Exam 1-Peds
A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? Select all that apply. 1. Difficulty consoling 2. Underdevelopment for age 3. Thumb-sucking 4. Bedwetting 5. Demands for physical closeness
Abused children may be difficult to console because they have not had positive past interpersonal experiences. Failure to thrive is often seen in abused children. It results from emotional stress, as well as from neglect of physical needs. The task of nighttime bladder training may not be completed until 4 or 5 years of age, and sometimes even later. Thumb-sucking is not noteworthy because many children, not just those who are abused, continue to suck their thumbs for several years. Abused children do not seek physical closeness because their needs for comfort have not been met in the past.
An adolescent is accompanied by the mother for an annual physical examination. The nurse is aware of privacy issues related to the adolescent. While the mother is in the room, the nurse should avoid which questions? Select all that apply. 1. Sexual activity 2. Cigarette smoking 3. School performance 4. Use of alcohol 5. Car seatbelt use
The nurse must maintain the nurse—client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. The nurse can ask general questions about seatbelt use and academic performance without breaching confidentiality.
Which pain scale should a nurse use to measure the intensity of pain in toddlers? 1. FACES scale 2. Visual analogue scale 3. Numerical rating scale 4. Verbal descriptor scale
The nurse should use a FACES scale to measure the intensity of painLinks to an external site. in children. The scale consists of six cartoon faces ranging from a smiling face ("no hurt") to increasingly less happy faces and finally to a sad, tearful face ("hurts worst"). The visual analogue scale, numerical rating scale, and verbal descriptor scale can be used in young children and adults.
Which major gross motor development skills would the nurse expect to see demonstrated during a teaching session with parents of a 12-month old client who is entering the toddler stage of development? 1.Walking alone 2.Drawing a stick figure person 3.Showing interest in cooperative play 4.Beginning to develop object permanence
A major gross motor development the nurse should include in the teaching session with the parents of a 12-month old client is walking alone. Drawing a stick figure person is a fine motor skill that is not developed until the preschool stage of development. Showing interest in cooperative play does not occur until late in the preschool stage of development. Object permanence occurs during infancy.
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 healthcare provider will order a skeletal survey. Why is a skeletal survey the preferred diagnostic tool? 1. The skeletal history of the current fracture and any previous healing or healed fractures are identified. 2. It is the first step toward a complete assessment before computed tomography and magnetic resonance imaging are done. 3. Three separate x-ray films of the leg and hip should be ordered, making it more cost-effective. 4. The exact location and extent of the fracture will be pinpointed.
Abusive parents may "shop" for hospitals that do not have a previous record of their child; the skeletal survey will provide a revealing injury historyLinks to an external site. if abuse has occurred. Pinpointing the exact location of a fracture is necessary to plan appropriate treatment and can be done with a single x-ray film of the area; a skeletal survey is more extensive and helpful when abuse is suspected. Cost-effectiveness is not the primary concern if abuse is suspected. Computed tomography and magnetic resonance imaging are not required unless internal injuries are suspected.
A nurse in the pediatric clinic is assessing an 8-year-old child who has had asthma since infancy. What clinical finding requires immediate intervention? 1.Audible wheezing 2.Barrel chest 3.Heart rate of 105 beats/min 4.Respiratory rate of 30 breaths/min
Audible wheezing that is heard without a stethoscope is an indication that the airways are significantly compromised, and this requires immediate medical intervention. Barrel chest is a sign of chronic asthma. Repeated attacks result in a fixed hyperaerated thoracic cavity; this clinical finding does not require intervention. A heart rate of 105 beats/min is expected in an 8-year-old child, as is a respiratory rate of 30 breaths/min
A nurse manager is providing a class on cystic fibrosis for the pediatric staff nurses. Physiologic adaptations to cystic fibrosis are a result of which problem? 1. Pathology of mucus-secreting glands 2. Dysfunction of sweat glands 3. Inactivity of respiratory tract cilia 4. Overproduction of endocrine gland activity
Cystic fibrosis is a genetic disorder affecting all mucus-secreting (exocrine) glandsLinks to an external site.. A sweat gland abnormality is not involved in cystic fibrosis; children with cystic fibrosis lose excessive amounts of sodium through perspiration caused by exocrine gland dysfunction. Cilia action may be influenced by the thickened secretions, but the cilia are not affected by cystic fibrosis. Exocrine, not endocrine, glands are involved in cystic fibrosis.
The nurse, talking with the parents of a toddler who is struggling with toilet training, reassures them that their child is demonstrating a typical developmental stage. According to Erikson, which developmental stage will the nurse document in the medical record for this toddler? 1.Autonomy versus shame and doubt 2.Trust versus mistrust 3.Initiative versus guilt 4.Industry versus inferiority
Erikson's stage of "autonomy versus shame and doubt" marks a period of time when the toddler is trying to gain some independence while still wanting to please adults.
A nurse is performing a respiratory assessment of an 8-month-old child with the diagnosis of viral pneumonia. The nurse identifies bronchial breath sounds over areas of consolidation, mild substernal retractions, profuse mucus production, pallor, and a temperature of 102° F (38.9° C). What is the priority nursing action? 1. Suctioning the nasopharynx so a patent airway can be maintained 2. Starting an intravenous infusion to provide necessary fluids and electrolytes 3. Calling the respiratory therapist to start preparations for oxygen administration 4. Notifying the practitioner of the fever so a prescription for an antipyretic can be issued
Establishment and maintenance of a patent airway is always the priority. This intervention follows the ABCs (airway, breathing, circulation) of emergency care. An intravenous infusion will likely be started; however, this is not essential right away. The practitioner, not the respiratory therapist, should be asked for a prescription to begin oxygen administration; this action is not the priority. Taking the time to obtain a prescription for an antipyretic will delay attention to the immediate problem of respiratory distress.
An infant with bronchiolitis caused by respiratory syncytial virus (RSV) is admitted to the pediatric unit. What does the nurse expect the prescribed treatment to include? 1. Humidified cool air and adequate hydration 2. Postural drainage and oxygen by hood 3. Bronchodilators and cough suppressants 4. Corticosteroids and broad-spectrum antibiotics
Humidified cool air and hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective with this disorder; oxygen is used only if the infant has severe dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spasm; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.
The nurse instructs parents to avoid placing their infant in a prone position while sleeping. Which risk does the nurse seek to prevent with this instruction? 1. Sudden infant death syndrome 2. Otitis media of the ear 3. Conjunctivitis of the eye 4. Infantile colic or baby colic
Infants should be placed on their backs while sleeping to prevent sudden infant death syndrome. Sleeping in the prone position can cause respiratory depression and death in infants. Otitis media does not result from sleeping in the prone position. The nurse instructs the parents about proper eye hygiene to prevent conjunctivitis. Infantile colic or baby colic is not caused by placing the infant in the prone position.
What assessment finding in a newborn is suggestive of cystic fibrosis? 1. Abdominal distention 2. Rapid heart rate 3. Excessive crying 4. Sternal retractions
Meconium ileus is an indication that a newborn may have cystic fibrosisLinks to an external site.. The small intestine is blocked with thick, tenacious, mucilaginous meconium, usually near the ileocecal valve. This causes intestinal obstruction with abdominal distention, vomiting, and fluid and electrolyte imbalance. Rapid heart rate is not a sign of cystic fibrosis in the newborn. Excessive crying does not have special significance in cystic fibrosis. Sternal retractions are not a sign of cystic fibrosis in the newborn.
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? 1. Maintain standard and contact precautions. 2. Place in a warm, dry environment. 3. Administer prescribed antibiotic immediately. 4. Allow parents and siblings to room in with the infant.
RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mask or in a croup tent. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant. Antibiotics are not effective against RSV, and their use is contraindicated.
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. 1. Instilling saline nose drops 2. Limiting fluid intake 3. Maintaining contact precautions 4. Administering warm humidified oxygen 5. Suctioning mucus with a bulb syringe
Saline nose dropsLinks to an external site. help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. The humidified oxygen should be cool. It relieves the dyspnea and hypoxia that is prevalent in infants with RSV.
The nurse educates the parents of a toddler-age client regarding play and toys appropriate for this stage of development. Which parental responses indicate correct understanding of the information presented? Select all that apply. 1. We should expect our child to participate in parallel play." 2."We should provide our child with finger paints to foster creativity." 3."We should allow our child to watch as much television as she wants." 4."We should provide our child with toys that foster her imagination, such as a doll." 5."We should provide our child with toys so that we are able to finish household chores."
The toddler-age client should participate in parallel play, use finger paints to foster creativity, and play with dolls to foster imagination. The toddler-age client should not be allowed to watch as much television as he wants. The toddler-age child should not be provided toys as a substitute for interaction with parents.
Several hours after admission of a child to the pediatric unit with laryngotracheobronchitis (viral croup), the nurse determines that tachypnea and tachycardia, accompanied by intercostal and substernal retractions and increased restlessness, have developed. What is the priority nursing action? 1. Reporting the respiratory status to the practitioner 2. Suctioning secretions from the trachea 3. Dislodging mucus by striking the back 4. Increasing the concentration of oxygen being delivered
These are signs of increasing hypoxia; intubation may be necessary to maintain an open airway. The signs are not indicative of increased secretions; suctioning could precipitate sudden laryngospasm. Striking the back is ineffective against laryngeal spasms. The inflammation is preventing the oxygen from reaching the lungs; increasing the amount of oxygen will not be effective until the inflammation is reduced.
The parents of an 8-year-old state that their son seems very interested in trying new activities. When the parents ask for suggested activities for this age child, the nurse recommends scouts as an activity that will foster growth and development. In which stage of Erikson's "psychosocial stages of development" is this child? 1. Industry versus inferiority 2. Trust versus mistrust 3. Initiative versus guilt 4. Identity versus role confusion
Trust versus mistrust (birth to 1 year)—The task of the first year of life is to establish trust in the people providing care. Trust is fostered by provision of food, clean clothing, touch, and comfort. If basic needs are not met, the infant will eventually learn to mistrust others. Initiative versus guilt (3 to 6 years)—The young child initiates new activities and considers new ideas. This interest in exploring the world creates a child who is involved and busy. Constant criticism, on the other hand, leads to feelings of guilt and a lack of purpose. Identity versus role confusion (12 to 18 years)—In adolescence, as the body matures and thought processes become more complex, a new sense of identity or self is established. The self, family, peer group, and community are all examined and redefined. The adolescent who is unable to establish a meaningful definition of self will experience confusion in one or more roles of life. Industry versus inferiority (6 to 12 years)—The middle years of childhood are characterized by development of new interests and by involvement in activities. The child takes pride in accomplishments in sports, school, home, and community. If the child cannot accomplish what is expected, however, the result will be a sense of inferiority.
Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) 1. Steatorrhea 2. Obesity 3. Foul-smelling stools 4. Delayed growth 5. Pulmonary congestion
Weight loss, not weight gain, is associated with cystic fibrosis. The other answers are all common assessment findings in the client with cystic fibrosis.
The nurse is providing care to an infant who is diagnosed with bronchiolitis. Which breath sounds indicate the infant is experiencing respiratory distress? Select all that apply. 1. Wheezing 2. Grunting 3. Retractions 4. Tachypnea
Wheezing and grunting are adventitious respiratory sounds that indicate respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachypnea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound.
Which nursing actions are developmentally appropriate when caring for a hospitalized preschool-age child? Select all that apply. 1. Using toys for distraction during a painful procedure 2.Providing brochures regarding home care options 3. Offering medical equipment to play with prior to a procedure 4. Providing clear instructions about details of a procedure that will occur near discharge
When providing care to a preschool-age client who is hospitalized, the nurse should use toys for distraction during a painful procedure and offer medical equipment for the client to play with prior to a procedure. Brochures are not an age-appropriate teaching strategy for the preschool-age client. Knocking on the door prior to entering the room is a hospital policy and not developmentally appropriate care. Instructions for any procedure should be provided just prior to initiation when caring for a preschool-age client.
