NCLEX CHILD HEALTH
The nurse is caring for a mother and her infant who was born 12 hours ago. Which statements made by the mother should prompt the nurse to have the baby evaluated for early heart failure? Select all that apply.
2. "I'm chilly but my baby's forehead is sweaty." 4. "I can feel my baby's heart rate when he's sleeping, it seems much faster than it did yesterday." 5. "My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."
The 16-year-old client presents to the dermatology clinic with a diagnosis of acne vulgaris. The client says to the nurse, "I don't know what else to do! I wash my face twice a day. I wear noncomedogenic makeup. I shower after I work out. I guess I'm just going to have acne on my face forever." Which responses by the nurse would be most appropriate? Select all that apply.
3. "You feel like there's nothing else you can do to cure your acne." 5. "You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating."
A child seen in the clinic is found to have rubeola (measles) and the mother asks the nurse how to care for the child. Which instruction should the nurse provide to the mother?
Keep the child in a room with dim lights.
The nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity should the nurse suggest that the child can safely participate in with peers?
Swimming
A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction should the nurse reinforce to the mother to prevent the transmission of the disease?
"Disease transmission is unknown."
The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?
"Has the child complained of a sore throat within the past few months?"
A client has been prescribed valproic acid (Depakene) for the treatment of generalized seizures, and the nurse reinforces instructions to the child about the potential side effects of the medication. Which statement by the client would indicate a need for further teaching?
"I am so glad that I won't lose any of my hair. I was worried what my friends would think."
The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if 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 nurse is reinforcing home care instructions to the mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for further teaching
"I can use a warm mist humidifier to keep the secretions loose."
The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching?
"I need to provide a well-balanced, high-fat diet to my child."
When reinforcing instructions to the caregiver of a child about cast care, the nurse anticipates the need for further teaching when the caregiver makes which statement?
"I will allow my child to put cotton balls inside the cast to relieve pressure."
The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching?
"I will give my child cough syrup if a cough develops."
The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement?
"In most cases, medication and diet will control fluid retention."
The nurse is preparing to administer a measles, mumps, rubella (MMR) vaccine to a 15-month-old child. Before administering the vaccine, which question should the nurse ask the mother of the child?
"Is the child allergic to any antibiotics?"
The nurse assists with providing an instructional session to parents regarding impetigo. Which statement by a parent indicates the need for further teaching?
"Lesions are most often located on the arms and chest."
A mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. The nurse reinforces instructions to the mother regarding care of the child. Which statement by the mother indicates the need for further teaching?
"My child will need to be treated with oral antibiotics."
The nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which statement should the nurse make to the mother?
"The fluid retention should be controlled by medication and diet."
The nurse is reinforcing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further teaching?
"The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."
A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period?
"The infectious period is 10 days before the onset of symptoms to 15 days after the rash appears."
The nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The child needs further teaching if which statement is made?
"This brace will correct my curve."
The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?
"We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."
Antibiotics are prescribed for a child following a myringotomy with insertion of tympanostomy tubes, and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement made by a parent would indicate that the instructions were understood?
"We will administer the antibiotics until they are gone."
The nurse is reinforcing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand these measures if they make which statement?
"We will provide comfort measures to reduce any crying periods by our child."
Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?
"When picking up your infant, support the infant's neck and head with the open palm of your hand."
The nurse is attempting to ensure the parent is able to safely administer at home the prescribed ear drops to the 2-year-old client. The parent demonstrates understanding of the teaching by listing the steps of the process in which priority order? Arrange the actions in the order that they should be performed. All options must be used.
1)Warm the bottle of ear drops by rolling it in the palms of the hands to help decrease discomfort. 2)Have the child lie on his or her back with the affected ear facing up. 3)Straighten the ear canal by pulling the pinna of the affected ear down and back. 4)Slowly instill the number of drops prescribed by the health care provider into the ear. 5)Massage the area anterior to the ear to facilitate entry of the drops. 6)Keep the child in the same position for 2 to 3 minutes.
The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the health care provider regarding this client's condition? Select all that apply.
1. "I am concerned this client has Kawasaki's disease. Can you please come assess this client?" 2. "This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days." 4. "I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." 5. "I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."
Which interventions should the nurse include when preparing a plan of care for a child with hepatitis? Select all that apply.
1. Providing a low-fat, well-balanced diet 2. Teaching the child effective hand-washing techniques 5. Instructing the parents about the risks associated with taking medications
A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 am, 12 noon, and at 6:00 pm. What times should the nurse tell the mother to perform postural drainage?
10:00 am, 2:00 pm, and 8:00 pm
The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply.
2. Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications.
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.
2. Propranolol (Inderal) 3. Atenolol (Tenormin) 4. Methimazole (Tapazole)
The nurse is planning education for the parent whose child has recently been prescribed cromolyn sodium (Intal) as a part of the treatment plan for asthma. Which information should the nurse reinforce in the teaching? Select all that apply.
2. This medication is inhaled using a Spinhaler. 3. This medication is not to be used as a rescue inhaler 5. This medication should be inhaled slowly to ensure the medication reaches the lower airways.
A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse should perform which actions in order to protect the child from injury? Select all that apply.
2. Turn the client to the side during a seizure. 3. Keep side rails and other hard objects padded.
The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than which value?
20,000 cells/mm3
A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which on the handout? Select all that apply.
3. It is transmitted as an autosomal recessive trait. 4. It is a disease that causes mucous formation to be abnormally thick. 5. It is a chronic multisystem disorder affecting the exocrine glands.
A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse should base the response on which description of this disorder?
A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel
The nurse is monitoring a child following a tonsillectomy. Which finding would indicate that the child is bleeding?
A decreased pulse rate
The nurse is preparing for the administration of ribavirin (Virazole) to a child with respiratory syncytial virus. Which supplies will the nurse obtain for the administration of this medication?
A pair of goggles
The nurse is caring for an 18-month-old child who has been vomiting. The appropriate position to place the child during naps and sleep time is which?
A side-lying position
The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?
An airway obstruction
The nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which food item should the nurse mix with the medication?
Applesauce
A nursing student is asked to administer a tepid bath to a child with a fever. The student should avoid which action when performing this procedure?
Applies alcohol-soaked cloths over the child's body
Permethrin (Elimite) is prescribed for a 4-year-old child with a diagnosis of scabies. The nurse reinforces instructions to the mother regarding the use of this treatment. Which instruction is appropriate?
Apply the lotion to cool, dry skin at least half an hour after bathing.
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 immediately following the procedure?
Assess for any bleeding on the dressing.
A urinalysis has been prescribed for an infant and the nurse plans to collect the specimen. The nurse implements which appropriate method to collect the specimen?
Attaches a urinary collection device to the infant's perineum
A nursing student caring for a 6-month-old infant is asked to collect a urine specimen from the infant. The student collects the specimen by performing which action?
Attaching a urinary collection device to the infant's perineum for collection
A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery should the nurse explain to the mother?
Before the child is 3 years old
The nurse is reviewing the record of a child scheduled for a health care provider's visit. Before data collection, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans to focus on which factor when collecting data?
Bladder function
Which test would the nurse anticipate for a teenage client who has been treated for vaginal Candida infections repeatedly in the last 6 months to assist in the identification of the underlying chronic pathology?
Blood glucose level
Which finding would indicate that a child had a tonic-clonic seizure during the night?
Blood on the pillow
The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?
Calcium
A child is to be admitted to the orthopedic unit following a Harrington rod insertion for the treatment of scoliosis. The nurse is assisting in preparing a plan of care for the child. The nurse plans to monitor which priority item in the immediate postoperative period?
Capillary refill, sensation, and motion in all extremities
The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign?
Changes in level of consciousness
The nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication?
Checking the child's ability to perform range of motion to the shoulder area of the affected extremity
The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record?
Choking with feedings
The nurse has reviewed the health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to do which?
Collect a 24-hour urine sample.
The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which nursing action is appropriate?
Consult with the registered nurse to verify the prescription.
The nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing which?
Decorticate posturing
The nurse is caring for an infant with congenital heart disease. Which signs, if noted in the infant, should alert the nurse to the early development of heart failure (HF)?
Diaphoresis during feeding
A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?
Diphtheria, tetanus, acellular pertussis (DTaP), Haemophilus influenzae type b (Hib), inactivated poliovirus vaccine (IPV), pneumococcal vaccine (PCV)
A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In planning care for this child, which nursing intervention should be of highest priority?
Dipstick the urine for protein every 4 hours
The nurse checks the vital signs of an infant with a respiratory infection and notes that the respiratory rate is 50 breaths per minute. Which action is appropriate?
Document the findings
A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor would the nurse expect to find documented in the child's record?
Elevated vanillylmandelic acid (VMA) levels in the urine
The nurse, caring for a child with aplastic anemia, is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 cells/mm3 and a platelet count of 20,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?
Encourage quiet play activities.
A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which information in the discussion?
Enteric precautions are necessary for hepatitis B (HBV) but not for hepatitis A (HAV).
A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor should the nurse take into account?
Fears of separation and mutilation are present.
The nurse is administering medications to a 6-year-old child with nephrotic syndrome. To reduce proteinuria, the nurse would expect which medication to be prescribed?
Furosemide (Lasix)
An adolescent client with type 1 diabetes is experiencing high glucose levels upon awakening in the morning. After reviewing the client's chart, the nurse determines that the elevated glucose level in the morning is due to the Somogyi effect. Which finding should lead the nurse to this conclusion? Refer to chart.
Glucose level at 2 am of 65 mg/dL
A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student should include which correct item in the discussion?
HIV virus attacks the immune system by destroying T lymphocytes.
The nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which is the priority concern?
Infection
A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct?
Is a type of skin traction that pulls the hip and leg into extension
A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which information?
It is a congenital aganglionosis or megacolon.
The nursing student is asked to discuss the topic of clubfoot at a clinical conference. The student plans to tell the group which fact about clubfoot?
It is a congenital anomaly.
The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period?
Maintain moisture of the normal saline dressing on the gibbus area.
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
The nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which is the priority nursing action?
Notify the registered nurse.
The nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which sign/symptom that is indicative of this common complication?
Nuchal rigidity
A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?
Pastia's sign
A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority concern is infection due to immunosuppression. Which interventions should the nurse include in the plan of care?
Perform oral hygiene four times a day.
The nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which should be the appropriate nursing action?
Plan to move the infant to a room with another child with RSV.
The nurse is assigned to care for a 2-year-old child who has been admitted to the hospital for surgical correction of cryptorchidism. What is the highest priority in the postoperative plan of care for this child?
Prevent tension on the suture.
A child is seen in the clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks the nurse about the diagnosis. Which should the nurse relay to the mother about primary nocturnal enuresis?
Primary nocturnal enuresis is common, and most children will outgrow bed-wetting without therapeutic intervention.
The nurse reviews the record of a 1-year-old child seen in the clinic and notes that the health care provider has documented a diagnosis of celiac crisis. Which symptom should the nurse expect to note in this condition?
Profuse, watery diarrhea
The nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which intervention is the priority for the child?
Promoting bed rest
After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?
Prone
A child is diagnosed with Reye's syndrome. The nurse assists to develop a nursing care plan for the child and should include which intervention in the plan?
Providing a quiet atmosphere with dimmed lighting
The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which should be included in the plan?
Pull the earlobe down and back before instilling the eardrops.
The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding should the nurse expect to note in this child?
Tachycardia
The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation may be indicative of this condition?
The child consistently tilts his or her head to see.
The nurse is reviewing the health record of a child who has been recently diagnosed with glomerulonephritis. Which finding noted in the child's record is associated with the diagnosis of glomerulonephritis?
The child had a streptococcal throat infection 2 weeks before diagnosis.
The nurse is reviewing a chart of a child with a head injury. The nurse notices that the level of consciousness has been documented as obtunded. Which observation should the nurse expect to make during data collection of the child?
The child sleeps unless aroused and, once aroused, interacts poorly with the environment.
A child is brought to a clinic after developing a rash on the trunk and on the scalp. The parents report that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox. Which statement by the nurse is accurate regarding chickenpox?
The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.
A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder?
The infrequent and difficult passage of dry stools
A 1-year-old child is seen in the health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media?
The mother states the child had purulent discharge from the ear last night.
An infant is suspected to be human immunodeficiency virus (HIV) positive, and the nurse provides information to the parents about the care of their infant. Which indicates to the nurse that the parents need further teaching about the care of their HIV-positive infant?
The parents plan to use rice cereal to help with watery stools when they occur.
The nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. The nurse understands that which is unassociated with this disorder?
The passage of currant jelly-like stools
The nurse is collecting data from a child with a diagnosis of diabetes insipidus. Which clinical finding is consistent with this diagnosis?
Urinary output is increased.
A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action?
Weighing the diapers
An infant with heart failure (HF) is receiving diuretic therapy, and the nurse is closely monitoring the intake and output. Which is the best method for the nurse to use to monitor the urine output?
Weighing the diapers
The health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant?
p24 antigen assay
The nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. Which supplement should the nurse give the child to treat the reaction?
½ cup of fruit juice