NCLEX Pediatric Questions
The school nurse assesses Brook, a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following symptoms are characteristic of the disorder? Select all that apply. A. Constant fidgeting and squirming B. Excessive fatigue and somatic complaints C. Difficulty paying attention to details D. Easily distracted E. Running away F. Talking constantly, even when inappropriate
Correct Answer: A, C, D, & F These behaviors are all characteristic of ADHD and indicate that the child is inattentive, hyperactive, and impulsive. Individuals suffering from this disorder show patterns of developmentally inappropriate levels of inattentiveness, hyperactivity, or impulsivity. Although there used to be two different diagnoses of Attention Deficit Disorder vs Attention Deficit Hyperactivity Disorder, the DSM IV combined this into one disorder with three subtypes: predominantly inattentive, predominantly hyperactive, or combined type.
Reye's syndrome is a rare and severe illness affecting children and teenagers. Its development has been linked with the use of aspirin and which of the following? A. Meningitis B. Encephalitis C. Strep throat D. Varicella
Reye's syndrome has been linked with the ingestion of aspirin in children with viral infections like varicella. Epidemiologic studies found a link between the use of salicylate and the development of Reye syndrome. While less than 0.1% of children who took aspirin developed Reye syndrome, more than 80% of children diagnosed with Reye syndro
Nurse Nancy is teaching Mr. and Mrs. Diaz about the early signs and symptoms of lead poisoning. Which of the following if stated by the couple would indicate the need for further understanding of the case? A. Anemia B. Seizures C. Irritability D. Anorexia
Seizures usually are associated with encephalopathy, a late sign of lead poisoning. Typically, lead levels have already exceeded 70 mg/dl. In the appropriate clinical setting, lead encephalopathy should be considered in patients presenting with delirium, altered mental status, or seizures. As lead encephalopathy often presents with altered sensorium, obtaining a history directly from the patient can be challenging.
Hydrocortisone cream 1% is given to a child with eczema. The nurse gives instruction to the mother to apply the cream by? A. Apply a thin layer of cream and spread it into the area thoroughly. B. Avoid cleansing the area before the application. C. Apply a thick layer of the cream to affected areas only. D. Apply the cream to other areas to avoid occurrence.
Correct Answer: A. Apply a thin layer of cream and spread it into the area thoroughly. Topical corticosteroids are administered sparingly and rubbed into the area thoroughly. Topical steroid creams and ointments should be applied in a thin layer and massaged into the affected area.
12-year-old Caroline has recurring nephrotic syndrome. Which of the following areas of potential disturbances should be a prime consideration when planning ongoing nursing care? A. Body image B. Sexual maturation C. Muscle coordination D. Intellectual development
Correct Answer: A. Body image Because of edema associated with nephrotic syndrome, potential self-concept, and body image disturbances related to changes in appearance and social isolation should be considered. Nephrotic syndrome is a condition that causes the kidneys to leak large amounts of protein into the urine. This can lead to a range of problems, including swelling of body tissues and a greater chance of catching infections.
Patient S is a sexually active adolescent. Which of the following instructions would be included in the preventive teaching plan about urinary tract infections? A. Drinking acidic juices B. Avoiding urinating before intercourse C. Wearing nylon underwear D. Wiping back to front
Correct Answer: A. Drinking acidic juices Drinking acidic juices, such as cranberry juice, helps keep the urine at its desired pH and reduces the chance of infection. Pure cranberry juice, cranberry extract, or cranberry supplements may help prevent repeated UTIs in women, but the benefit is small. It helps about as much as taking antibiotics to prevent another UTI.
Arvic who is diagnosed with diabetes mellitus type 1 displays symptoms of hypoglycemia. Which of the following actions should the nurse instruct the parents? A. Give the child honey (simple sugar) B. Give the child milk (complex sugar). C. Contact the healthcare provider before doing anything. D. Give the child nothing by mouth.
Correct Answer: A. Give the child honey (simple sugar). Immediate action is important. Therefore, providing little sugar temporarily corrects low serum glucose levels. Simple sugar is preferred because it is converted to glucose more quickly than complex sugar. A child with hyperglycemia needs fluid to prevent dehydration. Patients should be advised to wear a medical alert bracelet and to carry a glucose source like gel, candy, or tablets on their person in case symptoms arise.
Nurse Christine is planning a client education program for sickle cell disease (SCD) in children. Which of the following interventions would be included in the care plan? A. Health teaching to help reduce sickling crises B. Avoidance of the use of opioids C. Administration of an anticoagulant to prevent sickling D. Observation of the imposed fluid restriction
Correct Answer: A. Health teaching to help reduce sickling crisis. Prevention is one of the principal goals of therapeutic management because there is no cure for sickle cell disease. Consequently, health education to help lessen the sickling crisis is key. Early detection and rapid initiation of appropriate treatment for several acute conditions including the vaso-occlusive crisis, aplastic crisis, sequestration crisis, and hemolytic crisis is needed. These crises, if not treated early, can result in mortality.
The nurse is evaluating a female child with acute post streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement? A. Increased urine output B. Increased appetite C. Increased energy level D. Decreased diarrhea
Correct Answer: A. Increased urine output Increased urine output, a sign of improving kidney function, typically is the first sign that a child with acute post-streptococcal glomerulonephritis (APSGN) is improving. PSGN typically presents with features of the nephritic syndrome such as hematuria, oliguria, hypertension, and edema, though it can also present with significant proteinuria.
Mrs. Johnson tells the nurse that she is very worried because her 2-year old child does not finish his meals. What should the nurse advise the mother? A. Make the child seat with the family in the dining room until he finishes his meal B. Provide quiet environment for the child before meals C. Do not give snacks to the child before meals D. Put the child on a chair and feed him
Correct Answer: Answer C. Do not give snacks to the child before meals. If the child is hungry he/she is more likely to finish his meals. Therefore, the mother should be advised not to give snacks to the child. Set times for meals and snacks and try to stick to them. A child who skips a meal finds it reassuring to know when to expect the next one. Avoid offering snacks or pacifying hungry kids with cups of milk or juice right before a meal — this can diminish their appetite and decrease their willingness to try a new food being offered.
The community nurse visits the home of George, a child recently diagnosed with autism. The parents express feelings of shame and guilt about having somehow caused this problem. Which statement by the nurse would best help alleviate parental guilt? A. "Autism is a rare disorder. Your other children shouldn't be affected." B. "The specific cause of autism is unknown. However, it is known to be associated with problems in the structure of and chemicals in the brain." C. "Sometimes a lack of prenatal care can be the cause of autism." D. "Although autism is genetically inherited if you didn't have testing you could not have known this would happen."
Correct Answer: B. "The specific cause of autism is unknown. However, it is known to be associated with problems in the structure of and chemicals in the brain." This statement is factual and does not cast blame on anything the parents did or did not do. The cause is still not known. The onset is variable. It develops in days to weeks, while in other cases, it develops slowly. It is not known whether epilepsy causes it, but children that have an autism spectrum disorder have an increased risk of having epilepsy.
Niklaus was born with hypospadias; which of the following should be avoided when a child has such condition? A. Surgery B. Circumcision C. Intravenous pyelography (IVP) D. Catheterization
Correct Answer: B. Circumcision Hypospadias refers to a condition in which the urethral opening is located below the glans penis or anywhere along the ventral surface (underside) of the penile shaft. The ventral foreskin is lacking, and the distal portion gives an appearance of a hood. Early recognition is important so that circumcision is avoided; the foreskin is used for surgical repair.
Katie is admitted to the intensive care unit of Nurseslabs Medical Center for diabetic ketoacidosis. Which of the following is of primary importance when caring for the child? A. Giving I.V. NPH insulin in high doses B. Evaluating the child for cardiac abnormalities C. Limiting fluids to prevent aggravating cerebral edema D. Monitoring and recording the child's vital signs for hypertension
Correct Answer: B. Evaluating the child for cardiac abnormalities. As the fluid volume deficit is improved, total body potassium deficiency may occur, leaving the child vulnerable to hypokalemia and, afterward, cardiac arrest. The nurse should monitor the cardiac cycle for prolonged QT interval, low T wave, and depressed ST segment, which indicate weakened heart muscle and potential irregular heartbeat.
Nurse Gloria questions the parents of a child with oppositional defiant disorder about the roles of each parent in setting rules of behavior. The purpose of this type of questioning is to assess which element of the family system? A. Anxiety levels B. Generational boundaries C. Knowledge of growth and development D. Quality of communication
Correct Answer: B. Generational boundaries An important element in assessing the family system is determining if the parents establish and maintain appropriate generational boundaries, establishing clear rules and expectations as part of the parental role. Provide clear behavioral guidelines, including consequences for disruptive and manipulative behavior.
Mrs. Lodge's child requires the use of a Pavlik harness. Which of the following would Nurse Betty do to best assess the mother's ability to care for her child? A. Demonstrate to the mother how to remove and reapply the device. B. Have the mother remove and reapply the harness before discharge. C. Have the mother verbalize the purpose of using the device. D. Request a home health care nurse visit after discharge.
Correct Answer: B. Have the mother remove and reapply the harness before discharge. Having the mother remove and reapply the harness before discharge allows the nurse to directly observe the mother's method and comfort level. It also provides time for reinstruction if needed. A successful transition also depends on whether hospitals have adequately educated patients about key elements of care such as diagnosis and follow-up plans.
Martin Sanchez is a nine (9)-year-old child admitted to a psychiatric treatment unit accompanied by Mr. and Mrs. Sanchez. To establish trust and position of neutrality, which action would the nurse take? A. Encourage Mr. and Mrs. Sanchez to leave while Martin is being interviewed. B. Interview Martin with his parents together, observing their interaction. C. Provide diversion for Martin, and interview Mr. and Mrs. Sanchez alone. D. Review the clinical record prior to interviewing Mr. and Mrs. Sanchez.
Correct Answer: B. Interview Martin with his parents together, observing their interaction. It is important for the nurse to be seen as a neutral person who is interested in the family as an adaptive functioning unit. By conducting the admission interview with the parents and child together, the nurse establishes this neutral role from the beginning. Relationships with child and adolescent patients differ from those with adult patients and nurses build relationships in a different way with adults.
Which of the following parameters would Nurse Max monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)? A. Urine B. Vomiting C. Weight D. Stools
Correct Answer: B. Vomiting Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child's vomiting to evaluate the effectiveness of using the thickened feedings. The feeding management strategy has been shown to represent an effective approach in otherwise healthy infants with both GER and GERD. It involves modifying feeding frequency and volume, ensuring the intake of feed per kilogram of weight is appropriate. There is some evidence for the efficacy of feed thickeners on reducing visible regurgitation
Nurse Dorothy is caring for a child with Category A Near Drowning; she should do which of the following? Select all that apply. A. Give furosemide as ordered. B. Check for increased intracranial pressure C. Plan for discharge in 12 to 24 hours. D. Check for electrolyte imbalances. E. Keep mechanical ventilation. F. Provide oxygen as ordered.
Correct Answer: C, D, & F Near-drowning is defined as survival for at least 24 hours from suffocation by submersion. Aspiration of water causes the plasma to be pulled into the lungs, resulting in hypoxemia, acidosis, and hypovolemia. Hypoxemia results from the decrease in pulmonary surfactant caused by the absorbed water that leads to damage of the pulmonary capillary membrane. Children with Category A Near Drowning are awake with minimal injury. Care includes checking electrolyte status, administering oxygen and warming, and preparing for discharge in 12 to 24 hours.
Mandy, age 12, is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on the child's nutritional intake, the nurse should ask: A. "What activities do you engage in during the day?" B. "Do you have any allergies to foods?" C. "Do you like yourself physically?" D. "What kinds of food do you like to eat?"
Correct Answer: C. "Do you like yourself physically?" Role and relationship patterns focus on body image and the patient's relationship with others, which are commonly interrelated with food intake. Eating behaviors evolve during the first years of life; children learn what, when, and how much to eat through direct experiences with food and by observing the eating behaviors of others.
Nurse Charlotte suspects that a child, age 4, is being neglected physically. To best assess the child's nutritional status, the nurse should ask the parents which question? A. "Has your child always been so thin?" B. "Is your child a picky eater?" C. "What did your child eat for breakfast?" D. "Do you think your child eats enough?"
Correct Answer: C. "What did your child eat for breakfast?" The nurse should obtain objective information about the child's nutritional intake, such as by asking about what the child ate for a specific meal. In order to assess the adequacy of a child's nutritional intake, dietitians require detailed information about all food and drink consumed. As all children admitted to the hospital are at risk of nutritional deficit, a dietary record should be started on all in-patients, although this may subsequently be discontinued when deemed appropriate.
Tara is an 11-year-old girl diagnosed with type 1 diabetes mellitus (DM). She asks her attending nurse why she can't take a pill rather than shots like her grandmother does. Which of the following would be the nurse's best reply? A. "If your blood glucose levels are controlled, you can switch to using pills." B. "The pills correct fat and protein metabolism, not carbohydrate metabolism." C. "Your body does not make insulin, so the insulin injections help to replace it." D. "The pills work on the adult pancreas, you can switch when you are 18."
Correct Answer: C. "Your body does not make insulin, so the insulin injections help to replace it." The child has type 1 DM, indicating a lack of functioning pancreatic beta cells and an absolute insulin deficiency. Type 1 diabetes is an autoimmune condition that leads to the destruction of pancreatic beta cells which in turn causes insufficient insulin production, resulting in hyperglycemia. Type 1 diabetes is a chronic disease requiring insulin replacement and intensive effort by the patient.
Among toddlers and children up to age five, femur fractures usually result from a low energy fall. In most cases, the orthopedic surgeon realigns the fracture using fluoroscopy or x-ray imaging as a guide and immobilizes the leg in a type of cast called a spica cast. Approximately how many weeks does it take for a fractured femur to heal in a 3-year-old? A. 1-2 weeks B. 2-4 weeks C. 3-8 weeks D. 10-12 weeks
Correct Answer: C. 3-8 weeks In most cases, three to six weeks of early healing is necessary before the child can begin walking on the injured leg. When the bone is completely healed, usually around one year after the injury occurs, the child returns to the hospital to have the nails removed. Following treatment, the orthopedic surgeon continues to monitor the patient for a period of several years to ensure that there is no limb length discrepancy.
How should the nurse prepare a suspension before administration? A. By diluting it with normal saline solution B. By diluting it with 5% dextrose solution C. By shaking it so that all the drug particles are dispersed uniformly D. By crushing remaining particles with a mortar and pestle
Correct Answer: C. By shaking it so that all the drug particles are dispersed uniformly. The nurse should shake a suspension before administration to dispersed drug particles uniformly. First, the bottle should be tabbed a few times to loosen the powder, then approximately, half the volume of water should be added, the bottle is shaken vigorously, the remaining water should be added and shaken well.
Nurse Elizabeth is administering medication via the intraosseous route to a child. Intraosseous drug administration is typically used when a child is: A. Under age 3 B. Over age 3 C. Critically ill and under age 3 D. Critically ill and over age 3
Correct Answer: C. Critically ill and under age 3 In an emergency, intraosseous drug administration is typically used when a child is critically ill and under age 3. IO access provides a means of administering medications, glucose, and fluids, as well as (potentially) a means of obtaining blood samples. Such a situation would include any resuscitation; cardiopulmonary arrest; shock, regardless of etiology; life-threatening status epilepticus; or lack of venous access resulting from burns, edema, or obesity.
Which of the following is not true regarding the varicella vaccine? A. It is administered subcutaneously. B. Children 13 years and older (With no history of chickenpox or have not previously vaccinated) need two doses given at least 28 days apart. C. Give aspirin for any injection-related pain. D. The most common mild side effects are pain, redness, or swelling at the injection site.
Correct Answer: C. Give aspirin for any injection-related pain. Children receiving the varicella vaccine should avoid aspirin or aspirin-containing products because of the risk of Reye's syndrome. After administration of the vaccine, it is recommended to avoid salicylates for five weeks due to the risk of Reye's syndrome and to avoid contact with susceptible high-risk individuals.
Which of the following organisms is responsible for the development of rheumatic fever? A. Streptococcal pneumonia B. Haemophilus influenza C. Group A beta-hemolytic streptococcus D. Staphylococcus aureus
Correct Answer: C. Group A ?-hemolytic streptococcus Rheumatic fever results from a delayed reaction to inadequately treated group A ?-hemolytic streptococcal infection. In order for ARF to occur, it appears that a pharyngeal infection caused by S. pyogenes must occur in a host with a genetic susceptibility to the disease. Activation of the innate immune system begins with a pharyngeal infection that leads to the presentation of S. pyogenes antigens to T and B cells.
The long-term complications seen in thalassemia major are associated to which of the following? A. Anemia B. Growth retardation C. Hemochromatosis D. Splenomegaly
Correct Answer: C. Hemochromatosis Long-term complications arise from hemochromatosis, excessive iron deposits precipitating in the tissues, and causing destruction. Hemochromatosis is a disorder associated with deposits of excess iron that causes multiple organ dysfunction. Hemochromatosis occurs when there are high pathologic levels of iron accumulation in the body. Hemochromatosis has been called "bronze diabetes"
Nurse Karen is providing postoperative care for Dustin who has cleft palate (CP); she should position the child in which of the following? A. In an infant seat B. In the supine position C. In the prone position D. On his side
Correct Answer: C. In the prone position Postoperatively, children with a CP should be placed on their abdomens to facilitate drainage. A child who has had a cleft lip repair should be positioned on their side or back to keep them from rubbing their face in the bed. A child with only a cleft palate repair may sleep on their stomach. It is important to keep the stitches clean and without crusting.
Which behavioral assessment in a child is most consistent with a diagnosis of conduct disorder? A. Arguing with adults B. Gross impairment in communication C. Physical aggression toward others D. Refusal to separate from caretaker
Correct Answer: C. Physical aggression toward others Physical aggression toward others is a significant criterion consistent with the diagnoses of conduct disorder. Conduct disorder (CD) lies on a spectrum of disruptive behavioral disorders, which also include oppositional defiant disorder (ODD). In some cases, ODD is a precursor to CD. CD is characterized by a pattern of behaviors that demonstrate aggression and violation of the rights of others and evolves over time.
During a well-baby visit, Liza asks the nurse when she should start giving her infant solid foods. The nurse should instruct her to introduce which solid food first? A. Applesauce B. Egg whites C. Rice cereal D. Yogurt
Correct Answer: C. Rice cereal Rice cereal is the first solid food an infant should receive because it is easy to digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt, and finally, meat.
Spina bifida is one of the possible neural tube defects that can occur during early embryological development. Which of the following definitions most accurately describes meningocele? A. Complete exposure of spinal cord and meninges B. Herniation of the spinal cord and meninges into a sac C. Sac formation containing meninges and spinal fluid D. Spinal cord tumor containing nerve roots
Correct Answer: C. Sac formation containing meninges and spinal fluid. Meningocele is a sac formation containing meninges and cerebrospinal fluid (CSF). Meningocele is the simplest form of open neural tube defects characterized by cystic dilatation of meninges containing cerebrospinal fluid without any neural tissue. A complex meningocele is associated with other spinal anomalies. Meningocele is a typically asymptomatic spinal anomaly and is not associated with acute neurologic conditions.
Baby Jonathan was born with cleft lip (CL); Nurse Barbara would be alert that which of the following will most likely be compromised? A. GI function B. Locomotion C. Sucking ability D. Respiratory status
Correct Answer: C. Sucking ability Because of the defect, the child will be unable to form a mouth adequately around the nipple, thereby requiring special devices to allow for feeding and sucking gratification. Patients with cleft lips inherently will have some degree of alveolar cleft with potential for collapse of the maxillary arch and class III malocclusion (the maxillary teeth sit posterior to the mandibular teeth). These hard and soft tissue anatomic changes translate to the various changes in appearance, speech, and swallowing/feeding seen in cleft lip patients.
The following are considered functions of the Urinary System, EXCEPT: A. Vitamin D synthesis B. Regulation of red blood cell synthesis C. Excretion D. Absorption of digested molecules E. Regulation of blood volume and pressure
Correct Answer: D. Absorption of digested molecules This is a function of the digestive system. The small molecules that result from digestion are absorbed through the walls of the intestine for use in the body. Digestion is the process of mechanically and enzymatically breaking down food into substances for absorption into the bloodstream.
A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect: A. Gross hematuria B. Dysuria C. Nausea and vomiting D. An abdominal mass
Correct Answer: D. An abdominal mass The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Wilms tumor usually presents as an asymptomatic abdominal mass in the majority of children. The mother may have discovered the mass during bathing the infant.
Sickle cell disease (SCD) primarily affects: A. children of African descent and Hispanics of Caribbean ancestry. B. children of Middle-Eastern and Indian descent. C. children of Asian descent. D. both African descent and Hispanics of Caribbean ancestry and Middle-Eastern and Indian descent.
Correct Answer: D. Both African descent and Hispanics of Caribbean ancestry and Middle-Eastern and Indian descent. Sickle cell disease primarily affects children of African descent and Hispanics of Caribbean ancestry. It also occurs in children of Middle-Eastern and Indian descent. Sickle cell anemia is the most common monogenic disorder. Prevalence of the disease is high among the people of Sub-Saharan Africa, South Asia, the Middle East, and the Mediterranean.
Which of the following should the nurse include in the insulin administration instruction for the parents of a child being discharged on insulin? A. Insert the needle and aspirate prior to injecting B. Inject insulin into the extremity to be exercised to enhance absorption C. The muscles in the abdomen and thigh are the easiest to use for self-administration D. Clean the site of injection with soap and water and avoid alcohol
Correct Answer: D. Clean the site of injection with soap and water and avoid alcohol. Infection risk from insulin injections is negligible (at least in normal environments - some experts feel hospital environments are riskier), and an alcohol swab is a poor way to sanitize skin in the first place. Soap and hot water are actually more effective.
Benjamin was rushed to the emergency department with possible increased intracranial pressure (ICP); which of the following is an early clinical manifestation of increased ICP in older children? A. Macewen's sign B. Setting sun sign C. Papilledema D. Diplopia
Correct Answer: D. Diplopia Diplopia is an early sign of increased ICP in an older child. Visual changes can range from blurred vision, double vision from cranial nerve defects, photophobia to optic disc edema and eventually optic atrophy. Clinical suspicion for intracranial hypertension should be raised if a patient presents with the following signs and symptoms: headaches, vomiting, and altered mental status varying from drowsiness to coma.
A child with known hemophilia A was brought to the emergency room with complaints of nose bleeding and some bruises in the joints. Which of the following should the nurse anticipate to be given to the child? A. Oral iron supplement B. Cyclosporine C. Factor X Factor VIII
Correct Answer: D. Factor VIII Hemophilia A, also called factor VIII (FVIII) deficiency or classic hemophilia, is a genetic disorder caused by missing or defective factor VIII, a clotting protein. The initial treatment is the administration of factor VIII to replace the missing factor and decrease the bleeding episode.
Justine is admitted to the pediatric unit due to the occurrence of diabetic ketoacidosis signaling a new diagnosis of diabetes. The diabetes team explores the cause of the episode and takes steps to prevent a recurrence. Diabetic ketoacidosis (DKA) results from an excessive accumulation of which of the following? A. Sodium bicarbonate from renal compensation B. Potassium from cell death C. Glucose from carbohydrate metabolism D. Ketone bodies from fat metabolism
Correct Answer: D. Ketone bodies from fat metabolism. Inability to use glucose causes lipolysis, fatty acid oxidation, and release of ketones, resulting in metabolic acidosis and coma. Ketones accumulate and cause metabolic acidosis. The body tries to compensate by hyperventilation to eliminate carbon dioxide. When the blood glucose is low or cannot be used due to a lack of insulin, ketones are the major source of energy for the brain. The brain does not have any fuel stores and has no other non-glucose-derived energy sources.
A child was brought to the emergency department with complaints of nausea, vomiting, fruity-scented breath. The resident on duty diagnosed the child with diabetes ketoacidosis. Which of the following should the nurse expect to administer? A. Potassium chloride IV infusion. B. Dextrose 5% IV infusion. C. Ringer's Lactate. D. Normal saline IV infusion.
Correct Answer: D. Normal saline IV infusion. The initial priority in the treatment of diabetic ketoacidosis is the restoration of extracellular fluid volume through the intravenous administration of a normal saline(0.9 percent sodium chloride) solution. Treatment for DKA begins with ABCs and fluid resuscitation. Insulin therapy, usually by continuous infusion, can begin once the patient is stabilized.
A spica cast was put on Baby Betty after an unfortunate incident to immobilize her hips and thighs. Which of the following is the priority nursing action immediately after application? A. Keep the cast dry and clean. B. Cover the perineal area. C. Elevate the cast. D. Perform neurovascular checks.
Correct Answer: D. Perform neurovascular checks. A neurovascular assessment is always a priority in the assessment of a freshly applied cast to ensure adequate circulation and neurologic function and prevent complications or injury. Neurovascular observations should be conducted hourly for the first 24 hours then 2-4 hourly for the next 48 hours depending on the condition. Document findings on appropriate limb observation flowsheet.
Stephen was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder? A. Hypertension, edema, hematuria B. Hypertension, edema, proteinuria C. Gross hematuria, fever, proteinuria D. Poor appetite, edema, proteinuria
Correct Answer: D. Poor appetite, edema, proteinuria Clinical manifestations of nephrotic syndrome include loss of appetite due to edema of the intestinal mucosa, proteinuria, and edema. The classic NS presentation is edema, in the early phase is located in the face in the morning on waking with puffiness of the eyelids and the impression of the folds of sheets on the skin and ankles at the end of the day.
Nurse Nancy is assessing a child with pyloric stenosis; she is likely to note which of the following? A. "Currant jelly" stools B. Regurgitation C. Steatorrhea D. Projectile vomiting
Correct Answer: D. Projectile vomiting Projectile vomiting is a key sign of pyloric stenosis. Pyloric stenosis, also known as infantile hypertrophic pyloric stenosis (IHPS), is an uncommon condition in infants characterized by abnormal thickening of the pylorus muscles in the stomach leading to gastric outlet obstruction. Clinically infants are well at birth. Then, at 3 to 6 weeks of age, the infants present with "projectile" vomiting, potentially leading to dehydration and weight loss.
When performing a physical examination on an infant, the nurse in charge notes abnormally low-set ears. This finding is associated with: A. Otogenous tetanus B. Tracheoesophageal fistula C. Congenital heart defects D. Renal anomalies
Correct Answer: D. Renal anomalies Normally the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation. This is due to the observation that auricular malformations often are associated with specific MCA syndromes that have high incidences of renal anomalies.
You have learned that in babies and children with developmental dysplasia (dislocation) of the hip (DDH), the hip joint has not formed normally. Which of the following is the most common form of DDH? A. Acetabular dysplasia B. Dislocation C. Preluxation D. Subluxation
Correct Answer: D. Subluxation DDH is a group of congenital abnormalities of the hip joints, which includes subluxation, dislocation, and preluxation. Of the types of congenital hip abnormalities, subluxation is the most common. In mild cases of DDH, the head of the femur is simply loose in the socket. During a physical examination, the bone can be moved within the socket, but it will not dislocate
A nurse prepares to administer an intramuscular injection to a 6-month-old infant. The nurse selects which site to administer the medication? A. Rectus femoris B. Dorsal gluteal C. Ventrogluteal D. Vastus lateralis
Correct Answer: D. Vastus lateralis Intramuscular injection sites are selected based on the child's age and muscle development. The vastus lateralis is the only safe muscle group to use for intramuscular injection in a 6 month-old infant. Muscle has fewer pain-sensing nerves than subcutaneous tissue and is less sensitive to irritating and viscous medications, so pain is lessened.
When administering an I.M. injection to an infant, the nurse in charge should use which site? A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis
Correct Answer: D. Vastus lateralis The recommended injection site for an infant is the vastus lateralis or rectus femoris muscles. Skeletal muscle can accommodate larger volumes of medication than subcutaneous tissue, and absorption is faster because muscle tissue is highly vascular. Muscle has fewer pain-sensing nerves than subcutaneous tissue and is less sensitive to irritating and viscous medications, so pain is lessened.
Mrs. Baker was instructed by the nurse on foods to encourage her child's diet concerning the latter's iron deficiency anemia. which of the following if stated by the mother would indicate the need for further instruction? A. Fish B. Lean meats C. Whole-grain breads D. Yellow vegetables
Correct Answer: D. Yellow vegetables If a parent states that she should stress the intake of yellow vegetables, she needs additional teaching because yellow vegetables are not a good source of iron. Leafy greens, especially dark ones, are among the best sources of nonheme iron.
Archie is a child with iron deficiency anemia. He is required to receive elemental iron therapy at 6 mg/kg/day in three divided doses. He weighs 44 lbs. How many milligrams of iron should he receive per dose? A. 20 mg/dose B. 40 mg/dose C. 60 mg/dose D. 120 mg/dose
The child weighs 44 lbs, which is equal to 20 kg (1 kg=2.2 lb;44/2.2=20kg). Elemental iron therapy is ordered at 6 mg/kg/day in three doses. Therefore, the child receives 120 mg/day (6 mg/20 kg/day=120), divided into three doses (120/3), which is equal to 40 mg/dose.
