Exam Three silvestri practice questions
A client presents to the pediatrician's office with a temperature of 103°F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR) communication, which statements and/or questions would the nurse use in communication with the primary health care provider regarding this client's condition? Select all that apply. A. "I am concerned this client has Kawasaki's disease. Can you please come assess this client?" B. "This client is a 4-year-old male who presented to the clinic with a temperature of 103°F for the past 3 days." C. "It is most likely Kawasaki disease because it is the leading cause of acquired cardiovascular disease in the U.S." D. "I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." E. "I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."
A, b, d, e
The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate? A. Reinforce the dressing. B. Notify the registered nurse (RN). C. Document the findings and continue to monitor. D. Circle the area of drainage and continue to monitor.
B. Notify the registered nurse (RN).
The nurse is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse would would instruct the mother to do which? A. Use aspirin for pain relief. B. Pad crib rails and table corners. C. Use a soft toothbrush for dental hygiene. D. Use a generous amount of lubricant when taking a temperature rectally.
B. Pad crib rails and table corners.
The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic, and the oxygen saturation reading drops to 60%. The nurse would perform which action first? A. Assist to administer morphine sulfate. B. Place the child in a knee-chest position. C. Administer 100% oxygen by face mask. D.Prepare to administer intravenous fluids.
B. Place the child in a knee-chest position.
A nursing student is asked to discuss the pathophysiology related to childhood leukemia during a clinical conference and reviews the planned presentation with the nursing instructor. The nursing instructor advises the student to review the disorder before the clinical conference if the student states that which is associated with this type of cancer? A. The reticuloendothelial system is affected. B. Reed-Sternberg cells are found on biopsy. C. Normal bone marrow is replaced by blast cells. D. Red blood cells (RBCs) and platelet production become affected.
B. Reed-Sternberg cells are found on biopsy.
The nurse is caring for a child who is receiving chemotherapy for treatment of leukemia and prepares to address which expected needs of this client? Select all that apply. a. Fatigue b. Easy bruising c. Increased appetite d. Possible infections e. Excessive hair growth
A,b, d
A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and would question which intervention that is written in the plan? A. Palpate the abdomen for a mass. B. Check the urine for the presence of hematuria. C. Monitor the blood pressure for the presence of hypertension. D. Monitor the temperature for the presence of a kidney infection.
A. Palpate the abdomen for a mass.
The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis? A. Chest x-ray B. Blood cultures C. Echocardiogram D. Transesophageal echocardiography
B. Blood cultures
The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement by the nurse most accurately describes Kawasaki disease? A. It is an acquired cell-mediated immunodeficiency disorder. B. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue. C. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. D. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.
C. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.
The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching? A. "I will supervise my child closely." B. "I will pad the corners of the furniture." C. "I will remove household items that can easily fall over." D. "I will avoid immunizations and dental hygiene treatments for my child."
D. "I will avoid immunizations and dental hygiene treatments for my child."
A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder? A. Pain b. Diarrhea c. Bradycardia d. Blurred vision Submit
a. pain
The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching? A. The mother administered the iron with milk. B. The mother administered the iron with water. C. The mother administered the iron with apple juice. D. The mother administered the iron with orange juice.
A. The mother administered the iron with milk.
The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study would assist in confirming the diagnosis of RF? A. Immunoglobulin B. Red blood cell count C. Antistreptolysin O titer D. White blood cell count Submit
C. Antistreptolysin O titer
The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply. A. Our child will eventually grow out of this condition. B. It is likely our child will suffer from a failure to thrive. C. It is not necessary to avoid individuals with the common cold. D. It is vital that we keep track of how much our baby eats and any episodes of diarrhea. E. When our baby has difficulty breathing and turns blue, we should hold the baby in the knee-chest position.
A, C
A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of which condition? A. Peripheral hypoxia b. Chronic hypertension c. Delayed physical growth d. Destruction of bone marrow Submit
A. peripheral hypoxia
A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure? A.Assess for any bleeding on the dressing. b. Position the child's leg so that it is straight. c. Assess the strength and presence of the distal pulses. d. Take the vital signs including blood pressure and oxygen saturation.
A.Assess for any bleeding on the dressing.
The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted? A. Cracked lips B. A normal appearance C. Conjunctival hyperemia D. Desquamation of the skin
C. Conjunctival hyperemia
The nurse is reinforcing instructions to the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction would the nurse provide the mother? A. Administer the iron at mealtimes. B. Administer the iron through a straw. C. Mix the iron with cereal to administer. D. Add the iron to food for easy administration.
B. Administer the iron through a straw.
The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L). Which nursing intervention would be incorporated into the plan of care? A. Encourage naps. B. Encourage a diet high in iron. C. Encourage quiet play activities. D. Maintain strict isolation precautions
C. Encourage a quiet play activities
The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. Which action should the nurse take? A. Call a code. b. Place the infant in a prone position. c. Place the infant in a knee-chest position. d. Contact the respiratory therapy department.
c. Place the infant in a knee-chest position.
The nurse is assigned to care for a child with a diagnosis of Wilms' tumor. The child's mother asks the nurse what kind of tumor this is. What is the best response by the nurse? A. A renal tumor b. A nephroblastoma c. An abdominal tumor d. A common childhood tumor
b. A nephroblastoma
A preliminary diagnosis is made for a child with acute lymphoblastic leukemia (ALL). In reviewing the complete blood cell count (CBC) of the child, the nurse would expect to find which? A. A hematocrit count of 36 cells in 1 mL of peripheral blood b. A hemoglobin count of 12 cells in 1 mL of peripheral blood c. A white blood cell (WBC) count of 11,000 cells in 1 mL of peripheral blood d. An erythrocyte (red blood cell) count of 2 cells in 1 mL of peripheral blood
d. An erythrocyte (red blood cell) count of 2 cells in 1 mL of peripheral blood
The nurse is caring for an infant with congenital heart disease. Which signs, if noted in the infant, would alert the nurse to the early development of heart failure (HF)? A. Pallor b. Strong sucking reflex c. Slow and shallow breathing d. Diaphoresis during feeding
d. Diaphoresis during feeding
A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply. a. Restrict all visitors. b. Place the child on a low-bacteria diet. c. Change dressings using sterile technique. d. Encourage the consumption of fresh fruits and vegetables. e. Perform meticulous hand washing before caring for the child. f. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water.
C, D, E
The nurse monitors a 5-year-old child admitted to the hospital for neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply. A. Respiratory impairment B. Anorexia and weight loss C. Pallor, weakness, irritability D. Supraorbital ecchymosis and periorbital edema E. Firm, nontender, irregular mass in the abdomen F. Urinary frequency or retention from compression on the bladder
E, F
The nurse and a mother are discussing care of her child's iron deficiency anemia. The nurse would suggest including which foods in the child's diet that are highest in iron? Select all that apply. a. Spinach b. Apricots c. Raisins d. Egg whites e. Whole milk
a, b, c
The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than which value? a. 20,000 mm3 b. 100,000 mm3 c. 120,000 mm3 d. 150,000 mm3
a. 20,000 mm3
The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse? A. Bradypnea B. Diaphoresis C. Decreased blood pressure (BP) D. A weight gain of 1 lb in 1 day
D. A weight gain of 1 lb in 1 day
A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The primary health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse would expect which blood pressure readings in the child's legs and arms? A. Increased in the arms and the legs b. Decreased in the arms and the legs c. Decreased in the legs and increased in the arms d. Increased in the legs and decreased in the arms
c. Decreased in the legs and increased in the arms
A primary health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation would the nurse administer the oxygen to the child? A. When the child is sleeping B. When changing the child's diapers C. When the mother is holding the child D. When drawing blood for electrolyte levels
D. When drawing blood for electrolyte levels
The nurse reinforces home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further teaching? A. "I'm going to take a painting class." b. "I've learned to knit and sew my own clothes." c. "When I'm feeling better, I'm returning to the soccer team." d. I'm using a schedule to maintain my increased fluid intake.
c. "When I'm feeling better, I'm returning to the soccer team."
Laboratory studies are performed on a child suspected of iron deficiency anemia. The nurse reviews the laboratory results, knowing that which finding indicates this type of anemia? A. decreased reticulocyte count b. An elevated red blood cell (RBC) count c. RBCs that are microcytic and hypochromic d. An elevated hemoglobin level with a low hematocrit level
c. RBCs that are microcytic and hypochromic
The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding would the nurse expect to note in this child? A.Bradycardia B. Tachycardia c. Hyperactivity d. A reddened appearance to the cheeks
B. Tachycardia
The nurse is caring for a child with a platelet disorder and would expect which prescriptions from the primary health care provider? Select all that apply. a. Observe for bleeding. b. Encourage the child to rest. c. Aspirin 325 mg orally as needed for pain d. Provide a hard toothbrush for mouth care. e. Assist the registered nurse (RN) with blood transfusions.
A, b, e,
A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions would the nurse reinforce to prevent another crisis from occurring? Select all that apply. A. Drink plenty of fluids. b. Avoid foods high in folic acid. c. Report a sore throat immediately. d. Use cold packs to relieve joint pain. e. Restrict all activity to quiet board games. f. Wash hands before meals and after playing.
A, C, F
A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, would offer which items during an episode of nausea? A. Low-calorie foods B. Cool, clear liquids C. Low-protein foods D. The child's favorite foods
B. Cool, clear liquids
The nurse is caring for a child with heart failure and provides instructions to the mother regarding the procedure for administration of the prescribed digoxin. Which statement by the mother indicates a need for further teaching? A. "I can mix the medication with food." b. "If more than one dose is missed, I need to call the cardiologist." c. "I need to take the child's pulse before administering the medication." d. "If the child vomits after the medication is given, I should not repeat the dose."
A. "I can mix the medication with food."
The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching? A. "I know that my child will outgrow this problem; just give him time." B. "I know that I need to be alert for signs of heart failure with this defect until it is repaired." C. "The doctors tell me that my child has a heart murmur caused by the ductus not closing after birth." D. "As I understand it, my child may have to have his defect closed, either during a catheterization or by surgery."
A. "I know that my child will outgrow this problem; just give him time."
A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse about radiation therapy because it was not prescribed as a part of treatment. Which is the most appropriate response to the mother? A. "The child is too young to have radiation therapy." B. "It's very costly, and chemotherapy works just as well." C. "I'm not sure. I'll discuss it with the primary health care provider." D. "The primary health care provider would prefer that you discuss treatment options with the oncologist."
A. "The child is too young to have radiation therapy."
Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron in which way? A. Between meals b. Just after a meal c. Just before a meal d. With a fruit low in vitamin C
A. Between meals
The nurse has reviewed the primary health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to do which? A. Collect a 24-hour urine sample. b. Perform a neurological assessment. c. Assist with a bone marrow aspiration. d. Send the child to the radiology department for a chest x-ray.
A. Collect a 24-hour urine sample.
The nurse is reviewing the primary health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid is prescribed for the child. Which nursing action is appropriate? A. Consult with the registered nurse to verify the prescription. b. Administer the acetylsalicylic acid if the child's temperature is elevated. c. Administer the acetylsalicylic acid if the child experiences any joint pain. d. Administer acetaminophen instead of the acetylsalicylic acid for temperature elevation.
A. Consult with the registered nurse to verify the prescription.
The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse would observe for which early signs of HF? Select all that apply. A. Cough B. Irritability C. Scalp diaphoresis D. Tachypnea, tachycardia E. Slow and shallow breathing
B. C. D
The nurse is reviewing a primary health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription would the nurse anticipate being part of the treatment plan? A. Digoxin B. Heparin infusion C. Morphine sulfate D. Immune globulin
D. Immune globulin
A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease? A. Platelet count B. Hematocrit level C. Hemoglobin level D. Reticulocyte count
D. Reticulocyte count
The licensed practical nurse (LPN) is assisting in the admission of a child with suspected sickle cell crisis because of which signs/symptoms noted in this client? Select all that apply. A. Swollen knee joint b. Temperature, 97.3° F c. Pulse, 120 beats per minute d. Peripheral oxygen level of 89% e. Pain rated as a 6 on a scale of 1 to 10
a, c, d, e,
A nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which statement by the student indicates a need for further research? a. Males inherit hemophilia from their fathers. b. Females inherit the carrier status from their fathers. c. Hemophilia A results from deficiency of factor VIII. d. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome.
a. Males inherit hemophilia from their fathers.
The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse assists in developing a plan of care for the child and suggests including which intervention in the plan of care? A. Monitor the temperature for hypothermia. b. Monitor the blood pressure for hypotension. c. Inspect the urine for the presence of hematuria at each voiding. d. Palpate the abdomen for an increase in the size of the tumor every 8 hours.
c. Inspect the urine for the presence of hematuria at each voiding.
The nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis? A. Blindness b. Strabismus c. Cat's-eye reflex d. Red, painful eye
c. cat's-eye reflex
The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis would the nurse anticipate? A. Pallor B. Hyperactivity C. Exercise intolerance D. Gastrointestinal disturbances
C. exercise intolerance
The nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for which signs A. Bleeding b. Failure to thrive c. Heart failure (HF) d. Decreased tolerance to stimulation Submit
C. heart failure (HF)
The pediatric nursing instructor asks a nursing student to describe the cause of the symptoms that occur in sickle cell disease. Which is the correct response by the nursing student? A. "Bone marrow depression occurs because of the development of sickled cells." B. "Sickled cells increase the blood flow through the body and cause a great deal of pain." C. "The sickled cells mix with the unsickled cells and cause the immune system to become depressed." D. "Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow."
D. "Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow."
A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action? a. Weighing the diapers b. Monitoring the intake closely c. Comparing the intake with the output d. Asking the primary health care provider for permission to insert a Foley catheter
a. Weighing the diapers
The nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which item would the nurse place at the bedside in preparation for the child's return from surgery? a. A cooling blanket b. A suction machine c. Skeletal traction equipment d. Protective isolation equipment
a. a cooling blanket
A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority concern is infection due to immunosuppression. Which interventions would the nurse include in the plan of care? A. Monitor vital signs once a shift. b. Perform oral hygiene 4 times a day. c. Inspect the child's mouth daily for mouth ulcers. d. Administer acetaminophen suppositories for increased temperature.
b. Perform oral hygiene 4 times a day.
The nurse is caring for a child with osteosarcoma following amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. Which action would the nurse take? a. Request a referral for a psychiatric consultation. b. Reassure the child that this is a temporary condition. c. Tell the child that the prosthesis will relieve this sensation. d. Ask the pediatrician for a prescription for a placebo.
b. Reassure the child that this is a temporary condition.
A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which characteristic of this disease? a. Increased platelet count b. Increased hematocrit count c. Increased reticulocyte count d. increased hemoglobin count
c. Increased reticulocyte count
The nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 mm3, and the platelet count is 150,000 mm3. Which nursing intervention would the nurse incorporate into the plan of care? a. Avoid unnecessary injections. b. Encourage quiet play activities. c. Maintain strict isolation precautions. d. Encourage the child to use a soft toothbrush.
c. Maintain strict isolation precautions.
A nursing instructor asks a student nurse assigned to care for an infant with a diagnosis of tricuspid atresia to describe the infant's disorder. Which statement by the student indicates the need to further research this disorder? A. "The infant has a single vessel that overrides both ventricles of the heart." B. "This disorder causes frequent episodes of hypercyanotic spells." C. "The disorder means there is no communication from the right atrium to the right ventricle of the heart." D. "The disorder means there is no communication from the systemic and pulmonary circulations of the heart." Submit
C. "The disorder means there is no communication from the right atrium to the right ventricle of the heart."
A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse would prepare for which diagnostic study that can confirm this diagnosis? A. A platelet count B. A lumbar puncture C. A bone marrow biopsy D. A white blood cell (WBC) count
C. A bone marrow biopsy
The nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity would the nurse suggest that the child can safely participate in with peers? A. Soccer B. Basketball C. Swimming D. Field hockey
C. Swimming
The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching? A. "I will not mix the medication with food." B. "If more than one dose is missed, I will call the doctor" C. "I will take my child's pulse before administering the medication." D. "If my child vomits after medication administration, I will repeat the dose."
D. "If my child vomits after medication administration, I will repeat the dose."
The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need for further teaching? A. "The femur is the most common site of this sarcoma." B. "The child does not experience pain at the primary tumor site." C. "If a weight-bearing limb is affected, then limping is a clinical manifestation." D. "The symptoms of the disease during the early stage are almost always attributed to normal growing pains."
B. "The child does not experience pain at the primary tumor site."
The nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse monitors the child for central nervous system (CNS) involvement by checking which response? A. Pupillary reaction B. Level of consciousness (LOC) C. The presence of petechiae in the sclera D. Color, motion, and sensation of the extremities
B. Level of consciousness (LOC)
A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor would the nurse expect to find documented in the child's record? A. Positive Babinski's sign B. The presence of blast cells in the bone marrow C. Projectile vomiting occurring often in the morning D. Elevated vanillylmandelic acid (VMA) levels in the urine
D. Elevated vanillylmandelic acid (VMA) levels in the urine
The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching? A. Stress B. Trauma C. Infection D. Fluid overload
D. Fluid overload
The nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, the nurse would distinguish which attribute of normal adolescents from an adolescent with depression? A. Adolescents are moody and act out a lot. B. Adolescents self-reflect, so withdrawal is normal. C. Adolescents like to stay up late but rarely have insomnia. D. Adolescents like the unkempt look and are not concerned about their appearance.
C. Adolescents like to stay up late but rarely have insomnia.
The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child? A. "Has the child been vomiting?" b. "Has the child had any diarrhea?" c. "Does the child complain of chest pain?" d. "Has the child complained of a sore throat within the past few months?"
d. "Has the child complained of a sore throat within the past few months?"
A 12-year-old child is seen in the clinic, and a diagnosis of Hodgkin's disease is suspected. Several diagnostic studies are performed to determine the presence of this disease. When evaluating the diagnostic results, the nurse would expect to note which evidence if this child has Hodgkin's disease? A. Elevated creatinine level B. The presence of Epstein-Barr virus C. The presence of Reed-Sternberg cells D. The presence of blast cells in the bone marrow
C. The presence of Reed-Sternberg cells
The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question would the nurse ask the family to elicit information specific to the development of RF? A. "Has the child complained of back pain?" B. "Has the child complained of headaches?" C. "Has the child had any nausea or vomiting?" D. "Has the child had a sore throat or a fever within the past 2 months?"
D. "Has the child had a sore throat or a fever within the past 2 months?"
The nurse is caring for a mother and her infant who was born 12 hours ago. Which statements made by the mother would prompt the nurse to have the baby evaluated for early heart failure? Select all that apply. A. "My baby's cheeks turn red when he cries." b. "I'm chilly, but my baby's forehead is sweaty." c. "My baby doesn't seem to have any difficulty breathing." d. "I can feel my baby's heart rate when he's sleeping; it seems much faster than it did yesterday." e. "My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."
B, d, e
The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching? A. "I need to use proper hand-washing techniques." B. "I need to take my child's rectal temperature daily." C. "I need to inspect my child's skin daily for redness." D. "I need to inspect my child's mouth daily for lesions."
B. "I need to take my child's rectal temperature daily."
The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching? A. "A balance of rest and exercise is important." B. "I can apply lotion or powder to the incision if it is itchy." C. "Activities during which the child could fall need to be avoided for 2 to 4 weeks." D. "Large crowds of people need to be avoided for at least 2 weeks after this surgery."
B. "I can apply lotion or powder to the incision if it its itchy."
The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching? A. "I need to watch for diarrhea, so my child does not get dehydrated." B. "I think that once my child's hair starts to fall out that I can keep a hat on him." C. "I understand that the radiation will cause nausea and vomiting and I need to keep my child hydrated." D. "I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."
D. "I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."
The nursing instructor assigns a student nurse to present a clinical conference to the student group about brain tumors in children. Which statement by the student is accurate about brain tumors in children? A. The common site of metastasis is the kidneys. b. The significant symptoms are headaches and morning vomiting. c. Head shaving is no longer required before removal of the brain tumor. d. Surgery is not normally performed because of the risk of functional deficits occurring as a result of the surgery.
b. The significant symptoms are headaches and morning vomiting.
The nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which is the priority concern? A. Bleeding b. Infection c. Social isolation d. Sensory alterations
b. infection
The parents of a child with sickle cell disease ask the nurse why their child is always anemic. What is the best response by the nurse? a. "There is no cure, or specific treatment for sickle cell anemia." b. "The anemia from sickle cell disease can be managed with diet." c. "When you give your child folic acid regularly, this treats the anemia." d. "The sickle cells are very fragile and break easily, which leads to anemia."
d. "The sickle cells are very fragile and break easily, which leads to anemia."
The nurse is explaining causes and reasons of hemophilia A to the parents of a child with the disease. The nurse would make which statement about hemophilia A? A. "Hemophilia A is a Y-linked hereditary disorder." B."Hemophilia A results from a deficiency of factor IX." C. "Hemophilia A results from deficiency of factor VIII." D. "Hemophilia A is always inherited in a recessive manner."
C. "Hemophilia A results from deficiency of factor VIII."
