Infants Exam 1 (16, 22, 20,23)

During this stage of psyosexual development, child abuse is more pronounced.

Toddlers/anal stage

Well child care for a child with sickle-cell anemia will include which of the following?

Additional immunizations, because of the child's higher-risk status for infection All children with chronic conditions should receive additional immunizations appropriate for their higher risk status for infection. Genetic testing of the child is not needed at this time; parents should be tested for sickle cell and sickle-cell trait. Daily dietary supplements of folate and vitamin B12 are not necessary for sickle-cell anemia.

A mother confides to the nurse that she gets so frustrated at times that she is afraid that she will hurt her child, who is mentally and physically challenged. Which nursing diagnosis is the most appropriate in this situation?

Risk for Impaired Parenting related to feelings of anxiety

A child with cerebral palsy might be at high risk for neglect and abuse. Which nursing diagnoses address this risk? (Select all that apply.)

Risk of Parental Anxiety related to concerns of child's future Risk of Impaired Parenting related to child's care requirements

A preschool-age child has just had a moderate reaction to latex. When teaching the parents about latex allergy, the nurse should inform the parents of what common household items that contain latex? Select all that apply. Rubber bands Sneakers Toothbrushes Water toys

Rubber bands, sneakers, toothbrushes, and water toys are household items that might contain latex. A Big Wheel® tricycle is plastic and does not contain latex.

A child is diagnosed with sickle cell disease. The parents are unsure how their child contracted the disease. Which explanation by the nurse is the most appropriate?

"Both the mother and the father have the sickle cell trait." Sickle cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have the disease.

The toddler is admitted to the hospital during an acute asthma attack. The physician orders: methylprednisolone 80 mg infused IV push every 3 hours. Medication on hand: methylprednisolone 125 mg/2 mL Calculate how many ml of methylprednisolone the patient will receive.

1.28 mL

A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child? Risk for Infection

A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid-Volume Deficit, Ineffective Thermoregulation, and Ineffective Tissue Perfusion, Peripheral would not be priority problems with this disease process.

A child is prescribed rifampicin for treatment of tuberculosis. For which length of time will the nurse tell the parents that this child must remain on the medication? 6 months

Active and latent TB are treated with isoniazid, rifampicin, pyrazinamide, and ethambutol. Therapy for active TB usually involves a 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months and isoniazid and rifampicin for the remaining 4 months. Therefore, the child will remain on rifampicin for a total of 6 months.

The nurse is caring for a child with sickle cell anemia. The parents ask the nurse what they can do to enhance their child's health. What recommendation by the nurse is the most appropriate?

Additional immunizations, because of the child is at greater risk for infection.

This age group can think abstractly.

Adolescents

Parents of a child who experienced a moderately severe allergic reaction after eating peanuts ask the nurse what they can do to help if it happens again. Which response by the nurse is the most appropriate? "I will teach you how to use an Epi-Pen."

An Epi-Pen is the appropriate treatment if this reaction occurs again. Benadryl is fine, but most likely is not strong enough in light of the serious reaction the child had. Desensitization is not the appropriate instruction at this time. Telling the parents that they will be taught if it happens again is brushing off the seriousness of the situation.

A parent tells the nurse, "I just don't think my child will make it this time. We have had so many hospitalizations, but this time is different." This statement is consistent with which nursing diagnosis?

Anticipatory Grieving related to child's deteriorating health status

The family of a hospitalized child with leukemia believes that the child will be cured by prayer alone and plans to take the child home. Which nursing intervention will address this barrier to care?

Assess the family's understanding of leukemia.

When providing teaching to parents a families about SIDS, what should be discussed about sleep positioning?

Back to sleep Always place in the supine position

A child is prescribed Didanosine (Videx), a nucleoside reverse transcriptase inhibitor, for human immunodeficiency virus (HIV). Which lab value will the nurse monitor closely for this child? RBC count

Didanosine (Videx) causes bone-marrow suppression with resulting anemia. RBC counts are monitored at least monthly for changes. Potassium and sodium are electrolytes, and glucose is a laboratory test for checking diabetes. Didanosine (Videx) does not affect these values.

Which nursing intervention is directed to the school-age child's independent management of asthma symptoms?

Encourage the child to use his flowmeter and record the results every day.

Visual inspection of the mouth and throat is contraindicated in children with suspected _____.

Epiglottitis Medical Emergency!

The nurse is teaching parents how to prevent a sickle cell crisis in the child with sickle cell disease. Which precipitating factors to a sickle cell crisis will the nurse include in the explanation? Select all that apply.

Fever Dehydration Altitude Fever, dehydration, and altitude are precipitating factors contributing to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.

Coughing, gagging, or choking in a child with feeding may confirm this.

Foreign body aspiration (obstruction)

A nurse is assessing a neonate. Which assessment finding indicates that the neonate's respiratory status is worsening? Grunting respirations with nasal flaring

Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

What are the 4 categories of congenital heart defects in children?

Increased pulmonary blood flow, decreased pulmonary blood flow, decreased systemic blood flow, mixed defects.

What is the primary way that infants increase their cardiac output?

Increasing their HR

Which developmental stages does rapid physical growth occur?

Infancy and adolescence

What are 3 common symptoms of an upper airway disorder?

Inspiratory stridor, barking cough, hoarseness

A child who has beta-thalassemia is receiving numerous blood transfusions. The child is also receiving deferoxamine (Desferal) therapy. The parents ask how the deferoxamine will help their child. Which rationale does the nurse use when responding to the parents?

It prevents iron overload. Iron overload can be a side effect of a hypertransfusion therapy. Deferoxamine (Desferal) is an iron-chelating drug, which binds excess iron so it can be excreted by the kidneys. It does not prevent blood-transfusion reactions, stimulate RBC production, or provide vitamin supplementation.

What electrolytes need to be assessed in a child taking Digoxin?

K and Ca

Gastrointestinal findings in a child with cystic fibrosis would include:

Large, loose, fatty, sticky, foul-smelling stools

Screening test for TB

PPD skin test

This type of play emerges in toddlerhood when children play side by side but demonstrate little or no social interaction.

Parallel play

Child proofing the home may prevent this accident.

Poisoning

A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the infant was exposed to a brother who has the flu. Which action by the nurse is most appropriate based on these assessment findings? Give the vaccinations as scheduled.

Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

If Strep is left untreated, these two diseases may occur?

Rheumatic Fever Acute Glomerulonephritis (AGN)

Which medications are quick relief agents to treat Asthma?

Short acting beta agonists

What is the name of the potassium sparing diuretic most often used in children?

Spironolactone (aldactone)

Which action by the parents demonstrates an understanding of the nurse's teaching with regard to prevention of iron-deficient anemia?

Starting iron-fortified infant cereal at 4 to 6 months of age Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. Infants who are not breast-fed should get iron-fortified formula. Cow's milk should not be introduced until 12 months of age. Vitamin C should be started at 6 to 9 months of age and continued, because foods rich in vitamin C improve iron absorption.

Which nursing intervention is most important for the family of a premature infant of 26 weeks' gestational age with Down syndrome who is not expected to survive?

Support the family in anticipatory grieving.

This test is considered the Gold Standard for diagnosis of CF

Sweat test

A school-age child diagnosed with rheumatoid arthritis asks the nurse to recommend an exercise activity. Which activity is most appropriate for this child? Swimming

Swimming helps to exercise all of the extremities without putting undue stress on joints. Softball, football, and basketball could exacerbate joint discomfort.

Which behavior indicates that a 10-year-old girl with diabetes has achieved an expected outcome for the nursing diagnosis of Knowledge Deficit (child) related to learning self-care skills?

The child demonstrates correct technique of withdrawing insulin from the vial.

What age group should receive teaching about a procedure right before?

Toddlers

Children with severe respiratory distress with a narrowed airway, sit in this position.

Tripod positioning

What would be an appropriate nursing intervention for a child with cystic fibrosis?

administer pancreatic enzymes with meals and snacks

a child is experiencing is an asthma attack. the nurse should prepare to administer:

albuterol

prevention of RSV includes all of the following EXCEPT:

antibiotics

A child comes to the nurse office stating he is having trouble breathing. The nurse should:

auscultate the lungs

cystic fibrosis is inherited as what type genetic trait

autosomal recessive

what would be an expected finding in a child with cystic fibrosis

clubbing of fingers

a child is drooling and has a strident cough. epiglotitis is suspected. the nurse should:

get patient ready for the OR

symptoms of asthma includes all of the following EXCEPT

green mucous

a child with a history of asthma is diagnosed with status asthmaticus. This child:

has not responded to treatment

what symptoms suggest complete airway obstruction in a child?

inability to speak

chest physiotherapy should be performed 1 hour before meals or 2 hours after meals

true

when should the nurse administer pancreatic enzymes to a a child?

with meals

What are the clinical signs of initial respiratory distress?

↑RR, ↑HR, restlessness, grunting, nasal flaring

State the purpose of steroids and list 5 possible S/E's.

↓inflammation weight gain, Cushing syndrome, PMS s/s, diabetes, psychosis

all of the following are signs of impending respiratory failure in children EXCEPT

facial flushing

When providing teaching to parents of children with toddlers what safety information should be reviewed?

Drowning prevention strategies

What should nurses teach parents about temper tantrums?

Safety first, then ignore the behavior

A child is admitted to the hospital with pneumonia. The child's oximetry reading is 88 percent upon admission to the pediatric floor. Which is the priority nursing intervention for this child? Begin oxygen per nasal cannula.

Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child's oxygenation status has been addressed.

The adolescent is admitted to the hospital in sickle cell crisis with a pain level of 10/10. The physician orders: Morphine sulfate 5 mg IV q 2 hr prn Medication on hand: morphine sulfate 10 mg/mL Calculate how many ml of morphine sulfate will be given IV.

0.5 mL

Adolescents often engage in high risk behaviors because of this.

Peer groups, seeking acceptance, live for the here and now

A parent reports that her school-age child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which disease process does the nurse suspect based on the parent's description? Fifth disease (erythema infectiosum)

. Fifth disease manifests first with a flulike illness, followed by a red "slapped-cheek" sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

The nurse is providing an educational session for parents with children diagnosed with iron deficiency anemia. Which statements will the nurse include educate about the normal functions of RBCs?

1. "RBCs transport oxygen from the lungs to the tissue." 2. "RBCs transport carbon dioxide to the lungs." The normal function of RBCs includes transporting oxygen from the lungs to the tissue and transporting carbon dioxide to the lungs. WBCs protect the body against bacterial invaders. Platelets form hemostatic plugs to stop bleeding. RBCs are not directly responsible for psychosocial development.

The nurse is providing care to a school-age client with neutropenia. Which clinical manifestations does the nurse anticipate when assessing this client? Select all that apply.

1. Fever 2. Fatigue 3. Tachycardia 5. Tachypnea A school-age client who is diagnosed with neutropenia, or a decrease in WBCs, will likely exhibit fever, fatigue, tachycardia, and tachypnea (as a result of congestive heart failure). The nurse would not anticipate that the client will exhibit hypertension as a result of the diagnosis.

A child with the diagnosis of Wiskott-Aldrich syndrome has been ordered an IV infusion of gamma globulin. The child weighs 20 pounds. The healthcare provider orders: gamma globulin 2 g/kg IV over 12 hours. Calculate how many grams of gamma globulin will be given IV.

18 g

The nurse is caring for the 5-year-old just diagnosed with von Willebrand disease after a tooth extraction with increased bleeding. The family asks the nurse how the signs and symptoms of von Willebrand disease are manifested. What will the nurse tell the family? Select all that apply.

3. Frequent nosebleeds 4. Bleeding from mucous membranes 5. Frequent bruising Characteristic manifestations are prolonged and excessive mucocutaneous bleeding, in children this is exhibited through gingival bleeding, epistaxis, menorrhagia, bruising, and minor wounds or lacerations.

The infants airway is approximately _mm in diameter, as opposed to an adult who's airway is __mm.

4mm versus 20 mm

A child with human immunodeficiency virus is started on sulfamethoxazole and trimethoprim (Bactrim) for Pneumocystis carinii pneumonia (PCP) prophylaxis. The recommended dose is based on the trimethoprim (TMP) component and is 15 to 20 mg TMP/kg/day in divided doses every 6 to 8 hours. The child weighs 6.8 kg. The highest dose of TMP the child can receive a day is ________. Round your answer to the nearest whole number. 136

6.8 kg (the child's weight) is multiplied by 20 mg. This yields the answer, which is 136 mg a day.

The nurse is providing care to a preschool-age client who is diagnosed with acquired immune deficiency syndrome (AIDS). In planning the client's care, which vaccine is inappropriate for the client to receive? Varicella vaccine

A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be given on schedule.

The nurse is caring for a child who is in a sickle cell crisis and has severe pain. Which nursing intervention is the most appropriate for this child?

Administering pain medication Severe pain requires administration of pain medication for pain relief. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child and can be used after pain medication is given. A child in severe pain is not capable of participating in or enjoying diversional activities. Preparing the child for painful procedures is not appropriate when the child is already in pain.

Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)? Activity Intolerance

Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

A toddler client with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three times daily by mouth × 10 days for otitis media. Which teaching point will guard against antibiotic resistance to the disease process? Give the antibiotic for the full 10 days.

Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

A parent tells the nurse, "I just don't think my child will make it this time. We have had so many hospitalizations, but this time is different." This statement is consistent with which nursing diagnosis?

Anticipatory Grieving related to child's deteriorating health status The parent is preparing for the worst outcome and expresses an intuition. There is no behavioral evidence of problems with family coping, deficient knowledge, or impaired parenting.

A school-age child with hemophilia falls on the playground and goes to the nurse's office with superficial bleeding above the knee. Which action by the nurse is the most appropriate?

Apply pressure to the area for at least 15 minutes. If a hemophiliac child experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the area for at least 15 minutes. Ice should be applied, not heat. The extremity should be immobilized and elevated, so passive range of motion and keeping the extremity in a dependent position would not be appropriate interventions at this time.

The nurse is evaluating the activity tolerance of a 9-month-old with iron deficiency anemia. Which finding indicates that the infant is not tolerating activity?

Muscle weakness Iron deficiency anemia can result in less oxygen reaching the cells and tissues, causing activity intolerance. An indication that a 9-month-old child is not tolerating activity and that iron deficiency anemia is worsening would be the presence of muscle weakness during activity. A heart rate of 138, increased alertness, and a respiratory rate of less than 40 with activity are all signs that iron deficiency anemia is resolving and activity tolerance is improving.

A nurse working in a pediatric clinic is responsible for monitoring and maintaining the vaccinations on site. Which actions are appropriate for this nurse to implement? Select all that apply. 2. Store vaccines in the center of the unit. 3. Check and record the temperature of the unit twice each day. 4. Have a plan for power outages. 5. Place bottles of water in each unit to help keep temperatures consistent.

Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

A school nurse is planning care for a school-age child recently diagnosed with asthma. Which items will the school nurse include in the plan of care at the school? Select all that apply. 1. Maintain a log of quick-relief medication administration. 3. Assess for symptoms of exercise-induced bronchospasm. 4. Coordinate education of the child's teachers. 5. Conduct a support group for all children with asthma.

Appropriate interventions for the school nurse to include in the plan of care include: keeping a log of the quick-relief medications administered; assessing the child for exercise-induced bronchospasms and reporting, if needed; coordinating education of the child's teachers; and conducting a support group for all children in the school with asthma. The nurse would only call the parents if the quick-relief mediation was not effective in treating the child's symptoms.

A 2-month-old infant is hospitalized for surgical repair of a cleft lip and palate. What is the priority nursing intervention for this infant?

Assess the parents for parental-infant bonding.

A 2-month-old infant is hospitalized for surgical repair of a cleft lip and palate. Priority nursing interventions include:

Assess the parents for parental-infant bonding. Parental bonding might be impaired in an infant with a facial defect. Teaching about safety and about recommended immunization schedules is done during well child care visits; these are not priority nursing interventions at this time. Enteral nutrition equipment is not required for this infant.

Following parental teaching, the nurse is evaluating the parents' understanding of environmental control for their child's asthma management. Which statement by the parents indicates appropriate understanding of the teaching? "We will replace the carpet in our child's bedroom with tile."

Control of dust in the child's bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

A child is admitted with a diagnosis of early localized Lyme disease. Which clinical manifestations would the nurse expect to find on the initial assessment of this client? Select all that apply. Erythema 5 to 15 cm in diameter Fever Headache

Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

A mother refuses to have her child be immunized with measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which response by the nurse is most appropriate? Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mother's belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

A parent brings her school-age child to the clinic because the child has a temperature of 100.2°F. The child remains active without other symptoms. Which statement by the nurse to the parents is most appropriate? "Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection."

Fever is the body's response to an infection, and is not a disease. Allowing the body's natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, and so on. Taking the child's temperature more than every 4 to 6 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

The student nurse is learning a lesson about communicable diseases and how they are spread. On a quiz the next day the nurse uses the information learned in this lesson and demonstrates learning. For a communicable disease to occur what factors must be in place? Select all that apply. 3. Pathogen 4. Transmission 5. Host

For a communicable disease to occur, three factors need to be in place: an infectious agent or pathogen, means of transmission, and a host. This is not a factor needed for communicable disease to occur.

Which medication is used most frequently for rapid diuresis for CHF?

Furosemide (Lasix)

The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. The nurse may also give which of immunizations during the same well-child-care appointment? Haemophilus influenza type B (HIB)

Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12 to 15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12 to 15 months and 4 to 6 years of age (two doses). Varicella (Var) is given at 12 to 18 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 4 to 8 weeks apart.

A nurse begins an infusion of intravenous immune globulin (IVIG) to a child who has combined immunodeficiency disease. Which assessment finding indicates that the nurse should stop the infusion? Severe shaking, chills, and fever

Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but not a severe reaction. Thirst is not an indication of a reaction. Voiding clear yellow urine is a normal finding.

cystic fibrosis may be diagnosed by

IRT/Sweat chloride test

The nurse is teaching a prenatal class about infant care. Under which circumstances should the nurse emphasize that parents should call their healthcare provider immediately? Select all that apply. 2. Child under 3 months old and has a temperature over 40.1°C (104.2°F) 3. Child difficult to awaken and has a pulsing fontanel 4. Child has purple spots on the skin and is lethargic. 5. Child has a stiff neck and has been irritable for three days.

Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1°C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for 3 days in infants and children of any age may indicate meningitis. A mild fever of 38.0°C (100.4°F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Which medications should you teach the patient to rinse mouth afterwards?

Inhaled corticosteroids

A child comes to the clinic for an assessment 20 days post-bone marrow transplant. Which system should receive the highest priority during the nursing assessment?

Integumentary

Parents of a child admitted with respiratory distress are concerned because the child won't lie down and wants to sit in a chair leaning forward. Which response by the nurse is the most appropriate? "This position helps keep the airway open."

Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

The nurse is caring for a child with disseminated intravascular coagulation (DIC). Which nursing intervention is a priority for this child?

Maintenance of skin integrity Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on bed rest. Fluids need to be monitored but will not be restricted, and DIC is not diagnosed with x-ray examination but by serum lab studies.

The nurse is caring for an adolescent client diagnosed with rheumatoid arthritis. Which nonpharmacological measure to reduce joint pain is most appropriate for the nurse to recommend to this client? Moist heat

Moist heat can promote relief of pain and decrease joint stiffness. Elevation of extremity would not have an effect on reducing pain in rheumatoid arthritis. Massage of extremities should be avoided because of a potential risk for emboli. Immobilization can lead to contractures, and range of motion to the involved joint should be maintained.

The nurse is providing care for an adolescent client who is experiencing pain related to a sickle cell crisis. Which medication does the nurse prepare to administer to this client?

Morphine sulfate The pain during a sickling crisis is severe, and morphine is needed for pain control around the clock or by patient-controlled analgesia (PCA). Meperidine is not used for pain control for clients with sickle cell pain crisis because it could cause seizures. Acetaminophen or ibuprofen is used for mild pain and would not be effective for the severe pain experienced by a child in sickle cell pain crisis.

A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). Which nursing intervention is the priority for this child? Administer nebulized epinephrine and oral or IM dexamethasone.

Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

A nurse is providing information to a group of new mothers. Which statement best explains why newborns and young infants are more susceptible to infection? They have immune systems that are not fully mature at birth.

Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns' and young infants' high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse which symptoms made the practitioner suspect cystic fibrosis. Which response by the nurse is the most appropriate? Meconium ileus

Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

The nurse educator is teaching a group of nursing students how to perform a respiratory assessment for a newborn in the newborn intensive care unit (NICU) diagnosed with respiratory distress syndrome (RDS). Which normal characteristics of the newborn's respiratory system increase the risk for obstruction? Select all that apply. 1. Shorter and narrower airway 2. Higher trachea 3. Bronchial branching at different angles

Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.

The nurse is caring for the adolescent with systemic lupus erythematosus (SLE). What nursing diagnoses would the nurse address? Select all that apply. 5. Risk for infection 2. Risk for impaired skin integrity 3. Body image disturbed

Nursing diagnoses that may apply to the adolescent with SLE are: risk for impaired skin integrity, risk for activity intolerance, disturbed body image, risk for infection, acute pain, and ineffective family therapeutic regimen management.

The child actively searches for the object.

Object permanence

What are the general guidelines regarding time outs?

One minute per year of life

The nurse is teaching the parents of a newly diagnosed cystic fibrosis patient how to administer the pancreatic enzymes. How often will the nurse teach the parents to administer the enzymes? With meals and snacks

Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

The nurse is providing care to a school-age client with a documented immunodeficiency who is admitted to the general pediatric unit for intravenous medication administration. Which interventions are appropriate for this client? Select all that apply. 2. Place in a positive-pressure room. 3. Avoid live vaccines. 4. Perform frequent handwashing.

Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.

The nurse is providing care to an adolescent client diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of body changes associated with SLE? She discusses the body changes with a peer.

Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to body-image changes. Refusing to go to school or not going to social functions indicates nonacceptance of the changes to body image.

The charge nurse on a pediatric unit is making a room assignment for a school-age child diagnosed with sickle cell disease, who is in splenic sequestration crisis. Which room assignment is most appropriate for this client?

Private room Splenic sequestration can be life-threatening, and there is profound anemia. The child does not need an isolation room but should not be placed in a room with any child who may have an infectious illness. The private room is appropriate for this child.

A child with meningococcemia is being admitted to the pediatric intensive-care unit. Which room assignment is the most appropriate for this child?

Private room, in respiratory isolation Meningococcemia follows an infection with Neisseria meningitidis. N. meningitidis is transmitted through airborne droplets; thus, the child should be placed in a private room in respiratory isolation. A private room with protective isolation (child is essentially kept in a "bubble") would not be appropriate.

A child who has undergone a hematopoietic stem cell transplantation (HSCT) is ready for discharge. Which items will the nurse include in the discharge teaching for this child and family? Select all that apply.

Recognize the signs of graft-versus-host disease. Practice good handwashing. Avoid live plants and fresh vegetables. A child who is preparing for discharge after a HSCT will require specific interventions to decrease the risk of contracting communicable illnesses. Appropriate teaching points include: recognizing the signs of graft-versus-host disease; practicing good handwashing; and avoiding live plants and fresh vegetables. The child will require home schooling for 6 to 12 months. The child and family members should be encouraged to obtain yearly influenza vaccinations.

A child recently diagnosed with aplastic anemia is being prepared for discharge. When planning support for the family, which service should the nurse plan to include in the discharge plan?

Referrals to support groups and social services Families require support in dealing with a child who has a life-threatening disease. They should be referred to support groups for counseling, if indicated, and to social services. The support will be long term in nature. Aplastic anemia is not a genetically transmitted disease. Nutrition counseling is not a priority and may or may not be needed with aplastic anemia.

The nurse is providing care to a school-age client diagnosed with idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis is the priority for this client?

Risk for Injury ITP is the most common bleeding disorder in children, so risk for injury (bleeding) is the priority nursing diagnosis. The disease process does not usually cause ineffective breathing patterns, nausea, or fluid-volume deficits.

The practitioner changes the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse explains that salmeterol (Serevent) is used to treat asthma because the drug produces which characteristic? Dilates the bronchioles

Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

An HIV-positive mother states she is relieved after the birth of her child to hear that the child is HIV-negative. Which response by the nurse is the most appropriate? "Symptoms could still appear over the next 2 years."

Symptoms of HIV could still manifest within the first 2 years. An infant is retested 1 to 2 months after the initial negative result. The HIV-positive mother can infect the newborn regardless of how well she takes care of herself once she is HIV-positive. There is no reason to assess for signs of pneumonia if the newborn is HIV-negative.

List 3 signs of Congestive Heart Failure in infants?

Tachypnea, tiring with feedings, diaphoresis

The family and school-age child are at the healthcare clinic for immunizations. The nurse takes the time to talk with the child and family about reducing the transmission of infection. What practices should the nurse suggest for the family? Select all that apply. Do not share dishes, utensils, and cups. Dispose of diapers in a closed container.

Teach families to reduce transmission of infection among family members with the following practices: use disposable tissues and dispose immediately after using, wash hands thoroughly with soap/water after all contact with diapers/tissues/mucous, sneeze/cough into elbow, wash hands with soap/water after eating and toileting, do not share dishes/utensils/cups, wash hands thoroughly before preparing food and again several times during the preparation process, use soapy warm water to wash dishes/cutting boards, wipe counters/surfaces that are used for diaper changes or that the child touches with disinfectant, make sure diaper changing area is well away from food prep areas, dispose of diapers in closed containers. This is a practice that the nurse should suggest for the family.

The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. Which statement by the nurse indicates a correct understanding of the concepts presented? "I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room."

The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis? Haemophilus influenzae type B (HIB)

The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

A nurse delegates the task of neonatal vital-sign assessment to a nurse technician. Which instruction will the nurse give to the technician prior to assign care? Report any neonate with a breathing pause that lasts 20 seconds or longer.

The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.

The nurse is assessing a school-age client who experienced blunt force trauma to the chest when an airbag deployed following a motor vehicle crash. Which areas of assessment are essential for this client? Select all that apply. Monitor responsiveness and behavior. Monitor SpO2. Auscultate the lungs for crackles, wheezes, decreased breath sounds. Document input and output.

The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

Reducing the number of preventable childhood illnesses is a major national goal in Healthy People 2020. What will the school nurse teach families regarding immunizations in order to reach this goal? It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten.

The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

The hospital admitting nurse is taking a history of a child's illness from the parents. The nurse concludes that the parents treated their 6-year-old child appropriately for a fever related to otitis media. Which action by the parents brought the nurse to this conclusion? Offered generous amounts of fluids frequently

The body's need for fluids increases during a febrile illness. Aspirin has been associated with Reye syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the child's weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which needle, size and length, injection type, and injection site? 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh.

The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

Which outcome indicates a successful transition from hospital to home for the family of a 2-year-old child with a tracheostomy due to bronchopulmonary dysplasia?

The family provides appropriate home care for child while maintaining family routines. Maintenance of family routines while successfully caring for the ill child is the only answer that addresses the hospital-to-home transition. The child is too young to do self-care. Suctioning the child's tracheostomy and taking the child's vital signs are skills required of the parents before discharge, but performance of skills does not indicate that the parents will successfully navigate the transition to home care.

Which outcome indicates a successful transition from hospital to home for the family of a 2-year-old child with a tracheostomy due to bronchopulmonary dysplasia?

The family provides appropriate home care for the child while maintaining family routines.

A child with human immunodeficiency virus (HIV) also has oral candidiasis. Which type of mouth care solution will the nurse teach the child to use? Normal saline

The mouth care should be with a non-alcohol base. Normal saline can keep the child's lips and mouth moist. Listerine and Scope are commercial mouth rinses that can have an alcohol base and cause drying of the membranes. Viscous lidocaine causes numbing and could depress the gag reflex in a younger child.

The nurse is providing care to an infant in the emergency department. Upon assessment, the infant is noted to have to be experiencing tachypnea, wheezing, retractions, and nasal flaring. The infant is irritability and the parents state the infant has had poor fluid intake for two days. Pulse ox reading is currently at 85 percent on room air. The infant's blood gas is pending. Which diagnosis does the nurse anticipate for this infant? Bronchiolitis

The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes.

The nurse is discussing ways to treat fever in the home environment to a group of parents in the community. Which statement is appropriate for the nurse to include in the presentation? "Purchase a new bottle of acetaminophen for your newborn because it will have recommended medication concentration."

The recommendation to purchase a new bottle of acetaminophen due to recommended medication concentrations is an appropriate statement for the nurse to include in the teaching session. The other statements are inaccurate or inappropriate for the nurse to include in the teaching session.

The school nurse is trying to prevent the spread of a flu virus through the school. Which infection-control strategies can be employed to prevent the spread of the flu virus? Select all that apply. 3. Sanitizing toys, telephones, and door knobs to kill pathogens 4. Separating children with infections from children who are well 5. Teaching children to wash their hands after using the bathroom

To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

A child is showing signs of acute respiratory distress. Which position will the nurse place this child? Upright

Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowler's (head up slightly) do not allow for as optimal chest expansion as the upright position.

A child diagnosed with hemophilia plans on participating in a bicycling club. Which recommendation by the nurse is the most appropriate?

Wear kneepads, elbow pads, and a helmet while bicycling. Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option and is recommended along with swimming. The child should always use kneepads, elbow pads, and a helmet when participating in a physical sport. Participating only in the social aspects of the club would not encourage physical activity. Discouraging a child from joining a club would not foster growth and development.

The nurse is providing care to an infant who is diagnosed with bronchiolitis. Which breath sounds indicate the infant is experiencing respiratory distress? Select all that apply. 1. Tachypnea 2. Wheezing 3. Grunting

Wheezing and grunting are adventitious respiratory sounds that indicate respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachypnea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for "normal breathing."

The nurse is providing discharge teaching to a school-age client who was recently diagnosed with a latex allergy. Which product will the nurse educate the client and family to avoid? Chewing gum

When a child is diagnosed with a latex allergy, it is essential for the nurse to educate both the child and the family regarding sources of latex within the home and the community. The child and family should be educated to avoid chewing gum as it contains latex. The other items do not contain latex and do not pose a risk for this child in the community.

A nurse is administering an intramuscular vaccination to an infant diagnosed with Wiskott-Aldrich syndrome (WAS). Which reaction is the infant more at risk for due to the diagnosis of WAS? Bleeding at injection site

Wiskott-Aldrich syndrome is characterized by thrombocytopenia, with bleeding tendencies appearing during the neonatal period. The syndrome would not put the child at higher risk for pain, redness, swelling, or rash at the injection site.

The nurse is administering packed RBCs to a child with sickle cell disease (SCD). The nurse is monitoring for a transfusion reaction and knows it is most likely to occur during which time frame?

Within the first 20 minutes of administration of the transfusion Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.

a 15 month old with viral croup is admitted. the nurse is concerned that:

barking-seal cough

which symptoms in an 8 month old would suggest cystic fibrosis?

fatty stools

Following a tonsillectomy a child vomits what looks like blood. the nurse should

notify the physician

a result of repeated infections in children with cystic fibrosis is

pulmonary damage

cystic fibrosis affects the following body systems EXCEPT

stomach

epiglottitis is usually caused by Haemophilus influenza type B

true