Final Peds

The nurse cares for the child with suspected bacterial meningitis. Which action should the nurse take first? 1. Determine if the child has received the Haemophilus influenza type B and pneumococcal conjugate vaccines 2. Decrease environmental stimuli 3. Place the child on droplet precautions 4. Assess the child's level of pain

3. Place the child on droplet precautions

A school aged client diagnosed with cystic fibrosis returns to school following a hospitalization. Which nursing diagnosis is appropriate for this client? SATA a. Imbalanced nutrition: more than body requirements related to school food b. Noncompliance related to desire not to take medication at school c. Risk for delayed development related to disease process d. Risk for activity intolerance related to decreased air exchange e. Decreased cardiac output related to disease process and activity level f. Risk for impaired gas exchange related to pulmonary changes

- Risk for delayed development related to disease process - Risk for activity intolerance related to decreased air exchange -Risk for impaired gas exchange related to pulmonary changes -Noncompliance related to desire not to take medication at school

A client diagnosed with asthma asks the nurse how to prevent attacks. Which information does the nurse give the client? SATA a. Cover the nose and mouth with scarf or mask when in cold air b. Use inhalers at the first sign of an asthma attack c. Check the peak flow using a meter several times everyday d. Avoid environmental triggers that are most likely to cause attacks e. Learn purse lip breathing when symptoms begin f. Treat upper respiratory infections promptly

-Avoid environmental triggers that are most likely to cause attacks -Treat upper respiratory infections promptly -Cover the nose and mouth with scarf or mask when in cold air -Use inhalers at the first sign of an asthma attack

The adolescent comes to the clinic because of reoccurring headaches. Which questions does the nurse ask to determine the type of headache? SATA a. Do you participate in any sports? b. Do you have any nausea or vomiting? c. How long do the headaches last? d. How often do the headaches occur? e. Where does your head hurt? f. How much sleep are you getting at night?

-Do you participate in any sports? b. Do you have any nausea or vomiting? c. How long do the headaches last? d. How often do the headaches occur? e. Where does your head hurt?

The 2-year-old child is diagnosed with a congenital heart defect. The child undergoes an echocardiogram to observe for changes in the heart. Which nursing diagnosis is most appropriate for this child during the procedure? a. Noncompliance related to need to lie quietly b. Impaired gas exchange related to possible heart changes c. Risk for trauma related to diagnostic procedure d. Decreased cardiac output related to heart attack

-Noncompliance related to need to lie quietly - Impaired gas exchange related to possible heart changes

The parent asks the nurse how to tell if the 2-year-old has an ear infection. Which responses does the nurse give? SATA a. Usually the client will tell you the ear hurts b. There will be a temperature of over 103 if there is an ear infection c. Your child may pull on the ear and say it hurts when asked d. If you think the child has an ear infection, make a clinic appointment e. Your child will be fussy, may refuse to eat, and cry f. Tell me what you know about ear infections

-Your child may pull on the ear and say it hurts when asked -Your child will be fussy, may refuse to eat, and cry -Tell me what you know about ear infections -There will be a temperature of over 103 if there is an ear infection

The nurse instructs the parents of the 4-year-old diagnosed with grade II vesicoureteral reflux. It is most important for the nurse to include which statement in discharge teaching? 1. Your child will be receiving a continuous low dose antibacterial. 2. Your child should have no reoccurrence if you comply with treatment. 3. Do not allow your child to play sports. 4. Encourage your child to void frequently.

1. Your child will be receiving a continuous low dose antibacterial.

The student nurse prepares to discuss cardiac defects that cause increased pulmonary blood flow. The nurse identifies which cardiac defect increases pulmonary blood flow? 1. Atrial septal defect. 2. Tetralogy of below. 3. Coarctation of the aorta. 4. Tricuspid atresia

1. Atrial septal defect.

The school nurse plans scoliosis screening for a class of fifth graders. Which is the correct screening procedure for scoliosis? 1. Instruct the child to bend forward from the waist. 2. Observe the back for a small dimple containing a tuft of hair 3. Ask the child to sit up from a prone position. 4. Flex the child's neck

1. Instruct the child to bend forward from the waist.

The nurse admits a child diagnosed with hemophilia A. It is most important for the nurse to assess for which symptom? 1. Joint pain. 2. Constipation. 3. Irritability. 4. Pink gums

1. Joint pain.

The nurse admits the infant suspected of having pyloric stenosis. During the nursing history, the nurse expects the parents to make which statement? 1. My baby has frequent projectile vomiting. 2. My baby smiles at me frequently. 3. My baby seems to be constipated. 4. My baby has been gaining weight.

1. My baby has frequent projectile vomiting.

The nurse performs an assessment on the 5 year old suspected of having Duchenne muscular dystrophy. Which assessment data obtained from the parent will assist the medical team with this diagnosis? 1. My child can't ride a bike. 2. My child resist eating healthy foods. 3. My child is really defiant. 4. My child likes to sleep 8 to 10 hours a day

1. My child can't ride a bike.

The nurse in the pediatric clinic assesses a child reporting chronic headaches. Which statement, if made by the child to the nurse, requires immediate follow-up? 1. My headaches have started causing me to awaken at night. 2. Slow, deep breathing helps relieve my headache. 3. My mother has periodic migraine headaches. 4. My headaches seem to happen late in the day.

1. My headaches have started causing me to awaken at night

This nursing student presents at a conference about signs of cerebral palsy (CP). Which statement will the nursing student include in the presentation? 1. The infant has poor head control after 3 months of age. 2. The infant crawls using both arms and legs. 3. The infant smiles by 3 months of age. 4. The infant sits with support by 5 months of age

1. The infant has poor head control after 3 months of age.

The nurse at the local high school is discussing hypercholesterolemia and health class. Which statement if made by a student to the nurse, indicates the need for further teaching? 1. There is no treatment for hypercholesterolemia 2. My mom likes to use olive oil and canola oil in her cooking. 3. I'll ask my health care provider to check my blood for cholesterol and triglycerides. 4. If my lipid levels are elevated now, they will probably be elevated when I am an adult.

1. There is no treatment for hypercholesterolemia

The home care nurse cares for the child diagnosed with a seizure disorder. The child's parent calls to report that the child had a tonic-clonic seizure. It is most important for the nurse to follow up on which statement made by the child's parent? 1. When the seizure first began, I tried to move my child to the bed. 2. I timed the seizure episode. 3. I removed my child eyeglasses. 4. I cleared the area on the floor around my child.

1. When the seizure first began, I tried to move my child to the bed.

The nurse cares for the school-aged child reporting joint pain in the extremities. The parents state that their child had a sore throat about 10 days ago that did not require treatment. The nurse anticipates the healthcare provider will order which test? 1. Red blood cell count. 2. Antistreptolysin O (ASO) titre 3. Blood glucose. 4. Hematocrit

2. Antistreptolysin O (ASO) titre

The school nurse discusses triggers that precipitate asthma with school-aged children. The nurse determines that teaching is effective if a parent makes which statement? 1. Watching TV can aggravate my child's asthma. 2. Cold air can trigger my child's asthma. 3. Having difficulty with homework can trigger my child's asthma. 4. Playing outside and 70 degree weather for more than one hour can trigger an asthma attack

2. Cold air can trigger my child's asthma.

The nurse cares for the young child diagnosed with heart failure (HF). The nurse recognizes which finding is one of the earliest indications of heart failure? 1. Sudden weight loss. 2. Tachycardia. 3. Sudden burst of energy. 4. Bradycardia

2. Tachycardia.

The child is in the emergency room for a puncture wound contaminated with dirt. The nurse knows that the health care provider will order which medications? 1. Captopril 2. Tetanus immune globulin 3. Acetaminophen 4. Diazepam

2. Tetanus immune globulin

The pediatric nurse performs an exam on the three year old. The nurse suspects the child may have strabismus. Which observation, made by the nurse, may indicate this type of visual impairment? 1. The nurse notes grey opacities in the child's lens. 2. The nurse observes that the child closes one eye when looking around the room. 3. The child States, I can't see with this eye 4. When looking at a book, the child holds the book close to the eyes

2. The nurse observes that the child closes one eye when looking around the room

The nurse cares for a child after a tonsillectomy. The child vomits bright red blood. Which action should the nurse take first? 1. Contact the healthcare provider. 2. Turn the child to the side. 3. Place an NPO sign above the child's bed. 4. Observe the child's throat.

2. Turn the child to the side.

The nurse cares for the 2 week old infant diagnosed with developmental dysplasia of the hip. The nurse notes which finding is consistent with the diagnosis of DDH? 1. Elongation of the femur. 2. Positive Trendelenburg sign 3. Asymmetry of the gluteal fold. 4. Negative Ortolani test.

3. Asymmetry of the gluteal fold.

The nurse cares for the child with a diagnosis of rule out aplastic anemia. To confirm the diagnosis, the nurse expects the health care provider to order which test? 1. Red blood cell indices. 2. Blood glucose 3. Bone marrow aspiration 4. Complete blood count

3. Bone marrow aspiration

The pediatric nurse cares for the 4-year-old admitted with Hirschsprungs disease. The nurse expects to find which signs and symptoms? 1. Projectile vomiting, epigastric fullness, and anorexia. 2. Abdominal pain, diarrhea, and blood in the stool. 3. Constipation, abdominal distention and ribbon like stools. 4. Right lower quadrant abdominal pain, diarrhea, and rigid abdomen.

3. Constipation, abdominal distention and ribbon like stools.

The nurse performs a nutritional assessment on the 3 month old infant. Which question best assists the nurse to obtain a dietary history from the infants parents? 1. Does your baby like to look at different foods in a book? 2. When did you start feeding your baby solid foods? 3. How many ounces of formula does your infant drink each day? 4. How much did you weigh when you were born?

3. How many ounces of formula does your infant drink each day?

The nurse counsels the mother of a four year old diagnosed with group A B-hemolytic streptococcus infection of the upper airway. Which statement, is made by the mother to the nurse, indicates an understanding of the nurses instructions? 1." when my child feels better, they can stop taking the medication." 2. I will keep my child home until they complete the antibiotic therapy. 3. I will buy my child a new toothbrush tomorrow 4. I should not offer my child solid food for 72 hours.

3. I will buy my child a new toothbrush tomorrow

The nurse instruct the mother of the young child diagnosed with moderate dehydration due to diarrhea. The nurse determines that teaching is successful if the mother makes which statement? 1. I will only give my child bananas, rice, and apples to eat. 2. I will frequently offer my child fruit juices and gelatin. 3. I will offer my child half a cup of oral rehydration after each diarrheal stool. 4. I will encourage my child to drink one cup beef broth 3 times a day

3. I will offer my child half a cup of oral rehydration after each diarrheal stool.

A student nurse present a conference on hematological disorders in children. The student nurse identifies which information should be included in the presentation about immune thrombocytopenia purpura (ITP)? 1. Immune thrombocytopenia purpura occurs as a complication from shock/hypoxia 2. Immune thrombocytopenia purpura is caused by a profound depression of red blood cells. The white blood cells and platelets are also depressed. 3. Immune thrombocytopenia purpura is caused by excessive destruction of platelets. There is discoloration due to petechiae and the bone marrow is normal. 4. Immune thrombocytopenia purpura is the process that stops bleeding when a blood vessel is injured.

3. Immune thrombocytopenia purpura is caused by excessive destruction of platelets. There is discoloration due to petechiae and the bone marrow is normal.

The nurse cares for the child immediately after a supratentorial craniotomy to remove a brain tumor. The nurse notes that the child's apical pulse is elevated and the blood pressure is decreased. Which action should the nurse take first? 1. Contact the healthcare provider. 2. Place the Child flat with legs elevated above the level of the heart. 3. Increase the rate of IV fluids. 4. Repeat vital signs in 5 minutes.

3. Increase the rate of IV fluids.

The nurse plans care for infants on the pediatric unit. The nurse understands that careful assessment of the infant's fluid and electrolyte balance is required for which reason? 1. Infant kidneys are able to concentrate and dilute urine. 2. Infants have a smaller body surface area than adults 3. Infants have larger amounts of extracellular fluids (ECF) than adults. 4. Infants have a lower metabolic rate than adults

3. Infants have larger amounts of extracellular fluids (ECF) than adults.

The nurse observes the 10 year old child diagnosed with attention deficit hyperactivity disorder ADHD. The nurse expects to observe which behavior? 1. The child engages in a conversation with his mother. 2. The child sits quietly and read a book. 3. The child wonders the hallways. 4. The child plays a card game with another child

3. The child wonders the hallways.

The nurse cares for the infant receiving oxygen through an oxygen hood. Which observation requires an intervention by the nurse? 1. A nurse uses a bulb syringe to suction the infant's nose and mouth. 2. The oxygen sensor is secured to the great toe and sole of the foot. 3. The infant's parent covers the infant with a brightly colored nylon blanket. 4. The grandparent places a stuffed animal on the bedside table.

3. The infant's parent covers the infant with a brightly colored nylon blanket.

The parents of an infant bring the child to the pediatric clinic because of noticing the infant has edema of the hands and feet. The nurse observes widely spaced nipples and a low posterior hairline. The nurse knows these findings are consistent with the diagnosis of which genetic disorder? 1. Klinefelter syndrome. 2. Triple X syndrome. 3. Turner syndrome. 4. Fragile X syndrome

3. Turner syndrome.

The nurse cares for a 7-year-old girl diagnosed with central precocious puberty. It is most important for the nurse to include which statement when counseling the child's mother? 1. If your child demonstrates affection for another person, the affection is sexual in nature. 2. Precocious puberty will present greater problems when your child is an adolescent. 3. Your child should dress in age appropriate clothing. 4. You do not have to worry because your child is not fertile

3. Your child should dress in age appropriate clothing.

The nurse admits the infant suspected of having intussusception. During the nursing assessment, the nurse expects to obtain which information? 1. The nurse palpates an Olive-shaped mass in the infant's epigastrium. 2. The nurse notes that the infant is coughing and choking 3. The parents state that the infant has constipation. 4. The parents state that the infant stools look like currant jelly

4. The parents state that the infant stools look like currant jelly

The nurse cares for the 18-month-old diagnosed with stage IV neuroblastoma. During a discussion with the child's parents, the parents shout at the nurse, "I have brought my child in for all of the checkups. The healthcare provider should have found this sooner." Which response by the nurse is most appropriate? 1. "You appear angry that this has happened to your child." 2. "Are you afraid your child is going to die?" 3. "We are doing everything we can." 4. "Most children are diagnosed after the tumor metastasizes."

4. "Most children are diagnosed after the tumor metastasizes."

The nurse counsels the parents of a child diagnosed with iron deficiency anemia. The nurse instructs the parents about how to administer the prescribed liquid iron supplement. Which instruction is the most important for the nurse to include? 1. Administer the liquid iron supplement with food. 2. Administer the liquid iron supplement with a medicine cup. 3. Administer the liquid iron supplement with a spoon. 4. Administer the liquid iron supplement through a straw.

4. Administer the liquid iron supplement through a straw.

The nurse cares for the child diagnosed with Wilms tumor. Preoperatively, it is most important for the nurse to include which action in the plan of care? 1. Monitor intake and output. 2. Palpate the child's abdomen. 3. Measure the child's abdominal girth. 4. Assess for hypotension

4. Assess for hypotension

The nurse presents a conference about gastrointestinal dysfunction and children. The nurse discusses the difference between ulcerative colitis and Crohn's disease. The nurse determines that further teaching is required if an attendee makes which statement? 1. Abdominal pain occurs with ulcerative colitis. 2. Ulcerative colitis can cause anemia 3. Weight loss is severe in Crohn's disease 4. Bloody diarrhea is common in Crohn's disease

4. Bloody diarrhea is common in Crohn's disease

The nurse cares for an infant admitted to the emergency room. The mother reports that the child fell off the changing table. The nurse performs an assessment and identifies which symptom as an early sign of increased intracranial pressure (ICP)? 1. Decreased head circumference. 2. Constricted scalp veins. 3. Fixed and dilated pupils. 4. Bulging fontanel.

4. Bulging fontanel.

The nurse in the pediatric clinic assesses a 12 month old infant. The infant fell to the floor from a high chair. It is most important for the nurse to assess for which injury? 1. Fractured leg. 2. Ruptured spleen. 3. Fractured arm. 4. Head injury

4. Head injury

The nurse instruct the family of the child diagnosed with sickle cell disease on how to minimize the vaso-occlusive crisis. The nurse determines that further teaching is required if the family makes which statement? 1. I offer my child ice pops and frozen drinks. 2. I should contact the health care provider if my child has a fever. 3. I will encourage my child to drink fluids after playing. 4. If my child experiences pain, I will apply cold compresses.

4. If my child experiences pain, I will apply cold compresses.

The nurse cares for the young child scheduled to receive the hepatitis B vaccine. The nurse identifies which method is best to administer the vaccine? 1. Intradermally in the right forearm. 2. Subcutaneously in the left thigh 3. Intramuscularly in the ventrogluteal muscle. 4. Intramuscularly in the deltoid muscle

4. Intramuscularly in the deltoid muscle

The charge nurse of a newborn nursery and instructs mothers on how to assess their infants hearing. Which statement, if made by the mother to the nurse, indicates that teaching is successful? 1. My baby will start hearing noises at about eight months of age. 2. If my baby has hearing, she will startle when I rock the bassinet 3. If my baby maintains eye contact with me, it indicates good hearing. 4. My baby may startle when I make a loud noise close to her head.

4. My baby may startle when I make a loud noise close to her head.

The nurse identifies which statement as a true statement about otitis media? 1. Otitis media is caused by dysfunction of the pharyngeal cavity. 2. Otitis media is caused by dysfunction of the Eustachian tubes. 3. Otitis media is caused by irritation of the nasopharyngeal tissues. 4. Otitis media is caused by a dysfunction of the middle ear.

4. Otitis media is caused by a dysfunction of the middle ear.

The nurse cares for the 5-year-old diagnosed with asthma. The nurse demonstrates to the child's parents how to measure the peak expiratory flow rate. The nurse asks the child to forcefully exhale into the meter, and the nurse notes the results are in the red zone. The nurse knows that the red zone indicates which finding? 1. An acute exacerbation may be present. 2. Maintenance therapy may need to be increased 3. Asthma is well controlled 4. Severe airway narrowing maybe recurring.

4. Severe airway narrowing maybe recurring.

The nurse prepares to administer digoxin to an infant. Which finding would cause the nurse to hold the infants digoxin and contact the health care provider? 1. The parent states the infant has a runny nose. 2. The infant is sitting in an infant seat. 3. The infant's apical pulse is 142 bpm and regular. 4. The parent reports the infant vomited 4 times during the night.

4. The parent reports the infant vomited 4 times during the night.

The nurse cares for the child diagnosed with cardiac dysrhythmia. The nurse knows that which dysrhythmia is not a common one found in children? 1. Sinus tachycardia 2. Supraventricular tachycardia 3. Sinus bradycardia 4. Ventricular tachycardia

4. Ventricular tachycardia

The nurse cares for the child diagnosed with nephrotic syndrome. The nurse knows that which finding is a common characteristic associated with nephrotic syndrome? 1. Skin color appears red. 2. Hyperalbuminemia. 3. Urine specific gravity 1.005. 4. Weight gain

4. Weight gain

A child client requires oxygen at home. The nurse teaches the parents about the safe use of oxygen. Which information is most important? a. People need to be outside the house smoking cigarettes b. Oxygen tanks need to be stored on their sides, chained in their holders c. The child needs to be at least 10 feet away from the gas stove d. An "oxygen in use" sign must be by the child's bedside

An "oxygen in use" sign must be by the child's bedside

The nurse in the pediatric clinic counsels the mother of a 6-year-old who has developed new-onset constipation. Which is the most common reason for a new-onset constipation in a 6 year old? 1. Dietary changes. 2. Lack of exercise. 3. Hirschsprung disease. 4. Beginning school

Beginning school

A 2-year-old child has a congenital cardiac defect. The nurse teaches the parent to observe the child for changes that indicate the need for immediate care. Which assessment is most important to teach the parent? a. Excessive activity during the day b. Bradypnea during daily activities of play c. Restlessness after being held after a nap d. Tachycardia when resting after play

Bradypnea during daily activities of play

A parent brings an infant client to the emergency department after the infant fell out of the highchair. The nurse assesses the infant for a head injury. Which assessment data indicates the infant needs further testing? SATA a. Difficult to arouse from sleep b. Difficulty speaking c. Blurred vision d. Right eye pupil dilated e. Severe headache f. Bulging anterior fontanel

Bulging anterior fontanel Difficult to arouse from sleep Right eye pupil dilated

A 3-month-old has a hip spica cast due to a hip deformity. The nurse teaches the parent to assess for which problem associated with this type of cast? a. Excoriation of the perineum b. Items placed inside the cast c. Blanching of toes when walking d. Infection around the ankle

Excoriation of the perineum

A school aged client recovering from rheumatic fever finishes the 10-day course of antibiotics. There does not appear to be any permanent cardiac damage. The nurse teaches the parent about prophylactic antibiotics for the client. Which statement by the parent indicates to the nurse the teaching was understood? a. I will need to give my child antibiotics before a dentist appointment b. My child should use ibuprofen if there is fever or joint pain. c. I will need to give my child two doses of penicillin every day for 5 years d. My child will need to take penicillin every day until age 21

I will need to give my child two doses of penicillin every day for 5 years

The nurse performs an assessment on a 15-month-old. The infant's parents tell the nurse that the child has started to walk, is eating with a spoon, and build a two- block tower. During the visit, the parent mention that the toddlers' right eyes sometimes "glows". Which response by the nurse is best? 1. I will tell the healthcare provider about your observation 2. that is a normal response when light shines in a toddler's eyes. 3. Is light shining in the toddler's eyes when this happens? 4. I wouldn't worry about it.

I will tell the healthcare provider about your observation

The 3-year-old client is diagnosed with pneumonia secondary to GERD. Which nursing diagnosis is most appropriate for this child's plan of care? a. Dysfunctional gastrointestinal motility r/t respiratory changes b. Impaired spontaneous ventilation r/t gastric reflux c. Impaired gas exchange r/t aspiration from gastric reflux d. Risk for suffocation r/t excess fluid in the lungs

Impaired gas exchange r/t aspiration from gastric reflux

The 4-year-old child has an eye enucleation for retinal blastoma. The nurse cares for the child during a routine follow up visit. Which concern is the most important for the nurse to address first? a. Parental concern about moving and finding a new ocularist b. Childs concern about learning to replace the prosthesis c. Parental concern about development of osteosarcoma d. Childs concern about not being able to go swimming

Parental concern about development of osteosarcoma

The school nurse administer glucagon intramuscularly (IM) to a child with type 1 diabetes. The child immediately begins to vomit. Which action should the nurse take first? 1. Contact the child's family. 2 Contact the child health care provider. 3. Inform the teacher that the child will not be returning to class. 4. Place the child on the side.

Place the child on the side.

A preschool aged client who is HIV positive tells the nurse, "I can't play with other children because they might get sick." Which action by the nurse is best? a. Ask the parents why they are limiting the client's social activities b. Tell the client the truth about HIV/AIDS and how it is transmitted c. Explain to the parents how important it is for the client to play with others d. Plan an education session with the family and community regarding HIV/AIDS

Plan an education session with the family and community regarding HIV/AIDS

The 17-year-old client recovers after surgery to remove a ruptured appendix. The nurse changes the dressing with a drain frequently. Which is the most important intervention for this client? a. Discussion of feelings regarding surgery b. Assistance with schoolwork c. Provision of adequate pain relief d. Restriction of visit from peers

Provision of adequate pain relief

The 8-year-old child is diagnosed with type 1 diabetes. The child has frequent episodes of hypoglycemia. The health care provider has ordered glucagon to be available at all times. The school nurses keep the medication in the office. Which method does the nurse use to give the glucagon to this child if needed? a. Reconstituted with manufactures powder and given IV b. Mixed with fruit juice and taken through a straw c. Squeezed from the tube and taken orally d. Reconstituted with manufactures diluent and given IM

Reconstituted with manufactures diluent and given IM

The nurse cares for a young child diagnosed with a respiratory infection. The nurse understands that children are more prone to respiratory infections for which reason? 1. The child's trachea is longer than an adult's neck. 2. The child's larynx is lower in the neck than found it is in adults 3. The child's airway is a smaller diameter than is found in adults. 4. The child epiglottis is shorter than is found in adults

The child's airway is a smaller diameter than is found in adults

The nurse discusses dental hygiene with the parents of a 12 month old infant. Which statement, if made by the parents to the nurse, indicates the need for further instruction? 1. We use toothpaste to polish the teeth. 2. We wipe the teeth with a damp cloth. 3. We use only water to clean the teeth. 4. Good dental hygiene starts as soon as the first tooth erupts

We wipe the teeth with a damp cloth

A school aged client recovers from a streptococcal infection. Parents notice periorbital edema, dark urine with decreased output, and loss of appetite. The nurse plans which priority client goal? a. Will have no headache, dizziness, or vomiting b. Will eat regular diet with no salt added or salty foods c. Will observe strict bed rest with limited activities d. Will maintain urine output of 3,000ml/24hr

Will have no headache, dizziness, or vomiting

The nurse takes the vital signs of the 4-year-old child for a routine checkup. Which method does the nurse use to assess the pulse? a. Apical for 1 minute b. Femoral for 15 seconds c. Radial for 15 seconds d. Brachial for 1 minute

a. Apical for 1 minute

The 17-year-old client is scheduled for cranial surgery to remove a brain tumor. The nurse discusses what to expect after surgery with the client and parents. Which is the most important teaching from the client's point of view? a. Client will have head shaved b. Client may have intense pain c. Client may experience increased intracranial pressure d. Client will be in intensive care

a. Client will have head shaved

The 15-month-old child is diagnosed with Hirschsprung disease. The child was medically treated unsuccessfully for abdominal distention and constipation. Which nursing diagnosis is most appropriate of this child while awaiting surgery? a. Constipation related to inadequate intestinal mobility b. Toileting self-care deficit related to holding stool c. Fear related to upcoming surgery and uncertainty of outcome d. Imbalanced nutrition: more than body requirements related to abdominal distention

a. Constipation related to inadequate intestinal mobility

The 9-month-old infant is diagnosed with intussusception. The nurse prepares the infant for a barium enema with contrast. Which nursing action is most important prior to the procedure? a. Discuss the procedure and expected outcome with the parents b. Explain to the child what will happen before giving the sedative c. Administer enemas until clear prior to sending the child to X-ray d. Document any vomiting or stooling during the hospitalization

a. Discuss the procedure and expected outcome with the parents

The 4-year-old child is diagnosed with strabismus. The nurse prepares the nursing care plan. Which nursing diagnosis is included for this child? a. Disturbed sensory perception related to visual disturbance b. Impaired social interaction related to eye patch c. Ineffective coping related to being different from other children d. Disturbed body image related to inability to see clearly

a. Disturbed sensory perception related to visual disturbance

A child enters school for the first time. The bus picks the child up at 0700. The parent tells the nurse the child has become constipated for the first time. The nurse plans care for the child based on which most likely problem? a. Fear of using school bathrooms b. Anxiety about going to school c. Lack of fiber in school diet d. Decreased intake of fluid at school

a. Fear of using school bathrooms

A 5-year child diagnosed with iron deficiency anemia receives an iron supplement. The nurse teaches the parent about administering the medication. The nurse knows further teaching is required when the parent makes which statement? a. I will increase the amount of milk my child drinks b. My child will use a straw to take the liquid medication c. My child will most likely have greenish-black colored stools d. I will give the medicine twice a day between meals

a. I will increase the amount of milk my child drinks

The nurse cares for the 14-month-old child diagnosed with respiratory syncytial virus for the second time in life. The child has no underlining physical problems. Which order will the nurse anticipate for this child? a. Oxygen saturation monitoring b. Administration of antibiotics c. Take vital signs every hour for first 12 hours d. Palivizumab prophylaxis

a. Oxygen saturation monitoring

The nurse prepares the care plan for a 4-year-old with diarrhea. Which nursing diagnosis are appropriate for this child? a. Risk for infection r/t invasion of GI system with microorganisms b. Risk of deficit knowledge r/t cause of diarrhea c. Risk for impaired skin integrity r/t excoriation of rectal area d. Risk for deficit fluid volume r/t loss of water in stool e. Imbalanced nutrition: more than body requirements r/t loss of stool f. Toileting self-care deficit r/t frequent stooling

a. Risk for infection r/t invasion of GI system with microorganisms c. Risk for impaired skin integrity r/t excoriation of rectal area d. Risk for deficit fluid volume r/t loss of water in stool

The parent brings the 2-month-old infant to the clinic for a checkup. The parent tells the nurse the baby still wakes at night for a feeding. The parent wonders if adding cereal to the formula will help the baby sleep longer. Which is the best response by the nurse? a. The gastrointestinal system is not ready for solid foods yet b. Cereal can be added at this time if the nipple holes are large enough c. The baby will sleep through the night soon d. Mix the formula with less water to make it thicker

a. The gastrointestinal system is not ready for solid foods yet

The nurse teaches about prevention of iron deficiency. Which information is included? SATA a. Use ferric iron supplements as they are most readily absorbed b. Increased formula after introducing solid foods to preterm infants c. Give iron supplements to preterm infants starting at 2 months of age d. Use only iron fortified formula for first year of life if bottle feeding e. Give iron supplements to full term infants starting at 4-6 months of age f. Start iron fortified cereal at 2 months of age for full term infants

a. Use ferric iron supplements as they are most readily absorbed c. Give iron supplements to preterm infants starting at 2 months of age d. Use only iron fortified formula for first year of life if bottle feeding e. Give iron supplements to full term infants starting at 4-6 months of age

The school nurse holds a scoliosis screening clinic for 13-year-old children. Which observation requires a referral to the health care provider? a. With client bending at waist, thoracic area is not symmetrical b. With client sitting in a chair, the lumbar area is not symmetrical c. With client standing on one foot, both hips are symmetrical d. With client standing with back to nurse, hips are in line with neck and head

a. With client bending at waist, thoracic area is not symmetrical

A 15-year-old basketball player develops a sore throat and a throat culture reveals a group A beta hemolytic streptococcus infection. Which is the most appropriate client goal identified by the nurse? a. Client will return in 18 days for a rheumatic fever diagnosis and treatment. b. Client will remain at home for 24 hours after beginning antibiotics c. Client will gargle with warm saline every 3 hours while awake d. Client will test the urine for 10 days for possible acute nephritis

b. Client will remain at home for 24 hours after beginning antibiotics

The parent brings the 6-month-old to the clinic. The parent tells the nurse the childs feet and legs are always cold and sometimes slightly blue. The nurse determines the brachial pulses are strong and bounding. The femoral and pedal pulses are very faint. Which problem does the nurse suspect for this child? a. Ventricular septal defect b. Coaction of the aorta c. Aortic stenosis d. Patent ductus arteriosus

b. Coaction of the aorta

The 3-month-old infant takes digoxin daily because of heart failure related to cardiac deficits. The infant develops diarrhea with dehydration due to a gastrointestinal infection. The serum potassium level is 3.4mEq/L. Which current treatment is most concerning to the nurse? a. Fluid restrictions b. Digoxin dosage c. Metoprolol dosage d. Rehydration process

b. Digoxin dosage

An adolescent client is diagnosed with epilepsy. The client takes Phenytoin daily. The client understands the nurses teaching when the client makes which statement? a. I like to drink milk and my parents have to buy several gallons each week b. I wont be able to drive until I have been seizure free for the defined time c. I guess I wont be able to go to college now since I can't think well anymore d. I don't want to let my friends know about this disorder or they will tease me

b. I wont be able to drive until I have been seizure free for the defined time

The 9-year-old child is diagnosed with hemophilia. The child was hospitalized for a significant intestinal bleed. The nurse teaches about therapy to use if bleeding occurs. Which statement by the child indicates understanding of the discharge information? a. If I cut my leg outside, I will wash it with soap and water, then apply heat b. If I hurt my knee and think it is bleeding inside, I will put ice on it right away c. I need to avoid sports at school, so I am on the chess team instead d. I will use an elastic bandage and an ice pack the next time I get a nosebleed

b. If I hurt my knee and think it is bleeding inside, I will put ice on it right away

The nurse teaches about car seats. Which action by the parents tells the nurse they understand the instructions? a. Placing a 44lb preschooler in a rear facing booster seat in the back seat of the car b. Placing an infant in a rear facing seat in the back seat of the car c. Placing a toddler in the front facing seat in the front seat of the car d. Placing an infant in a front facing seat in the front seat of the car

b. Placing an infant in a rear facing seat in the back seat of the car

The 14-month-old child with infantile spinal muscular atrophy type 1 comes to the clinic. The parent does not talk to the child and leaves the child in the infant carrier. Which information does the nurse teach this parent? a. The child will soon die, so needs no further treatment b. Child has limited intellect but can see colors c. Child has normal intellect but needs stimulation d. Child will soon grow too large for the infant carrier

c. Child has normal intellect but needs stimulation

The parent brings the 4-year-old to the clinic for a well child visit. The nurse determines the child has normal language development when which occurs? a. Child says, "where dog?" b. Child tells nurse, "ball is round and box is square." c. Child says, "I play with my ball." d. Child talks constantly when no one is listening.

c. Child says, "I play with my ball."

A 10-year-old child takes methylphenidate for ADHD. The child leaves class early to take the medication and is often late to lunch. The child begins to skip taking the medication at noon. The school nurses adds which client goal to the child's plan of care? a. Child will make new friends who understand the illness and treatment b. Child will tell teachers why there is a need to leave early and be late c. Child will understand the need for compliance for treatment d. Child will share lunch time with friends in the cafeteria

c. Child will understand the need for compliance for treatment

A 17-year-old female has not experienced puberty yet, and the parents report concern. The child is 4 ft 9 in tall, has slight webbing of the neck, and widely spaced nipples. The child has a known congenital cardiac defect previously treated with surgery. Which treatment does the nurse anticipate? a. Surgery to repair the ovaries b. Chromosome therapy c. Female hormone therapy d. Ovarian replacement surgery

c. Female hormone therapy

A parent receives teaching regarding dental hygiene for a 6-month-old child with two teeth. The nurse knows the client needs further education when which parent statement is made? a. A will clean the babies' teeth with a small toothbrush twice a day b. I will wipe the babies' gum with a damp cloth after each feeding c. I can start propping the bottle now at bedtime and nap time d. I will use a children's toothpaste with fluoride everyday

c. I can start propping the bottle now at bedtime and nap time

The nurse assesses the newborn. There is asymmetry of the gluteal folds of the thighs. The nurse anticipates teaching the parents which treatment technique? a. Surgery and casting b. No treatment, this is normal c. Pavlik harness for 6 weeks d. Hip spica cast for 6 months

c. Pavlik harness for 6 weeks

The nurse prepares a 4th grade class for the new student who has down syndrome. Which information does the nurse teach the students? a. The new student will like to run races at recess b. The new student will like to read many books c. The new student may be very affectionate d. The new student may be taller than most other students

c. The new student may be very affectionate

The 9-year-old child has had frequent streptococcal infections. The nurse gives instructions about the surgery for and recovery from a tonsillectomy. Which information is the most important for the child to hear? a. After surgery, a side lying position will be used b. The child will likely go home the day of surgery c. The throat will be sore for a while after the surgery d. Surgery may be cancelled if there is a upper respiratory infection

c. The throat will be sore for a while after the surgery

The 3-year-old child is diagnosed with meningitis. Which information indicates to the nurse this is a viral instead of a bacterial disease? a. Cloudy spinal fluid with normal glucose content b. Clear spinal fluid with normal protein count c. Cloudy spinal fluid with elevated protein count d. Clear spinal fluid with increased white cell count

d. Clear spinal fluid with increased white cell count

The parent brings a 10-month-old child to the client. The infant has been vomiting for 24 hours. There is loss of skin turgor and the fontanelle is depressed. The child's weight has gone from 20lbs at the first visit to 18lbs today. Which nursing diagnosis does the nurse identify as the most important? a. Dysfunctional gastrointestinal mobility r/t rehydration b. Risk for electrolyte imbalance r/t rehydration c. Imbalanced nutrition: less than body requirements r/t vomiting d. Fluid volume deficit r/t vomiting

d. Fluid volume deficit r/t vomiting

The nurse provides care for a young child screened for elevated lipids because of a strong family history. The lipids are found to be severely elevated. Which sample menu is best for the nurse to suggest to the client and family? a. Meatloaf, mashed potatoes, corn, banana pudding b. Eggs, sausage, grits, whole wheat toast c. Ham slices, macaroni and cheese, white roll d. Grilled fish, brown rice, broccoli, apple nut tar

d. Grilled fish, brown rice, broccoli, apple nut tar

The 13-month-old child comes to the clinic for a routine well child visit. The child is following the normal immunization schedule. Which vaccine does the nurse plan to give this child? a. Meningococcal vaccine #1 b. DTaP vaccine #2 c. MMR vaccine #3 d. Hepatitis B vaccine #3

d. Hepatitis B vaccine #3

The 16-year-old client reports a 15lb weight loss over 10 weeks, fatigue, blurred vision, excessive thirst, and hunger, and a urinary tract infection. The nurse anticipates which treatment plan? a. Long term antibiotics b. Appendectomy c. Nutritional counseling for weight gain d. Insulin replacement therapy

d. Insulin replacement therapy

The parent brings the 8-year-old child to the clinic following a vaso-occlusive crisis. The parent says, "I am going to homeschool my child now to prevent further infections. My child will not contact other children unless a mask is worn." Which is the nurses best response to the parent? a. Your child must learn to socialize with other children and a mask is not helpful b. You cannot protect your child from all infections, so do not even try. c. It is hard to see your child be sick. Maybe your healthcare professional can help. d. Let's talk about your understanding of your child's needs.

d. Let's talk about your understanding of your child's needs.

A toddler client fell off a swing yesterday morning. The parent brings the client to the ED, and the client says the head and eyes hurt. The parent says the client has vomited several times since the fall, has had difficulty walking, and wants to sleep all of the time. The nurse takes which action first? a. Explains the process of a CT scan to the client before sending to Xray b. Nothing, as this is normal occurrence for a client of this age c. Prepares the client for immediate cranial to place an intracranial pressure monitor d. Notifies the health care provider of possible increased of intracranial pressure

d. Notifies the health care provider of possible increased of intracranial pressure

The adolescent client's grades have declined over the last several months. The client tells the school nurse, "things have been difficult at home since I told my parents that I was homosexual. I have started using marijuana. I don't care anymore." Which nursing diagnosis category is most appropriate for this client? a. No hope related to parental confusion b. Not coping well related to home life and sexuality c. Not performing normal roles related to sexuality d. Suicide risk related to home life and sexuality

d. Suicide risk related to home life and sexuality