergoing chemotherapy. The parents ask why the child needs prednisone. How should the nurse respond?
It decreases inflammation.
A nurse is teaching the parents of a toddler with a recent diagnosis of hemophilia about the disease. What area of the body should the nurse include as the most common site for bleeding?
Joints
A 6-year-old child comes to the well-child clinic for a routine examination. The nurse identifies black lines on the teeth at the gum line. What does the nurse suspect as the cause of this finding?
Lead poisoning
The parents of a newborn discuss their infant's need for immunizations with the nurse. Which vaccine will not be administered until the child is at least 12 months of age?
Measles
A nurse is caring for an infant who has just undergone myelomeningocele repair. What should the nursing plan of care include?
Monitoring for cerebrospinal fluid leakage
A nurse notes the weights attached to a 7-year-old child in traction are touching the floor. What action should the nurse take?
Moving the child toward the head of the bed
The alkylating agent cyclophosphamide (Cytoxan) is prescribed for a school-aged child with cancer. What is the most important sign or symptom for the nurse to be alert for while the child is receiving this medication?
Pain with urination
An 18-month-old toddler who stepped on a rusty nail is brought to the emergency department a week later. The nurse determines that the family lives in a rural area and that the toddler has never received health care. The child shows signs of generalized tetanus, including neck and jaw stiffness and facial muscle spasms. What does the nurse conclude is the cause of these clinical findings?
Painful muscle rigidity caused by exposure of the nervous system to the exotoxin of the causative organism
An infant is admitted to the hospital with gastroenteritis. The infant vomits shortly after admission. Under standard precautions, what protective equipment should the nurse wear when cleaning the infant after the vomiting episode?
Pair of gloves
A nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiological changes does the nurse expect the parents to report? (Select all that apply.)
Pale skin Eating less food Purplish spots on the skin
A nurse in the pediatric clinic is caring for an 11-month-old infant with iron-deficiency anemia. The infant's hemoglobin is 8 g/dL. What does the nurse expect to observe when evaluating the infant?
Pallor
Which behavior does the nurse expect when observing a 5-month-old infant?
Picking up a toy and putting it in the mouth
What should the nursing care of an 8-month-old infant with tetralogy of Fallot include?
Prevention of increased respiratory effort to promote oxygenation
While in the hospital's playroom a male toddler suddenly has a nosebleed that leaves blood on the play table. What is the nurse's first response in this situation?
Providing nursing care to stop his nosebleed
A nurse sees another health team member cover an infant with a blanket to prevent heat loss. What heat loss mechanism is being minimized by this action?
Radiation
A nurse is caring for a 3-month-old infant who was admitted to the pediatric unit with severe dehydration caused by diarrhea. After fluid and electrolyte balance is restored, Lactobacillus granules (Lactinex) are prescribed. The nurse expects this medication to:
Recolonize flora in the intestinal tract
A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung disease. What definitive diagnostic test does the nurse expect to prepare the infant for?
Rectal biopsy
A health care provider writes prescriptions for a young child with a tentative diagnosis of Wilms tumor. Which prescription should the nurse question?
Renal biopsy
A child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing care for this child?
Rest
Which cardiac defects are associated with tetralogy of Fallot?
Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta
Methylphenidate (Ritalin) has been prescribed for a 7-year-old child with attention deficit-hyperactivity disorder (ADHD) and is to be taken with meals. What rationale should the nurse provide for the parents about the timing of medication administration?
Ritalin depresses the appetite.
Which topic would be most appropriate for health education for adolescents?
Safe sexual practices
The parent of a child says, "My child is repeatedly banging the table to make loud sounds." Which sensorimotor stage of cognitive development best explains this behavior of the child?
Secondary circular reactions
A 7-year-old child has a moderate cognitive disability. What should the nurse suggest that the parents provide for the child?
Simple, repetitive tasks
Which games may help develop muscle strength in preschoolers? Select all that apply.
Skating Riding a tricycle
The parents of a 6-month-old infant ask the nurse about the best toy to buy for their baby. What type of toy should the nurse suggest?
Soft stuffed animals
A 4-month-old infant is admitted to the pediatric unit with severe tachypnea, flaring of the nares, wheezing, and irritability. The parents are told that the child has bronchiolitis and needs to be hospitalized for observation and treatment. While evaluating the infant, the nurse determines that the infant is in respiratory failure. What clinical finding supports the nurse's conclusion?
Sudden absence of breath sounds
A school-aged child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. What reason should the nurse include in the reply?
Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.
While collecting data on a 7-year-old child, the nurse suspects that the child has impaired cognitive development. Which behavior supports the nurse's conclusion?
The child is unable to copy a diamond shape.
The practitioner prescribes no weight bearing on a leg that has been casted because of a fracture of the femur. How should the nurse determine the appropriate length of the crutches for this child? (Select all that apply.)
The crutches should reach 2 inches below the axillae. The crutches' tips should rest 6 inches outside the feet.
A 16-year-old single mother of a 1-month-old infant and the infant's grandmother bring the baby to the emergency department and report that the infant accidentally fell down the stairs. The nurse knows that a consent form for treatment should be signed. Who has the responsibility for signing the consent?
The mother, despite her age
The nurse finds that a newborn has a flattened forehead and the circumference of the head has decreased. What information does the nurse document?
The newborn has a normal head.
A family has decided to withhold extraordinary care for a newborn with severe abnormalities. How should the nurse interpret this decision?
The newborn is being allowed to die.
During recess, a 5-year-old child loses a tooth. What is the best action by the school health nurse?
The nurse should provide support and reassurance during the dental trauma.
The parents of a critically ill 7-year-old child constantly blame each other for their child's illness. What parental response suggests that the nurse's intervention has been successful?
The parents make an appointment with a family counselor.
An adolescent sustains a sports-related fracture of the femur, and open reduction and internal fixation with a rod insertion is performed. After the surgery, a nurse notes that the adolescent is very upset. In light of the client's developmental level, what does the nurse conclude is the most likely explanation for this distress?
The perception that the rod is a body intrusion
A parent tells the nurse, "Our 2½ -year-old child only uses two-word phrases when he's talking, and we can only understood him maybe a quarter of the time. We're really concerned." What should the nurse consider before responding?
This seems to be slow language development for a 2½ -year-old.
A registered nurse advises parents to assist their child with stretching exercises. The child has impaired physical mobility due to neuromuscular impairment. What is the rationale for performing stretching exercises?
To prevent contractures
Which is observed in the preoperational stage of Piaget's cognitive development?
Transductive reasoning
A nurse in the pediatric clinic is evaluating the fine motor skills of a 5-year-old child. According to the principles of developmental direction, in which order does a child develop these skills? Begin with the skill that is accomplished first.
Turns a doorknob Places objects into a narrow-necked bottle Uses scissors Copies a square on a piece of paper
What is the best approach for the nurse to use when preparing a preschooler for surgery?
Using a doll to demonstrate perioperative care
Which statement by the practicing nurse indicates the need for additional teaching about communication with adolescents?
"I will ask closed-ended questions."
A 13-year-old boy tells the nurse, "I'm so much shorter than the other kids in my class, and I don't get picked for sports teams." What should the nurse's initial response be?
"It must be difficult being shorter than the other kids."
A 10-year-old boy who is about to begin chemotherapy for acute myelogenous leukemia (AML) tells the nurse that he is old enough to refuse treatment. What is the nurse's most appropriate response?
"You seem frightened. Let's talk about it."
A practitioner prescribes 160 mg of acetaminophen (Tylenol) elixir for a child. The label on the bottle reads "100 mg/mL." How many milliliters of acetaminophen should the nurse instruct the mother to administer? Record your answer using a whole number. __________ mL
1.6 mL
Which reading of a newborn's pulse may indicate an abnormality in the function of the cardiovascular system?
100 beats/min
An intravenous infusion of 30 mg of an antibiotic in 50 mL of D5W every 6 hours is prescribed for an adolescent. It is to run over 30 minutes. At what hourly rate should the nurse set the infusion device? Record your answer using a whole number. __________ mL/hr
100 ml
An adolescent is hospitalized with multiple internal injuries after an automobile collision. The adolescent is being kept NPO and is receiving an IV infusion at 125 mL/hr and an antibiotic reconstituted in 10 mL of normal saline every 6 hours (6 am, 12 pm, 6 pm, 12 am). What is the intake from 7 am to 3 pm? Record your answer using a whole number and no punctuation. __________ mL
1010 mL
A nurse notes that a child is exhibiting signs of cerebral palsy. At what age are these signs usually first noticeable?
12 months
While reviewing the admission assessment the nurse finds that a 2-year-old child has not received immunization for measles, mumps, and rubella (MMR). At what age should the child have received this vaccine?
12 months
A nurse is caring for a severely dehydrated infant. After adequate kidney function is confirmed, potassium is added to the intravenous rehydration solution. It is to be infused at a rate of 15 mL/kg body weight every 24 hours. The infant weighs 13 lb. What does the nurse calculate for the infant's intravenous fluid intake per day? Record your answer using a whole number. __________ mL
13/2.2 = 5.9. 15 × 5.9 = 88.5 mL rounded up equals 89 mL/24 hours
A 5-year-old child is admitted with burns covering the face and anterior arms and hands. Using the total body surface area (TBSA) percentages shown in the diagram, determine what percentage of the child's body has been burned. Record your answer using a whole number. __________%
15
A 7-year-old child with cystic fibrosis is receiving an intravenous antibiotic. The medication is supplied in a 125-mL bag of 0.45% sodium chloride. It is to be infused over 30 minutes. At what rate should the infusion pump be set to deliver the medication in the prescribed time? Record your answer using a whole number. __________ mL/hr
250 mL/hr
A 6-month-old infant weighing 15 lb is admitted with a diagnosis of dehydration. A prescription for oral rehydration therapy 4 mL/kg Pedialyte over 4 hours is made. What is the approximate amount of fluid that the infant should ingest during the 4 hours?
28 mL -At 15 lb the infant weighs about 7 kg; 4 mL × 7 kg is 28 mL. The other amounts (32 mL, 38 mL, 42 mL) are too much.
The health care provider has prescribed 700 mL of intravenous fluid, to be infused over 24 hours. At what rate should the nurse set the volume-control device? Record your answer using a whole number. __________ mL/hr
29 mL/hr
A 7-year-old child with juvenile idiopathic arthritis has difficulty getting ready for school in the morning because of joint pain and stiffness. Which recommendation should the nurse make to the family?
5
A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child?
Abduction of the hip
The nurse is assessing a newborn. Which finding should raise a concern and require further investigation?
Absence of red reflex
An 8-year-old child with a history of asthma is brought to the emergency department because of respiratory distress. The nurse immediately places the child in a bed with the head of the bed elevated and administers oxygen by means of a facemask. The health care provider performs a physical assessment, writes prescriptions, and admits the child to the pediatric unit. Which instruction should the nurse carry out first?
Administer the nebulizer treatment.
The day after undergoing an abdominal appendectomy, a school-aged child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation?
Administering the prescribed pain medication
During a clinic visit a 4-year-old girl suddenly yells, "Don't sit on Erin!" The parent whispers that Erin is an imaginary friend. What is the nurse's best action?
Avoiding sitting where the child says her imaginary friend is located
A nurse is reviewing the report of a biopsy taken from a preschool child's brain tumor. The tumor is a cerebellar astrocytoma. The nurse determines that this tumor is:
Benign and associated with a high rate of cure
An infant with talipes equinovarus has a plaster cast applied to the involved foot. How should the nurse move the infant while the cast is wet?
By handling the cast with just the palms
The nurse is collecting data on a few children at the community health care center. Which child is most likely at high risk for injury and delinquent behavior?
Child A
A nurse is obtaining the health history of a 5-year-old child who has been admitted to the child health unit with acute glomerulonephritis. The nurse expects the child's mother to report that the:
Child had a sore throat a few weeks ago
What behavior does the nurse anticipate while feeding a newborn with choanal atresia?
Chokes on the feeding
A nurse is caring for a 9-year-old child with juvenile idiopathic arthritis (JIA). What is most important for the nurse to attempt to prevent?
Contracture deformities
An 18-month-old toddler who stepped on a rusty nail 4 days ago shows signs of generalized tetanus, including neck and jaw stiffness and facial muscle spasms. The toddler is receiving intravenous diazepam (Valium) as a muscle relaxant every 4 hours. What response to the medication does the nurse anticipate?
Control of hypertonicity and prevention of seizures
An 18-month-old toddler is admitted to the pediatric unit. The child has never been separated from the mother before this admission. What behavior does the nurse expect from the toddler?
Crying relentlessly and consoled by no one but a parent
A nurse in the pediatric clinic is evaluating a 6-year-old child with sickle cell anemia whose spleen autoinfarcted by age 4. What is the priority nursing care at this time?
Determining parental knowledge about infection
A nurse is caring for an infant who has undergone myringotomy because of recurrent otitis media. What does the nurse expect to note when providing care to this child?
Drainage into the external auditory canal
A nurse in the child life center is evaluating a 15-month-old toddler's ability to perform physical tasks. What behavior indicates to the nurse that the child's development is age appropriate? (Select all that apply.)
Drinking from a cup Walking with a wide-based gait Throwing toys around the room
While caring for a child, the nurse observes that the child turns onto the side, flexes the knees to assume a kneeling position, and then pushes the torso upright by walking the hands up the legs. Which condition does the nurse suspect in this patient?
Duchenne muscular dystrophy
A nurse in the pediatric clinic should be most observant for signs of cerebral palsy in a 6-month-old infant who was born:
During the 32nd week of gestation
Which condition results from an abnormal organization of cells into a particular tissue type?
Dysplasia
A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). The nurse tells the parents that they will have to bring their baby back to the clinic for a cast change:
Each week
A 4-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). The mother states that changes in her child's behavior and the "black and blue" marks were noticed several days ago. She blames herself for not bringing her child to the clinic sooner. On what information about the pathophysiology of leukemia should the nurse base a response?
Early signs and symptoms of leukemia are similar to those of other mild illnesses of childhood.
A nurse counsels the mother of an 8-month-old infant to be sure that the floors are free of small objects when her child is crawling. What is the rationale for this instruction?
Eight-month-old infants pick up small objects and place them in their mouths.
A 4-week-old infant is found to have hypertrophic pyloric stenosis (HPS) and is scheduled for surgery. Oral feedings are usually initiated a few hours after surgery. What does the nurse expect the practitioner to prescribe initially?
Electrolyte solution
An adolescent with type 1 diabetes is brought to the emergency department in ketoacidosis. The adolescent admits to not adhering to the diabetic regimen. What can the nurse do to help the adolescent become more accepting of the diabetic regimen?
Encourage the adolescent to express feelings about having diabetes
An 8-year-old child is being discharged after recovery from a sickle cell vasoocclusive (painful crisis) episode. The nurse teaches the parents the do's and don'ts of the child's care. The nurse is satisfied that the parents understand the principles of care when they state that they are planning to:
Encourage the child to engage in low-intensity activities
A 3-year-old child is admitted to the pediatric unit with a diagnosis of nephrotic syndrome. The child has ascites, oliguria, respirations of 40 breaths/min, and a recent weight gain of 10 lb. What nursing intervention may help ease the child's respiratory difficulty?
Ensuring bedrest in the low Fowler position
The nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child's urine for the presence of:
Erythrocytes
A 7-year-old child with cerebral palsy who wears leg braces has a slight sensory loss in the lower extremities. What is the most essential information for the nurse to teach the child and parents?
Examine the skin for evidence of pressure points.
What should the nurse teach parents is the most important influence on the eating habits of early school-age children?
Example of parents and siblings at mealtimes
A child with recently diagnosed idiopathic scoliosis has a mild structural curve. The child's mother asks whether the problem can be corrected with exercise. What should the nurse tell the mother concerning an exercise program?
Exercise is used in conjunction with a brace.
The nurse in the pediatric clinic is reviewing the health history of a 10-year-old girl with a diagnosis of juvenile idiopathic arthritis (JIA). Currently the child is experiencing recurrent pain and swelling of the joints, particularly her knees and ankles. What organ is commonly affected in children with this disorder?
Eyes
A nurse is caring for a 3-year-old child with acute laryngotracheobronchitis. The child has severe dyspnea and a temperature of 104.0º F (40.0° C) and is receiving cool mist by way of a facemask. The mother asks why her child is not receiving warm mist. The nurse explains that cool mist:
Facilitates reduction of mucosal edema
Upon interacting with the parent of an infant, the nurse observes that the parent is using an incorrect formula preparation method. Which risk does this pose to the infant?
Failure to thrive
Obesity in children is an ever-increasing problem. What should a nurse consider before confronting the problem with individual children?
Familial and cultural influences are deciding factors in eating habits.
Which physiologic changes are observed in pregnant women during the third trimester? Select all that apply.
Fatigue Urinary frequency Braxton Hicks contractions
A 4½-year-old child is admitted to the pediatric unit in preparation for surgery. What psychological responses to hospitalization does the nurse anticipate from this preschooler? (Select all that apply.)
Fearfulness regarding intrusive procedures Misgivings about being punished for a misdeed
What feeding instruction should a nurse give the mother of a 2-month-old infant with the diagnosis of heart failure?
Feed slowly while allowing time for adequate periods of rest.
For how long should a nurse maintain isolation of a child with bacterial meningitis?
For 48 hours after antibiotic therapy begins
Which is the cognitive developmental stage of adolescents according to Piaget?
Formal operations stage
An 18-month-old toddler who has received the appropriate immunizations on time is visiting the pediatric clinic for the next scheduled immunization. What vaccine should the nurse administer?
Fourth diphtheria toxoid, tetanus toxoid and acellular pertussis (DTaP) vaccine
A 10-month-old boy is in a restaurant with his parents and grandparents. The grandfather places several pieces of bread on the high chair tray for the infant. A nurse sitting nearby sees the infant gag and become red-faced, then turn cyanotic. With permission from the family, the nurse holds the child with the head downward and:
Gives the infant five back blows
Which action by a mother indicates the need for additional teaching about the administration of oral iron supplements in children?
Giving a liquid iron supplement with whole cow's milk
While reviewing the blood test reports of a 12-month-old infant, the nurse finds that the infant's blood shows phenylalanine levels as 25 mg/dL and implements measures to be followed for the infant to reduce the risk. During follow-up visits the nurse finds that the infant's condition is not improving, even after treatment. Which actions by the mother may be contributing to the infant's condition?
Giving milk to the infant Giving peanut butter to the infant
A 13-month-old toddler has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention should the nurse emphasize?
Giving small amounts of clear liquids frequently to prevent dehydration
A pale, lethargic 1-year-old infant weighs 28 lb (12.6 kg) and has a hemoglobin level of 9 g/dL. The parent tells the nurse that the infant refuses solid food when it is offered by spoon and drinks between four and six full bottles of milk per day. What should the nurse recommend?
Giving the infant finger foods such as dry cereal and chopped meat
A nurse is reviewing the laboratory report of a 13-year-old child with type 1 diabetes. What test is considered the most accurate in the evaluation of the effectiveness of diet and insulin therapy over time?
Glycosylated hemoglobin
A nurse provides nutrition instruction to the parents of a school-aged child with celiac disease, including foods that their child may safely eat. What foods selected by the parents indicate that the teaching has been successful?
Hamburgers and fries
A nurse is obtaining a health history from the mother of a 15-month-old toddler with celiac disease. The nurse expects the mother to indicate that her toddler:
Has bulky, foul, frothy stools
During a regular examination of a child, the nurse suspects that the child may be at a risk for obesity. What does the nurse advise to prevent obesity in the child?
Have small and frequent family meals.
A 3-year-old child is to receive a liquid iron preparation. What should the nurse teach the mother regarding this medication?
Have the child drink the diluted iron preparation through a straw.
What activity beyond the capabilities of a toddler does the nurse conducting an evaluation expect of a 4-year-old child?
Having a vocabulary of about 1500 words
A 13-year-old child states, "I don't know if I want to go to college or start working after high school." Which stage of psychosocial development is indicated by this child's uncertainty?
Identity vs. role confusion
A nurse teaches the parents of an infant with a cardiac defect how to detect impending heart failure. What should the parents be taught to identify as an early sign?
Increased heart rate
The nurse is caring for four full-term infants in a primary health care setting. Which infant does the nurse suspect to have craniosynostosis?
Infant 1
The nurse is assessing motor development in four infants. In which infant does the nurse suspect delayed gross motor development?
Infant 2
The nurse is collecting data from a few infants in a pediatric unit. Which infant has impaired growth and development?
Infant D
Which stage of psychosocial development is observed in a 5-year-old child according to Erikson's theory? Correct
Initiative vs. guilt
A nurse who volunteers in a daycare for preschoolers has been asked to give a presentation to parents about health promotion. Which topics should the nurse include?
Injury prevention and dental health
After many episodes of otitis media a 3-year-old child is to undergo myringotomy and have tubes implanted surgically. What should the nurse include in the discharge preparation for this family?
Insert earplugs during the child's bath.
A mother brings her 6-month-old infant to the emergency department with a 3-day history of gastroenteritis. What priority intervention does the nurse anticipate?
Insertion of an intravenous catheter
What should a nurse emphasize when teaching lifelong management of type 1 diabetes to an adolescent?
Inspecting both feet frequently for signs of trauma
Which stage of spiritual development is characterized by imitation of religious gestures and behavior of others without understanding their significance?
Intuitive-projective stage
During the course of treatment a toddler is to receive an intramuscular injection. What is the priority nursing intervention that should be included in the plan of care to comfort the child?
Involving the parents in comforting the toddler after the injection
Which is a characteristic of the developmental theory?
It provides a dynamic, rather than a static, view of the family.
What characteristics does a nurse expect infants and young children with failure to thrive to exhibit? (Select all that apply.)
Language deficit Tendency to illness
The nurse is teaching crutch-walking to a 12-year-old child. What does the child do that indicates the need for more teaching?
Looks down when placing the crutches
The nurse anticipates that the family of a child with cerebral palsy is at risk for difficult parenting issues. What does the nurse conclude is the probable basis for this difficulty?
Loss of the expected healthy child
A nurse is caring for an infant who just underwent surgery for a cleft lip. In which position should the nurse place the infant?
Low Fowler
A nurse explains to the parents of a toddler with a diagnosis of tetralogy of Fallot that the aim of palliative surgery is to directly increase the blood flow to the:
Lungs
A nurse teaches the mother of a 2-year-old child who has celiac disease which foods to avoid. Which foods identified by the mother indicate that she understands the teaching?
Macaroni and cheese
The mother of a 6-week-old infant asks the nurse at the pediatric clinic why, with the exception of hepatitis B, her baby's immunizations will not be started until the infant is 2 months old. How should the nurse respond?
Maternal antibodies interfere with younger infants' antibody production.
A nurse confirms that a 9-month-old infant's immunization schedule is up to date. Which immunization will the infant receive at 15 months of age?
Measles, mumps, and rubella (MMR)
A 2-year-old toddler has hearing loss caused by recurrent otitis media. What treatment does the nurse anticipate that the practitioner will recommend?
Myringotomy
The mother of a preschooler with acute glomerulonephritis (AGN) asks the nurse whether her child will have to stay in bed. The nurse responds that bedrest is:
No longer a necessary part of the treatment plan
A nurse in the family planning clinic reviews the health history of a sexually active 16-year-old girl whose chief concern is a thick, burning vaginal discharge accompanied by low abdominal pain. After her examination, the girl is informed that she may have a sexually transmitted infection (STI) that requires treatment. The adolescent is concerned that her parents will discover that she is sexually active. She asks the nurse whether her parents will be contacted. The nurse explains that her parents will:
Not be contacted, because treatment at the clinic is confidential
A 4-month-old infant had a spica cast applied. What should the nurse include in the discharge instructions to the parents?
Obtain a specially designed car seat.
A 6-year-old child has a fractured arm and multiple old injuries. Child maltreatment is suspected. What parental characteristic supports this suspicion?
Offering inconsistent stories about the injuries
Immediately after being placed in the supine position, an adolescent child experiences shortness of breath and must sit up to breathe. What term should the nurse use to document this clinical phenomenon?
Orthopnea
A nurse is discussing the care of an infant with colic. What should the nurse explain to the parents is the cause of colicky behavior?
Paroxysmal abdominal pain
A mother tells her neighbor, a nurse, that her toddler has been found to have parasites (worms) and that the whole family will need to be treated. She asks the nurse what kind of worm it is. What is the most likely type of worm infestation?
Pinworm (Enterobius)
What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?
Placing a tracheotomy set at the bedside
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?
Placing the child in a private room, restricting ill visitors, and using strict handwashing techniques
When providing care to a 6-year-old child with leukemia, a nurse notes blood on the pillowcase and several bloody tissues. What blood component value on the child's laboratory results should the nurse verify?
Platelets
After teaching from the nurse about common infant injuries, the parent says, "I will not allow my child to go near the plants in our house." Which risk to the infant can be prevented by this action?
Poisonings
On return to the pediatric unit after a tonsillectomy, a nurse notes that a 4-year-old child is swallowing frequently. What is the probable cause of this response?
Postoperative bleeding
A nurse is caring for 3-year-old children. At what stage of cognitive thought does the nurse expect them to be?
Preconceptional
A 2-year-old boy who has fallen from a tree tells his parents and the nurse, "Bad, bad tree." The nurse concludes that the child is within the cognitive developmental norm of Piaget's:
Preconceptual operations
Which statement is accurate regarding the typical growth and development of preschoolers?
Preschoolers believe they are the center of the world.
After an above-the-knee amputation for bone cancer, an adolescent boy is returned to his room. He is monitored closely because of the potential for hemorrhage from the residual limb. What should the nurse plan to keep at the bedside?
Pressure dressing
A 5-month-old infant experiences severe diarrhea and is given intravenous fluids. What is the most important reason for the nurse to closely monitor the IV flow rate?
Prevention of cardiac overload
In addition to standard precautions, what protective equipment or precautions should the nurse use when caring for a 4-year-old child admitted with pertussis?
Private room
Status epilepticus develops in an adolescent with a seizure disorder who is taking antiseizure medication. The nurse remembers that the most common reason for the development of status epilepticus is that the prescribed dosage of medication is:
Probably not taken consistently
The nurse notes that a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure. What is the priority nursing responsibility at this time?
Protecting the child from self-injury
An 11-year-old child with type 1 diabetes who also has a learning disability has difficulty measuring the required insulin dose. The child frequently draws up 42 units of insulin instead of the prescribed 24 units. What is the most appropriate intervention to ensure dosage safety?
Providing the child with a preset syringe that was developed for the visually impaired
The nurse is caring for a child with spasmodic croup. The nurse knows that immediate nursing intervention is required for:
Rapid respiration
A 7-year-old child who has sustained frostbite of the toes after skiing in below-freezing weather is brought to the emergency department. What is the nurse's initial intervention?
Rapidly rewarming the toes by placing the feet in warm water
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action?
Removing excess clothing from the infant
A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? (Select all that apply.)
Report swelling of fingers. Elevate casted arm when the child is standing.
A nurse determines that no further health teaching is needed for the parents of a 6-month-old infant when they state that they will introduce new foods in the recommended order. List the order in which these new foods should be introduced.
Rice cereal Oatmeal cereal Mashed bananas Pureed beef Soft-boiled eggs
A nurse is feeding an infant who recently underwent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding?
Rinse the suture line
A 10-year-old child has sustained an injury resulting in avulsion of a permanent tooth. Which interventions should the nurse implement to keep the tooth alive and suitable for reimplantation? Select all that apply.
Rinse the tooth with saline, if dirty. Insert the tooth back into the socket. Transport child to the dentist immediately.
An 8-year-old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room?
Say the child's name and touch the child's arm before starting care
Which assessment finding on a newborn's skin would need further investigation?
Sclerema
A 10-year-old child who is developmentally delayed and blind must be fed all meals. The child has problems swallowing and frequently chokes and coughs during the feeding. What technique should the nurse use when feeding this child?
Seating the child in a wheelchair, giving small bites of food with metal tableware, and encouraging participation
A newborn has just been admitted to the pediatric surgical unit from the birth hospital with a diagnosis of tracheoesophageal fistula. In what position should this child be maintained?
Semi-Fowler, to reduce the risk of chemical pneumonia
A child who is unable to master his schoolwork received low scores. What behavior could result if the child is not encouraged by teacher or parents?
Sense of inferiority
In which type of play does a child experience pleasure by swinging?
Sense pleasure play
While playing with her child, a mother takes a toy from the child and hides it. She then observes that the child begins to look for the hidden object. According to Piaget, which developmental stage is indicated by this behavior?
Sensorimotor
While sitting on the counter, a child touches a pan on the stove and burns her hands. The child learns that it is not safe to touch objects on the stove. Which stage of Piaget's cognitive development does the child's behavior demonstrate?
Sensorimotor
A nurse anticipates that a preschooler will perceive death as:
Separation that is reversible
An adolescent child is admitted to a pediatric unit with the tentative diagnosis of acute poststreptococcal glomerulonephritis (APSGN). What diagnostic tests does the nurse expect will be performed to confirm this diagnosis?
Serum complement (C3) activity level and urinalysis
When is the best time to prepare a toddler for impending surgery?
Shortly before the procedure
A 3½-year-old boy from Central America who has tetralogy of Fallot attends the pediatric cardiac clinic for a diagnostic workup before corrective surgery is scheduled. The nurse's evaluation of the child's motor ability demonstrates that he is just beginning to walk unsupported. When comparing this child with other 3½-year-old children, the nurse determines that the child:
Should have started to walk about 2 years earlier
A school-aged child is receiving a blood transfusion. What should the nurse do first if an allergic reaction to the blood occurs?
Shut off the infusion
A nurse is caring for a 4-year-old child whose arm is immobilized. What play activity is most appropriate for this child?
Solving jigsaw puzzles
While caring for a newborn in a neonatal intensive care unit, the nurse notices that the neonate is not moving his legs simultaneously. Which condition might the nurse suspect to be the reason for this?
Spinal cord injury
A nurse takes a 1-year-old child to the hospital playroom. What toy should the nurse select for this child?
Squeaky plastic duck
What chelating agent does the nurse anticipate will be prescribed for a toddler with lead poisoning?
Succimer (Chemet)
A nurse is caring for a first-grader receiving prednisone (Meticorten). What outcome does the nurse expect with adrenocorticosteroid therapy?
Suppressed inflammatory process
A nurse is counseling the family of a child with AIDS. What is the most important concern that the nurse should discuss with the parents?
Susceptibility to infection
A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant?
Tachycardia
A 16-year-old adolescent sustains an ankle injury while playing soccer. Crutches and no weight-bearing are prescribed by the practitioner. What must the nurse ensure when adjusting the crutches?
That they extend to 6 inches from the side of each foot
Following a regular health checkup and health interview of an 8-year-old child, the nurse concludes that the child's gastrointestinal system is well developed. Which findings support the nurse's conclusion? Select all that apply.
The child is able to maintain stable blood sugar levels. The child eats after 3 to 4 hours without feeling hungry in between. The child had less than three episodes of stomach upset in the previous year.
The mother of a 2-year-old child expresses concern to the nurse in the pediatric clinic that her child still takes a bottle of milk to bed at night. How should the nurse explain to the mother that this practice should be stopped?
The child is at increased risk for dental caries.
According to Kohlberg's moral judgment theory, which characteristic behavior would the nurse find in the child who is in the naive instrumental orientation stage?
The child is motivated by a selfish desire to obtain rewards and benefits.
Following the assessment of a child, the nurse concludes that the child has an easy temperament. Which observation in the child supports the nurse's conclusion?
The child is open to changes and adapts positively.
A preschool child presents to the clinic for a well-child examination. What feature of the child's dress is most important for the nurse to address with the parents?
The child's name is embroidered on a jacket pocket.
During a well-baby clinic visit, the nurse finds that a 1-year-old infant says "ma" and "pa." The infant does not say anything else and uses gestures to communicate. What should the nurse infer from this finding?
The infant exhibits normal language development.
On the fourth day after birth, an infant passes light brown stools that are firm and have an offensive odor. What should the nurse infer from these findings?
The infant is exclusively formula-fed.
A 7-month-old girl is to be catheterized so a sterile urine specimen may be obtained. One of the infant's parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance?
The procedure is uncomfortable, but there should not be a damaging long-term effect.
A 6-year-old child with a leg fracture of suspicious origin is brought into the emergency department by the mother and the mother's boyfriend. It is the child's first visit to this hospital. After assessing the child, a nurse anticipates that the health care provider will order a skeletal survey. Why is a skeletal survey the preferred diagnostic tool?
The skeletal history of the current fracture and any previous healing or healed fractures are identified.
A 1-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes eqinovarus); new casts have just been applied. The goal at this time is ensuring that circulation to the feet remains sufficient. How will the nurse determine that the goal is being met?
The toes, when compressed, exhibit a quick return of circulation.
The mother of a boy with recently diagnosed hemophilia is pregnant with her second child. She asks the nurse what the chances are that her baby will also have hemophilia. How should the nurse respond?
There is a 25% chance that the baby will be affected.
A child who has been undergoing prolonged steroid therapy takes on a cushingoid appearance. What will the nursing evaluation probably reveal? (Select all that apply.)
Truncal obesity Thin extremities
A 9-month-old infant who appears well nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Erikson's theory of development, the nurse determines that the infant is in the process of achieving the task of:
Trust
Which of the following signs are indications of hydration status during a sickle cell crisis? (Select all that apply.)
Turgor of tissue
A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. These goals should be set with the understanding that:
Unknown extent of the disability requires continual adjustments
A nurse is monitoring a 6-year-old child for toxicity precipitated by digoxin (Lanoxin). For what sign, the most common, of digoxin toxicity should the nurse assess the child?
Vomiting
What is the priority nursing responsibility in the care of a young toddler after a circumcision?
Watching for bleeding around the penis
A girl comes to the physician's office for her 14-year-old check-up. What is the most important anticipatory guidance that can be offered to the client?
Ways to prevent accidents
After 3 months of supplemental oral iron therapy, there is no significant increase in a female adolescent's hemoglobin level. Iron dextran (Imferon) is ordered. What is the best way for the nurse to administer this medication?
With the use of the Z-track method
As the working mother of a toddler is preparing to take her child home after a prolonged hospitalization during which she was not able to visit often, she asks the nurse what type of behavior she should expect. What is the most appropriate description by the nurse of her child's probable behavior?
Withdrawn, without emotional ties to the mother
Which statement by a mother indicates the need for additional teaching about safety guidelines for infants and toddlers?
"I will give my child hard candies for chewing."
A nurse plans care of 4-year-old hospitalized children on the basis of their developmental level. What is the major vulnerability of children this age?
Intrusive procedures
A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure?
Placing the child in the side-lying position
A nurse is caring for a school-aged child who has had a tonic-clonic seizure. How should the nurse describe the clonic phase?
Spasmodic body jerking
The nurse is teaching a parent group about the reason to adhere to the immunization schedule. What complication of mumps is important for adolescents to avoid?
Sterility
Which statement is true regarding nightmares in preschoolers?
The child may be reassured by another's presence.
What is the outcome of an authoritative parenting style?
The child may become self-reliant.
The mother of a 7-month-old infant who becomes irritable when teething tells the nurse, "My aunt said to wipe my baby's gums with wine to ease the pain." What is the best response by the nurse?
"An over-the-counter topical gel can be used, but make sure it's for teething."
A pregnant mother asks about the best time to begin weaning her 2-year-old son from the bottle. What is the best reply by the nurse?
"Anytime, as long as there aren't other changes going on in his life."
The parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it all right if I give him 2 baby aspirins?" What is the best response by the nurse?
"Aspirin may cause more bleeding. Give him acetaminophen instead."
What treatment should the nurse suggest to an adolescent with type 1 diabetes if an insulin reaction is experienced while the adolescent is at a basketball game?
"Buy a soda and hamburger to eat."
The parent of a 2-year-old calls a nurse who is a neighbor and reports that the child just ate several multivitamins with iron. What should the nurse say to the parent?
"Call the poison control center."
After treatment for Lyme disease, a child expresses fear of going camping again because of the ticks. What is the best response by the nurse?
"Checking yourself frequently for ticks will help prevent another infection."
The nurse teaches a group of adolescents about contraception. Which statements made by the adolescents indicate effective learning? Select all that apply.
"Condoms require consistent use and decrease spontaneity." "Lea's shield is less effective in women who have given birth." "Spermicidal creams may not be completely effective in preventing pregnancy."
A nurse is teaching a 12-year-old child about a bone marrow aspiration. What statement indicates that the preadolescent needs further explanation of the procedure?
"I'll have to rest after the procedure."
Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. What is the best response by the nurse?
"Electrical activity in the baby's heart is recorded, then printed on graph paper."
An adolescent who has just been found to have type 1 diabetes asks a nurse about exercise. What is the best response by the nurse?
"Extra snacks are needed before exercise."
The parents of a school-aged child with cystic fibrosis tell the nurse that they have changed to generic pancreatic enzymes because of money issues. An appropriate response by the nurse is:
"Generic enzymes are not as effective as the brand-name one. This is something you need to discuss with your healthcare provider."
The parents of a 6-year-old boy tell the nurse in the pediatric clinic that their son has recently started to wet the bed at night. What is the most helpful response by the nurse?
"Have there been any changes in his life recently?"
An infant has been admitted with failure to thrive (FTT). The nurse knows that more education is required when she hears one of the parents say:
"I can double the amount of water in the formula to save money."
An infant with a myelomeningocele undergoes surgery and is returned to the pediatric unit. The father appears anxious and tends to avoid physical contact with the infant. Later he says to the nurse, "My wife seems so wrapped up with the baby; I hope she has time for me." What is the most therapeutic response by the nurse?
"I can understand your concern about the changes you'll have to make."
A nurse teaches an adolescent undergoing chemotherapy for cancer about the need for special mouth care because of the potential for oral lesions. What statement indicates to the nurse that the instructions have been understood?
"I can use foam-tipped applicators to wipe my teeth and gums."
A Girl Scout leader arrives at the hospital's emergency department with a 7-year-old child who may have a broken ankle. The history reveals that the child fell about 1 mile from the camp while on a hike with the scout leader and four other 7-year-olds. The nurse asks whether all of the other children are safely back in camp. Assuming that the scout leader acted appropriately, the nurse expects the scout leader to respond:
"I carried the injured girl and led the rest of the girls back to camp."
A father calls the clinic because he wants information about how to care for his child's severe diaper rash. The nurse asks the father what he has been doing so far and determines that the father needs further teaching when he says:
"I direct a heat lamp at the buttocks."
The nurse discusses discipline with parents of a 4-year-old child. Which parental statement regarding time-out reflects an appropriate application of this method of discipline?
"I explain the reason for the time-out before and after disciplining him."
The mother of a 2-year-old toddler tells the nurse that her child is frequently constipated. The nurse asks the mother how she handles the child's toileting. Which response indicates to the nurse that the mother requires further education?
"I schedule my child's toileting for before each meal."
The nurse is reinforcing best parenting practices to the parents of a 13-year-old child. Which statements made by the parent need correction? Select all that apply.
"I should motivate my child to perform well in exams by comparing her to her siblings." "I should teach my child to make decisions and understand consequences as an adult would."
After collecting data on a 2-month-old infant, the nurse reinforces proper safety measures to the infant's mother to reduce the risk of injury in the infant. Which statements made by the infant's mother need correction? Select all that apply.
"I should protect my child's crib mattress with a plastic covering." "I should ensure that my child's car seat is rear-facing in a seat with an airbag."
The nurse is teaching a group of school-age children about bicycle safety. Which statement of the children may indicate effective learning? Select all that apply.
"I should watch for drain grates and potholes." "I should not carry packages that interfere with my vision." "I should equip the bicycle with proper lights and reflectors."
A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teaching?
"I'll have to be careful not to cut my baby's nails short."
A nurse teaches the mother of a child with a pinworm infestation how pinworms are transmitted. Which statement indicates that the teaching has been effective?
"I'll have to reinforce her handwashing habits, especially before she handles food."
A 4-year-old child is found to have acute lymphoblastic leukemia. One of the parents tells the nurse, "We just had a discussion with our pediatrician about starting chemotherapy, consolidation therapy, and radiation therapy. We're so confused, and we don't know what to do. We want to do what is best for our child, but we don't want any unnecessary suffering." What is the best response by the nurse?
"Maybe you could talk with your health care provider about getting a second opinion from a specialist in leukemia."
A 16-year-old client with full-thickness burns of the entire right arm states, "I'll never be able to use my arm again. I'll be scarred forever." What is the best initial response by the nurse?
"Minimizing scarring is the goal of the entire professional staff."
A nurse is teaching parenting to a group of teenage mothers. After a discussion of child safety, the young mothers provide feedback. Which comment indicates the need for additional information?
"My baby could drown if I leave her alone in water higher than her waist."
Which statement made by the mother of a 9-month-old infant supports the nurse's conclusion that the infant has good fine motor development?
"My baby picks up small objects."
Which statement by the parent of a 9-month-old supports the nurse's conclusion that the infant displays developmental accomplishments appropriate for this age?
"My child can throw a ball."
The nurse is collecting data from a 6-year-old child during a well-child visit. After interacting with the child's mother, the nurse suspects that the child requires psychiatric screening. Which statement by the mother supports the nurse's conclusion?
"My child still wets the bed at night."
The nurse is explaining which developmental milestones a child's parents should expect to see at the age of 18 months. Which statements made by the parents indicate the need for further instruction? Select all that apply.
"My child will be able to take a few steps on tiptoe." "My child will be able to take a few steps on tiptoe." "My child will be able to kick a ball without losing balance."
The nurse is interacting with the parent of a male adolescent and interprets that the adolescent is in the fourth stage of Piaget's cognitive development theory. Which statement made by the parent supports the nurse's conclusion?
"My child yells at me when I forbid him from attending any late night parties."
A 3-year-old boy is found to have X-linked Duchenne muscular dystrophy. Neither parent has muscular dystrophy. Which statement indicates that the parents understand how the disorder is transmitted?
"Our daughters may be carriers of the disease."
A 2-year-old child with developmental dysplasia of the hip has a spica cast applied. The mother asks the nurse how to keep the cast clean. How should the nurse respond?
"Place plastic wrap or duct tape around the perineal edges of the cast."
A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges?
"Put an ice pack on the affected area."
The mother of an adolescent asks the nurse, "What's the best way to remove a tick from the skin?" What is the best response by the nurse?
"Remove the tick carefully with tweezers."
An 8-year-old child has experienced the death of a sister. The child begins to ask many questions about what happens to the body after death. The parents wonder whether this is abnormal or morbid behavior picked up from playing video games. What is the best response by the nurse?
"School-aged children are inquisitive and ask a lot of questions about death."
A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be prevented. The nurse responds:
"Scratching results in skin breaks that can lead to infection."
After surgery for a ruptured appendix, a 12-year-old child is receiving morphine for pain control by way of a patient-controlled analgesia (PCA) infusion. A bolus of morphine can be delivered every 6 minutes. A parent will be staying with the child during the immediate postoperative period. What statement indicates to the nurse that the instructions about the PCA pump have been understood?
"She needs to push the PCA button whenever she needs pain medication."
During a routine visit to the child health clinic the parent of a 3-year-old girl reports, "My daughter is still sucking her thumb." What is the nurse's best response?
"She'll stop when she's ready."
An adolescent is admitted to the unit with a tentative diagnosis of a bone tumor of the left femur. During the admission procedure the adolescent casually asks, "Do they ever have to cut off a leg if someone has bone cancer?" How should the nurse respond?
"Sometimes it's necessary. What do you think about that treatment?"
The registered nurse is teaching a mother about the introduction of solid foods to her infant. Which statement should the nurse include in the teaching?
"Spoon-feed your child after giving the child a small amount of breast milk."
A nurse reviews the preoperative instructions for a 3½-year-old child who is to undergo follow-up cleft palate surgery. Which instruction should the nurse question?
"Tapwater enema until clear this pm."
After her child's visit to the pediatrician a mother tells the nurse that she is concerned that an antidepressant has been prescribed for her adolescent son. What is the best response by the nurse?
"Tell me more about what's bothering you."
A 17-year-old mother is to sign the consent for her son's myringotomy. What should the nurse say to the mother about this procedure?
"Tell me what you know about this procedure."
The parents of an infant ask the nurse why their baby is scheduled to receive the intramuscular polio vaccine rather than the oral vaccine. What is the best response by the nurse?
"The American Academy of Pediatrics recommends the intramuscular vaccine because it is safer."
An IV catheter is to be inserted into a 3-year-old toddler's peripheral vein. As local topical anesthetic is applied, the toddler starts to cry and asks whether the insertion is going to hurt. How should the nurse respond?
"Yes, it may hurt, but not for very long."
Which statement or question is best when asking a toddler about breakfast?
"You can have an egg and toast or cereal with milk."
The mother of an 18-month-old boy with a cleft palate asks the nurse why the pediatrician has recommended that closure of the palate be performed before the child is 2 years old. How should the nurse respond?
"You need to have the surgery performed before he starts to use faulty speech patterns."
The nurse is reinforcing methods to enhance gross motor skill development in toddlers to the parents of a 24-month-old child. Which should the nurse include in the teaching to provide effective teaching?
"You should encourage your child to play soccer."
The school health nurse sees many students carrying heavy bags to school. What instruction should the nurse give to the children to prevent soft tissue injury?
"You should move the books from one arm to another."
A 9-year-old child with a tentative diagnosis of leukemia is to undergo bone marrow aspiration. What information should the nurse give the child before the procedure?
"You'll be given medication to relax you before the test, and you'll remember nothing afterward."
The parents of a 3½ -year-old tell the nurse that their child has become a "picky eater" and has not gained much weight. How should the nurse respond?
"Your child is growing slower; preschoolers don't have large appetites."
Parents are considering a bone marrow transplant for their child who has recurrent leukemia. The parents ask the nurse for clarification about the procedure. What is the best response by the nurse?
"Your child's immune system must be destroyed before the transplantation can take place."
A nurse is changing the dressing of a sixth-grader with severe burns. What basic principles of surgical asepsis must the nurse consider? (Select all that apply.)
1 A paper field must remain dry to be considered sterile. 3 A 1-inch border around a sterile field is considered contaminated. 4 Sterile objects in contact with clean objects are considered contaminated.
A 2-year-old child attempts to jump, but falls down, and everyone around starts laughing at the child. What would be the result, if this pattern keeps repeating?
The child will develop doubt and shame.
An infant is to receive an intravenous antibiotic as a piggyback. The prescription is 10 mg/kg body weight/24 hr, to be administered in equal doses every 12 hours. The infant weighs 22 lb. How many milligrams of the antibiotic should the infant receive per dose? Record your answer using a whole number. ___ mg
100 mg/day
While a 3-month-old infant is at the well-baby clinic for a checkup, the parents express concern that their baby still has a soft spot on the top of the head. The nurse informs the parents that their infant's anterior fontanel will close around:
13 to 18 months of age
A 6-month-old infant is admitted to the pediatric unit with a diagnosis of failure to thrive. The birthweight was 7 lb. Judging from growth and development charts, how many pounds does the nurse conclude that the infant should weigh?
14
The nurse is reviewing discharge instructions for a mother whose school-aged child was recently found to have celiac disease. Which statements by the mother demonstrate understanding of the child's nutritional needs? (Select all that apply.)
2 "I'll try to provide meals that are lower in fats and higher in carbohydrates." 4 "She loves raw carrots for snacking, so I'll have to avoid those when the disease is worse." 5 "I'll be sure to look at the labels more closely from now on—we need to avoid hydrolyzed vegetable protein."
The mother of a toddler is anxious about her child's eating habits because the child is very fussy and doesn't eat well. What should the nurse explain to the mother?
The child's eating habits are normal for this age.
A nurse is performing health screenings of toddlers in a culturally diverse neighborhood. Which child should the nurse consider at risk for β-thalassemia (Cooley anemia)?
2-year-old child of Greek descent with a large abdomen
What would be the Apgar score of a newborn in severe distress, which may predict a developmental delay?
3
Which spiritual development stage is observed in early childhood, as per Fowler?
3
The nurse is teaching a parent of a 2-year-old toddler how to administer eardrops. In what direction should the nurse teach the parent to gently pull the pinna?
Down and back
The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition?
Down syndrome
Basing the decision on developmental norms for a 5-year-old child, a nurse decides to withhold a scheduled dose of digoxin (Lanoxin) elixir and notify the health care provider. Below what apical pulse did the nurse withhold the medication?
70 beats/min
A 6-year-old child is experiencing tonic-clonic seizures, and carbamazepine (Tegretol) 15 mg/kg/day divided into two doses is prescribed. The child weighs 44 lb. The medication available is carbamazepine suspension 100 mg/5 mL. How many milliliters should the nurse administer in one dose? Record your answer rounding to one decimal place. __________ mL
7.5 mL
Which playtime activity would best promote linguistic development in toddlers?
A children's TV program
A toddler with a history of enlarged lymph nodes, prolonged fever that is unresponsive to antibiotics, erythema of the extremities, and a rash is admitted to the pediatric unit with a diagnosis of Kawasaki disease. What does the nurse suspect was essential in confirming this diagnosis?
A combination of signs
The mother of a preschool-age child tells the nurse that her husband is dying of cancer and that she is worried about how her child will cope. As part of their discussion, the nurse includes that preschool-age children view death as:
A form of sleep
A 4-year-old child with nephrotic syndrome has repeated relapses. As the child gets older, what is the most important attribute for the child to develop?
A positive body image
When teaching an adolescent with type 1 diabetes about dietary management, what instruction should the nurse include?
A ready source of glucose should be available.
Which belief should a nurse expect a preschooler to hold regarding the concept of death?
A temporary condition
A preschool child with a spinal cord injury will be on prolonged bedrest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as restricted in the teaching plan?
Cheese
Permethrin 1% lotion (Nix) is prescribed for a 5-year-old child with pediculosis capitis (head lice). What instruction should the nurse include while teaching the parents about treating the head lice?
The child's hair must be combed with a fine-toothed comb to remove nits.
How can a nurse best accomplish therapeutic communication with an adolescent?
By establishing a relationship over time
Loratadine (Claritin), 10 mg by mouth once a day in the morning, is prescribed for a 15-year-old girl with hay fever. The girl tells the school nurse that she is concerned that she will be sleepy for a quiz the next day. How should the nurse respond?
By explaining that this medication rarely causes drowsiness
A nurse is teaching the parents of an 18-month-old child the procedure for instilling ear drops. How should this procedure be done?
By pulling the pinna down and back to straighten the auditory canal before instillation of the drops
What is the best way for the nurse to greet a 3-year-old child sitting in the waiting room of the pediatric clinic?
By walking into the waiting room to greet the child
The New Ballard Scale score of a newborn reveals abundant lanugo, smooth pink, visible veins on the skin, plantar creases ant. 2/3, flat areola, stiff ears with thick cartilage, and a prominent clitoris with enlarging minora. What would be the maturity rating in this newborn? Record your answer using a whole number.______
Abundant lanugo = 1, smooth pink, visible veins = 1, plantar surface creases ant. 2/3 = 3, flat areola = 1, stiff ear with thick cartilage = 4, prominent clitoris with enlarging minora = 1. Therefore, the maturity scale in this newborn is summed up as 9.
A nurse is caring for a hospitalized school-age child. What development-related activity is most important for the nurse to encourage?
Academic studies
A nurse is teaching a group of assistants in a daycare center about toddlers' developmental milestones. What behavior should indicate to the assistants that one of the milestones has been achieved?
Accepting external limits
A nurse is teaching a group of parents about the developmental needs of young toddlers. What is the priority topic that the nurse should include?
Accident prevention
The mother of an 18-month-old toddler tells the nurse in the pediatric clinic that her child is "unmanageable and into everything." What is the most important teaching to include during this clinic visit?
Accidents are the leading cause of death and injury in this age group.
A 5-year-old child is admitted to the pediatric unit complaining of colicky abdominal pain with guarding, nausea, anorexia, and a low-grade fever. Palpation of the right lower quadrant of the abdomen elicits pain. What is the most likely diagnosis the nurse should expect when planning care for this child?
Acute appendicitis
A new mother who is unable to breastfeed her newborn expresses breast milk to feed the baby. Which actions of the mother should be corrected by the nurse? Select all that apply.
Adding water to dilute the expressed milk Storing expressed milk at room temperature Adding honey to expressed milk to improve taste
A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that this is necessary to:
Allow the intestinal tract to rest
The parents of a 2-year-old child who is being admitted to the hospital tell the nurse that their child is accustomed to sleeping with a favorite blanket. What should the nurse do, knowing that the blanket is worn and dirty?
Allow the parents to give it to the child
A 4-year-old child is brought to the emergency department after falling on the handlebars of a tricycle. The child is guarding the abdomen, crying, and not allowing any physical contact with the staff. What is the best action by the nurse?
Allowing the child to guide the examiner's hand to the area that hurts
A mother of three children, who was abandoned by her husband shortly after the birth of her youngest child, brings her daughter, now 9 months old, to the pediatric clinic. The infant is found to have nonorganic failure to thrive and is admitted to the hospital. What infant behavior does the nurse anticipate as the mother leaves to return home to care for her other children?
Allowing the nurse to take her but remaining stiff while being held
What should the nurse encourage the parents of a child with plumbism (lead poisoning) to do?
Assess the family's home environment for lead sources and have them removed
A child's body mass index (BMI) is 26. Which dietary habits would increase the health risks in the child? Select all that apply.
Avoiding beans and legumes in the diet Excluding calcium-rich foods from the diet
In which type of play do children play together, share toys, and communicate with each other?
Associative play -Children from 2 years of age are mostly involved in associative play, in which they play together, share toys, and communicate with other children. In parallel play, children play next to each other but have little interaction. In solitary play, the child plays alone, which is usually seen in infants. In onlooker play, a child watches others playing, but does not interact.
A newborn has been found to have with developmental dysplasia of the hips and is placed in a Pavlik harness. The parents have been instructed that the infant is to wear the appliance full time except for bathing. What additional instruction should the nurse give the parents about the harness?
Avoid using the legs to lift the infant's buttocks when changing the diaper at bathtime.
A nurse discusses with a group of parents in the well-baby clinic the appropriate car restraints to be used for children. The nurse determines that one of the parents understands the teaching about car restraints for newborns when the parent says that infants should be buckled into an infant car seat and that the car seat must be in the:
Back seat, facing backward
A nurse is providing preoperative teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is:
Bacterial
The nurse is caring for a group of patients who require various interventions. What patient care may be delegated to unlicensed assistive personnel (UAP)?
Bathing a child with an intravenous line and a PCA pump
An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube?
Before each feeding
The parents of a 5-month-old infant tell a nurse at the well-baby clinic that they are concerned because their baby weighs only 14 lb. After reviewing the infant's health history, the nurse assures them that their baby's weight is within the expected range for age. What information prompted this reply?
Birthweight
A mother in the postpartum unit expresses concern that her 3-year-old daughter will be jealous of her new brother. What should the nurse suggest?
Bringing home a new baby doll for the daughter when her baby brother is brought home
A 1-year-old infant is receiving zidovudine (AZT) for management of HIV infection. The nurse determines that the infant is exhibiting signs of life-threatening zidovudine toxicity. What clinical finding supports this conclusion?
Bruises over the body
What are the best ways to remove plaque from a toddler's teeth? Select all that apply.
Brushing Flossing
An infant with a cleft lip is fed with a special nipple. What should the nurse teach the parents about feeding their infant to minimize regurgitation?
Burp frequently during a feeding
An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How should the nurse respond when the client complains of pain and requests medication?
By acknowledging that the pain is real and administering medication to relieve it
A preschooler is to have a peripheral intravenous catheter inserted. How can the nurse make the experience minimally traumatic for the child?
By applying an epidermal analgesic before the procedure
A 4-year-old child with newly diagnosed leukemia is admitted for chemotherapy. While assisting with morning care the nurse observes bloody expectorant after the child has brushed the teeth. How should the nurse respond to this occurrence?
By documenting the incident without alarming the child
How should parents practice "time-out" with preschoolers?
By encouraging quiet time alone without toys
A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin (Lanoxin) 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item should the nurse teach the mother to use when administering the medication?
Calibrated syringe
An infant is receiving the first diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) at 2 months of age. What instructions should the nurse give the parents?
Call the clinic if marked drowsiness occurs.
The mother of a 2-year-old child calls her neighbor, who is a nurse, exclaiming that her child just ate some automatic dishwasher powder. What should the nurse tell the mother to do first?
Call the poison control center
Which sensory skill can be observed in a 5-month-old infant?
Can localize sounds made below the ear
The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. What body system does the nurse expect will be affected?
Cardiopulmonary
The mother of a healthy 10-month-old infant asks the nurse what type of milk and puréed foods she should give her baby. What is the best response by the nurse?
Carrots, chicken, applesauce, and breast milk
A nurse is caring for a 9-month-old infant with gluten-induced enteropathy. What common term for this disorder should the nurse use when discussing the infant's diagnosis with the parents?
Celiac disease
At 20 hours of age a newborn is found to have a bilirubin concentration of 13 mg/dL. Which finding most likely contributed to this bilirubin level?
Cephalhematoma
During a nap, a 3-year-old hospitalized child wets the bed. What is the best response by the nurse?
Change the child's clothes without discussing the incident
An infant is admitted to the pediatric unit with gastroenteritis and dehydration. The nurse determines that the parents understand the teaching about contact precautions when they note that after washing their hands they need to:
Change their gloves each time they change the baby's diaper
After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. What observation should the nurse document that will aid confirmation of the diagnosis?
Characteristics of stools
A 6-year-old child is hospitalized with nephrotic syndrome. The mother asks the nurse what she may bring for her child to play with during the hospitalization. In light of the child's age, what should the nurse suggest? (Select all that apply.)
Checkers Paper and crayons Simple card games
What is the priority nursing care in the immediate postoperative period for a toddler with a newly applied hip spica cast?
Checking the toddler's peripheral circulation
What behavior does a nurse expect from a toddler subjected to prolonged hospitalization with limited parental visits?
Cheerful interactions with staff members
A nurse is obtaining the health history from the mother of a preschooler with Reye syndrome. The nurse should ask the mother if the child has recently had:
Chickenpox
A child with leukemia is to continue taking prednisone (Meticorten) at home. The nurse discovers that the child's sibling is home from school with chickenpox. What is the nurse's priority concern?
Chickenpox can be fatal to individuals with leukemia.
A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and got a positive result. She confides that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl whether she has told anyone else, she replies, "Yes, but my mother doesn't believe me." Legally, who should the nurse notify?
Child protective services for immediate intervention
A nurse in the pediatric clinic is teaching the parents of a toddler how to prevent accidental poisoning. What should the nurse emphasize?
Child's need for exploration
A nurse is conducting a health class for adolescents. What modifiable risk factor, most closely associated with the development of coronary heart disease (CHD) in both men and women, should the nurse discuss?
Cigarette smoking
A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should prompt the nurse to have further assessment by the care provider?
Circumoral cyanosis
The nurse has assisted in the delivery of a newborn who weighs 8.6 pounds and is born postterm. The nurse performs physical examination of the newborn to assess the newborn's use of both arms and the Moro reflex. Which condition is the nurse trying to rule out in the newborn?
Clavicle fracture
A 3-year-old child with the diagnosis of tetralogy of Fallot is brought to the United States by a charitable organization for cardiac surgery. What should the nurse expect to observe when caring for the child?
Clubbing of fingers
A 4-year-old child is admitted to the pediatric unit for a tonsillectomy. During preoperative planning a nurse reviews the child's laboratory report. Which lab value is of most significance in this situation?
Coagulation studies
A nurse is caring for a 3-month-old infant with congenital hypothyroidism. What should the parents be taught about the probable effect of the condition on the infant's future if treatment is not begun immediately?
Cognitive impairment
A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage?
Coin in the umbilicus
Which stage of development is observed in a 9-year-old child according to Jean Piaget's cognitive development theory?
Concrete operational
What is the cognitive developmental stage of school-age children?
Concrete operations
What is the most appropriate toy for the nurse to give a 6-year-old child on complete bedrest?
Coloring book and crayons
A woman and her children, who have not received immunizations for childhood diseases, immigrate to the United States. Before being immunized, one of the school-aged children contracts varicella (chickenpox). The nurse teaches the mother that varicella is:
Communicable until all vesicles are dry
While playing, a child takes a few pebbles and places them in order from smallest to largest. Which stage of cognitive development does the child's behavior demonstrate?
Concrete operations
A parent of a 20-month-old toddler who has experienced an episode of diarrhea calls the pediatric clinic for advice. What instructions should the nurse give the parent, according to evidence-based practice for this situation?
Continue the child's feedings as usual, observe the frequency of stools, and bring the child to the clinic tomorrow if the diarrhea continues.
An adolescent is admitted with an acute hemophilia episode. Rest, ice, compression, and elevation will be most helpful in:
Controlling bleeding and retaining joint function
A 2-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia major (Cooley anemia). The parents are told that there is no cure but the anemia can be treated with frequent blood transfusions. The father tells the nurse he is glad that there is a treatment that "fixes" his child's problem. Before responding, the nurse should recall that blood transfusions:
Correct the anemia but may cause other problems
The parents of a 4½-year-old child are concerned about the effects of hospitalization on the child. Which behavior should the nurse expect the child to exhibit?
Crying when the parents leave and return but not during their absence
What is the nurse's priority concern when caring for an infant born with exstrophy of the bladder?
Development of an infection
A nurse is planning to communicate with a preschool child. What is most important for the nurse to know about the child first?
Developmental level
A nurse in the pediatric clinic receives a call from a mother who states that her 2½-year-old daughter, whom she discovered in a kitchen cabinet, is crying that her mouth hurts. She is drooling, and her tongue and gums are white. The nurse gives the mother the number of the poison control center, telling her to call immediately because the nurse suspects that the child has ingested:
Dishwashing detergent
A 5-year-old child is brought into the clinic with lethargy, abdominal ascites, and peripheral and periorbital edema. The history indicates ongoing diarrhea and decreased urine output. The child is found to have nephrotic syndrome and started on corticosteroid therapy. The nurse informs the parents that after a week or two of medication therapy, they can expect the child to exhibit:
Diuresis
The nurse observes a toddler saying sentences such as, "I play," and "No sleep." Upon interacting with the mother, the nurse finds that the child is 20 months old. What does the nurse conclude?
The child's language acquisition is right on track.
During the assessment of a newborn, the nurse pulls the infant from a lying to a sitting position and observes that the infant is unable to control the head in an upright position. Which problem does the nurse suspect?
Down Syndrome
An infant who is exhibiting signs of increased intracranial pressure (ICP) is admitted to the pediatric intensive care unit. What care should the nurse implement that is specific for this infant's condition?
Elevating the infant's head higher than the hips
When preparing a child with asthma for discharge, what instructions must the nurse emphasize to the family? (Select all that apply.)
Eliminate allergens in the home. Continue the medications even if the child is asymptomatic.
Which condition does the nurse suspect in the newborn who has a fluid-filled sac, probably due to herniation of the brain and meninges through a defect in the skull?
Encephalocele
What is the best intervention of the nurse to help foster the development of a trusting parent-child relationship?
Encouraging face-to-face contact between the parents and infant
A nurse is caring for a 6-year-old child with sickle cell anemia. What is the priority nursing intervention to prevent thrombus formation?
Encouraging fluids
An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, what nursing action is most therapeutic?
Encouraging her peers to visit
What intervention should be included in the nursing plan of care to help a 10-year-old girl live with Crohn disease?
Encouraging her to express feelings while focusing on the ways she is like her friends
A 4-year-old child with a new colostomy is to be discharged in several days. What should the nurse teach the parents about their child's home care?
Encouraging physical activity
The parents of an 11-year-old child with a terminal illness appear overwhelmed and anxious. What is the best response by the nurse?
Encouraging the parents to express their feelings
A 19-month-old boy who has been in the hospital for 2 weeks becomes increasingly withdrawn and mute. What is the most appropriate nursing action?
Encouraging the parents to stay with him as much as possible
An infant with a myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates the parent-child relationship in the preoperative period?
Encouraging the parents to stroke their infant
A nurse is determining whether a 5-year-old child is displaying appropriate behaviors for this age. What developmental findings does the nurse expect? (Select all that apply.)
Enjoys imitative play Makes up rules for a new game
An infant who has undergone cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administration of the prescribed antibiotic?
Ensure that the antibiotic is administered as prescribed.
An infant vomits after feedings and starts to lose weight. Galactosemia is diagnosed. The nurse explains to the parents that galactosemia is an inherited autosomal recessive disorder that results in an:
Error in carbohydrate metabolism
What is the most appropriate communication strategy for the nurse working with adolescents in a clinic in a large city health center?
Establishing a relationship over time
After surgery a 5-year-old child experiences intense pain and an analgesic is prescribed. What should the nurse consider when administering the analgesic?
Even though children do not like medicines, analgesics will make them more comfortable.
After abdominal surgery, a 5-year-old child is experiencing pain, and an opioid analgesic is prescribed. What should the nurse consider about children in pain and their response to opioid analgesics when an opioid analgesic is prescribed?
Even though children do not like taking medicines, analgesics will make them more comfortable.
A toddler who was physically abused is admitted to the pediatric unit. What behavior does the nurse expect when approaching the child?
Exhibiting fear of physical contact initiated by anyone
During data collection, the nurse finds that a preschool-age child is stressed about the family relocating to a different city. The nurse tells the parents about ways to reduce the child's stress during the transition. What is the best approach the parents can take to help their child cope with the transition?
Explaining what the child can expect
An 11-year-old child is found to have acute lymphocytic leukemia (ALL), and the health care provider discusses the diagnosis and treatment with the child and family. What age-appropriate behavior does the nurse expect from the child regarding the life-threatening diagnosis?
Expressing anger by being insolent
The mother of an infant with Down syndrome asks the nurse what causes the disorder. Before responding, the nurse recalls that the genetic factor of Down syndrome results from:
Extra chromosomal material
The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiological factor has the greatest impact on the child's health status and is of priority in the care plan?
Extremely thick mucus causes obstructed airways.
A nurse is caring for an underweight adolescent girl with a diagnosis of anorexia nervosa. What common characteristics of girls with this disorder should the nurse recognize when obtaining a health history? (Select all that apply.)
Fatigue Secondary amenorrhea
A nurse is caring for a preschooler who is being prepared for surgery. What does the nurse expect to have the most influence on the child's response to hospitalization?
Fear of bodily harm
A 4-year-old child begins screaming and kicking when the laboratory technician arrives to draw blood. What does the nurse identify as the most likely cause of the child's behavior?
Fear of intrusive procedures
A nurse is caring for a 15-year-old client who is undergoing chemotherapy for leukemia. The nurse expects that adolescents with health problems are most concerned about:
Feeling different regarding changes in body image
A nurse is discussing an infant's diet with a mother who is breastfeeding. Why should the nurse recommend that the infant be offered solid foods by 5 or 6 months of age? (Select all that apply.)
Fetal iron reserves are depleted. Food can be taken from a spoon.
An infant who underwent revision of a ventriculoperitoneal shunt is found to have meningitis, the result of an infected shunt. What clinical manifestations support this conclusion? (Select all that apply.)
Fever Stiff neck Poor feeding
During change-of-shift report, the oncoming nurse receives information about a 14-month-old infant who underwent cleft palate repair the previous day. The child is currently on a full-liquid diet from cups only. No spoons or straws are allowed in the child's mouth. In addition, the child has elbow restraints on both arms. What care should the nurse include during the course of the shift?
Finishing each meal with a drink of water
A nurse explains to the parents of a newborn with developmental dysplasia of the hip (DDH) that the infant most likely will be:
Fitted with a Pavlik harness
The mother of 10-year-old twin boys tells the nurse in the pediatric clinic that she is concerned because the boys want to spend all their time with their father. What is the best response regarding this behavior?
Gender identification is natural at this age.
A middle-aged adult contributes to future generations through parenthood, teaching, and community involvement. To which stage of Erikson's theory does this relate?
Generativity versus stagnation
What is a primary factor influencing the onset of puberty in adolescents?
Genetics
A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction?
Give acetaminophen for fever; call the health care provider if the child exhibits marked drowsiness or seizures.
A nurse is teaching a class to parents about keeping medications and household cleaning supplies out of the reach of toddlers. The nurse explains that this is necessary because toddlers:
Have a high level of oral activity
A 4-year-old child who has never been separated from parents or siblings is admitted to the hospital. What is most important for the nurse to encourage the parents to do?
Have one of them stay with the child
The parents of a 3-year-old child who has recurrent attacks of acute spasmodic laryngitis (spasmodic croup) ask the nurse why this happens to their child. The best rationale for the nurse to convey why this is a disorder of young children is that they:
Have small airways
An 8-year-old child is found to have Legg-Calvé-Perthe disease. The health care provider orders an abduction brace 23 hours a day and non-weight-bearing activity. What should the nurse teach the parents to do?
Have the child transfer to a wheelchair, using the unaffected leg
A 4-year-old boy with acute lymphocytic leukemia (ALL) is to undergo bone marrow aspiration. While involving the child in therapeutic play before the procedure the nurse should help him understand that:
He did nothing to cause his current illness
Which observation during a developmental appraisal of a 6-month-old infant is most important to the nurse in light of a diagnosis of hydrocephalus?
Head lag
A child complains of stomach pain, and the nurse suspects it is a symptom of stress. Which other signs and symptoms of stress would lead the nurse to investigate the situation further? Select all that apply.
Headache Passing urine in bed Difficulty sleeping
A child visits the pediatric clinic for a 6-week checkup after an adenoidectomy. The nurse should evaluate the child's ability to:
Hear
Which physical parameter indicates inadequate growth and development in a school-age child?
The child's leg length has decreased in comparison to height.
A parent of a 7-year-old child asks a nurse how to tell the difference between measles (rubeola) and German measles (rubella). What should the nurse tell the parent differentiates rubeola from rubella?
High fever and Koplik spots
A nurse in the pediatric unit is caring for an 8-year-old child with asthma after an exacerbation at home. The child is short of breath. In what position should the child be placed to facilitate breathing and to promote respiratory drainage?
High-Fowler
The nurse is observing a group of school-age children riding bicycles. Which actions of the children might increase their risk of injury? Select all that apply.
Hitching a ride behind a car Two people riding side by side Riding bicycles near parked cars
A nurse in the well-baby clinic determines that a 15-month-old toddler's motor development is age appropriate. Which behavior confirms this conclusion?
Holding and scribbling with a crayon
A nurse is planning care for a school-aged child experiencing respiratory acidosis. What is the sequence of events that occurs in the child's respiratory response to acidosis? Place the physiological responses in the order in which they occur.
Hyperventilation Increased CO2 elimination Decreased blood H+ ions Increased pH
A nurse in the clinic is taking the health history of a 16-year-old girl. When the nurse asks questions concerning sexual activity, the adolescent begins to perspire and hyperventilate. As her anxiety increases, she indicates that she feels dizzy and short of breath and that her heart is racing. What condition does the nurse identify?
Hyperventilation syndrome
An adolescent with type 1 diabetes who has a history of inadequate adherence to therapy is admitted to the hospital with a blood glucose level of 700 mg/dL. A continuous insulin infusion is started. What complication should the nurse make a priority of detecting while the adolescent is receiving the infusion?
Hypokalemia
A child with nephrotic syndrome visits the clinic for a follow-up visit. During the visit the parent states that the child is always tired and has no appetite. The nurse notes that the child has a muddy, pale complexion. What problem does the nurse suspect?
Impending renal failure
A 16-month-old toddler has had large, frothy, foul-smelling stools since the introduction of table foods and is irritable and apathetic. The child is diagnosed with celiac disease and a gluten-free diet is prescribed. What response does the nurse anticipate in the child after 2 days on the diet?
Improved behavior
A toddler may not be able to confirm that two glasses of water contain the same amount of liquid if one glass of water is poured into a taller, thinner vessel. What is this behavior characteristic called?
Inability to conserve
A 6-week-old infant and his mother arrive in the emergency department in an ambulance. The father arrives several minutes later with two children, 7 and 9 years old. The infant is not breathing, and the eventual diagnosis is sudden infant death syndrome (SIDS). The parents take turns holding the infant in another room. The nurse remains present and provides emotional support to the parents. What is an important short-term goal for this family?
Including the infant's siblings in the events and grieving in the wake of the infant's death
The site of choice for administration of an intramuscular (IM) medication to an infant is:
Vastus lateralis
Temperature: 98.2 °F Pulse: 96 bpm Respirations: 26 breaths/min Blood pressure: 150/90 mmHg A 7-year-old child is admitted for a diagnostic workup and is transferred from the emergency department to the pediatric unit. The nurse reviews the admission note and physical assessment. The nurse obtains the child's vital signs and talks with the parents. The parents ask the nurse why their child has severe headaches. What explanation should the nurse give for the cause of the headaches?
Increased blood pressure
An adolescent visits the allergy clinic because of seasonal environmental allergies, and blood is drawn for testing. Which laboratory finding indicates to the nurse that an allergic response is in progress?
Increased eosinophil level
A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect?
Increased hematocrit
A teenager with allergies is using oxymetazoline (Afrin) nasal spray. What effect should the nurse evaluate the client for if more than the recommended dose is taken?
Increased nasal congestion
A 3½ -year-old child with severe iron-deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit?
Increased pulse rate
A nurse is caring for a toddler with severe dehydration and its associated acid-base imbalance. What compensatory mechanism within the body is activated to counteract the effects of the child's acid-base imbalance?
Increased respiratory rate
An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify?
Increased respiratory rate
A 10-year-old child is receiving oxygen 2 L/min by way of nasal cannula. The health care provider asks that pulse oximetry be started. What is the appropriate placement for the oximetry probe in a child of this age?
Index finger
An 8-year-old girl boasts to the nurse that she got a gold star every day last week for doing all her daily chores. What is this child's developmental stage according to Erikson?
Industry vs. inferiority
An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond?
Infants' hip joints are cartilaginous, allowing molding of the acetabulum.
The parents of a 14-month-old boy with bilateral cryptorchidism ask the nurse in the pediatric clinic why it is important for him to have surgery before he is 2 years old. Before responding, the nurse takes into consideration the fact that uncorrected cryptorchidism can result in:
Infertility
What age-related fear should the nurse expect when preparing a 4-year-old child for surgery?
Intrusive procedures
A child with a diagnosis of tuberculosis is admitted to the pediatric unit. Which location should the nurse select as the best placement for the child?
Isolation room
A health care provider prescribes a tapwater enema for a 6-month-old infant with suspected Hirschsprung disease. What rationale causes the nurse to question this prescription?
It could cause a fluid and electrolyte imbalance.
A nurse in the child life center encourages preschool children to engage in role play. Why does the nurse consider this an important part of socialization?
It encourages expression of concerns.
After a discussion with the health care provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?
It is a connection between the pulmonary artery and the aorta.
While in the playroom of a pediatric unit the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. What does the nurse conclude about this behavioral interaction?
It is a typical expression of toddlers' social development.
A nurse is planning to teach the four-point alternate crutch gait to a 9-year-old child with cerebral palsy. The nurse teaches the parents that this gait was chosen because:
It provides for equal but partial weight bearing on each limb
A parent arrives in the emergency clinic with a 3-month-old baby and says, "My baby stopped breathing for a while!" The infant continues to have difficulty breathing, with prolonged periods of apnea. Which data should prompt the nurse to suspect shaken baby syndrome (SBS)?
Lack of stridor and adventitious breath sounds
A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant?
Large snap beads
A toddler is placed in a bilateral hip spica cast for the treatment of developmental dysplasia of the hip. The nurse should teach the parents to monitor their child and report to the practitioner the occurrence of:
Leg numbness
A father asks the nurse about the immunization schedule for his 15-month-old toddler, who is being treated for acute lymphoid leukemia. What vaccine is contraindicated for a child undergoing chemotherapy?
MMR (measles, mumps, rubella)
A 3-year-old child has a tentative diagnosis of pinworm infestation. What should the nurse teach the parents about obtaining a specimen to confirm the diagnosis?
Make an anal impression on cellophane tape when the child awakens.
A parent and 4-year-old child who recently emigrated from Colombia arrive at the pediatric clinic. The child has a temperature of 102° F (38.8° C), is irritable, and has a runny nose. Inspection reveals a rash and several small, red, irregularly shaped spots with blue-white centers in the mouth. What illness does the nurse suspect?
Measles
Which behaviors are observed in individuals at a conventional level of moral development? Select all that apply.
Obeying the rules Respecting authority Maintaining social order
After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. A diagnosis of intussusception is made. What is the priority nursing intervention that will help confirm the diagnosis?
Observing characteristics of stools
A 9-year-old child with type 1 diabetes is hospitalized for insulin dosage regulation. A nurse observes the child sneaking food and trying to talk family members into bringing candy. What action should the nurse take when the child complains of feeling hypoglycemic?
Obtain a blood glucose level
A 9-year-old child with type 1 diabetes has a history of erratic blood glucose readings. During a visit to the clinic the child is seen sneaking food and trying to talk the mother into providing sweets. The child complains of feeling hypoglycemic. What is the priority nursing action?
Obtaining a blood glucose level
An adolescent who was admitted to the hospital with ketoacidosis is stable and receiving Novolin R subcutaneously. One hour after its administration the nurse enters the room and notes that the adolescent is diaphoretic and irritable. What is the nurse's priority intervention?
Obtaining a blood glucose reading
A nurse is caring for an 11-year-old child with type 1 diabetes. Two hours after breakfast the child becomes pale, diaphoretic, and shaky. What action should the nurse take?
Obtaining a current blood glucose level
A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric unit. Oral rehydration therapy is instituted. What is the most accurate method of monitoring the infant's hydration status?
Obtaining daily weights
An 8-year-old child is being given insulin glargine (Lantus) before breakfast. What is the most appropriate information for the nurse to give the parents concerning a bedtime snack?
Offer a snack to prevent hypoglycemia during the night.
A nurse is caring for a 6-year-old child with a diagnosis of glomerulonephritis. The child's urine output decreases to less than100 mL/24 hr, the creatinine clearance is 60 mL/min, and there is an irregular apical pulse. A diagnosis of acute renal failure is made. Blood is drawn for testing. Which serum level requires immediate intervention?
Potassium 6.1 mEq/L
An infant with a diagnosis of heart failure is being given furosemide (Lasix) twice a day. Which laboratory value should the nurse report to the health care provider?
Potassium of 3.0 mEq/L
A parent tells a nurse at the clinic, "Each morning I offer my 24-month-old juice, and all I hear is 'No.' What should I do? I know she needs fluid!" What is the best response by the nurse?
Offer the child a choice of two juices.
A 5-year-old child is receiving dactinomycin (Cosmegen) and doxorubicin therapy after nephrectomy for Wilms tumor. What intervention should the nurse include when planning care?
Offering warm saline mouthwash
The mother of a 2-year-old child tells the nurse that she is concerned about her child's vision. What behavior when the child is tired leads the nurse to suspect strabismus?
One eye moves inward.
The nurse manager of the infection control service is teaching a class for nurses on the care of young children with viral infection-related diarrhea. What therapy should the nurse manager recommend?
Oral rehydration therapy until fluid balance is restored
A 9-month-old infant who appears well nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Freud's psychosocial theory of development, the nurse determines that the infant is in the:
Oral-sensory stage
A nurse in the pediatric clinic observes an 11-month-old boy who is sitting on his mother's lap crying and tugging at his right ear. What probable problem does this behavior indicate?
Otitis media
Which reactions does a nurse expect of a 4-year-old child in response to illness and hospitalization?
Out-of-control behavior, regression to overdependency, and fear of bodily mutilation
An adolescent is undergoing radiation for Hodgkin's lymphoma. The nurse talks with the family about the importance of:
Overwhelming fatigue and the need for rest
A nurse is caring for an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular observation cannot be performed while the cast is in place?
Pulse
A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? (Select all that apply.)
Pureed pears Pureed carrots Mashed sweet potatoes
A nurse is caring for a child with newly diagnosed acute lymphoblastic leukemia. What clinical findings does the nurse anticipate when caring for the child? (Select all that apply.)
Pallor Fatigue Multiple bruises
A nurse plans to talk to the parents of a toddler about toilet training. What should the nurse tell the parents is the most important factor in the process of toilet training?
Parents' attitude about it
The health care provider prescribes mebendazole (Vermox) for a 4-year-old child with pinworms. For which expected response to the medication does the nurse teach the parents to be alert?
Passage of worms
A school-aged child who has just arrived from Africa has been exposed to diphtheria, and a nurse in the pediatric clinic is to administer the antitoxin. Which type of immunity does the antitoxin confer?
Passive artificial
The mother of a 5-year-old child recovering from varicella (chickenpox) calls the nurse in the pediatric clinic, asking how the child's itching can be relieved. What is the best response by the nurse?
Pat the lesions while applying the prescribed calamine lotion.
During a vaccination drive at a well-child clinic, a nurse notes that a recently hired nurse is not wearing gloves while caring for an infant. What should the nurse advise the newly hired nurse to do?
Put on gloves because standard precautions are required
Elbow restraints are prescribed for an 18-month-old toddler who just had surgery for a cleft palate. The nurse explains to the parents that the restraints are used to keep the child from:
Putting fingers into the mouth
A 14-year-old adolescent is severely injured in a motor vehicle collision. There are multiple fractures, contusions, and muscle spasms, causing the teenager to refuse to move. How can the nurse best support the adolescent and encourage movement?
Permitting decision-making regarding care
A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?
Placing the prescribed as-needed warm, wet compress on the elbow
A nurse is caring for an adolescent in the postanesthesia care unit. What action should the nurse take to ensure accuracy of a pulse oximeter reading?
Placing the probe on a finger or earlobe
A toddler who was admitted in acute respiratory distress is now resting quietly. The parents tell the nurse that they must leave. What should the nurse suggest that the parents do?
Plan to visit the child as frequently as possible
What is most important to be included in the plan of care to best meet the needs of a neglected 6-month-old infant?
Provide consistent caregivers who will provide stimulation that is moderate and purposeful
What should the nurse do to meet the emotional needs of a 4-year-old child who is receiving daily injections?
Provide the child with a doll and related equipment, and observe what happens
During chemotherapy, altered nutrition is a common side effect. Knowing that compromised nutrition can contribute to an increased risk of infection and other problems, the nurse:
Provides oral supplements
A 6-week-old infant has just been found to have gastroesophageal reflux. What teaching is most important to discuss with the parents at this time?
Providing formula thickened with cereal
A 9-year-old boy is told that he must stay in the hospital for at least 2 weeks. The nurse finds him crying and unwilling to talk. What is the priority nursing care at this time?
Providing privacy to allow him to express his feelings
A 4-year-old abused child, after being hospitalized for severe injuries, is placed in temporary foster care. The foster family comes to the hospital to meet the child. What action should the nurse take to facilitate their first meeting?
Providing the child and foster family with a private room
A nurse anticipates that surgery will be needed for an 18-month-old child with undescended testes because:
Psychological damage is limited
A nurse is caring for an infant with exstrophy of the bladder. What other defect associated with this condition does the nurse expect?
Pubic bone malformation
The nurse finds a child to be unmotivated and disheartened due to dysfluency of speech. What should the nurse advise the parents to do to build the child's confidence to speaking? Select all that apply.
Resist the urge to complete the child's sentences. Listen attentively to what the child says. Speak to the child in a slow and relaxed way.
While assessing a newborn, the nurse strokes the newborn's cheek and observes for a response. What reflex does the newborn produce in response to the nurse's stimulation?
Rooting reflex
While assessing an infant, the nurse strokes the infant's cheek and the infant turns toward the nurse while making sucking sounds. What reflex did the nurse elicit?
Rooting reflex
An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. What should the nurse tell the girl that may help her wear the bracelet consistently?
Select a bracelet similar to bracelets worn by her peers
The nurse is caring for a child with cerebral palsy. After reviewing the child's medical file, the nurse finds that the child has spastic deformities. Which treatment option would the nurse expect to be beneficial in this child?
Selective dorsal rhizotomy
A nurse has just finished feeding a 4-year-old child through a nasogastric tube. In what position should the child be placed to help ensure retention of the feeding and prevent aspiration?
Semi-Fowler
A nurse is teaching a mother how to care for her toddler who is in a spica cast. In what position should the nurse suggest that the mother place the toddler during a feeding?
Semi-Fowler on a padded, adjustable tilt board
A teacher encourages a 10-year-old boy to play with his fellow students in school, but he is unable to make friends. He also has trouble completing the tasks he is given at school, so his parents try to motivate him. Which characteristics can be observed in this child due to failure at this stage of development, according to Erikson's theory? Select all that apply.
Sense of inferiority Sense of inadequacy
What should the nurse teach a mother that will best help her 2½ -year-old son learn to control his behavior?
Set limits and be consistent.
A 16-year-old girl has been admitted to the pediatric eating disorders unit with a diagnosis of anorexia and is undergoing behavioral therapy. Unit privileges are based on weight gain and have been explained to the client. What is the most appropriate intervention for the nurse to use when taking the lunch tray to the client's room?
Setting the tray down and say nothing
A nurse is preparing an infant for a lumbar puncture. In what position should the nurse hold the infant?
Side-lying with the back at the table's edge and the head flexed with the knees brought to the chin
An infant who weighed 7.5 lb at birth now weighs 15 lb at 1 year. The nurse concludes that this infant's weight gain:
Signifies an inadequate weight gain
A nurse reviews with the parents of a young infant the principles of growth and development. Place the milestones in the order of their usual achievement.
Sits momentarily without support and rolls over Waves bye-bye and sits alone Walks alone and builds a tower of two blocks Climbs stairs and drinks from a cup Draws a vertical line and walks on tiptoe
A 2-year-old child who was admitted to the hospital for further surgical repair of a clubfoot is standing in the crib, crying. The child refuses to be comforted and calls for the mother. As the nurse approaches the crib to provide morning care, the child screams louder. In light of the fact that this behavior is typical of the stage of protest, what is the most appropriate nursing intervention?
Sitting by the crib and bathing the child later when the anxiety decreases
While performing care of an infant with hypertrophic pyloric stenosis (HPS) the nurse observes visible peristaltic waves. What other sign of HPS should the nurse expect?
Small mass in the right upper quadrant
A nurse knows that play is an integral part of a child's social development. Place in order the types of play children engage in as they get older.
Solitary play Parallel play Dramatic play Peer group team play Competitive team play
A 14-year-old girl in whom scoliosis has been diagnosed undergoes spinal fusion. On the first postoperative day her face is red, she is rigid, and she is crying because she is in pain. She has prescriptions for morphine sulfate for severe pain and an acetaminophen-codeine compound for moderate pain. What information should influence the nurse's choice of analgesic?
Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic.
Which stage of moral development is indicated when a child says, "I must follow the rules; otherwise, I will be punished"?
Stage 1
Which stage of spiritual development is characterized by the child's belief that good behavior is rewarded and bad behavior is punished?
Stage 2
During a home visit, a mother reports to the nurse that her preadolescent child has been trying to avoid the family's routine religious practices such as attending church and reciting prayers. The mother also reports that her child keeps saying religion is "pointless". Which stage of development does the child belong to, according to Fowler's theory?
Stage 3
Which of Duvall's developmental stages of the family is characterized by parents adjusting to their children's peers and school influences?
Stage IV
An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting?
Start with small, frequent feedings.
A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. What is the nurse's priority intervention?
Starting an intravenous line with a large-bore catheter
The health care provider is assessing a 2-year-old child for the presence of celiac disease. For what specific signs and symptoms should the nurse be alert? (Select all that apply.)
Steatorrhea Distended abdomen Iron-deficiency anemia
An infant is born with exstrophy of the bladder. What instruction by the health care provider does the nurse expect to protect the exposed bladder until surgery is performed?
Sterile nonadherent dressings
A health care provider prescribes steroid therapy for a 4-year-old child who has nephrotic syndrome. What goal of this treatment does the nurse explain to the child's parents?
Stimulates diuresis
A 6-year-old child is admitted with an acute infection and dehydration. There is a prescription for an IV antibiotic to be piggybacked to a continuous hydration solution. During the administration of the antibiotic the child becomes restless, flushes, and begins to wheeze. Place the nursing actions in order of their priority.
Stopping the antibiotic infusion Assessing the respiratory status Maintaining the hydration infusion Notifying the practitioner
A 6-year-old child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. What is the most appropriate nursing intervention?
Stopping the bath and replacing the mask
A nursing student is selecting liquids for an 18-month-old toddler after oral surgery. Which choice by the student should cause the nurse to intervene?
Strawberry gelatin
The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections?
Structural differences between eustachian tubes of younger and older children
An adolescent who has had type 1 diabetes for 5 years stops adhering to the therapeutic regimen. In light of the client's developmental level, the nurse concludes that the behavior is a reflection of a:
Struggle for identity
A preschool child is found to have chickenpox during the acute phase. The nurse tells the parents, "It's important not to expose your child to anyone undergoing certain types of prolonged medication therapy." What medication therapy puts a person at risk?
Systemic steroid
An adolescent is admitted to the hospital in respiratory distress, and the health care provider orders oxygen at 40% by way of a Venturi mask. The instructions for the Venturi mask indicate that delivery of 4 L/min equals 24% to 28% oxygen, delivery of 8 L/min equals 35% to 40% oxygen, and 12 L/min equals 50% to 60% oxygen. Mark where the ball of the flow meter should be raised to deliver the percentage of oxygen ordered by the health care provider.
The ball of the oxygen flowmeter should be set at 8 L/min to deliver 40% oxygen through the Venturi mask.
What would be the weight of an infant by the age of 2.5 years who had a birth weight of 7 pounds? Record your answer using a whole number.___________
The birth weight doubles by 4 to 7 months of age and triples by the end of the first year. By the age of 2.5 years, the birth weight usually quadruples. Therefore, the infant who had a birth weight of 7 pounds would weigh 28 pounds by 2.5 years of age (7 x 4 = 28).
A nurse is trying to involve a hospitalized preschooler in therapeutic play. Why is this so important?
The child can work out ways of coping with fears.
According to Piaget, what behavior should the nurse expect to find in a 7-year-old child?
The child classifies and sorts facts to solve problems.
A nurse is evaluating a toddler and the family dynamics of the child's family, in which abuse is suspected. What behavior is expected? (Select all that apply.)
The child cringes when approached. The child has unexplained healed injuries. The child lies still while surveying the environment.
The nurse sees a 4-year-old girl with a webbed neck and short stature. What could be the probable finding in genetic testing?
The child has mutated chromosome 45 with XO inheritance.
After interacting with a preschooler, the nurse concludes that the child has normal development according to Fowler's spiritual development. Which behavior of the child supports the nurse's conclusion?
The child imitates the adults as they pray.
Which observations does the nurse expect in a 4-year-old child with normal growth and development? Select all that apply.
The child is able to catch a ball reliably. The child is able to throw a ball overhand. The child walks down the stairs using alternating feet.
A 2-year-old child who has been restricted to bedrest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse?
The child is trying to assert independence.
Following the assessment of a child, the nurse concludes that the child is in the conventional stage of Kohlberg's theory of moral development. Which behaviors may be evident in the child? Select all that apply.
The child maintains the expectations of the family. The child is concerned with conformity and loyalty. The child considers obeying the rules to be correct behavior.
A toddler with lead poisoning is started on chelation therapy. Succimer (Chemet) is ordered. What information should the nurse give the parents concerning the administration of this medication?
The contents of the capsules may be sprinkled on food.
Which physical findings can be observed in a 2-month-old infant? Select all that apply.
The crawling reflex disappears. The posterior fontanel is closed.
A mother introducing cereal into her infant's diet asks the nurse about the sequence she should follow when introducing new foods. What order should the nurse suggest?
Vegetables Fruits Meats Table foods
After receiving levothyroxine (Synthroid) for 3 months for congenital hypothyroidism an infant is brought to the pediatric clinic for a checkup. What does the mother tell the nurse about her baby that indicates that the drug is effective?
The infant's stools are soft.
A nurse is observing the growth and development skills of several 2-year-olds in the clinic playroom. The nurse determines that the child requiring further evaluation is the one who:
Uses echolalia when speaking
Which skill, if it cannot be performed by a 3-year-old child, should alert the nurse that the child may be developmentally delayed?
Using a spoon effectively
A nurse instructs the parents of an adolescent with asthma how to reduce the allergens in the child's bedroom. The mother tells the nurse what she plans to do to make the room hypoallergenic. Which idea indicates that further teaching is needed?
Using flat outdoor carpeting to cover hardwood floors
An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip?
Using modified techniques for feeding
A nurse is caring for a 9-year-old child who is undergoing chemotherapy to treat leukemia. What is the priority nursing action?
Using techniques to minimize risk of infection
A 2-month-old infant is to receive the second hepatitis B vaccination. What muscle should the nurse select for the injection?
Vastus lateralis
An 8-year-old child with a supracondylar fracture of the right humerus is being prepared for surgery. What clinical finding related to the fracture should the nurse report immediately?
Weak radial pulse in the right wrist
Which characteristics are observed in a preschooler? Select all that apply.
Weight gain of about 5 pounds per year Increase in height of 6.2 to 7.5 cm per year Participation in associative play with others
A 2-year-old toddler is admitted to the pediatric unit with tachycardia, tachypnea, and shortness of breath. The nurse auscultates the toddler's lungs. What term should the nurse use in the medical record to document the following sound heard during auscultation of the lungs? Listen to the audio.
Wheezes
A preschooler who is allergic to environmental pollutants is to be given a hyposensitization injection. What clinical finding prompts the nurse to withhold the injection?
Wheezing and dyspnea
A new nurse has been assigned to a school-aged child who is in contact isolation for methicillin-resistant Staphylococcus aureus (MRSA). The primary nurse observes the new nurse during morning care. Which behavior should the primary nurse address to improve isolation technique?
While changing the bed the nurse wears gloves but no gown.
The mother of a kindergartener tells the nurse that her daughter is constantly scratching behind her ears. The nurse suspects pediculosis capitis (head lice). What does the nurse expect to find during inspection?
White spots attached to the bases of hair shafts
A nurse teaches the mother of a toddler which foods are the best sources of thiamine, a B-complex vitamin. What food that is high in thiamine should the nurse include in the teaching plan?
Whole grains
Which is the most appropriate toy for a nurse to offer a 2½-year-old child?
Wooden puzzle with large pieces
A 7-year-old child must remain quietly in bed while undergoing peritoneal dialysis. What activity is most appropriate for the nurse to plan for this child?
Working multiple-piece puzzles with another child
