NCLEX 10000 Toddler
A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern?
Bradycardia Correct Explanation: Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the nurse always should measure the apical heart rate before administering each digoxin dose.
When assessing for pain in a toddler, which method should be the most appropriate? a) Use a numeric pain scale. b) Observe the child for restlessness. c) Assess for changes in vital signs. d) Ask the child about the pain.
Observe the child for restlessness. Correct Explanation: Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability, and crying. It is not particularly helpful to ask toddlers about pain
A nurse is caring for a young child with tetralogy of Fallot (TOF). The child is upset and crying. The nurse observes that he's dyspneic and cyanotic. Which position would help relieve the child's dyspnea and cyanosis? a) Lying flat in bed b) Sitting in bed with the head of the bed at a 45-degree angle c) Lying on his right side d) Squatting
Squatting Correct Explanation: Placing the child in a squatting position sequesters a large amount of blood to the legs, reducing venous return.
Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused? a) talking easily with the nurse b) absence of crying during the examination c) playing with toys on the examination room floor d) clinging to the parent during the examination
absence of crying during the examination Correct Explanation: Children who are being abused may demonstrate behaviors such as withdrawal, apparent fear of parents, and lack of an appropriate reaction, such as crying and attempting to get away when faced with a frightening event (an examination or procedure).
When teaching the mother of a toddler diagnosed with lead poisoning, what should the nurse include as the most serious complication if the condition goes untreated? a) cirrhosis of the liver b) neurologic deficits c) heart failure d) stunted growth rate
neurologic deficits Correct Explanation: The most serious and irreversible consequence of lead poisoning is to neurologic changes leading to an intellectual disability. It can be expected if lead poisoning is long-standing and goes untreated. Lead poisoning also affects the hematologic and renal systems
A nurse observes a play group of 2-year-old children. The nurse expects to see: a) one child playing with clay and another child using flash cards. b) three children playing tag. c) two children side by side in the sandbox building sand castles. d) four children playing dodgeball.
two children side by side in the sandbox building sand castles. Correct Explanation: Two-year-olds exhibit parallel play; that is, they engage in similar activity, side by side.
A nurse is caring for a toddler who is assessed as having hypertonicity, delayed fine motor skills, and poor control of coordinated motion. This is indicative of what cerebral palsy (CP) classification? Select all that apply.
• Poor coordination. • Gross motor skills impairment. • Hypertonicity. Explanation: Spastic CP is the most common type, characterized by poor coordination and balance, gross motor skills impairment, and hypertonicity. CP is nonprogressive and is caused by a variety of prenatal, perinatal, and postnatal factors. Dyskinetic or athetoid CP is the next most common type and is characterized by abnormal involuntary movements and wormlike writhing movements.
When assessing a toddler's growth and development, the nurse understands that a child in this age-group displays behavior that fosters which developmental task? a) Industry b) Trust c) Autonomy d) Initiative
Autonomy Correct Explanation: The toddler's developmental task is to achieve autonomy while overcoming shame and doubt.
A nurse is caring for a group of pediatric clients. The nurse understands that which age group would most likely identify their pain as punishment for past behavior? a) School age children (age 6 -11 years) b) Preschool or toddler (age 2-5 years) c) Infant (age 9-12 months) d) Adolescents (age 12-17 years)
Preschool or toddler (age 2-5 years) Correct Explanation: Children in this age group are in Piaget's preoperational stage of cognitive development and relate pain as punishment for past behavior. A priority nursing action is to provide reassurance.
A toddler has a temperature above 101° F (38.3° C). The physician orders acetaminophen, 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of: a) thrombocytopenia. b) sepsis. c) leukocytosis. d) anemia.
thrombocytopenia. Correct Explanation: A child with thrombocytopenia or neutropenia shouldn't receive rectal medication because of the increased risk of infection and bleeding that may result from tissue trauma.
Which parent statement would suggest to the nurse that a child may have celiac disease and should be referred to a health care provider (HCP)? a) "His belly is so small." b) "He is so short." c) "His urine is so dark in color." d) "His stools are large and smelly."
"His stools are large and smelly." Explanation: Celiac disease is a disorder involving intolerance to the protein gluten, which is found in wheat, rye, oats, and barley. The stools of a child with celiac disease are characteristically malodorous, pale, large (bulky), and soft (loose). Excessive flatus is common, and bouts of diarrhea may occur.
A 2-year-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress? a) Intercostal retractions b) Decreased level of consciousness (LOC) c) Bradycardia d) Flushed skin
Intercostal retractions Correct Explanation: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal retractions, and cyanosis.
A toddler is diagnosed with iron deficiency anemia. When teaching the parents about using supplemental iron elixir, the nurse should provide which instruction? a) "Give the elixir with water or juice." b) "Monitor the child for episodes of diarrhea." c) "Give the iron preparation before meals." d) "Give the iron preparation with milk."
"Give the elixir with water or juice." Correct Explanation: Because iron preparations may stain the teeth, the nurse should instruct the parents to give the elixir with water or juice. The iron preparation shouldn't be given with milk because milk impedes iron absorption
The nurse teaches the parents of a 2-year-old child how to instill antibiotic eardrops. Which of the following statements about the direction to pull on the earlobe indicates that the child's father has understood the teaching? a) "I should pull the earlobe up and backward." b) "I should pull the earlobe down and backward." c) "I should pull the earlobe down and outward." d) "I should pull the earlobe up and forward."
"I should pull the earlobe down and backward." Correct Explanation: For children age 3 years and younger, the external auditory canal is straightened by gently pulling the earlobe down and backward. For an older child or an adult, the earlobe is gently pulled up and backward.
During a well-baby visit, a toddler's mother states that she keeps all of the medications out of the toddler's reach in the kitchen cabinet. Which of the following is an appropriate response by the nurse? a) "Medications should be kept out of the toddler's sight." b) "Keeping medications out of reach is a good idea." c) "Medications should be kept in the bathroom medicine cabinet." d) "Medications should be kept in a locked location."
"Medications should be kept in a locked location." Explanation: Most toddler deaths are accidental. Medications should be kept in a locked location to prevent accidental ingestion by the toddler. Toddlers are curious and are beginning to climb and explore. Keeping medications out of sight and/or out of reach is not enough to prevent the toddler from finding/reaching and accidentally ingesting medication.
A parent asks the nurse about using a car seat for a toddler who is in a hip spica cast. The nurse should tell the parent: a) "You can still use the car seat you already have." b) "You'll need to get a special release from the police so that a car seat will not be needed." c) "You can use a seat belt because of the spica cast." d) "You will need a specially designed car seat for your toddler."
"You will need a specially designed car seat for your toddler." Correct Explanation: The toddler in a hip spica cast needs a specially designed car seat. The one that the mother already has will not be appropriate because of the need for the car seat to accommodate the cast and abductor bar.
A child weighing 44 lb is to receive 45 mg/kg/day of penicillin V potassium oral suspension in four divided doses for every 6 hours. The suspension that is available is penicillin V potassium 125 mg/5 ml. How many milliliters should the nurse administer for each dose? Record your answer using a whole number
9 Explanation: First, convert the child's weight to kilograms: 44 lb ÷: 2.2 lb/kg = 20 kg. Next, determine the daily dose: 45 mg/1 kg = X/20 kg X = 45 X 20 = 900 mg. Then, determine the dose to administer every 6 hours (four doses): 900 mg ÷ 4 = 225 mg. Finally, determine the volume to be given at each dose: 125 mg/5 ml = 225 mg/X. X = (225 mg X 5 ml) ÷ 125 mg = 9 ml.
A 2-year-old child brought to the clinic by her parents is uncooperative when the nurse tries to look in her ears. What should the nurse try first? a) Ask another nurse to assist. b) Allow a parent to assist. c) Restrain the child's arms. d) Wait until the child calms down.
Allow a parent to assist. Correct Explanation: Parents can be asked to assist when their child becomes uncooperative during a procedure. Most commonly, the child's difficulty in cooperating is caused by fear. In most situations, the child will feel more secure with a parent present
Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which of the following clinical finding? a) Alterations in levels of consciousness. b) Fluctuations of fluid in the collection chamber of the chest drainage system. c) Strong peripheral pulses in all four extremities. d) A urine output of 60ml in 4 hours.
Alterations in levels of consciousness. Correct Explanation: Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness. An adequate urine output for a child over 1 year should be 1ml/kg/hour. Therefore 60ml/4hr is satisfactory.
For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority? a) Avoiding abdominal palpation b) Monitoring acid-base balance c) Maintaining strict isolation d) Restricting oral intake
Avoiding abdominal palpation Correct Explanation: Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a child with a Wilms' tumor is to avoid palpating the abdomen
When teaching a mother of a 17-month-old about toilet training, which instruction would initially be most appropriate? a) Remove the diaper and use training pants to begin the process. b) Offer a reward every time the child has a bowel movement in the potty chair. c) Place the toddler on the potty chair every 2 hours for 10 minutes. d) Be sure the child is ready before starting to toilet train.
Be sure the child is ready before starting to toilet train. Correct Explanation: All of the instructions are appropriate, but knowing whether the child is ready to toilet train is initially most appropriate. Many 17-month-olds do not have the neuromuscular control to be able to be trained. Waiting a few more months until the child is closer to age 2 years allows the child to develop more control. The mother should be taught the signs of readiness for toilet training.
The parents report that their child has a runny nose, fever, and cough and is irritable and constantly rubbing his ears. When assessing the ear, how should the nurse expect the child's tympanic membrane to appear a) Clear and inverted. b) Scarred. c) Bulging and red. d) Pearly gray.
Bulging and red. Correct Explanation: Based on the report of the child's signs and symptoms, the nurse should suspect otitis media. On assessment, the tympanic membrane would appear bulging and bright red (because of increased middle ear pressure), typically indicative of otitis media.
A parent brings a toddler, age 19 months, to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?
Closed anterior and posterior fontanels Correct Explanation: By age 18 months, the anterior and posterior fontanels should be closed.
Which of the following nursing interventions would be most effective in helping a 2-year-old child stay quiet after a bronchoscopy? a) Turning on the television so the child can watch cartoons. b) Allowing the child to go to the playroom. c) Having the child play with another child in the room. d) Having the parents stay at the bedside.
Having the parents stay at the bedside. Correct Explanation: A toddler has a short attention span and is energetic. Thus, keeping a 2-year-old child quiet is a challenge. Because the parents know their child well, the parents have a better chance of helping the child stay quiet. Therefore, they should be encouraged to stay with the child at the bedside
A 3-year-old child is admitted to the hospital with an acute exacerbation of asthma. The child's history reveals that the child was exposed to chickenpox 1 week ago. When would this child require isolation? a) Immediate isolation is required. b) Isolation isn't required. c) Isolation is required 10 days after exposure. d) Isolation is required 12 days after exposure.
Immediate isolation is required. Correct Explanation: Immediate isolation is required because the incubation period for chickenpox is 2 to 3 weeks, and a client is commonly isolated 1 week after exposure to avoid the risk of an outbreak. A person is infectious from 1 day before eruption of lesions to 6 days after the lesions have formed crusts.
After insertion of bilateral tympanostomy tubes in a toddler, which instruction should the nurse include in the child's discharge plan for the parents? a) Insert ear plugs into the canals when the child bathes. b) Gently clean the ear canal with cotton swabs. c) Disregard any drainage from the ear after 1 week. d) Administer the prescribed antibiotic while the tubes are in place.
Insert ear plugs into the canals when the child bathes. Correct Explanation: Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle ear through the tympanostomy tube and causing an infection.
A 15-month-old child with the diagnosis of pneumonia is placed in a mist tent. Which of the following toys would be appropriate for this child? a) Storybooks. b) Plastic blocks. c) A pull toy. d) Crayons and paper.
Plastic blocks. Correct Explanation: Plastic blocks are the most appropriate toy for a toddler in a mist tent. Because the blocks are plastic, they can be washed.
A nurse's assessment of a 6-month-old infant reveals a respiratory rate of 52 breaths/minute, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which action would be most appropriate? a) Provide teaching about cold care to the mother. b) Refer the infant to the emergency department. c) Send the infant for a chest radiograph. d) Administer a nebulizer treatment.
Refer the infant to the emergency department. Correct Explanation: Based on the assessment findings of increased respiratory rate, retractions, and wheezing, this infant needs further evaluation, which could be obtained in an emergency department.
A toddler with croup is given an epinephrine treatment because of increasing respiratory distress. The nurse evaluates the treatment as being effective when the child's: a) Pulse oximeter reads 90. b) Color is normal. c) Heart rate is 100 beats/minute. d) Retractions are less severe.
Retractions are less severe. Correct Explanation: Epinephrine can be given in an inhalant form to decrease inflammation in the upper airway through vasoconstriction. It also has bronchodilator effects. In the case of croup, epinephrine is used to increase the opening of the narrowed airway. A decrease in the severity of retractions is the only answer indicating a change that reflects an increase in the airway opening.
Which statement obtained from the nursing history of a toddler should alert the nurse to suspect that the child has had a febrile seizure? a) The seizure resulted in respiratory arrest. b) The family history is negative for convulsions. c) The seizure occurred when the child had a respiratory infection. d) The child has had a low-grade fever for several weeks
The seizure occurred when the child had a respiratory infection. Correct Explanation: Most febrile seizures occur in the presence of an upper respiratory infection, otitis media, or tonsillitis. Febrile seizures typically occur during a temperature rise rather than after prolonged fever.
A child's parents state that they childproofed their home for their 2-year-old. During a home visit, the nurse discovers some situations that show the parents don't fully understand the developmental abilities of their toddler. Which situation displays misunderstanding by the parents? a) Hot water heater temperature set at 120° F (48.9° C) or below b) Pot handles turned toward the back of the stove c) Toy chest in front of a second-story, locked window d) Safety latches on kitchen cabinets
Toy chest in front of a second-story, locked window Correct Explanation: A toy chest in front of a second-story locked window displays misunderstanding because toddlers are able to climb on low furniture and open windows that may not always be locked, especially in the summer. In such situations, the child could fall out of the window.
A 14-month-old child has a severe diaper rash. Which recommendation should the nurse provide to the parents? a) Wash the buttocks using mild soap. b) Change the diaper every 4 to 6 hours. c) Apply powder to the diaper area. d) Continue to use the baby wipes.
Wash the buttocks using mild soap. Correct Explanation: Because the toddler has a severe diaper rash, it may be best to change all that the parents are doing. The buttocks need to be washed thoroughly with mild soap and dried well. In fact, it is helpful to leave the diaper off and expose the buttocks to the air.
Which family should the nurse determine as most in need of follow-up? a) a two-parent family with a foster child who has a history of caustic liquid ingestion b) a two-parent family whose 3-year-old has a fractured leg from an automobile accident c) a single parent with a toddler who has third-degree burns over 20% of the body d) a single mother with a 7-month-old child whose immunizations are delayed
a single parent with a toddler who has third-degree burns over 20% of the body Correct Explanation: Toddlers receive burns usually as the result of not being closely supervised. Toddlers are very inquisitive and need constant supervision; therefore, close follow-up is necessary. In addition, the child probably will need some type of wound care requiring involvement of the parent and possibly others.
The nurse observes an 18-month-old who has been admitted with a respiratory tract infection who is drooling (see figure). The nurse should first: a) position the child supine. b) suction the airway. c) administer oxygen. d) call the rapid response team.
call the rapid response team. Correct Explanation: The nurse should suspect epiglottitis in any young child with a respiratory infection who sits leaning forward with an open mouth and protruding tongue and is drooling. Epiglottitis is a medical emergency. The rapid response team should be notified to secure the airway. While waiting for the team, the child should remain sitting upright to facilitate breathing; complete obstruction may occur if the child is placed prone or becomes agitated. Therefore, it is important to avoid any procedures that upset the child such as suctioning or applying oxygen.
On a home visit following discharge from the hospital after treatment for severe gastroenteritis, the parent tells the nurse that a toddler answers "No!" and is difficult to manage. After discussing this further with the parent, the nurse explains that the child's behavior is most likely the result of which factor? a) expression of individuality b) inherited personality trait c) usual lack of interest in everything d) beginning leadership skills
expression of individuality Correct Explanation: The "no" behavior demonstrated by a toddler is typical of this age group as the child attempts to be self-assertive as an individual. The negativism does not demonstrate an inherited personality trait or disinterest. Rather, it reflects the developmental task of establishing autonomy. The toddler is attempting to exert control over the environment
A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can: a) count and sing with the child. b) establish a time limit to get ready for the procedure. c) hold and rock him and give him a security object. d) prepare the child by positive self-talk.
hold and rock him and give him a security object. Correct Explanation: The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness. Holding, rocking, and giving the child a security object is helpful because it may be comforting to the child.
When caring for a toddler with epiglottitis, the nurse should first: a) examine his throat. b) administer I.V. fluids. c) administer antibiotics. d) place a tracheotomy tray at the bedside.
place a tracheotomy tray at the bedside. Correct Explanation: Placing a tracheotomy tray at the bedside should take priority because acute epiglottitis is an emergency situation in which inflammation can cause the epiglottis to swell, totally obstructing the airway. This situation may require tracheotomy or endotracheal intubation.
A 22-month-old infant is to have moderate sedation for an outpatient procedure. The nurse knows that: a) the infant will remember the procedure. b) the infant's reflexes will be decreased or absent. c) the infant should respond to gentle tactile or verbal stimulation. d) the infant will need a patient-controlled analgesia (PCA) pump during sedation.
the infant should respond to gentle tactile or verbal stimulation. Explanation: An infant under moderate sedation should respond to verbal or tactile stimuli. Infants under general anesthesia have decreased or absent reflexes
The mother asks the nurse for advice about discipline for her 18-month-old. Which discipline strategy should the nurse suggest that the mother use? a) reprimand b) spanking c) reasoning d) time-out
time-out Correct Explanation: Time-out is the most appropriate discipline for toddlers. It helps to remove them from the situation and allows them to regain control. Structuring interactions with 3-year-olds helps minimize unacceptable behavior. This approach involves setting clear and reasonable rules and calling attention to unacceptable behavior as soon as it occurs.
The nurse is educating the parents of a 2-year-old child regarding immunizations. When the parents ask where the injections will be given the nurse answers that the most appropriate site for an intramuscular injection for a child this age is the: a) vastus lateralis muscle. b) ventrogluteal muscle. c) dorsogluteal muscle. d) deltoid muscle.
vastus lateralis muscle. Explanation: When administering an intramuscular injection to a 2-year-old child, the preferred site is the vastus lateralis. The dorsogluteal muscle is not a recommended injection site for any age, due to the risk of damaging nerves in the area. The deltoid muscle is underdeveloped in this age group, and therefore not recommended. The ventrogluteal muscle may be developed enough, but is not the first choice. (
Which statement by a mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective? a) "I'm sure that my child will be back to normal soon and I won't have to worry about this anymore." b) "I know that I'll need to keep my child as quiet as possible." c) "I've been checking the urine for protein so I'll be able to do it at home." d) "I just went out and bought all I'll need for the special diet."
"I've been checking the urine for protein so I'll be able to do it at home." Correct Explanation: The mother stating that she'll check her toddler's urine for protein indicates effective teaching because such testing helps detect the progression of nephrotic syndrome.
A parent asks the nurse about the nutritional needs of her toddler. Which of the following responses by the nurse would be most appropriate?
"Toddlers have definite food preferences." Correct Explanation: Toddlers have definite food preferences, typically wanting the same food item for several days in a row.
The primary care provider prescribes an eye patch for a child with strabismus. Which of the following statements by the child's mother would indicate the need for additional teaching about this treatment?
"You see, his problem eye is patched." Correct Explanation: When an eye patch is used to correct strabismus, the normal eye is patched. That forces the child to use the abnormal, or "lazy," eye, thereby increasing that eye's muscle strength
Which of the following toys should the nurse give to a toddler to use in the hospital playroom? a) Tricycle. b) Truck with four wheels. c) Blocks. d) Wheelbarrow.
Blocks. Explanation: As toddlers begin imaginative play, blocks are an excellent toy choice. Children can use blocks any way they desire, thus fostering imaginative play
A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. His urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the primary care provider? a) Pulse rate of 85 beats/minute. b) Blood pressure of 80/45 mm Hg. c) Respiratory rate of 28 breaths/minute. d) Body temperature of 102.8° F (39.3° C).
Body temperature of 102.8° F (39.3° C). Correct Explanation: Temperature of 102.8° F (39.3° C) is elevated, suggesting an infection. The nurse should notify the primary care provider. The child is displaying signs and symptoms of nephrotic syndrome
A 2-year-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress? a) Flushed skin b) Decreased level of consciousness (LOC) c) Intercostal retractions d) Bradycardia
Intercostal retractions Correct Explanation: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal retractions, and cyanosis.
A nurse is caring for a 2-year-old child with tetralogy of Fallot (TOF) who is scheduled for surgery in 24 hours. What intervention is the most important for the nurse to include in the plan of care? a) Encourage activity in the playroom b) Meperidine for pain c) Position the child with knees to the chest d) Oxygen at 2L/nasal cannula
Position the child with knees to the chest Correct Explanation: TOF consists of four congenital anomalies: pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy. Interventions for care include high flow oxygen, morphine, beta-blockers and positioning with knees to chest.
When observing the parent instilling prescribed ear drops prescribed twice a day for a two-year-old toddler, the nurse decides that the teaching about positioning of the pinna for instillation of the drops is effective when the parent pulls the toddler's pinna in which direction? a) down and forward b) up and backward c) down and backward d) up and forward
down and backward Correct Explanation: In a child younger than 3 years of age, the pinna is pulled back and down because the auditory canals are almost straight in children.
A nurse is providing health teaching about pediatric immunizations to the parents of a child. Which of the following is the most appropriate information for the nurse to give the parents about immunizations?
"Your child may need medication for a low-grade fever." Explanation: Fever with most vaccines begins within 24 hours, lasts 2 to 3 days, and may require pharmacologic intervention. The other options are incorrect
A parent calls the pediatric clinic to express concern over her child's eating habits. She says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of: a) adolescents. b) school-age children. c) preschool-age children. d) toddlers.
toddlers. Correct Explanation: The nurse knows that erratic eating is typical of toddlers because the physiologic need for food decreases at about age 18 months as growth declines from the rapid rate of infancy. The toddler also develops strong food and taste preferences, sometimes eating just one type of food for days or weeks and then switching to another.
A nurse on the pediatric floor is caring for a toddler refusing to take liquid acetaminophen for fever. What would be the best option? a) Give it up and try again in a couple hours. b) Call the health care provider to change the order. c) Allow the mother to hold the child and give the medication. d) Explain to the child why it is important.
Allow the mother to hold the child and give the medication. Correct Explanation: A toddler's increasing autonomy is commonly expressed by negativism. They are unreliable in expressing pain — they respond just as strongly to painless procedures as they do to painful ones. Toddlers have little concept of danger and have common fears. The toddler has trust in mother and may be more willing to take the medication from her.
After teaching the mother of a toddler with iron deficiency anemia about diet modifications, the nurse determines that the teaching was initially effective when the mother verbalizes dietary changes involving which of the following? a) Twice-daily offerings of dairy food snacks to the child. b) Provision of several meals per day to the child. c) Increased intake of iron-rich solids and decreased milk intake. d) Ingestion of equal amounts of iron-rich solids and milk products
Increased intake of iron-rich solids and decreased milk intake. Correct Explanation: In iron deficiency anemia, the child's intake of iron-rich solids needs to be increased, while the intake of milk, which is low in iron, needs to be decreased to 1 quart (0.95 L) per day. Decreasing milk intake will increase the child's hunger for and tolerance of solids that contain higher amounts of iron. The intake of foods rich in iron must be increased while the consumption of milk must be decreased.
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? a) Sweat test b) Total iron-binding capacity c) Total protein d) Hemoglobin (Hb)
Total protein Correct Explanation: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake.
A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN?
A 2-year-old child who nearly drowned 2 days earlier Explanation: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary.
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first?
Clamp the catheter. Correct Explanation: First, the nurse must clamp the catheter to prevent air entry, which could lead to air embolism. If an air embolism occurs, the nurse should position the child on the side after clamping the catheter.
Parents ask the nurse for advice about handling their 2-year-old's negativism. Which of the following is the best recommendation? a) Punish the child for misbehaving or violating set, strict limits. b) Set realistic limits for the child, then be sure to stick to them. c) Ignore this behavior because it is a stage the child is going through. d) Encourage the grandmother to visit frequently to relieve them.
Set realistic limits for the child, then be sure to stick to them. Correct Explanation: A characteristic of 2-year-olds is negativism, a response to their developing autonomy. Setting realistic limits is important so that the toddler learns what behavior is and is not acceptable. Ignoring the behavior may lead the child to believe that there are no limits. As a result, the child does not learn appropriate behavior.
A nurse is caring for a child with intussusception. Which of the following is an expected client outcome related to the nursing diagnosis Acute pain related to cramping, which might be made for this child? a) The child has a normal bowel movement. b) The child has not vomited in 3 hours. c) The child exhibits no manifestations of discomfort. d) The child is very still.
The child exhibits no manifestations of discomfort. Correct Explanation: An expected client outcome relative to the nursing diagnosis of Acute pain related to cramping is that the client exhibits no manifestations of discomfort, such as crying or drawing the legs to the abdomen.
A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child? a) engaging in play therapy b) reporting the abuse to a prosecutor c) giving the child's drawings to the abuser d) role-playing
engaging in play therapy Correct Explanation: The dolls and toys in a play therapy room are useful props to help the child remember situations and reexperience the feelings, acting out the experience with the toys rather than putting the feelings into words.
A parent of a toddler brings the child to the emergency department because the child has accidentally been scalded by hot water spilling from the stove. In order to differentiate the burn from potential abuse, the nurse first should assess the child: a) on the buttocks. b) for a circular pattern. c) on the front of the body. d) on the back of the body.
on the front of the body. Explanation: Accidental scaldings are usually splash-related and occur on the front of the body. Any burns on the back of the body or in a well-defined circular or glove pattern may indicate physical abuse.
A nurse is teaching a parent how to administer antibiotics at home to a toddler with acute otitis media. Which statement by the parent indicates that teaching has been successful? a) "Whenever my child is cranky or pulls on an ear, I'll give a dose of antibiotics." b) "If the ear pain is gone, there's no need to see the physician for another examination of the ears." c) "I'll give the antibiotics for the full 10-day course of treatment." d) "I'll give the antibiotics until my child's ear pain is gone."
"I'll give the antibiotics for the full 10-day course of treatment." Correct Explanation: The mother demonstrates understanding of antibiotic therapy by stating she'll give the full 10-day course of treatment. Antibiotics must be given for the full course of therapy, even if the child feels well.
A nurse is giving discharge instructions to a parent of a 13-month-old infant who weighs 18 lb (8.2 kg). Which statement by the parent demonstrates understanding of car-seat safety? a) "My infant may ride in a front-facing car seat because he's 1 year old." b) "My infant may ride in a front-facing car seat as soon as he weighs 21 pounds." c) "If I have a sports utility vehicle, my infant may ride in a rear-facing or front-facing car seat." d) "My child will need to ride in a rear-facing care seat until he's 3 years old."
"My infant may ride in a front-facing car seat as soon as he weighs 21 pounds." Explanation: An infant must be at least 1-year old and weigh at least 20 lb (9.1 kg) to move from a rear-facing car seat to a front-facing car seat. The make or model of the vehicle is irrelevant.
Which toxic adverse reaction should the nurse monitor for in a toddler taking digoxin? a) Seizures b) Weight gain c) Tachycardia d) Nausea and vomiting
Nausea and vomiting Explanation: Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures aren't findings in digoxin toxicity.
During assessment of a child with celiac disease, the nurse should most likely note which physical finding? a) periorbital edema b) protuberant abdomen c) tender inguinal lymph nodes d) enlarged liver
protuberant abdomen Correct Explanation: The intestines of a child with celiac disease fill with accumulated undigested food and flatus, causing the characteristic protuberant abdomen
A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? a) "I don't have to worry because I've had the measles." b) "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." c) "I told my husband to give my son aspirin for his fever." d) "I'll ask the physician about giving the baby an immunization shot."
"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." Correct Explanation: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella
When developing the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery, which method is appropriate? a) Tell the child that his penis and scrotum will be "fixed." b) Use an anatomically correct doll to show the child what will be "fixed." c) Explain to the parents how the defect will be corrected. d) Tell the child that he will not see any incisions after surgery.
Explain to the parents how the defect will be corrected. Correct Explanation: Preoperative teaching would be directed at the parents because the child is too young to understand the teaching.
A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff? a) Logging off a computer containing client information b) New education materials for the management of diabetes c) Policy changes in the administration of opioids d) Proper documentation of a verbal order from a physician
Logging off a computer containing client information Correct Explanation: All members of the health care team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use.
A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child? a) giving the child's drawings to the abuser b) role-playing c) engaging in play therapy d) reporting the abuse to a prosecutor
engaging in play therapy Correct Explanation: The dolls and toys in a play therapy room are useful props to help the child remember situations and reexperience the feelings, acting out the experience with the toys rather than putting the feelings into words.
The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I do not know what to do!" After teaching the parent about ways to manage this behavior, which statement indicates that the nurse's teaching was successful? a) "When she behaves like this, I will tell her that she is being a bad girl." b) "Next time she screams and throws her legs, I'll ignore the behavior." c) "I'll explain why she cannot have what she wants." d) "I will allow her to have what she wants once in a while.
"Next time she screams and throws her legs, I'll ignore the behavior." Explanation: The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control.
A mother brings a 15-month-old child to the well-baby clinic. She states the child has been taking approximately 18 to 20 oz (540 to 600 mL) of whole milk per day from a bottle with meals and at bedtime. The nurse should suggest that she begin weaning the child from the bottle to avoid risking:
dental caries. Explanation: Nursing bottle caries occur when a child is routinely given a bottle of milk or juice at nap and bedtime. When teeth become coated in sugar before sleep, the lack of activity in the child's mouth for several hours during sleep allows the sugar to convert to acid, leading to decay.
The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption by the toddler because excess milk consumption can lead to: a) folate deficiency. b) vitamin C deficiency. c) biotin deficiency. d) iron deficiency.
iron deficiency. Correct Explanation: Excessive milk consumption can lead to the displacement of iron-rich foods in the diet. This can result in iron deficiency anemia.
A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating which stage of separation anxiety? a) regression b) detachment c) protest d) despair
protest Correct Explanation: Young children have specific reactions to separation and hospitalization. In the protest stage, the toddler physically and verbally attacks anyone who attempts to provide care. Here, the child is fussing and crying and visibly pushes the nurse away. In the despair stage, the toddler becomes withdrawn and obviously depressed (e.g., not engaging in play activities and sleeping more than usual). Regression is a return to a developmentally earlier phase because of stress or crisis (e.g., a toddler who could feed himself before this event is not doing so now). Denial or detachment occurs if the toddler's stay in the hospital without the parent is prolonged because the toddler settles in to the hospital life and denies the parents' existence (e.g., not reacting when the parents come to visit)
A child with osteomyelitis is to receive nafcillin I.V. every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable? a) 50 mg every 6 hours b) 250 mg every 6 hours c) 100 mg every 6 hours d) 500 mg every 6 hours
250 mg every 6 hours Correct Explanation: First, the nurse determines the minimum dose: 50 mg × 10 kg = 500 mg/day
A boy, age 2, is diagnosed with hemophilia, an X-linked recessive disorder. His parents and newborn sister are healthy. The nurse explains how the gene for hemophilia is transmitted. Which statement by the father indicates an understanding of X-linked recessive disorders? a) "Our newborn daughter may be a carrier of the trait." b) "If we have more sons, all of them will have hemophilia." c) "All of our offspring will carry the trait for hemophilia." d) "Our daughter will develop hemophilia when she gets older."
"Our newborn daughter may be a carrier of the trait." Correct Explanation: The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of X-linked recessive disorders. X-linked recessive genes behave like other recessive genes. A normal dominant gene hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a 50% chance of expressing the trait whereas female offspring are more likely to carry the trait than express it.
A parent aks the nurse about using corporal punishment. The nurse should tell the parent that corporal punishment: a) Reinforces the idea that violence is not acceptable. b) Does not physically harm the child. c) Can result in children becoming accustomed to spanking. d) Can be beneficial in teaching children what they should do.
Can result in children becoming accustomed to spanking. Correct Explanation: Corporeal punishment is an aversion technique that teaches children what not to do. Children can commonly become accustomed to physical punishment, so the punishment must be more severe to get the same results. Parents commonly use physical punishment when they are in a rage; injury to the child can result. Corporeal punishment, such as spanking, can reinforce the idea that violence is acceptable in certain circumstances. Corporal punishment is not beneficial. It causes children to be fearful and to direct their anger in other ways.
The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from social work or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship? a) The mother's fear that the staff do not respect her b) The mother's feelings of loss of control over her child c) Lack of knowledge about the child's illness and treatment d) Communication barriers between the mother and staff
Communication barriers between the mother and staff Correct Explanation: The communication barrier is the most significant and would require immediate attention. Strategies need to be implemented that include taking the time to share information via the written word with all new members of the healthcare team and the mother.
Which of the following actions should the nurse take when suspecting that a child has been abused by the mother? a) Ensure that any and all findings are reported to the proper authorities. b) Keep the findings confidential because they represent legal privileged communication between the nurse and the mother. c) Continue to collect information until there is no doubt in the nurse's mind that abuse has occurred. d) Report the findings to the primary care provider so the primary care provider can report the suspected abuse.
Ensure that any and all findings are reported to the proper authorities. Correct Explanation: Evidence of child abuse is legally reportable by anyone who works with children. The nurse should ensure that the findings are reported to the proper authorities. Laws ordinarily provide immunity from legal actions for people who are required to report suspicion of child abuse, if the report is done in good faith. Suspicion, not absolute proof, is necessary for reporting abuse.
A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff? a) Logging off a computer containing client information b) Proper documentation of a verbal order from a physician c) Policy changes in the administration of opioids d) New education materials for the management of diabetes
Logging off a computer containing client information Correct Explanation: All members of the health care team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use.
Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery? a) Risk for infection b) Impaired physical mobility c) Constipation d) Disturbed body image
Risk for infection Correct Explanation: Because infection is a serious risk for a client in the early stages of burn recovery, a diagnosis of Risk for infection takes highest priority.
Which of the following assessments would be the priority for a 2-year-old child after a bronchoscopy a) Pulse pressure changes. b) Sputum color. c) Heart rate. d) Respiratory quality.
Respiratory quality. Correct Explanation: After bronchoscopy, airway obstruction secondary to laryngeal edema may occur. Therefore, assessment of the child's respiratory quality is the priority. The child should be observed for signs and symptoms of respiratory distress including tachypnea, increased stridor and retractions, and tachycardia.
