More Peds Q&A's: NCLEX
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question should the nurse ask the parent?
"Does the child respond when called by name?"
The clinic nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement made by one of the parents indicates an understanding of the use of the harness?
"I can remove the harness to bathe my infant."
The clinic nurse is providing home care instructions to the mother of a child diagnosed with human immunodeficiency virus (HIV) infection. Which statement by the mother indicates a need for further teaching?
"I should delay the polio virus vaccine."
The mother of the child with a diagnosis of hepatitis B calls the health care clinic to report that the jaundice seems to be worsening. Which response should the nurse make to the mother?
"The jaundice may appear to get worse before it begins to resolve."
The nurse is reviewing the record of a child with a head injury exhibiting increased intracranial pressure and notes that the child shows signs of decerebrate posturing. On assessment of the child, what additional signs should the nurse expect to note if this type of posturing is present? Select all that apply.
-Vomiting -Decreased consciousness -Alteration in pupil size and reactivity
The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?
Hypertrophic pyloric stenosis
A child is seen in the emergency department with a diagnosis of possible bacterial meningitis (fulminating meningococcemia). Which finding should the nurse specifically expect to note in this infection?
A fine rash with some bruising
A 6-year-old child diagnosed with diabetes mellitus is seen in the clinic for a routine examination. The nurse analyzes the data collected during the visit to determine whether the child was euglycemic since the last visit. Which assessment will provide reliable information about euglycemia?
A glycosylated hemoglobin
The nurse is monitoring a child after spinal fusion for the treatment of scoliosis for complications related to the procedure. The nurse prepares to monitor for superior mesenteric artery syndrome by assessing the child for which sign/symptom?
Abdominal discomfort and episodes of vomiting
The community health nurse is visiting a local school in the community and is performing musculoskeletal assessments of the school children. The nurse performs assessments, knowing that which child is at most risk of developing Osgood-Schlatter disease?
An active adolescent boy involved in sports activities
A 12-month-old child has just returned from the recovery room after a palatoplasty. The nurse performs an assessment and determines that which finding requires further intervention and indicates a need for follow-up?
Clove-hitch restraints are secured to the arms.
The registered nurse (RN) is reviewing a plan of care developed by a new nurse for a child who is being admitted to the pediatric unit with a diagnosis of seizures. The RN determines that the new nurse needs further teaching and should revise the plan of care if which incorrect intervention is documented?
Immobilize the child if a seizure occurs.
The nurse caring for a child with a diagnosis of human immunodeficiency virus (HIV) plans care based on which description of this disorder?
It is an acquired cell-mediated immunodeficiency disorder.
The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?
Monitor the mouth and anus each shift for signs of breakdown.
The nurse is monitoring a 7-year-old child who sustained a head injury in a motor-vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?
Nausea
When obtaining a history from parents of a 5-month-old child suspected of having intussusception, which assessment area should be most important for the nurse to address?
Pattern of abdominal pain
A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority client problem is that the client is at risk for infection because of the immunosuppressed state. Which intervention should the nurse include in the plan of care?
Perform oral hygiene four times a day.
The nurse is assessing for the presence of bleeding in a child diagnosed with leukemia. A decrease in which laboratory result will assist the nurse in planning appropriate care?
Platelets
The clinic nurse is providing instructions to the mother of a child with impetigo. The nurse instructs the mother to notify the primary health care provider if which sign occurs?
Swelling around the eyes
The nurse is conducting an assessment of a child suspected of having Reye's syndrome. Which data, as reported by the mother, should the nurse interpret as being associated with this syndrome?
The child had influenza 2 weeks ago.
The nurse instructs a mother on measures to take to reduce the incidence of gastroesophageal reflux disease (GERD) in a child. Which statement by the mother indicates a need for further teaching?
"I will buy bottle nipples that have smaller holes for my child."
The nurse provides home care instructions to a mother of an infant who has had a surgical procedure to insert a ventriculoperitoneal shunt for the treatment of hydrocephalus. Which statement by the mother indicates an understanding of the complications associated with this surgical procedure?
"If my infant has a screaming cry, I should call my pediatrician."
A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and chemotherapy, it has been decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement is most appropriate to assist in alleviating the child's fear?
"This aching and cramping is normal and temporary and will subside."
The parents of a 10-year-old child in remission from leukemia are upset over the appearance of cushingoid characteristics in the child from long-term use of corticosteroids, currently being administered every other day. Which therapeutic statements should the nurse make to the parents about the cushingoid appearance? Select all that apply.
-"Which manifestations of this condition do you find most troublesome?" -"The manifestations are lessened by taking the prednisone every other day instead of daily." -"The cushingoid appearance will gradually disappear once the corticosteroids are tapered and discontinued."
The nurse is planning care for a pediatric client experiencing thyrotoxicosis (thyroid storm). Which prescribed medications should the nurse plan to administer? Select all that apply.
-Atenolol -Propranolol -Methimazole
The nurse is doing discharge teaching with a client diagnosed with sickle cell disease. The nurse instructs the client to avoid which situations that could precipitate a sickle cell crisis? Select all that apply.
-Dehydration -Exposure to infection -High-altitude locations
A school-age child has a history of upper respiratory infection (URI) accompanied by a sore throat, and the primary health care provider suspects rheumatic fever. The nurse identifies which of the modified Jones criteria as being used to diagnose rheumatic fever? Select all that apply.
-Evidence of streptococcal infection -The presence of two major manifestations of rheumatic fever -The presence of one major and two minor manifestations of rheumatic fever
The nurse is assessing a child diagnosed with celiac disease. Which assessment finding validates the diagnosis? Select all that apply.
-Irritability -Fretfulness -Malodorous stools -Severe abdominal distention
The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 × 109/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.
-Monitor stools for blood. -Clean oral cavity with soft swabs. -Provide appropriate play activities.
The nurse is planning care for a child with type 1 diabetes mellitus. Which items should the nurse plan to provide to treat early signs of a hypoglycemic episode? Select all that apply.
-Orange juice -Glucose tablets -Candy (e.g., Skittles)
An adolescent is diagnosed with scoliosis. Which statements regarding scoliosis are correct? Select all that apply.
-Scoliosis is an abnormal lateral curvature of the spine. -Scoliosis is most typically diagnosed in the adolescent child. -Surgical intervention may be necessary when severe curves exist. -Selection of instrumentation systems to be used during surgery depends on client needs and surgeon's preferences.
The nurse is preparing a plan of care for the child diagnosed with beta thalassemia. Which problem should the nurse identify as a priority for this client?
Inadequate tissue perfusion
A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child after the procedure?
Assess for any bleeding on the dressing.
The clinic nurse is performing an assessment of a 5-month-old infant suspected of having unilateral developmental dysplasia of the hip (DDH). Which assessment finding should the nurse expect to note in this condition?
Asymmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table
The nurse provides instructions to the mother of a child diagnosed with an iron deficiency anemia regarding the administration of prescribed oral iron. How should the nurse instruct the mother to administer the iron?
Between meals
A child is admitted to the hospital with a diagnosis of acute rheumatic fever. The nurse analyzes the laboratory results and determines that which finding would confirm the likelihood of acute rheumatic fever?
Increased antibody level
The nurse is caring for an adolescent diagnosed with sickle cell anemia hospitalized for the treatment of vaso-occlusive crisis. The nurse should determine that what problem should receive priority in the client's plan of care?
Compromised tissue perfusion
An adolescent is hospitalized with a diagnosis of Rocky Mountain spotted fever (RMSF). The nurse anticipates that which medication will be prescribed?
Doxycycline
The nurse is providing instructions to the mother of a child with a diagnosis of megaloblastic anemia. Which dietary sources of vitamin B12 should the nurse instruct the mother to include in the diet?
Eggs
An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety?
Elevating the head with the infant in the prone position
The registered nurse is discussing care of a child with acute laryngotracheobronchitis (croup) with a nursing student. The registered nurse determines that the nursing student needs further teaching regarding this disorder if the student states that which finding is a clinical characteristic of LTB?
Has a sudden onset and usually occurs during the day
The clinic nurse is providing an in-service education program to the nursing staff on immunizations, and the topic of discussion is human immune globulin. Which information should the clinic nurse share with the staff regarding human immune globulin vaccine?
Has been obtained from the pooled blood of many people and provides antibodies to a variety of diseases
The nurse is performing an assessment on a child, and the parents report the presence of ribbon-like and foul-smelling stools, episodes of constipation since birth, and poor feeding habits. The nurse notes a distended abdomen. Based on these data, the nurse analyzes these signs/symptoms as indicative of which condition?
Hirschsprung's disease
A 2-year-old child is admitted to the hospital with juvenile idiopathic arthritis (JIA). During the focused assessment, the nurse makes it a priority to note the presence of which finding?
Increased irritability and the child's insistence to be carried
The clinic nurse is providing home care instructions to the mother of a 3-year-old child with a diagnosis of gastroenteritis-induced vomiting and diarrhea who is at risk for dehydration. What should the nurse instruct the mother to give the child to help maintain hydration status?
Oral electrolyte drink
When an infant is suspected of being human immunodeficiency virus (HIV) positive, the nurse provides information to the parents about appropriate care. Which action on the part of the parents indicates to the nurse that they need further teaching about the care of their HIV-positive infant?
Planning to use rice cereal to help with watery stools when they occur
The nurse is caring for an infant diagnosed with laryngomalacia (congenital laryngeal stridor). In which position should the nurse place the infant to decrease the incidence of stridor?
Prone with the neck hyperextended
During an assessment interview, the nurse notes that a child, who is due for a measles, mumps, rubella (MMR) vaccine, has recently been prescribed a corticosteroid. What information regarding the vaccination should the nurse provide the child's parent?
The vaccination's effectiveness would be affected by the corticosteroid.
The nurse is giving instructions to an 8-year-old child regarding measures to take to identify the early signs of an asthma episode. What instruction would be important for the nurse to give the child?
Use a peak flowmeter to measure for a drop in the expiratory flow rate.
A child with a diagnosis of umbilical hernia has been scheduled for surgical repair in 2 weeks. The clinic nurse instructs the parents about the signs of possible hernia strangulation. The nurse tells the parents that which sign requires primary health care provider notification?
Vomiting
The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure. Which intervention should the nurse recognize as needing revision?
Wake the infant for feedings to ensure adequate nutrition.
The nurse is planning discharge instructions for the mother of a child after orchiopexy, which was performed on an outpatient basis. Which should be a priority in the plan?
Wound care
