Hesi-PEDS same as the picture docu
A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history which finding should the nurse expect to obtain?
A recent strep throat infection
A 4 year old girl returns to the pediatricians office for a post op visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal for this age child?
"talks" to an imaginary friend
A two-year-old child with heart failure is admitted for a replacement of graft for cortication of the aorta. Prior to administering the next dose of digoxin, the nurse obtains an apical heart rate of 128 BPM what action should the nurse implement?
-Administers a scheduled dose
The HR of a 3 year old with CHF has steadily decreased over the last few hours, now is 76 bpm, the previous reading 4 hours ago was 110bpm. Which additional finding should be reported immediately to a healthcare provider?
-BP: 70/40
Which nursing intervention is most important to assist in detecting, hypo, pituitary, ism, and hyperpituitarism in children?
-Carefully recording the height and weight of children to detect inappropriate growth rates
When administering indomethacin (Indocin) to a premature infant who has patent ductus arteriosus, the nurse should anticipate which outcome?
-Decreased cardiac murmur
The nurse is communicating with a 12-year-old who is hearing impaired. Which action is best for the nurse to use when attempting to communicate with this child?
-Emphasize emotions with facial expressions
during the physical exam of an 11-year-old girl, the nurse observes, budding breast and scant pubic hair. Which Tanger stage should the nurse choose when documenting these findings?
-III
A one month old male infant is brought to the clinic for his mother, who states that her son has been vomiting forcefully after each meal for the last three days. The infant is a febrile, dehydrated, and pyloric stenosis is suspected. What other findings should the nurse identify that are consistent with pyloric stenosis?
-In olive shaped mass in the abdominal area
Well, administering the final dose of oral amoxicillin to a preschool age. Boy, he tells the nurse said his throat hurts. Which intervention is most important for the nurse to implement?
-Inspect the child oropharynx
The nurse is caring for a child with sickle cell disease who is experiencing sickle cell crisis. Which findings should the nurse report to the healthcare provider immediately?
-Jaundice
One week after removing a tick, a student arrives at the school nurses office with reports of flu like symptoms. Which intervention should the school nurse implement first?
-Observe for a rash around the tick bite site
An infant with tetralogy of Fallot becomes acutely cyanotic and hyper apneic. Which action should the nurse implement first?
-Place the infant in a knee-chest position
Email child is being prepared for a CT scan when he begins to have a tonic clonic seizure. His mother is hysterical. I'm trying to hold a child down. What actions should the nurse take?
-Play pillows inside the side rails -Ask the mother to release the child -Monitor the child's airway and tongue
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports her child is irritable, refuses to eat, it has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
-Play the child in a quiet environment
The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12-year-old sibling are at the child's bedside. Which instruction best supports family?
-Please decide who will stay when the healthcare provider begins suturing
The mother of a 14 month old child tells the nurse that she feeds her child nothing but prepared food and feels they provide the best nutrition for her child, but is concerned about the cost. How should the nurse respond?
-Reassure the mother that beginning to replace prepared foods, wood table food can provide the needed nutrients
The nurse is administering a nebulizer albuterol treatment to a young girl who is having asthmatic exacerbation. The client is unable to hold her lips tightly around the mouth piece. Which intervention should the nurse implement?
-Replace the mouthpiece with a mask
Hey, breast-feeding, infant, screen for congenital, hypothyroidism, is found to have low levels of T4 and high levels of TSH. What is the best explanation For this finding?
-TSH is high because of the little production of T4 by the thyroid
The mother of 3 young children calls the clinic concerned about the recent exposure of her oldest child chicken pox. The nurse should provide the mother with information about the contagious period for chickenpox. What is the contagious period?
-Two days prior to the onset o the rash, until all lesions are crusted
A mother brings her preteen daughter to the clinic for her first female exam. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?
-Use the tanner staging to determine sexual maturity
A two-year-old boy who had hypospadias repair yesterday goes to the hospital play room with his mother. Which activities should the nurse recommend?
-Using a large piece puzzle
The nurse is caring for a school-age child who has lab results that reveal the presence of anti-Gliadin and anti-endomysial immunoglobulin G and immunoglobulin A antibodies. The nurse should identify with the parent and child which food to avoid after discharge home?
-Wheat bread
The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute post-streptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant?
-a sore throat last week
A nine-year-old with leukemia is admitted with a ruptured appendix. An NG tube is inserted and attached to low intermittent section. Which finding is most important for the nurse to report to the healthcare provider?
-absolute neutrophil count of 400/mm3
The nurse is giving an im injection of antibiotic to a 16 month old toddler with pneumonia. Toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
-administer the injection into the middle of the lateral aspect of the thigh
A mother brings her 2 month old son to the clinic for a well baby exam. During the assessment the nurse finds that the right testicle is not descended into the scrotum but the left is palpable. Which action should the nurse take?
-ask if the right tests has been seen in the scrotum before.
An infant is admitted for surgery who has wilms tumor. Which nursing intervention should the nurse implement during a preop period?
-careful bathing in handling that avoids abdominal manipulation
A male infant is admitted to the pediatric unit with pertussis and is exhibiting a "whooping-like cough." The mother brings the infant to the nurse's station to seek assistance. Which intervention should the nurse implement first?
-cover the infants mouth and assist the mother to take the infant back to the room
A 9 year old with celiac disease is admitted to the pediatric unit following an appendectomy. Which food should the nurse remove from this child's tray?
-crackers
The nurse is assessing a 6-month old infant. Which response requires further evaluation by the nurse?
-demonstrate startle reflex
The nurse is caring for a preschool aged child with a congenital heart defect who is admitted with intermittent low grade fever, fatigue, and weight loss. Further physical assessment findings include a new murmur, splinter hemorrhages under the nails, and painless red lesions on the palms of the hands. Which diagnostic procedure should the nurse prepare the parents to expect the healthcare provider to prescribe?
-echocardiogram
A 6 month old, diagnosed with short bowel syndrome, began enteral feedings yesterday. To maintain growth and development of the child during this period, what action should the nurse include in the infants plan of care?
-give the infant a pacifier during feedings
The mother of an 11 year old boy who has juvenile idiopathic arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting." Which information is most important for the nurse to provide to the mother?
-giving pain meds around the clock helps control the pain
A 10 year old girl is diagnosed with inflammatory bowel disease. Her mother is concerned that she will experience delays as the result of this disorder. How should the nurse respond?
-growth failure is a concern, but development delays are not likely to occur
The school nurse is assessing a child who reports having an itchy scalp. The nurse has sent home instructions for pediculosis capitis for several children in the school. Which assessment should the nurse implement to this child?
-inspect hair follicle shafts for adherence of nits
A nurse is teaching a class for mothers of premature infants, and is asked about "a shot for respiratory virus" what information about palivizumab us correct?
-it is recommended for infants who meet established high risk criteria
What drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia understands dietary considerations related to the disease?
-lemonade
The caregiver of a preschooler learns about long term endocrine dysfunctions resulting from their child's craniospinal radiation. Which statement made by the caregiver should the nurse recognize as needing additional education?
-make plans for growth hormone injections to enhance growth
A child admitted with diabetic ketoacidosis is demonstrating kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid based alteration?
-metabolic acidosis
Patient with diarrhea for 3 days- what does this cause?
-metabolic alkalosis
A child with possible Duchenne muscular dystrophy (DMD) undergoes an electromyogram (EMG). Following the procedure, the child's parents tell the nurse that the child is complaining of sore muscle. How should the nurse respond?
Offer reassurance that muscle soreness following these procedures is temporary and does not indicate a problem
The teacher notifies the school nurse that a child's nose is bleeding for no apparent reason. What action should the nurse implement first?
Pinch the nose using thumb and finger for 10 minutes
An infant with Tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
Place the infant in a knee- chest position
The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used?
Place the infant in a warm room and use a calm approach
The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active
In caring for an client with acute epiglottitis, which nursing action takes priority?
Prepare for endotracheal intubation
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
The chorea or movements are temporary and will eventually disappear
a female infant recently admitted with vomiting and diarrhea now weighs 10kg. Her weight at a previous well-baby visit was 11kg. What is the percentage of body weight loss for this infant?
9%
A preschool aged child is experiencing respiratory distress is brought ti the er by the parents. The child is anxious, has a temp of 102.8 and is drooling from the mouth while leaning forward while sitting. Which action should the nurse prepare for the child next?
-obtain bedside trays for intubation or tracheostomy by the healthcare provider.
The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next?
-palpate the anterior fontanel for tension and bulging
The nurse is performing a routine assessment of a 3-year old at a community health center. Which behavior by the child should alert the nurse to request a follow-up for a possible autistic spectrum disorder?
-performs odd repetitive behaviors
The nurse plans to conduct a physical assessment of a toddler. Which protocol is best for the nurse to implement?
-prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing
A six year old male with the BMI in the 90th percentile for gender and age arrives at the clinic after a referral from the school nurse. His lab findings include hemoglobin A1c of 5.5%, blood pressure in the 50th percentile for age, height in the 75th percentile, and LDL cholesterol of 90 mg/dL, which lifestyle modification should the nurse discuss with the parents?
-recommend increasing daily fruits and vegetables and daily exercise
An adolescent with seasonal, allergies, asthma, and eczema. Is it obtaining a physical in medical clearance for an overnight week-long summer camp. Which action should the nurse prioritize?
-remind a pack a rescue inhaler with adequate doses of medication
A 3 year old child with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster parent calls the clinic and asks the nurse what they should do. What action should the nurse take first?
-review immunization records of the child with an HIV infection
The nurse is caring for a 3-year old child who is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?
-right foot is cool to touch and appears pale and blanched
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?
-sore throat
A male high school student with Type 1 diabetes tests his blood glucose level before playing a game of soccer, and he obtains a reading of 180. Based on this reading, which action should the nurse take?
-tell him to eat a sandwich and fruit before beginning the game
The parents of a 3 year old boy who has duchenne muscular dystrophy ask, "how can our son have this disease? We are wondering if we should have any more children" which information should the nurse provide to these parents?
-this is an X-linked recessive disorder, which primarily affects male children in the family
During a well-baby clinic visit, the mother of a 6 month old infant asks the nurse if she can have prescription for Poly Vi Sol with fluoride. Thought he infant is still breast feeding, the mother provides the child with supplemental formula feedings. Which assessment is most important for the nurse to obtain?
-water source used with supplemental feedings
The nurse is planning care for a newborn infant scheduled for a cardiac catheterization. Which occurrence poses the greatest risk for this child?
Acute hemorrhage from the entry site of the catheter after the procedure
A toddler with hemophilia is being discharged from the hospital. Which teaching should the nurse include in the discharge instructions to the mother?
Apply padding on the sharp corners of the furniture
A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child's oral temperature is 101.2 F (38 C). Which intervention should the nurse implement?
Ask the mother if the child has had a runny nose
A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child's oral temperature is 101.2 F. Which intervention should the nurse implement?
Ask the mother if the child has had a runny nose
During a follow-up clinical visit a mother tells the nurse that her 5-month-old son who had surgical correction for Tetralogy of Fallot has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?
Auscultate heart and lungs while infant is held.
he heart rate for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours and is now at 76 beats/minute; the previousreading 4 hours ago was 110 beats/minute. Which additional clinical finding should be reported immediately to the healthcare provider?
Blood pressureof 70/40
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse notes thatthe child has developed episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
Change to latex-free gloves when handling infan
An adolescent with pelvic inflammatory disease (PID) is admitted to the hospital after 14 days of taking levofloxacin (Levaquin) 500 mg orally once daily and metronidazole (flagyl) 500 mg twice daily. She ask the nurse why I am in the hospital, why cant I get treatment at home? Which purpose should the nurse provide?
administration of a supervised antibiotic protocol
Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?
Contact their healthcare provider immediately
The parents of a 4 week-old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitation and pyloric stenosis, which information is most important for the nurse to obtain?
Degree of forcefulness of vomiting episodes
A 12-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is schedule. Which information should the nurse provide concerning to this procedure?
Describe the side-lying, knee to the chest position that must be assumed during the procedure
A 12-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is schedule. Which information should the nurse provide concerning to this procedure? • Explain that fluids cannot be taken for 8 hours before the procedure and 4 hours after the procedure • Tell the child to expend loud clicking during the procedure that may be annoying • Describe the side-lying, knee to the chest position that must be assumed during the procedure • Reassure the child that there will be no restrictions on activity after the procedure is completed
Describe the side-lying, knee to the chest position that must be assumed during the procedure
An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?
Explain that the information cannot be released without the18-year old's permission
The nurse is developing the plan of care for a hospitalized child with von Willebrand disease. What priority nursing intervention should be included inthis child's plan of care?
Guard against bleeding injurie
The nurse is assessing an 8-month-old who has a cough, axillary temperature of 100 F, and rhinorrhea. What information is most important for the nurse to obtain from this child's mother?
Immunization status of the infan
A mother brings her 8-month-old baby boy to the clinic because he has been vomiting and had diarrhea for the last 3 days. Which assessment is moreimportant for the nurse to make?
Measure the infant's pulse
A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit?
Metabolic alkalosis
Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?
Reduction of edema
A breast-feeding mother returns to work when her infant is 5 months old. She is having difficulty pumping enough milk to meet her infant's dietary requirements. Which suggestion should the nurse provide to this mother?
Supplement with an iron-rich formula
A hospitalized child stiffens and stars to seize as the nurse enters the room. What actions should the nurse take? (Select all apply
Turn client to the side if possible • Pad side rails with available pillows and blankets • Monitor duration and progress of the seizure
The nurse is administering an oral medication to a reluctant preschool-age boy. Which intervention should the nurse implement?
Use straightforwardapproach with the child
A child with leukemia admitted for chemotherapy and nursing diagnosis "altered nutrition, less those body requirements related to anorexia, nausea and vomiting" is identified. Which interventions should the nurse include?
allow the child to eat any food desired and tolerated
A patient has a low platelet count in his blood. Based on this, for which one of the following is he at risk?
bleeding precautions
A month old girl is brought to the clinic by her mother because she has had a cold for 2 to 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?
flaring of the nares
During a well-baby visit the parents explain that the soft bulge appears in the groin of their 4 month old son when he cries or strains with stool. The infant is scheduled for surgical repair of the inguinal hernia in 2 weeks. The parent should be instructed to take which measure if the hernia becomes incarcerated prior to surgery?
gently manipulate the hernia for reduction
The nurse plan to screen only the highest risk child for scoliosis. which group of children should the nurse screen first?
girls ages 10-14
A 6 month old diagnosed with short bowel syndrome, began eternal feedings yesterday. To maintain normal growth and development of the child during the period, what action is should the nurse include in the infants plan of care?
give infant pacifier during feedings
A 9-year-old boy is diagnosed with diabetes mellitus Type 1. Which stage of Erikson's theory of psychosocial development is the nurse addressing when teaching this client about insulin injections
industry
A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base is this child likely to exhibit?
metabolic alkalosis
Insulin therapy is initiated for a 12 year old child who is admitted with diabetic ketoacidos (KDA) . Which action is most important for the nurse to include in plan of care?
monitor serum glucose for adjustment in infusion rate of regular insulin (Novocain R)
Several Children at a day camp return from playing in a tick-infested field. What action should the nurse take first?
observe the children's skin for attached ticks
When caring for a child sickle cell disease, the nurse knows that the child will most likely exhibit which sign when experiencing a sickle cell crisis?
pain
Prior to discharge, the parents of a child with cystic fibrosis are demonstrating CPT that they will perform for their child at home which action?
percussion and postural drainage
n assessing a 10-year-old newly diagnosed with osteomyelitis, which information is most for the nurse to obtain?
recent recurrence of infection
A 3 year old with HIV infection is staying with a foster family who is caring for 3 other foster children in the home. When of the children acquire pertussis, the foster mother calls the clinic and ask the nurse what should she do, which actions should the nurse take first?
review the immunization documentation of the child with HIV
the nurse is evaluating diet teaching for a client who is nontropical spruce (celiac disease). Choosing which food indicates an understanding of the teaching?
rice
Teaching a parent class to new parents the nurse describes the needs of infants and toddlers regarding discipline and limit setting. what is the most important reason for implementing such parenting behaviors?
they provide child with a sense of security
How should then nurse instruct the parents of a 4-month-old with seborrheic dermatitis (cradle cap) to shampoo the child's hair?
use a soft brush and gently scrub the are
The mother of a 4 year old ask the nurse advice in preventing diaper rash. What suggestions should the nurse provide?
use barrier cream: such as zinc oxide, which does not have to be completely removed before diaper change
