Kyle and Carman: Essentials of Pediatric Nursing
A nurse is performing a physical examination on a newborn. Which assessment should the nurse include? Temporal temperature, blood pressure, reflexes Axillary temperature, femoral pulse, head circumference Oral temperature, blood pressure, head circumference Rectal temperature, femoral pulse, head circumference
Axillary temperature, femoral pulse, head circumference
The nurse is establishing a long-term relationship with a child who will be seeking treatment for cancer. What is the most important factor in this relationship? determining appointment times for meetings establishing a timeline for the relationship establishing trust setting goals for the relationship
establishing trust
The nurse is caring for a client who is having an acute attack of asthma that is not responding to standard asthma treatment. Which medication does the nurse anticipate administering? rocuronium ketamine fentanyl citrate lidocaine
ketamine
A 12-year-old client is hospitalized. Which finding will the nurse expect while providing care to this client? uncomfortable during genital assessment separation anxiety refusal of treatments inability to understand explanation
uncomfortable during genital assessment
A few days after discharge, the parent of an 8-year-old calls the pediatric clinic, expressing concern about the child's behavior now that she is home. The child has been treating her siblings badly and using inappropriate language. Which suggestion should the nurse prioritize to this caregiver as an appropriate way to handle this situation? "Children often feel guilty for the attention they've taken away from their siblings and act out as a way of earning the attention." "Coming home is a difficult adjustment. Warn your daughter that you expect her to begin to behave better over the next few weeks." "Respond to her behavior in a firm, loving, consistent way." "Tell her you don't like her behavior and have her stay in her room until she can be nicer to her siblings."
"Respond to her behavior in a firm, loving, consistent way."
The nurse is assessing a child with a suspected head injury. The child opens the eyes only in response to the nurse placing pressure in the child's nail bed. What score on the Glasgow coma scale for eye opening should the nurse assign based on this assessment finding? 3 2 4 1
2
The student nurse is caring for a child who weighs 48 pounds and is 38 inches tall. Which is the child's body mass index (BMI)? 33 28 32 23
23 (Weight in pounds X 703) ÷ (height in inches X height in inches) (48*703)/(38*38)
The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take? Count abdominal movements. Count the respiratory rate for 30 seconds. Place a stethoscope to count respirations. Count after the child stops crying and is comfortable.
Count after the child stops crying and is comfortable.
The nurse is preparing to conduct the cover test with a preschool-age child. Which body system is the nurse preparing to assess? Ears Eyes Neck Nose
Eyes
A young client is admitted with a fever, vomiting, and diarrhea. Upon taking the health history, the nurse asks the client's parent, "What did you do to help your child before coming to health facility?" This is an example of which type of question? Leading Compound Expansive Closed-ended Open-ended
Open-ended
A 4-year-old girl injured in an automobile accident is suspected of having a head injury. What would be the priority action? Providing manual stabilization of the head and neck. Stabilizing the head and neck with a pediatric backboard. Hyperventilating the child with a bag-valve-mask. Opening the airway using the jaw thrust maneuver.
Opening the airway using the jaw thrust maneuver.
The nurse is providing staff education regarding the use of the BroselowTM tape for pediatric emergencies. What would the nurse include in the education plan? One disadvantage is the tape doesn't include medication dose information. The child should be measured while in a sitting position. The tape is useful to estimate the child's weight based on the length. The tape is ideal for estimating the child's age when the information is needed quickly.
The tape is useful to estimate the child's weight based on the length.
The nurse is caring for a 7-year-old boy in a body cast. He is shy and seems fearful of the numerous personnel moving in and out of his room. How can the nurse help reduce his fear? Write the name of his nurse on a board and identify all staff on each shift, every day. Encourage the boy's parents to stay with him at all times to reduce his fears. Tell him not to worry; explain that everyone is here to care for him. Remind the boy he will be out of the hospital and going home soon.
Write the name of his nurse on a board and identify all staff on each shift, every day.
The child presents to the emergency department via ambulance in uncompensated SVT at a rate of 262 beats per minute. The nurse receives an order to administer adenosine IV. In addition to adenosine, what would the nurse bring to the bedside in preparation to administer the adenosine? an emesis basin for the child to use if vomiting a consent form for the child or parent to sign a generous saline flush to follow the IV medication a blood pressure cuff in the appropriate size
a generous saline flush to follow the IV medication
An 8-year-old girl with tachycardia is alert, breathing comfortably, and exhibiting signs of adequate tissue perfusion. Which nursing intervention would be most appropriate for this child? initiating cardiac compressions oxygenating and ventilating the child applying ice to the child's face administering epinephrine as ordered
applying ice to the child's face
Which medication is used for symptomatic bradycardia unresponsive to ventilation and oxygenation? calcium carbonate atropine sodium bicarbonate naloxone
atropine
The nurse is assisting with the physical examination on a sleeping 10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment? eyes, ears, nose, mouth; back and extremities; then the head and neck head and neck; eyes, ears, nose, mouth; then the back and extremities back and extremities; head and neck; then the ears, nose, mouth, and eyes back and extremities; eyes, ears, nose, mouth; then the head and neck
back and extremities; head and neck; then the ears, nose, mouth, and eyes
The nurse is caring for a hospitalized toddler who is prescribed bedrest. Which item(s) would the nurse recognize as appropriate for the toddler? Select all that apply. fine-print books or magazines to read jigsaw puzzle with pieces 1/2 in (1.25 cm) or smaller stacking blocks or small boxes nursery rhymes or sing-along songs on tape boxes to put toys in and/or take out toys coins, small tokens, or marbles to organize and sort
boxes to put toys in and/or take out toys stacking blocks or small boxes nursery rhymes or sing-along songs on tape
The nurse is examining a child's skin for lesions and rashes. When documenting the findings, which would the nurse include? Select all that apply. location color jaundice distribution size
color location size distribution
The nurse is taking vital signs on a group of assigned preschool children. Which assessment finding would indicate the need for further action? respiratory rate of 20 breaths per minute heart rate of 89 beats per minute respiratory rate of 24 breaths per minute heart rate of 120 beats per minute
heart rate of 120 beats per minute Explanation: The normal range for heart rate for a preschooler is between 65 and 110 beats per minute. The normal range for respiratory rate for a preschooler is between 20 and 25 breaths per minute. A heart rate of 120 would be abnormal.
The nurse is examining a 10-month-old infant who has fallen from the back porch. Which nursing action has priority? maintaining an adequate airway assessing neurological status palpating the anterior fontanel (fontanelle) assessing skin color and perfusion
maintaining an adequate airway
During the physical examination, the nurse notes a positive Kernig and Brudzinski sign. The nurse interprets these findings to suggest which condition? meningeal irritation auditory problems organic heart murmur visual impairment
meningeal irritation
The nurse is assessing an 8-year-old child in the emergency department. Which assessment finding would be a priority and alert the nurse to intervene immediately? a pleural fiction rub systolic blood pressure of 86 expiratory wheezing minimal air movement in the lung fields
minimal air movement in the lung fields
A nurse is conducting an in-service education program for a group of pediatric nurses working on the pediatric unit of a local facility. The nurse is comparing the adult chain of survival with the pediatric chain of survival. The nurse determines that the teaching was successful when the group identifies which activity as the first step in the pediatric chain? early advanced care early access to emergency response system prevention of cardiac arrest and injuries early CPR
prevention of cardiac arrest and injuries
On the first postoperative day, a 4-year-old child who was hospitalized for an emergency appendectomy has begun to cry relentlessly, will not let the nurse touch him or her, and keeps asking for the parent. The pediatric nurse is aware that this client is in which stage of separation? despair grief denial protest
protest Explanation: Separation anxiety is very real for the hospitalized child who is separated from parents or caretakers. Separation anxiety has three stages. This child is displaying symptoms of the first stage of separation, which is protest. The child reacts aggressively, cries, and exhibits great distress. The child rejects others who would attempt to provide care or comfort. The second stage is despair. During this stage the child displays hopelessness, is quiet without crying, and lacks any interest in play or food. The third stage is denial. During this phase, the child is detached and has formed coping mechanisms to avoid any further emotional pain. Grief is not a stage of separation anxiety.
The registered nurse (RN) will intervene if the unlicensed assistive personnel (UAP) is noted performing which task? obtaining blood pressure reading on a toddler admitted for recurrent urinary tract infections obtaining an infant's apical pulse while the infant is asleep in the crib pulling the earlobe down and back while checking a school-age client's tympanic temperature counting the respirations on a preschool-age client for a full minute
pulling the earlobe down and back while checking a school-age client's tympanic temperature
The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding? labial adhesions swollen and red anal area swollen labia minora lesions on the external genitalia
swollen labia minora
The charge nurse is planning staffing on a pediatric unit. Which client will the charge nurse assign to the registered nurse? the 1-year-old client with a respiratory disorder prescribed oxygen therapy the 6-year-old client admitted yesterday for oral rehydration following a mild gastrointestinal disorder the 12-year-old client with a urinary tract infection taking oral antibiotics the 8-year-old client recovering from an appendectomy who is ambulating
the 1-year-old client with a respiratory disorder prescribed oxygen therapy
Where is the point of maximal impulse (PMI) found in a 5-year-old child? the fourth intercostal space the third intercostal space the clavicle the sternum
the fourth intercostal space
The nurse is working with a child-life specialist to assist a young preadolescent who is preparing for treatment for cancer. Which technique will the nurse and specialist prioritize to assist this child in better understanding what will be happening in the treatment of the cancer? therapeutic play play therapy onlooker play cooperative play
therapeutic play
A nurse caring for a 5-year-old who had abdominal surgery yesterday is trying to teach the child how to take deep breaths. The best way that the nurse can accomplish this is by: teaching pursed-lip breathing. using a pinwheel. using a flow meter. using a spirometer.
using a pinwheel.
The nurse is auscultating the lungs of a lethargic, irritable 6-year-old boy and hears wheezing. The nurse will most likely include which teaching point if the child is suspected of having asthma? "We're going to go take a look at your lungs to see if there are any sores on them." "I'm going to have this hospital worker take a picture of your lungs." "I'm going to have the respiratory therapist get some of the mucus from your lungs." "I'm going to hold your hand while the phlebotomist gets blood from your arm."
"I'm going to have this hospital worker take a picture of your lungs."
The nurse is caring for a preschooler who is hospitalized with a suspected blood disorder and receives an order to draw a blood sample. Which approach is best? "Why don't you sit on your mom's lap?" "I need to take some blood." "We need to put a little hole in your arm." "I need to remove a little blood."
"Why don't you sit on your mom's lap?"
The nurse is caring for a preschooler who requires postsurgical breathing exercises. Which approach will best elicit the child's cooperation? "Let's see who can blow these cotton balls off the table first." "You will need to cooperate. Otherwise, you might not feel better." "Do you want to play a breathing exercise game with me?" "You need to do the breathing or you could get pneumonia."
"Let's see who can blow these cotton balls off the table first."
When obtaining information from a teen concerning the reason for seeking health care, which question would be most important? "Do you have any health concerns?" "How long have you been ill?" "What health concerns are you having?" "Have you been feeling well lately?"
"What health concerns are you having?"
A child is hospitalized with suspected sepsis. The health care provider has prescribed an intravenous fluid bolus of lactated Ringer's solution 15 ml/kg to infuse over 20 minutes. The child weighs 52 lb (23.6 kg). How much fluid should the nurse administer? Record your answer using a whole number.
354
A 14-year-old female has been brought to the pediatric ambulatory care clinic for a "sports physical" by her mother. The teen tells the nurse she does not want to have her mother present during the examination. What action by the nurse is most appropriate? Explain to the teen that since she is under the age of 16 she must be examined with a parent in attendance. Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed. Talk with the teen and her mother together to ask for each to sign a consent waiver for this request to be granted. Ask the physician for permission to proceed with the teen's request.
Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed.
Which approach by the nurse best demonstrates the correct way to prepare a Hispanic child for a planned hospital admission? Tell the child that the procedure will not hurt because we have "magic medicine." Discourage questions so as to not frighten the child. Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening. Since the family is Hispanic, all preparation needs to be in Spanish.
Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening.
A child has fallen from a swing at the playground and the parent states that the child became groggy. After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next? Provide pain management. Obtain blood glucose. Assess the level of consciousness. Obtain a full set of vital signs.
Assess the level of consciousness.
The nurse is caring for a 6-year-old client who is prescribed to cough and deep breathe following surgery. Which nursing action is best for this client? Arrange for respiratory therapy to do coughing and deep breathing exercises with the child. Blow a pinwheel and bubbles with the child. Have the parents encourage the child to cough and deep breathe every 2 hours. Teach the child to use an incentive spirometer.
Blow a pinwheel and bubbles with the child.
A toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point? Obtaining the health history Determining the chief complaint Obtaining biographical data Interviewing the client
Determining the chief complaint
A nursing instructor is reviewing a care plan written by a student on a hospitalized child. Which nursing intervention for the diagnosis of self-care deficit related to regression would the nursing instructor question? Provide child-sized equipment and devices as needed. Encourage the parents to do as much self-care for the child as possible. Assess the child's usual home routine for self-care. Encourage rest periods for the child as needed.
Encourage the parents to do as much self-care for the child as possible.
The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately? High-pitched breath sounds over the trachea Minimal air movement through the lungs Low-pitched bronchial sounds over the periphery Resonance over the lungs on percussion
Minimal air movement through the lungs
The nurse is caring for a 13-year-old girl. As part of a routine health assessment the nurse needs to address areas relating to sexuality and substance use. Which statement or question should the nurse say first to encourage communication? Tell me about some of your current activities at school. I promise not to tell your mother any of your responses. Do you smoke cigarettes or marijuana? Are you considering sexual activity?
Tell me about some of your current activities at school.
The nurse is assessing a 6-year-old child. The nurse instructs the child, "Let me see all of your pretty white teeth." Which cranial nerve is the nurse assessing? VI IV VII II
VII
A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction? up up and back down and back forward
down and back
A nurse who has worked in a variety of settings over the past several years is trying to determine what setting she would most like to work in now. The nurse is very organized, works well in an autonomous environment, and prefers one-on-one care. Which setting would best fit this nurse's needs? school nurse home health health department physician's office
home health
A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe? black and blue areas on the skin bluish coloration of lips and nail beds round flat lesions on the neck redness of the cheeks and lips
redness of the cheeks and lips
The nurse is preparing to start an intravenous (IV) line on a stable pediatric client in the hospital. Which location is most appropriate for the nurse to use for this procedure? the pediatric treatment room room selected by the client the unit's playroom the child's hospital room
the pediatric treatment room
The nurse is caring for a 10-year-old child admitted for a surgical procedure to be done the next day. The nurse takes the child to a special area in the playroom and lets the child "start" an IV on a stuffed bear. This is an example of: age-related activity. therapeutic play. play therapy. positive reinforcement.
therapeutic play.
Blood pressure monitoring becomes part of the routine health assessment at what age and older? 2 years birth 3 years 4 years 1 year
3 years
The nurse collects a client history including biographical data regarding the child being admitted. Which responsibility is most important related to the data collected? The information collected such as food likes/dislikes and eating habits, should be relayed to appropriate departments in the health care setting. This information is part of the legal record and should be treated as confidential. The data need to be shared and communicated to the medical and nursing staff. Documentation of the information collected should be done as soon as these data are gathered.
This information is part of the legal record and should be treated as confidential.
A 10-year-old child comes to the emergency department as a victim of abuse. The child's parent reports that the child was hit repeatedly with a baseball bat a few hours prior. The initial assessment indicates the child's blood pressure is 84/40 mm Hg. The nurse would further assess the child for what finding? allergies, specifically any history of anaphylactic reactions signs of septic shock resulting from infection history of cardiac structural heart disease or arrhythmias injuries resulting in ongoing blood loss
injuries resulting in ongoing blood loss
A nurse is interviewing a parent regarding the 2-year-old child's recent illness. The nurse would like the parent to elaborate about any symptoms of the illness noticed. Which would be the most effective question for the nurse to ask the parent in this situation? "Has your child exhibited a fever and vomiting?" "Has your child exhibited any symptoms?" "What symptoms has your child exhibited?" "Your child hasn't exhibited a fever, has she?"
"What symptoms has your child exhibited?"
A nurse is caring for a very shy 4-year-old girl. During the course of a well-child assessment, the nurse must take the girl's blood pressure. Which approach is best? "May I take your blood pressure?" "Help me take your doll's blood pressure" "Your sister did a great job when I took hers." "Will you let me put this cuff on your arm?"
"Help me take your doll's blood pressure"
The nurse is providing teaching for the parents of an 8-year-old girl who has undergone surgery. The nurse emphasizes the importance of maintaining adequate hydration. Which response by the mother would indicate a need for further teaching? "I will remind her that she will need an IV if she does not drink." "I should offer her small amounts of fluid frequently." "Anything that melts at body temperature is counted as a fluid." "Ice chips count as fluid intake. One cup of ice equals a half-cup of water."
"I will remind her that she will need an IV if she does not drink."
The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation? A mobile tympanic membrane A bubble behind the tympanic membrane A gray tympanic membrane Visible bony landmarks behind the membrane A pearly pink membrane
A bubble behind the tympanic membrane
A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which treatment is most likely appropriate in the immediate treatment of the girl's poisoning? Gastric lavage Inducing vomiting Intravenous rehydration Administration of activated charcoal
Administration of activated charcoal
The nurse is caring for a child who has had an endotracheal tube placed and is hooked to a ventilator. When assessing the child, the nurse notes that they child is exhibiting signs of poor oxygenation. What should the nurse do? Select all that apply. Assess the ventilator equipment, checking to see that all tubing is connected correctly. Assess for tracheal tube obstruction. Assess for the presence of decreased breath sounds on one side of the chest. Assess tracheal tube placement. Assess for decreased body temperature.
Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly.
The nurse is performing a physical exam on a 3-year-old boy. What method would the nurse use to perform the exam? Examine the child's chest and then go to the head and down. Examine the child's head and work down to the child's toes. Examine the child's extremities first and then the chest. Examine different sections of the body at various times.
Examine the child's head and work down to the child's toes.
A preschooler is admitted to the pediatric floor for dehydration and is frightened. Which nursing intervention would be least effective in alleviating the child's anxiety? Encourage a caregiver to stay with the child when possible. Explain all procedures using medical terminology. Assign the child to the same nurse each day. Allow the child to handle the blood pressure cuff before using it.
Explain all procedures using medical terminology.
The nurse is assessing a 4-year-old child who reports having ear pain. What would the nurse incorporate into the assessment? Sit the child on the examination table before examining the child's ears. Use diagrams and pictures to explain how the nurse will assess the ear. Grasp the pinna and pull up and back gently in order to assess the ear. Avoid having the child see or touch the otoscope prior to the examination.
Grasp the pinna and pull up and back gently in order to assess the ear.
A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history database? Recent or past hospitalizations Past accidents the child was involved in Coping strategies of the child Immunization record
Immunization record
A community health nurse is planning a class on water safety for families. What information is important for the nurse to include in the class? Select all that apply. Children who have learned to swim require less supervision. It is important for adult supervision at poolside at all times. The family needs to maintain fencing around pools to deter unsupervised swimming. Personal floatation devices are recommended for children riding in boats. Small inflatable wading pools are safe options for toddlers.
It is important for adult supervision at poolside at all times. The family needs to maintain fencing around pools to deter unsupervised swimming. Personal floatation devices are recommended for children riding in boats.
The nurse is assessing the neurologic status of an infant. What would the nurse identify as an abnormal finding? Vigorous crying Making eye contact with the nurse Soft, flat anterior fontanel (fontanelle) Lack of interest in surroundings
Lack of interest in surroundings
The nurse has been assigned to care for a child who is on transmission-based precautions. This nurse has not cared for this child before. Which action would be the best way to help the child feel comfortable with the nurse? Let the child see the nurse's face before the mask is put on. Read to the child for a few minutes before starting care. Remind the child that her caregivers will be in to visit soon. Ask the parent to introduce the new nurse.
Let the child see the nurse's face before the mask is put on.
The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing? root palmar grasp Moro Babinski
Moro
The parents bring the child for a health exam. After eliciting a chief concern from the parents, the nurse continues gathering information about related and other health concerns. Why is it important for the nurse to ask a second time at the end of the interview if there are other concerns? Parents might have concerns that are not so important and should accurately be addressed at the end of the interview. The nurse should help assuage any parental fears before ending the interview. Parents always have more than one concern. Parents will not always reveal their most important concern in the initial minutes of the interview.
Parents will not always reveal their most important concern in the initial minutes of the interview.
A preschool teacher calls the hospital and wants to introduce the concept of a hospital to her preschool class in case they ever get sick and need to be admitted. What resources could the child life specialist provide for this group to aid in their learning? Select all that apply. Provide a room for the class with hospital gowns, masks and equipment used on children. Tell the children that hospitals are places for sick people to come and sometimes they don't leave. Offer to let them see and play with the injection equipment such as syringes and needles. Let the children lie in the beds, use the call lights and practice being a patient. Tour the hospital, including the playrooms on the pediatric floors.
Provide a room for the class with hospital gowns, masks and equipment used on children. Tour the hospital, including the playrooms on the pediatric floors. Let the children lie in the beds, use the call lights and practice being a patient.
A 7-year-old girl is in the intensive care unit following a bicycle accident. Which would be most helpful in providing support to the girl's parents? Giving them brief explanations of procedures Providing honest answers in a reassuring manner Encouraging them to read to their daughter Describing the treatment plan for their daughter
Providing honest answers in a reassuring manner
The nurse is preparing to measure an infant's temperature with a tympanic thermometer. Which is the correct way to position the device? Pull the child's earlobe back and up, and point the sensor beam toward the side of the ear canal. Pull the child's earlobe back and down and point the sensor beam toward the center of the tympanic membrane. Pull the child's earlobe back and up, and point the sensor beam toward the center of the tympanic membrane. Pull the child's earlobe back and down, and point the sensor beam toward the side of the ear canal.
Pull the child's earlobe back and down and point the sensor beam toward the center of the tympanic membrane.
The toddler needs elbow restraints to keep his hands away from a facial wound. What will the nurse do to best ensure their safe use? Have the parent check for equal warmth bilaterally in his hands and fingers. Choose restraints long enough to fit closely under the arm and extend over the wrist. Apply lotion to the skin prior to putting on the restraints. Remove one restraint at a time on a regular basis to check for skin irritation.
Remove one restraint at a time on a regular basis to check for skin irritation.
The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated? Document the finding as normal. Ask the mother if this was a problem in her other children. Explain to the child's mother that this is normal until about one year of age. Report the findings to the physician.
Report the findings to the physician.
A 3-year-old child has sustained injuries from a fall. Once the airway is secured, what interventions would be next? Check mouth for debris. Stabilize the cervical spine. Administer 100% oxygen. Set up antecubital IV access.
Stabilize the cervical spine.
The nurse is caring for a 7-year-old client who suffered extensive burns from a house fire. Which finding in the client's history most concerns the nurse? The child appears withdrawn and frightened. The child was home alone when the fire started. The child's clothing was burned when exiting the home. The child was trapped in a burning bedroom.
The child was trapped in a burning bedroom.
The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct? These lesions are associated with the development of Sturge-Weber syndrome. Once the child has grown these lesions are usually removed by lasers. Biopsies of these areas are usually taken once the child is a teen. These lesions will normally fade as the child ages.
These lesions will normally fade as the child ages.
The nursing student correctly identifies the major cause of death in the 1- to 4-year-old age group to be which of the following? congenital disorders immunosuppressive disorders accidents cancer
accidents
The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent? Adolescents will share more about themselves in a private conversation. Adolescents will not likely share information related to sexual relationships or to use of substances. Adolescents should be asked if they would like a peer in the room during the interview. Adolescents will talk more openly if their caregiver is in the same room.
in a room with a child near the same age
A school-aged child needs to have an IV started. Where would be the best place for the nurse to perform this procedure? off the floor in a procedural suite in the child's room, ensuring privacy in a treatment room in the playroom where there are distractions
in a treatment room
The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement? "I used one of those thermometers that goes in the ear, but I don't think it was accurate." "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better." "I know rectal temperature is pretty accurate but I didn't see that it was necessary to cause the discomfort of that route." "We have an electronic oral thermometer. It seemed to match our child's symptoms of fever better."
"My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better."
A nurse is assessing the blood pressure of a 5-year-old child brought into the emergency department after being involved in a motor vehicle accident. Which systolic blood pressure would the nurse identify as a cause for concern? 70 mm Hg 99 mm Hg 82 mm Hg 90 mm Hg
70 mm Hg
The nurse has performed an across-the-room assessment of an 8-year-old child and has classified her as emergent. Which of the following signs and symptoms has the nurse seen? The child is asleep on the mother's lap. The child's lips are blue. The child is guarding one hand. The child is scratching a rash.
The child's lips are blue.
The nurse is conducting an educational class regarding the use of the intraosseous site for administration of fluid to the pediatric client experiencing an emergency, such as shock. What would the nurse include in this educational presentation? The nurse will utilize a small gauge catheter for children, such as a 25 gauge. The child must be in a left-side lying position with the spine flexed to access properly. The intraosseous site is used only for crystalloid fluids such as normal saline. The intraosseous site is preferred if peripheral access cannot be attained rapidly.
The intraosseous site is preferred if peripheral access cannot be attained rapidly.
A nurse in a pediatrician's office is assessing a 4-year-old child. What assessment techniques will the nurse use with a preschool-age child? To improve the assessment process with a preschool-age child, the nurse will _________(1) and _________________(2). (1): have the child sit on the parent's lap involve the child in the assessment set firm rules (2): direct all questions to the parents perform most invasive procedures first allow the child to play with safe medical equipment
To improve the assessment process with a preschool-age child, the nurse will (1) involve the child in the assessment and (2) allow the child to play with safe medical equipment
The nurse is doing an assessment of a 10-year-old girl. She whispers the girl's name from behind the girl. Which cranial nerve is the nurse assessing for? III VIII IV V
VIII
A 2-year-old boy is in respiratory distress. Which nursing assessment finding would suggest the child aspirated a foreign body? noting absent breath sounds in one lung hearing dullness when percussing the lungs hearing a hyperresonant sound on percussion auscultating a low-pitched, grating breath sound
noting absent breath sounds in one lung
The nurse begins the physical exam to obtain the child's vital signs. Which would the nurse assess first? respirations blood pressure temperature pulse
respirations
The nurse is weighing a 20-month-old child who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child? The nurse should weigh the parent on a standing scale and then weigh the parent again while holding the child. The nurse should lay the parent on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight. The nurse should ask the parent to lightly hold the child's hands while the child is sitting on the scale. The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.
The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.
A 15-year-old female is being seen for an annual physical examination. The teen asks the nurse if what they talk about will be kept private. What is the appropriate response by the nurse? "Since you are 15 there are some things we can keep private if you wish." "There are some things I may need to share with your parents or physician." "Until you are 16 years of age you will not be afforded total privacy from your parents with regard to your health care concerns." "Privacy is important and I will not share anything we talk about with your parents."
"There are some things I may need to share with your parents or physician."
The parents of an 8 year-old state, "I am happy that our child is healthy," when the nurse says that the child falls into the 95th percentile for BMI. How should the nurse respond? "For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level." "Being in the 95th percentile for BMI is not a good thing. Your child is on the verge of obesity. It would be a good idea to consider this with meal planning." "I will let the physician know that your child is in the 95th percentile for BMI." "The 95th percentile is not an indication of health."
"For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level."
The nurse is collecting a brief health history from the parents of a 3-year-old child brought to the emergency department experiencing a cardiac emergency. What questions are appropriate for inclusion? Select all that apply. "What foods or drugs is your child allergic to?" "Has your child had any recent illnesses?" "How many children live in the home?" "Tell me about any coughing or wheezing you may have noticed when your child has been playing lately." "What activities does your child like to do?"
"Has your child had any recent illnesses?" "What foods or drugs is your child allergic to?" "Tell me about any coughing or wheezing you may have noticed when your child has been playing lately."
The nurse is providing care for a hospitalized child who is scheduled to receive morning medications. Place the statements in order that the nurse will state them, beginning with what the nurse will say first during the medication administration. Use all options. - "Hello, I am going to be your nurse for today." - "Would you like your medicine before or after your mom helps you take a bath?" - "You are doing great today. Would you like to play a game now?" - "It is time for you to take your morning medications."
"Hello, I am going to be your nurse for today." "It is time for you to take your morning medications." "Would you like your medicine before or after your mom helps you take a bath?" "You are doing great today. Would you like to play a game now?"
The nurse has completed teaching a CPR course for a local day care. Which statement by a participant indicates a need for further education? "I will use one hand to compress the chest of a toddler." "I will compress 30 times and then give 2 breaths if I am giving CPR to a child or infant." "I will place the heel of my hand on the sternum of a 9-month-old when performing CPR." "I will compress 30 times and then give 2 breaths if I have to give CPR to an infant."
"I will place the heel of my hand on the sternum of a 9-month-old when performing CPR."
A child's parent calls the clinic nurse and states, "My child just drank an unknown amount of a cleaning solution. What should I do?" Which statement by the nurse is best? "Monitor your child's breathing and heart rate closely for the next 24 hours." "You need to give your child ipecac syrup to induce vomiting." "You need to hang up with me and call the poison control center now." "Immediately take your child to your local emergency facility."
"You need to hang up with me and call the poison control center now."
A child is to undergo synchronized cardioversion. The child weighs 44 lb (20 kg). The nurse would expect how many joules to be delivered? 5 to 10 joules 2 to 4 joules 30 to 40 joules 10 to 20 joules
10 to 20 joules Explanation: Energy for cardioversion is delivered at 0.5 to 1 joule/kg. The child weighs 44 lb or 20 kg. Therefore, the child would receive 10 to 20 joules.
The nurse is documenting the child's intake. The child ate 4 cups of ice during this shift. How many cups of fluid did the child ingest? 4 cups of fluid ½ cup of fluid 1 cup of fluid 2 cups of fluid
2 cups of fluid
A nurse is reviewing the physical exam of a child. The nurse notes that the child's deep tendon reflexes were normal, because they were graded as: 3+ 2+ 1+ 4+
2+
A nurse realizes the importance of nutritional assessment during the health history. When doing so, the nurse must assess the quality as well as quantity of food eaten. The best way to assess food intake is to do a: 24-hour recall. 12-hour recall. 1-week recall. 3-day recall.
24-hour recall.
The nurse is assessing a child who has been injured. What assessment finding would support the need to initiate a notification to the abuse registry so that child protection specialists can investigate? There is bruising to various parts of the body after reported fall from a swing. The child and both parents' descriptions of the accident are the same. The child and parent have conflicting stories on what caused the injury. The child has a greenstick fracture.
The child and parent have conflicting stories on what caused the injury.
Due to casts on both arms, the nurse must measure an 11-year-old client's blood pressure in the thigh. After placing the blood pressure cuff on the thigh, which action by the nurse demonstrates understanding of the procedure? The nurse places the stethoscope over the popliteal artery. The nurse places the stethoscope over the femoral artery. The nurse places the stethoscope over the dorsalis pedis artery. The nurse places the stethoscope over the posterior tibial artery.
The nurse places the stethoscope over the popliteal artery.
The nurse is providing support to the parents of a 10-year-old boy receiving emergency care. The boy is their foster child. Which comment will be most effective? "Hold your child's hand while this is going on." "I think you had better stay out here and wait to hear from us." "Your child is hypovolemic and needs fluid." "Since you are not his biological parents, you must wait outside."
"Hold your child's hand while this is going on."
A 9-year-old has suffered a severe anaphylactic reaction and dies. The nurse is providing support for the grieving parents. Which comment would best help them cope? "How can I help you get through this?" "You would be more comfortable here in the lounge." "Can I get you something to eat?" "Would you like to see the chaplain?"
"How can I help you get through this?"
A nurse with no pediatric experience has been transferred to a pediatric unit to work for the day. Which comment by the nurse indicate knowledge of developmental considerations when providing hygiene needs to a 3-month-old infant? "I will be sure to only leave the infant for a very short time if I forget anything during the bath." "I think the baby is old enough for me to use the bathtub if I am careful." "I need to find the talcum powder to use after the bath." "I plan on using a sponge bath to bathe the infant."
"I plan on using a sponge bath to bathe the infant."
A nurse is educating the parents on how to help their 10-year-old daughter deal with an extended hospital stay due to surgery, followed by traction. Which response indicates a need for further teaching? "We must prepare her in advance." "She will be sensitive to our concerns." "I should not tell her how long she will be here." "She will watch our reactions carefully."
"I should not tell her how long she will be here."
The nurse is speaking to a hospitalized child's parent about ways to encourage good nutrition while the child is hospitalized and after discharge. Which statement by the parent would indicate the need for further education? "I will bring his favorite sippy cup from home to use." "I will make the menu choices for my child so I make sure he is getting a balanced diet." "I will make sure my husband or I are here for all meals." "I will make sure we always have ice chips in the room for him to suck on."
"I will make the menu choices for my child so I make sure he is getting a balanced diet."
The nurse is performing an assessment of the genitalia of a 15-year-old male. The nurse notes that the pigment of the skin of the scrotum is much lighter than the rest of the client's skin color. What is the nurse's best action? Ask the client if the scrotal skin has always been lighter in pigment than the rest of the patient's skin. Document the findings so there is proof of the assessment findings. There is no need to address this issue since this is a normal finding for an adolescent male. Talk with the client's parents to see if they were aware of this pigment issue.
Ask the client if the scrotal skin has always been lighter in pigment than the rest of the patient's skin.
The nurse is preparing to assess and intubate a school-aged child who presents via ambulance to the emergency department. The child has been manually ventilated prior to arrival. The nurse obtains a nasogastric tube in preparation to care for the child for what reason? In order to intubate the child quickly, the nasogastric tube must be inserted before intubation The child will be restricted from eating or drinking while the endotracheal tube is in place The nasogastric tube will alleviate any accumulation of air in the stomach A nasogastric tube will permit the endotracheal tube to be secured properly
The nasogastric tube will alleviate any accumulation of air in the stomach
While at school, the client is called to the school nurse's office. The school nurse is performing secondary prevention interventions. Which would the nurse most likely be performing? assessing vision checking temperature asking the client if he or she likes school asking the client about what he or she usually eats each day
assessing vision
The nurse is developing a preoperative plan of care for a 2-year-old toddler. The nurse will focus attention to which of the toddler's age-related fears? loss of control separation anxiety loss of independence lack of trust
separation anxiety
A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his parent. Which statement by the parent should the nurse prioritize for further investigation after noting the father has a history of alcohol use disorder? "I think I know how my son feels about drinking. He has had substance use disorder education in school." "I wish there was a blood test for alcohol use disorder. I know my son is at risk." "Our next door neighbor is older than my son, and he drinks when they hang out together." "Sometimes my son asks me questions about his father's low tolerance for alcohol."
"Our next door neighbor is older than my son, and he drinks when they hang out together."
The health care team is performing cardiopulmonary resuscitation on a child following a suspected poisoning. Which action by the nurse would indicate that CPR is warranted? The nurse assesses the child's neurological status following chest compressions. The nurse assesses the child's heart rate at 45 and begins chest compressions. The child is monitored for respiratory complications such as pneumonia. The child is assessed for injury before applying the cardiac monitor.
The nurse assesses the child's heart rate at 45 and begins chest compressions. Explanation: The child with a pulse of less than 60 beats per minute should receive chest compressions to maintain adequate perfusion and circulation.
The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting. The nurse observes the general appearance of the child. The nurse interviews the child's caregiver. The nurse takes the child's vital signs and height and weight.
The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting.
The nurse is caring for a 10-year-old girl with the diagnosis of leukemia. The parents of the child are divorced but are very attentive to their child. The nurse notices that the parents seldom talk to each other, and when they do, they are very rude to one another. The child has voiced to the nurse that she is sad that her parents "don't like each other anymore." What is the best nursing action? The nurse should ask to speak to both parents in a private setting and convey their daughter's feelings to them. The nurse should not address this with the parents since the relationship between the parents is not the nurse's concern. The nurse should ask the child if she has told her parents how she feels, and offer to be with her when she talks to them. The nurse should encourage the child to speak to each parent separately so as not to anger either parent.
The nurse should ask the child if she has told her parents how she feels, and offer to be with her when she talks to them.
A 3-year-old who has just been admitted with pneumonia needs to have an intravenous (IV) line inserted for antibiotic therapy. What is the best nursing action? Take the patient to the treatment room to have the IV inserted. Tell the patient that it will feel like a bumble bee sting when inserted. Tell the patient to stay with the mother in his room while the IV is inserted. Inform the patient's mother that she can stay in the room and hold the child while the IV is inserted.
Take the patient to the treatment room to have the IV inserted.
The nurse must calculate the adolescent's cardiac output. The child's heart rate is 76 beats per minute and the stroke volume is 75 ml. Calculate the child's cardiac output in ml/min. Record your answer using a whole number.
5700 Explanation: Cardiac output (CO) is equal to heart rate (HR) times ventricular stroke volume (SV). That is, CO = HR x SV 76 beats per minute x 75 mL = 5,700 ml/min
The nurse is caring for a 13-year-old who is hospitalized for management of his recently diagnosed diabetes. The child has been withdrawn, and when asked she reports she is "just tired of being sick". What action by the nurse will be of the greatest benefit to helping the child with this concern? Encourage the child to participate in planning her daily care. Provide books and magazines of interest to her. Encourage the child to call her friends on the phone. Ask one of the parents to stay with her at all times.
Encourage the child to participate in planning her daily care.
The child's ability to perfuse is poor due to inadequate circulation. The physician writes an order for the child to receive 20 ml of normal saline for each kilogram of body weight. The child will receive the normal saline as a bolus through a central intravenous line. The child weighs 78 lb (35.46 kg). Calculate the amount of normal saline the nurse should administer as a bolus. Record your answer using a whole number.
709
The nursing instructor is speaking with a group of nursing students about medication used in rapid sequence intubation. Which statement by a student indicates a need for further education? "Succinylcholine is used to induce short-term paralysis during intubation." "Ketamine is the anesthetic typically used for children who have suffered head trauma and need to be intubated." "Atropine is used to help decrease the risk of bradycardia." "When midazolam is used with other opioids, we need to be aware to watch for respiratory depression."
"Ketamine is the anesthetic typically used for children who have suffered head trauma and need to be intubated."
The nurse is educating a student nurse about the importance of avoiding overventilation using too much tidal volume when ventilating a pediatric client with a bag-valve mask (BVM). What complications would the nurse include in the teaching plan for this concern? Select all that apply. The rescuer should ventilate until the child's chest rises above the level of the rescuer's hand. A child with a head injury may suffer from decreased cerebral flow. The BVM is not optimal when compared to mouth-to-mouth ventilation as BVM delivers less concentration of oxygen. The child's cardiac output may be reduced due to increased intrathoracic pressure. A poor seal may lead to an air leak, thus reducing oxygen delivery to the child.
A child with a head injury may suffer from decreased cerebral flow. The child's cardiac output may be reduced due to increased intrathoracic pressure. A poor seal may lead to an air leak, thus reducing oxygen delivery to the child.
A nurse is preparing discharge instructions for a child treated for ingestion of an unknown amount of ibuprofen. The child was treated with an activated charcoal gastric lavage. Which piece of information should the nurse include to provide anticipatory guidance to the parent? The mouth sores will heal over several weeks. The child will continue taking the chelating agent. Stools will be black in color for the next few days. Blood tests will be needed to check liver function.
Stools will be black in color for the next few days.
The nurse working in the pediatric unit of the hospital is always monitoring for safety issues on the unit. The nurse determines the greatest concern related to safety of the hospitalized child is related to which situation? Taking a child in and out of bed, doing frequent checks and procedures, and caregivers sitting at the side of the bed all bring on an opportunity for the side rails to be left down. The caregivers are in a high-stress situation and are unable to concentrate and pay attention to what the child is doing at all times. A variety of nursing staff and other hospital staff are in and out of the child's room during hospitalization, and close observation of the child by the staff is difficult. The child is out of the home environment he or she is used to, without safety locks on doors and cabinets and things being placed in safe storage.
Taking a child in and out of bed, doing frequent checks and procedures, and caregivers sitting at the side of the bed all bring on an opportunity for the side rails to be left down.
A nurse is caring for an 18-month-old girl undergoing traction therapy in a rehabilitation unit. The nurse understands that the girl is in the second phase of separation anxiety when she observes what behavior? The girl ignores her. The toddler is quiet, looks sad, and is disinterested in playing. The toddler cries inconsolably. The girl acts extremely agitated. The child exhibits signs of anger.
The toddler is quiet, looks sad, and is disinterested in playing. Explanation: Despair is the second phase of separation anxiety. During this phase the child appears hopeless, depressed, and apathetic. Exhibiting signs of anger and agitation or crying inconsolably all indicate the first phase of separation anxiety called protest. Denial or detachment is the third phase of separation anxiety. The child uses this to protect against further emotional pain. When parents return the child will ignore them and, instead, has formed superficial relationships with other caretakers. This third stage is seen infrequently when family-centered care is in place.
The nurse is caring for a 9-year-old child on an inpatient pediatric unit who is admitted for an extended stay. The child continually refuses meals. What can the nurse do to help increase the child's intake? Select all that apply. Tell the child that play time will be shortened if he or she does not eat. If approved by the physician, allow the parents to bring food from home for the child. Assist the child to choose foods he or she likes from the facility menu. Encourage the child to eat several small meals instead of fewer larger meals. Ask the dietitian to visit the child to help determine foods the child prefers.
Assist the child to choose foods he or she likes from the facility menu. Encourage the child to eat several small meals instead of fewer larger meals. Ask the dietitian to visit the child to help determine foods the child prefers. If approved by the physician, allow the parents to bring food from home for the child.
The nurse is working with a group of caregivers of children in a community setting. The topic of hospitalization and the effects of hospitalization on the child are being discussed. Which statement made by the caregivers supports the most effective way for children to be educated about hospitals? "We are going to take our child to an open house at the hospital so she can see the pediatric unit." "The school nurse set up posters and displays showing pictures of what the inside of a hospital looked like, and we made sure our daughter saw the display." "Our next door neighbor was sick and died in the hospital. We explained to our son that usually babies are born and people get well in hospitals." "My wife brought home several books about hospitalization and surgery, and she and I are reading them to our son."
"We are going to take our child to an open house at the hospital so she can see the pediatric unit."
The nurse is taking the health history of a 15-year-old client. What would be an appropriate way for the nurse to ask about the client's drug use history? "Have you smoked crack before?" "Some teens like to smoke. Have you tried this?" "Have you had alcohol at parties before?" "Have you smoked cigarettes?"
"Some teens like to smoke. Have you tried this?"
The nurse is obtaining the health history for a 9-year-old child who has been brought to the ambulatory care clinic with reports of a backache. Which initial action by the nurse is most appropriate? Ask the child to demonstrate movements involving the back. Ask the child's parent about when the parent was first made aware of the discomfort. Palpate the child's back while asking the severity of discomfort being experienced. Ask the child when the pain started.
Ask the child when the pain started.
Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels (fontanelles), what should the nurse expect to find? Open anterior and posterior fontanels (fontanelles) Closed anterior fontanel (fontanelle) and open posterior fontanel (fontanelle) Closed anterior and posterior fontanels (fontanelles) Open anterior fontanel (fontanelle) and closed posterior fontanel (fontanelle)
Closed anterior and posterior fontanels (fontanelles)
The charge nurse observes a new graduate nurse assess the cremasteric reflex in an 8-month-old boy. The new graduate nurse strokes the lateral aspect of the thigh. Which action should the charge nurse take? Counsel the new graduate. Demonstrate the appropriate technique. Explain why the technique is incorrect. Applaud the good technique.
Demonstrate the appropriate technique.
The nurse is caring for a preoperative pediatric client. What would it be best for the nurse to do with this client? Keep the child away from any food or drinks to ensure the child is NPO. Explain how the therapeutic plan can be used in preparing the child for surgery. Determine how much the child knows and is capable of understanding. Teach technical terminology to the caregivers so they will understand what is being said postoperatively.
Determine how much the child knows and is capable of understanding.
An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first? Determine the type of ingestion. Initiate a nasogastric tube. Call poison control. Administer activated charcoal.
Determine the type of ingestion.
A 5-year-old child is scheduled for hospitalization in 2 weeks. Which is the best intervention to help ease the potential stress of hospitalization in this child? Have the parents explain the situation. Allow the child to talk to a client who recently had the same procedure. Arrange for the child to tour the hospital. Encourage the family and client to participate in a program to prepare for the hospitalization.
Encourage the family and client to participate in a program to prepare for the hospitalization.
The nurse is preparing a postsurgical care plan for an infant girl located on a general hospital unit that only occasionally admits children. To ensure the infant's safety, what should the nurse include in the plan? Place the infant in a room with an ambulatory adolescent. Place the infant in a room close to the nurses' station. Ask the family to stay with the infant at all times. Put the infant in a carrier and bring her to the nurses' station.
Place the infant in a room close to the nurses' station.