NU373 EAQ Evolve Elsevier: HESI Prep Pediatrics

Which nursing assessment indicates dehydration in an infant? o Flat anterior fontanel o Decreased urine output o Warm skin temperature o Slow, labored respirations

o Decreased urine output · Dehydration leads to reduced blood volume, which in turn reduces kidney perfusion, resulting in a decreased urine output. The anterior fontanel is depressed in the dehydrated infant; it is flat in an adequately hydrated infant. A dehydrated infant's skin is cold, and respiration is rapid.

Which assessment finding would the nurse recognize as needing further evaluation during a head-to-toe assessment of a newborn? o Red reflex o Head circumference 30 cm, chest circumference 34 cm o Temperature 97.7°F (36.5°C) axillary, pulse 148 beats per minute, respirations 48 breaths per minute o The top of the pinna crosses an imaginary line drawn from the inner canthus to the outer canthus of the eye to the ear

o Head circumference 30 cm, chest circumference 34 cm · The head circumference should exceed the chest circumference. This could be an indication of microcephaly. When the nurse evaluates the eye with an ophthalmoscope, the retina should appear as a red circle, called the red reflex. Vital signs are normal, and the ear placement is normal.

Which athletic safety equipment would the nurse recommend for a school-aged child? Select all that apply. o Gloves o Helmet o Padding o Eye shields o Mouth shields

o Helmet o Padding o Eye shields o Mouth shields · General safety equipment recommended for a school-aged child playing active sports includes a safety helmet, padding, eye shields, and mouth shields. Gloves are not necessary unless participating in a specific activity that requires them.

Which happens during the transition from infanthood to toddlerhood? o Reduced activity levels o Increased need for fats o Increased food choices o Reduced need for sleep

o Reduced need for sleep · As the infant enters the toddler stage, the need for sleep declines, and the activity level increases. Toddlers need less fat and more proteins. Children establish lifetime eating habits during toddlerhood, and there is increased emphasis on food choices.

Which statements are true regarding ectopic pregnancy? Select all that apply. o Smoking is one of the risk factors for ectopic pregnancy. o Ectopic pregnancy is directly related to fetopelvic incompatibility. o Ectopic pregnancy occurs when the fertilized egg implants in the fallopian tubes. o When a young woman exhibits abdominal pain, ectopic pregnancy is suspected. o If the adolescent exhibits abdominal pain and hypotension, the ectopic pregnancy may have ruptured.

o Smoking is one of the risk factors for ectopic pregnancy. o Ectopic pregnancy occurs when the fertilized egg implants in the fallopian tubes. o When a young woman exhibits abdominal pain, ectopic pregnancy is suspected. o If the adolescent exhibits abdominal pain and hypotension, the ectopic pregnancy may have ruptured. · Smoking is a risk factor for ectopic pregnancy. Ectopic pregnancy occurs when the fertilized egg implants outside the uterus, usually in the fallopian tubes. An adolescent exhibiting severe abdominal pain with hypotension is indicative of rupture of ectopic pregnancy and may need immediate surgery. Fetopelvic incompatibility is related to prolonged labor in younger teenagers of 12 to 16 years of age. However, it is not associated with ectopic pregnancy. Abdominal pain associated with or without bleeding, may indicate possible ectopic pregnancy. A pregnancy test and further assessment is needed.

The parent of a toddler tells the nurse, "Whenever I go to the store, my child has a screaming tantrum for a toy or candy on the shelves. How can I deal with this situation?" Which is the best response by the nurse? o "Try distracting your child by offering a toy." o "Don't say anything—just let the tantrum play itself out." o "Have a babysitter stay with your child when you go out until the child outgrows it." o "Give your child the item while you're in the store and then return it to the shelf once the child has lost interest in it."

o "Don't say anything—just let the tantrum play itself out." · Ignoring the tantrum while staying close by provides security but doesn't give attention to or reinforce the behavior. Although toddlers may be easily distracted, offering a toy will reinforce the negative behavior. It is unreasonable to tell the parent to find someone to babysit the child; this may not be a viable option. Giving the child the item acknowledges the tantrum and reinforces the behavior.

The nurse teaches a student about how to interview an adolescent. Which statements made by the student indicate the need for further education? Select all that apply. o "I should begin with less sensitive issues." o "I should ask open-ended questions if possible." o "I should use language that is common for adolescents." o "I should make assumptions regarding his or her feelings." o "I should interview an adolescent along with his or her parents."

o "I should make assumptions regarding his or her feelings." o "I should interview an adolescent along with his or her parents." · The nurse would not make assumptions regarding an adolescent's feelings; the nurse would maintain objectivity. The nurse would be confidential and maintain an adolescent's privacy by not interviewing him or her in front of his or her parents. The nurse would begin the interview with less sensitive issues and then proceed to more sensitive ones. The nurse would ask open-ended questions if possible. The nurse would use language that is known to the adolescent so he or she can understand.

The nurse is counseling an HIV positive woman on precautions to be followed. Which statement by the client indicates the need for further counseling? o "I will avoid smoking and have nutritious food." o "I will go for pelvic examination every 12 months." o "I will use female condoms if my partner refuses to use condoms." o "I will undergo regular screening for syphilis, gonorrhea, and other vaginal infections."

o "I will go for pelvic examination every 12 months." · The routine gynecological care for HIV positive clients includes pelvic examination every 6 months. General prevention strategies such as smoking cessation and sound nutrition are an important part of care in HIV positive clients. HIV positive clients are at increased risk for opportunistic infections. They should be regularly screened for syphilis, gonorrhea, and other vaginal infections. Women should use female condoms or practice abstinence if the partner is not willing to use condoms to prevent the transmission of HIV.

A child with sickle cell disease experiences a sequestration crisis. The parents ask how it differs from a painful episode (vasoocclusive crisis). Which is the best response by the nurse? o Peripheral ischemia occurs along with the pain. o Blood volume decreases and signs of shock appear. o Red blood cell (RBC) production diminishes with severe anemia. o Destruction of RBCs is accelerated and jaundice becomes evident.

o Blood volume decreases and signs of shock appear. · In this type of episode, there is pooling of blood in the liver and spleen, with subsequent decreased circulating blood volume and shock. Peripheral ischemia, along with the pain, is characteristic of a vasoocclusive crisis. Decreased RBC production and the profound anemia that ensues are characteristics of aplastic crisis. Increased hemolysis and concomitant anemia, jaundice, and reticulocytosis are characteristics of hyperhemolytic crisis.

Which toys would the nurse offer a young toddler during hospitalization? Select all that apply. o Mobile o Tricycle o Pounding toy o Carton of clay o Ten-piece puzzle

o Pounding toy o Carton of clay · A pounding toy requires the use of gross motor movements and provides an avenue by which to expend energy and work out feelings. Clay is age-appropriate and nontoxic; manipulating, rolling, and pounding it may help the toddler work out feelings about being hospitalized. An infant will enjoy a mobile. A tricycle is too advanced for a 2-year-old child. A 10-piece puzzle may be too complicated for a toddler.

Which action would the nurse take when an infant begins to cough and gag after a nasogastric tube insertion? o Auscultating for breath sounds o Removing the tube, then reinserting it o Administering the tube feeding slowly o Observing the infant for circumoral cyanosis

o Removing the tube, then reinserting it · The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.

Which herbal remedies sometimes used by clients of Mexican descent would the nurse include in the assessment process to determine the source of lead poisoning in a toddler? Select all that apply. o Greta o Surma o Azarcon o Lozeena o Tamarindo jellied fruit candy

o Greta o Azarcon o Tamarindo jellied fruit candy · Greta, azarcon, and tamarindo jellied fruit candy may all be sources of lead for a toddler of Mexican descent; therefore the nurse would include these items in the client's assessment. Surma and lozeena are not herbal remedies used by clients of Mexican descent.

Which statements correctly states how toddlers are different from infants? o Toddlers grow at a slower rate. o Toddlers are more prone to lead poisoning. o Toddlers lack the anteroposterior curves of the spine. o Toddlers face difficulties in recovering from upper respiratory tract infections (URTIs).

o Toddlers grow at a slower rate. · The growth rate of toddlers is slower than that of infants. The incidence of lead poisoning is highest in both late infancy and toddlerhood. Toddlers have accentuated cervical and lumbar vertebral curves, whereas infants lack them. URTIs are usually not dangerous, and infants and toddlers both recover from them with little difficulty.

The student nurse is learning about the social milestones reached by children at different stages of development. Which statement made by the student nurse demonstrates adequate knowledge on the topic? o "A 10-year-old child is a boaster." o "A 9-year-old child spends a lot of time alone." o "An 8-year-old child begins to get interested in boy-girl relationships." o "A 6-year-old child plays mostly with groups of the same sex but is beginning to play with children of the opposite sex."

o "An 8-year-old child begins to get interested in boy-girl relationships." · Children in the age group of 8 to 9 years develop interest in boy-girl relationships but will not admit it. So, this statement made by the nurse indicates adequate knowledge about the social milestones reached by children at different stages of development. A 6-year-old child is a boaster; children in the age group of 10 to 12 years are more diplomatic. A 7-year-old child spends a lot of time alone and does not require a lot of companionship. A 9-year-old, in contrast, is more social and enjoys organizations, clubs, and group sports. Children in the age group of 8 to 9 years play mostly with groups of their same sex, but are beginning to mix genders in playgroups; this is not seen in 6-year-old children.

The nurse is comparing meso-2,3-dimercaptosuccinic acid (DMSA) and British antilewisite (BAL) as chelating agents to be used as a treatment for lead poisoning. Which statements reflect accurate comparisons between these two chelating agents? Select all that apply. o "DMSA is given orally, whereas BAL is given intramuscularly." o "Neither DMSA nor BAL can be given in conjunction with iron." o "Both DMSA and BAL are given in repeated doses over several days." o "The client's lead level should be over 70 mcg/dL for both DMSA and BAL." o "DMSA is contraindicated in clients with peanut allergies, but BAL carries no such warning."

o "DMSA is given orally, whereas BAL is given intramuscularly." o "Both DMSA and BAL are given in repeated doses over several days." · Meso-2,3-dimercaptosuccinic acid (DMSA) is given orally. The capsule can be opened and sprinkled on a small amount of food or can be swallowed whole. British antilewisite (BAL) is administered as a deep intramuscular injection. DMSA is given over a 19-day course of treatment, and BAL is also administered in repeated doses over several days. BAL should not be given in conjunction with iron, whereas DMSA can be used in conjunction with iron. BAL is used for severe lead toxicity, with lead levels greater than or equal to 70 mcg/dL. DMSA is used in lead levels of 45 to 69 mcg/dL and an absence of symptoms. BAL is contraindicated in children with peanut allergies, but DMSA carries no such warning.

The nurse is caring for several adolescent clients. Which are at increased risk for testicular cancer? Select all that apply. o Client with infertility o Client with hemophilia o Client with liver disease o Client with cryptorchidism o Client with Klinefelter syndrome

o Client with infertility o Client with cryptorchidism o Client with Klinefelter syndrome · Risk factors for testicular cancer include cryptorchidism, Klinefelter syndrome, and infertility. The client with liver disease may be at increased risk of gynecomastia. Hemophilia, a hematologic disorder, is not a risk factor for testicular cancer.

Which education would the nurse provide to a mother of a newborn regarding the safe use of breast milk? Select all that apply. o "Do not thaw the breast milk in the microwave." o "Expressed breast milk must be stored in a glass container." o "Breast milk can be stored for up to 6 months in the freezer." o "Breast milk may be thawed by mixing it with lukewarm water."

o "Do not thaw the breast milk in the microwave." o "Breast milk can be stored for up to 6 months in the freezer." · Breast milk should never be thawed or heated in the microwave. Breast milk can be stored for up to 6 months in the freezer. Expressed breast milk can be stored in either a glass or plastic container. Breast milk can be thawed by placing the container of milk in lukewarm water bath (40.5°C [105°F]). Expressed breast milk stored in the refrigerator must be used within 48 hours.

The nurse is providing care to a child of Iraqi descent diagnosed with lead toxicity. Which question is most appropriate for the nurse to include in the assessment process to determine the source of the lead? o "Do you use lozeena when cooking for your child?" o "Do you use surma for your child's teething pain?" o "Do you use Ba-baw-san to treat your child's colic pain?" o "Do you use greta to treat your child's digestive problems?"

o "Do you use lozeena when cooking for your child?" · Lozeena, a source of lead, may be used by clients of Iraqi descent. Surma, Ba-baw-san, and greta are all sources of lead; however, these are used in clients of Indian, Asian, and Mexican descent respectively.

Which statement would the nurse include when educating parents on the prevention of sudden infant death syndrome (SIDS)? o "Do not prop your infant's bottle." o "Place an infant monitor where your baby sleeps." o "Place your infant in an appropriately sized, rear-facing car seat." o "Encourage your infant to use a pacifier for the first 6 months of life."

o "Encourage your infant to use a pacifier for the first 6 months of life." · The American Academy of Pediatrics recommends the use of a pacifier in the first 6 months of life to help prevent SIDS. Propping a bottle places the infant at risk for dental caries. An infant monitor will not prevent SIDs. Using the appropriate size of car seat positioned correctly in a vehicle prevents motor vehicle injuries.

The nurse is teaching health promotion tips to the mother of a 2-year-old child. During the follow-up visit, the nurse observes that the child has diarrhea and dental caries. Which action is responsible for this condition? o "I give my child 1 cup of fruit daily." o "I give my child 8 oz of fruit juice daily." o "I give my child vitamin C-rich foods daily." o "I do not rinse my child's mouth after brushing with fluoridated gels."

o "I give my child 8 oz of fruit juice daily." · Providing 4 to 6 oz of 100% fruit juice per day is recommended for toddlers. Consumption of high amounts of fruit juice can contribute to diarrhea, overnutrition, and dental caries. One cup of fruit is sufficient for good health in toddlers. Vitamin C enhances iron absorption in the body. The mother should not rinse the child's mouth after brushing with fluoridated pastes and gels to maximize the action of the fluoridated gels.

Which condition would the infant with chordee be at risk for if surgical correction is not performed? o Renal failure o Testicular cancer o Testicular torsion o Sexual dysfunction

o Sexual dysfunction · Chordee causes the penis to be curved; if uncorrected, it may affect future sexual function. While erect, the curvature of the penis may restrict sexual penetration. Kidney function is not affected. The incidence of testicular cancer is not increased; nor is the risk of testicular torsion.

Which parental statement would the nurse recognize as a car seat safety concern? o "I place padding between my baby's legs." o "I place an extra blanket under my baby to pad the seat." o "I make sure my baby is dressed with sleeves and long pants." o "I rolled up small blankets to place on each side of my baby's head."

o "I place an extra blanket under my baby to pad the seat." · Placing an extra blanket to pad a car seat is a safety risk because during the impact of an accident the padding will compress, leaving the harness straps loose. Placing padding between the baby's legs, dressing the baby in clothing with sleeves and pant legs, or rolling up small blankets to put on either side of the baby's head to minimize movement are not safety concerns.

Which parental statements indicate correct understanding related to dental health for the preschool-aged client? Select all that apply. o "I will need to floss my child's teeth." o "My child no longer requires fluoride treatments." o "My child only needs to brush the teeth before bedtime." o "My child does not need to begin flossing until kindergarten." o "I should continue to help my child brush his or her teeth."

o "I will need to floss my child's teeth." o "I should continue to help my child brush his or her teeth." · The preschool-aged client will require his or her parent to continue helping brush and floss the teeth; preschool-aged children do not have sufficient manual dexterity to perform dental health independently. Fluoride treatments should continue throughout the preschool years. The preschool-aged client should brush the teeth at least twice per day. The preschool-aged client should floss; however, the parent will be responsible for completing this task.

Which response would the nurse have to parents who are concerned that their 4-year-old child is spending a large amount of time playing with an imaginary friend? o "You have good reason to be concerned. This is not typical." o "Perhaps your child needs more interaction with real friends." o "Imaginary playmates are an important part of a young child's life." o "This is a sign of social immaturity. I recommend psychological counseling."

o "Imaginary playmates are an important part of a young child's life." · Most 4-year-old children are imaginative; because the line between fantasy and reality is blurred, imaginary playmates are common at this age. Generally, these friends are given up when the child starts school. Suggesting that the child needs more interaction with real friends is an assumption that is not relevant at this age; it becomes a concern when the child reaches school age. Telling the parents that they have reason to be concerned or that counseling is needed may cause unnecessary concern; both statements provide false information.

Which question would the nurse ask the parents of a 3-year-old client to assess gross motor skills? o "Is your child able to use scissors?" o "Is your child able to ride a tricycle?" o "Is your child able to build a bridge using three cubes?" o "Is your child able to build a tower using nine or ten blocks?"

o "Is your child able to ride a tricycle?" · The appropriate question the nurse would ask the parents of a 3-year-old client to assess gross motor skills is whether the child is able to ride a tricycle, which is a gross motor skill. The use of scissors, a fine motor skill, is not anticipated until 4 years of age. Building a bridge using three cubes and building a tower using nine or ten blocks are both expected fine, not gross, motor skills, for a 3-year-old client.

A client with full-thickness burns of the entire right arm states, "I'll never be able to use my arm again. I'll be scarred forever." Which is the best initial response by the nurse? o "Think about how lucky you are. You're still alive." o "Minimizing scarring is the goal of the entire professional staff." o "Being worried is understandable, but it's really too early to tell." o "Try not to worry. Concentrate on doing your range-of-motion exercises."

o "Minimizing scarring is the goal of the entire professional staff." · Telling the client that a positive outcome is the goal of the staff is a truthful answer that offers some hope without providing false reassurance. The adolescent is not concerned about having escaped death; telling the client to be glad to be alive will cut off communication. Telling the adolescent that it is too early to anticipate scarring is misinformation. Ignoring the adolescent's concerns is not therapeutic and cuts off communication.

Which strategy would the nurse recommend to a parent about helping a stressed preschooler? o "Offer to help your child with self-care." o "Prepare your child to be ready for a new sibling." o "Start sending your child to a preschool." o "Consult a specialist if your child begins sucking his or her thumb."

o "Offer to help your child with self-care." · In times of stress, preschoolers may regress and prefer that their parents assume self-care such as feeding, dressing, or holding them. Preschoolers get stressed about the birth of a new sibling. The mother should not plan to send her child to preschool because the new location will increase the child's stress. During times of stress, preschoolers may begin thumb sucking. This is considered a normal coping behavior.

The nurse is obtaining the health history of a 7-month-old infant who has had repeated episodes of otitis media. Which question is most important for the nurse to include in the interview with the mother? o "Please describe how you position your child during feedings." o "Tell me how often your child has had ear infections." o "What medicine do you give your child for the ear infections?" o "Please describe your oral health practices."

o "Please describe how you position your child during feedings." · It is important to determine the infant's feeding position because drinking formula from a bottle while in a recumbent position may lead to pooling of fluid in the pharyngeal cavity, which impairs eustachian tube drainage. Although knowing the frequency of ear infections is important, the factor that precipitated the otitis media is more significant. Although it is important to determine what medication has been given for otitis media, it is more important to determine the cause of this infection. Oral health is important but is not linked with otitis media.

Which treatment would the nurse prepare to administer when providing care to a toddler-age client who presents after an accidental overdose of aspirin? o Gastric lavage o Activated charcoal o Peritoneal dialysis o Vitamin D injection

o Activated charcoal · The nurse would prepare to administer activated charcoal and repeat every 4 hours, if needed, for a client with active bowel sounds. Gastric lavage will not remove concentrations of aspirin. Hemodialysis, not peritoneal dialysis, is a treatment that may be prescribed for a client who presents with an overdose of aspirin. Vitamin K, not D, is administered to assist with clotting.

Which education would the nurse include when teaching a parent about various psychosocial changes common in preschoolers o "Preschoolers are fearful about bodily harm." o "Preschoolers experience a sense of autonomy." o "Preschoolers develop a close attachment to the caregivers." o "Preschoolers believe that inanimate objects have lifelike qualities." o "Preschoolers believe that punishment is automatically connected to an act."

o "Preschoolers are fearful about bodily harm." o "Preschoolers believe that punishment is automatically connected to an act." · The greatest fear of preschoolers is bodily harm. Children tend to fear the dark, animals, thunderstorms, and medical personnel. Preschoolers also believe that a punishment is automatically connected to an act and do not yet realize that it is socially mediated. Toddlers experience a sense of autonomy. Close attachment to primary caregivers usually occurs at infancy. Preschoolers also believe that inanimate objects have lifelike qualities; this is a cognitive change and not a psychosocial change.

Which parental statement would the nurse determine indicates a need for further education about development in a 15-month-old? o "She's always trying to get out of her car seat." o "She cries when I leave her at the daycare center." o "She gets into everything and scatters toys everywhere." o "She has a temper tantrum every time I put her on the potty chair."

o "She has a temper tantrum every time I put her on the potty chair." · Most 15-month-old toddlers are not ready for toilet training. Voluntary sphincter control usually develops between 18 and 24 months of age. A tantrum on being placed on the potty chair is autonomous behavior, typical of a 15-month-old toddler. Crying when the mother leaves her at the daycare center demonstrates separation anxiety, common in 15-month-old toddlers. Scattering toys everywhere and trying to get out of a car seat demonstrate autonomous behavior, typical of a 15-month-old toddler.

The nurse is conducting a home visit for a 4-week-old infant who underwent surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. Which is the most appropriate statement by the nurse who observes the mother appearing tired and the baby crying? o "Tell me about your daily routine." o "You look tired. Is everything all right?" o "When was the last time the baby had a bottle?" o "Oh, it looks as if you two are having a bad day."

o "Tell me about your daily routine." · Asking the client to describe her daily routine makes it possible to collect more data. Telling the client that she looks tired and asking whether everything is all right implies that things are not well and that the mother may be to blame. Asking when the baby last had a bottle may make the mother feel guilty about not meeting her baby's needs. Saying that it looks as if the mother and child are having a bad day is a negative comment that closes off communication.

Parents express concern over their 1-month-old infant's dependence on a pacifier. Which would be the best reply by the nurse? o "This is a natural behavior because young infants have a need to suck for comfort."

o "This is a natural behavior because young infants have a need to suck for comfort." · Sucking is a natural behavior for newborn babies and infants; it even begins in utero. A pacifier helps address that need and provides comfort. It is not necessary to wean the baby at only 1 month of age. Some infants need a pacifier to help with pain management and as a method to help them soothe. Pacifier use in the breast-fed infant is best once the breast-feeding relationship has been established.

Which parental statement would the nurse interpret as indicating a need for further teaching when educating the Hispanic parents of a preschooler about preventing lead exposure? o o "We'll use cold water to cook and drink." o "We know to not store food in open cans." o "We can use orange powders for diarrhea." o "We'll start planning healthy midmorning and afternoon snacks."

o "We can use orange powders for diarrhea." Greta and azarcon (also known as alarcon, coral, luiga, maria luisa, and rueda), traditional Hispanic remedies taken for upset stomach, constipation, diarrhea, and vomiting, are also used for teething babies. Both are fine orange powders with a lead content as high as 90%. Further teaching is required if the family indicates that they will continue treating diarrhea with a home remedy. Food should not be stored in open cans, particularly those that have been imported. Cold water for consumption (drinking, cooking, and especially reconstitution of powdered infant formula) should be used; hot water dissolves lead more quickly than does cold water, yielding a higher level of lead. Frequent healthy snacks are encouraged because lead is absorbed better on an empty stomach.

Which parental statement would the nurse recognize as indicating a need for further education about the importance of play in the development of their preschool-age child? Select all that apply. o "Playing helps the child socialize with others." o "Pretend play helps children learn to understand others." o "Playing is important because it helps the child release frustration." o "We should eliminate all television, electronic games, and computer programs." o "If the child fantasizes about imaginary playmates, we should bring him or her back to reality."

o "We should eliminate all television, electronic games, and computer programs." o "If the child fantasizes about imaginary playmates, we should bring him or her back to reality." · Television, videos, electronic games, and computer programs support development and the learning of basic skills. There should be limited use of these items for preschoolers, but these need not be completely avoided. Imaginary playmates are developmentally normal and allow the child to distinguish between reality and fantasy. The parents should know that playing helps the child socialize with others. Pretend play allows children to learn to understand others' points of view, develop skills in solving social problems, and become more creative. Playing also serves as a medium for the child to release frustration.

Which question will the nurse find most effective when eliciting information from a 5-year-old child regarding the reason for the child's hospitalization? o "Do you know what this place is?" o "What are you doing here at the hospital?" o "Do you know what's going to happen to you?" o "You do know why you're in the hospital, don't you?"

o "What are you doing here at the hospital?" · "What are you doing here at the hospital?" is an open-ended question that should elicit the desired information. Asking the child whether he knows where he is, what's going to happen to him, or why he's in the hospital may not elicit the desired information because each is a yes-or-no question.

The nurse is assessing a school-age child who suffers from encopresis. Which advice provides effective treatment for this condition? Select all that apply. o "You should drink lots of fluid." o "You should include cereals in your diet." o "You should eat fresh fruit for breakfast."

o "You should drink lots of fluid." o "You should include cereals in your diet." o "You should eat fresh fruit for breakfast." · Encopresis is the voluntary or involuntary passage of feces of varying consistency in inappropriate settings. The child with encopresis usually has constipation. Cereals should be included in the child's diet, because they contain high amounts of fiber, which helps in the formation and passage of regular stools. Sufficient water is necessary to prevent constipation or pain during defecation. The nurse instructs the child to drink sufficient fluids. Fruits are also rich fiber sources and ease the process of defecation. Milk increases the risk of uncontrolled defecation. The nurse instructs the child to avoid milk. Delaying defecation results in water absorption from the stool, which may cause constipation and increased pain during defecation.

The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements would the nurse include in the teaching plan? Select all that apply. o "Your child should be able to show the grasp reflex." o "Your child should be able to coo, babble, and chuckle." o "Your child should be able to pull at blankets or clothes." o "Your child should be able to put the feet into the mouth when supine." o "Your child's head can come up to a 45- to 90-degree angle from the table."

o "Your child should be able to coo, babble, and chuckle." o "Your child should be able to pull at blankets or clothes." o "Your child's head can come up to a 45- to 90-degree angle from the table." · Cooing, babbling, and chuckling in a 3-month-old infant indicate normal development. A 3-month-old infant can pull at blankets or clothes and can raise his or her head to a 45- to 90-degree angle from the table. The grasp reflex generally disappears by the age of 3 months. A 3-month-old infant may not able to put his or her feet in the mouth when lying in the supine position. Generally a 5-month-old infant can put his or her feet in the mouth when lying in the supine position.

Which statement correctly describes a bone marrow transplant? o "Bone marrow transplantation is rarely performed in children these days." o "The hematopoietic stem cells are surgically implanted in the bone marrow." o "Your child's immune system must be destroyed before the transplantation can take place." o "It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion."

o "Your child's immune system must be destroyed before the transplantation can take place." · An intensive preparatory regimen is needed to destroy the child's immune system. The procedure is performed in children for recurrent malignancies. Once the process is started, no rescue therapy except for the transplant is provided. The child's bone marrow must be clear of all cells before transfusion of the stem cells is performed.

During the routine assessment of an infant, the nurse finds that the child demonstrates a certain neurological reflex for the first time. When the infant is suspended in a horizontal prone position, the head is raised and legs and spine are extended. Which is most likely to be the infant's age? o 2 months o 3 months o 7 months o 36 months

o 7 months · An infant demonstrates the Landau reflex when, on being suspended in a horizontal prone position, the head is raised and legs and spine are extended. This reflex appears at 6 to 8 months and lasts until 12 to 24 months. So, the infant in this scenario is most likely to be 7 months old as she is demonstrating this reflex for the first time. The Landau reflex is not seen at ages 2 or 3 months. Instead, labyrinth righting appears at 2 months, and neck righting appears at 3 months. The Landau reflex lasts until 12 to 24 months. So, the age of the infant is not likely to be 36 months.

Which is the priority topic that the nurse would include when teaching parents about the developmental needs of young toddlers? o Toilet training o Temper tantrums o Adequate nutrition o Accident prevention

o Accident prevention · Because of the young toddler's increased mobility, high level of oral activity, and relative lack of fear or appreciation for danger, accidents are the primary cause of death in children older than 1 year of age. This is too early for a discussion of toilet training. Although learning how to handle temper tantrums is important, it is not the priority. Although adequate nutrition is always important, it is not the priority.

Which intervention would the nurse recommend to the mother of a 6-month-old infant who experiences injection site redness, swelling, and discomfort? o Place a hot compress on the area. o Administer a dose of acetaminophen. o Give a cool sponge bath for 15 minutes. o Apply an Ace bandage to the swollen site

o Administer a dose of acetaminophen. · Acetaminophen will relieve any discomfort. A cold rather than a hot compress will be soothing and help relieve the redness and swelling. A sponge bath is likely to give the infant chills and is not indicated. An Ace (compression) bandage is contraindicated and likely to restrict circulation.

Which action would the nurse include when preparing a toddler with the diagnosis of hydrocephalus for a computed tomography scan? o Shaving the head o Administering the prescribed sedative o Starting the prescribed intravenous infusion o Giving the child a simple explanation of the procedure

o Administering the prescribed sedative · A 15-month-old toddler will have difficulty complying with directions to remain still and may be extremely frightened by the equipment, so sedatives are usually prescribed. Shaving the head is not necessary; the head must remain still but need not be shaved. Starting the prescribed infusion is not necessary unless a contrast medium is being used. The child is too young to understand even a simple explanation of the procedure.

Which conservation exercises would the nurse include in the assessment of a 6-year-old child? Select all that apply. o Asking the child to compare the mass of 2 balls o Asking the child to compare the weight of 2 balls o Asking the child to compare the length of pencils o Asking the child to compare the volume in 2 cups o Asking the child to compare the number of marbles

o Asking the child to compare the mass of 2 balls o Asking the child to compare the length of pencils o Asking the child to compare the number of marbles · A 6-year-old client is expected to be able to demonstrate understanding of conservation of mass, length, and number; therefore, these exercises are appropriate for the nurse to include in the assessment process. Conservation of weight is not expected until 9 to 10 years of age, while conservation of volume is not expected until 9 to 10 years of age; therefore, the nurse would not include these conservation exercises in the assessment process.

A preschooler is seen in the emergency department for suspected poisoning. In which order would the nurse perform the following actions? o Assess the victim. o Terminate poison exposure. o Identify the poison. o Prevent poison absorption.

o Assess the victim. o Terminate poison exposure. o Identify the poison. o Prevent poison absorption. · While providing emergency treatment to a preschooler who has ingested poison, the nurse would first assess the client's mental status and vital signs. Then, the nurse would terminate poison exposure by emptying the mouth and flushing any body surfaces exposed to the poison with water or saline. After this step, the nurse would identify the poison by questioning the victim and witnesses. Once the poison is identified, the nurse would prevent poison absorption by placing the child in a side-lying, sitting, or kneeling position with the head below the chest to prevent aspiration.

Which is the most important factor in preparing a 2-year-old child for admission to the hospital for surgery? o Gratification of the child's wishes o Previous experience of being hospitalized o Avoiding leaving the child with strangers o Assurance of continued parental affection

o Assurance of continued parental affection · A 2-year-old toddler is still attached to and dependent on the parents. Fear of separation is a great stress. Gratification of the child's wishes is neither possible nor desirable. A previous experience of being hospitalized will probably not be remembered accurately. It is not possible to avoid leaving a child with strangers in the health care setting.

After the nurse feeds and burps an infant with a cardiac defect, the infant has a bowel movement and almost immediately becomes cyanotic, diaphoretic, and limp. Which activity most likely caused the infant's response? o Burping o Feeding o Position change o Bowel movement

o Bowel movement · During a bowel movement the Valsalva maneuver can occasionally initiate a hypercyanotic spell ("tet spell," "blue spell") by inducing an increase in intrathoracic pressure, a decrease in the return of blood to the heart, an increase in venous pressure, and a decrease in heart rate. Burping does not influence cardiovascular function. Although feeding can cause fatigue and increase the heart rate, it will not precipitate such an immediate response as the one described in the scenario. Likewise, a position change will not precipitate such an immediate response.

Which intervention would be included when counseling a group of parents about ways to improve the sleep of preschoolers? Select all that apply. o Avoid all fluids before bedtime. o Avoid media use in the evening. o Provide a lovey or favorite blanket at bedtime. o Establish a soothing and consistent bedtime routine. o Allow children to set their own bedtime so they learn to go to bed when tired.

o Avoid media use in the evening. o Provide a lovey or favorite blanket at bedtime. o Establish a soothing and consistent bedtime routine. · Preschoolers can sometimes struggle with bedtime because they are becoming more aware of their fears and increased sleep disturbances. Avoiding media use at bedtime, providing a lovey or favorite blanket or stuffed animal, and establishing a soothing and consistent bedtime routine can all help a child this age sleep better. Avoiding all fluids at bedtime and allowing preschoolers to set their own bedtime are not appropriate interventions for preschoolers.

In which order would the nurse recommend introducing new foods into an infant's diet? o Table foods o Vegetables and fruits o Baby cereal o Cow's milk

o Baby cereal o Vegetables and fruits o Table foods o Cow's milk · Babies usually begin solid foods with infant cereal mixed with formula or breast milk. Vegetables and fruits should be introduced next because of their soft textures and the generous amounts of vitamins and minerals they supply. Table foods are introduced after the infant can chew or bite (6-7 months). It is recommended that only one new food be introduced at a time to help identify possible allergic reactions. Cow's milk should not be introduced until after age 12 months.

Which complication would the nurse be particularly alert for in a child with Reye syndrome? o Bladder distention and overflow o Macular rash on the face and trunk o Bleeding and ecchymoses from liver involvement o Systemic and periorbital edema from renal shutdown

o Bleeding and ecchymoses from liver involvement · Reye syndrome affects the liver, causing problems with blood coagulation because liver-dependent clotting factors, such as prothrombin, are diminished. Bladder function is not impaired. Reye syndrome does not produce a rash. Reye syndrome does not involve the kidneys.

Which statement is true regarding the similarity between the preoperational period and the formal operations period? o Both periods are associated with egocentrism. o Both periods are associated with animism. o Both periods outline play as a means for fostering development. o Both periods are characterized by an individual's capacity to reason related to possibilities.

o Both periods are associated with egocentrism. · Both the preoperational period and the formal operations period show that there is a prevalence of egocentric thought in the individual. The preoperational period demonstrates animism in an individual and demonstrates play as a means of fostering development in the child. During the formal operations period, an individual develops the capacity to reason with respect to possibilities.

Which education would the nurse give the parents of a preschool-aged client to promote school readiness? Select all that apply. o Recommending a full-day program for the child o Bringing a toy to assist the child with adjustment o Sitting with the child in class until acclimation occurs o Introducing the child to the teacher before the first day o Providing personal information, such as the name of the child's pet, to the teacher

o Bringing a toy to assist the child with adjustment o Introducing the child to the teacher before the first day o Providing personal information, such as the name of the child's pet, to the teacher · To assist the preschool-aged client with school readiness, the nurse should recommend that the child bring a toy to help with adjustment. Introducing the child to the teacher before the first day and providing personal information to the teacher, such as the name of the child's pet, are also recommended. A half-day, not full-day, program is often recommended to assist with this transition. Staying with the child is appropriate; however, the parent should be available but inconspicuous.

Which parental occupations would require the nurse to closely monitor a toddler for lead toxicity? Select all that apply. o Ceramics o Radiator repair o Health care o Bridge repair o Brass foundry work

o Ceramics o Radiator repair o Bridge repair o Brass foundry work · Parental occupations that may place a toddler at risk for lead toxicity include ceramics, radiator repair, bridge repair, and brass foundry work. Health care work does not lead to an increased risk for lead toxicity.

The day after brain surgery a child with type 1 diabetes has a temperature of 103.0°F (39.4°C). What does the nurse suspect as the probable cause of the fever? o Infection usually develops in children with diabetes after surgery. o High temperatures are expected in children after surgical procedures. o Cerebral edema after brain surgery exerts pressure on the hypothalamus. o Excessive viscid secretions result in inadequate respiratory ventilation.

o Cerebral edema after brain surgery exerts pressure on the hypothalamus. · Pressure on the hypothalamus, the temperature-regulating mechanism of the brain, causes temperature imbalances. Infection after surgery is not expected, even if the child has diabetes; infection occurs when there is a break in aseptic technique. After an operation, a temperature caused by an inflammatory response rarely exceeds 101°F (38.3°C); a high fever is not expected after surgical procedures. Viscid secretions do not cause an increase in temperature unless an infection is present.

Which rationale would the nurse understand for placing a chest tube after an infant's open-heart surgery? o Chest tubes increase tidal volume. o Chest tubes facilitate drainage of air and fluid. o Chest tubes maintain positive intrapleural pressure. o Chest tubes regulate pressure on the pericardium and chest wall.

o Chest tubes facilitate drainage of air and fluid. · The intrapleural space must be drained of fluid and air to facilitate the reestablishment of negative pressure in the intrapleural space. The tidal volume increases as the lung reexpands, but it is not the reason for the insertion of chest tubes. Intrapleural pressure should be negative, not positive; positive intrapleural pressure causes collapse of the lung. Closed chest drainage is related to intrapleural pressure, not pericardial and chest wall pressure.

Which would the nurse expect a 24-month-old toddler to be able to do? o Build a tower of eight blocks o Balance on one foot momentarily o Construct a bridge with three blocks o Climb stairs with two feet on each step

o Climb stairs with two feet on each step · The ability to ascend steps develops in increments over time. At 15 months of age, the toddler creeps up the stairs; at 18 months of age, the child climbs stairs while holding someone's hand; and by 24 months of age, the toddler can climb stairs alone, with two feet on each step. Building a tower of eight blocks is a fine motor skill that develops around 30 months of age. Balancing on one foot momentarily is a gross motor skill that develops around 30 months of age. Constructing a bridge with three blocks is a fine motor skill that develops around 36 months of age.

A 2-year-old child who is hospitalized for repair of tetralogy of Fallot is seen squatting in the playroom. In response to this behavior, which would the nurse do? o Administer oxygen through a mask. o Call the respiratory therapist for a nebulizer treatment. o Continue to observe the child if there are no other signs of distress. o Notify the health care provide that the child's condition is deteriorating.

o Continue to observe the child if there are no other signs of distress. · Squatting is a physiologic adaptation for children with tetralogy of Fallot. By squatting, the child decreases the amount of arterial blood that is flowing to the extremities, which in turn decreases venous return to the heart and reduces preload. Oxygen is not indicated. The child has a heart, not respiratory problem, so a nebulizer treatment is not indicated. The child's condition has not deteriorated; squatting is a physiologic adaptation.

Which points related to poison prevention would the nurse include when teaching parents of a toddler? Select all that apply. o Use of plants for teas or medicine o Correct administration of medications o Safe storage of toxic substances o Strategies for effective discipline o Taking medications out of the child's sight

o Correct administration of medications o Safe storage of toxic substances o Strategies for effective discipline o Taking medications out of the child's sight · Evidence-supported poison prevention teaching points that the nurse would include in a teaching session for parents of a toddler include information on correct administration of medications, safe storage of toxic substances, strategies for effective discipline, and the importance of taking medications out of the child's sight. The use of plants for teas or medicine should be avoided because this is known to increase the risk for poisoning.

A toddler has had a fever for 2 days and now presents with decreasing oral intake and a rash over the hands and feet. Which condition would the nurse suspect? o Teething o Food aversion o Streptococcus infection o Coxsackievirus infection

o Coxsackievirus infection · Coxsackievirus is one of the most common enteroviruses. Also known as hand-foot-mouth disease, it is most often caused by coxsackievirus A16 and is most common in children younger than 10 years. The signs and symptoms of hand-foot-mouth disease include a fever and small but painful sores on the throat, gums, and tongue and inside the cheeks. It may also cause a rash, often with blisters, on the hands, soles, and diaper area, as well as headache and a poor appetite. Teething could bring with it a slight fever, as well as decreased oral intake, but the rash on the hands and feet is specific to coxsackievirus infection. Food aversion with simple decreased intake is usually a chronic issue without any associated fever or rash. Although a streptococcal infection could produce a fever and rash, the rash on the feet and hands and the decreased oral intake resulting from sores in the mouth are specific to coxsackievirus infection.

A client with a history of liver disease is found to have endometriosis. Which medication is contraindicated in this client? o Danazol o Celecoxib o Leuprolide o Ketoconazole

o Danazol · Danazol is a synthetic androgenic steroid that acts by suppressing secretion of follicle-stimulating hormone and luteinizing hormone. This results in decreased secretion of estrogen and progesterone and regression of endometrial tissue. It may result in decreased lipoprotein levels and an increase in low-density lipoprotein. It is contraindicated in clients with liver disease. Celecoxib, a nonsteroidal anti-inflammatory drug, should be used with caution in liver disease. Leuprolide is a gonadotropin-releasing hormone (GnRH) agonist; it may be safe for use in clients with liver disease. Ketoconazole is a nonsteroidal anti-inflammatory drug and should be used with caution in clients with liver disease.

A community health nurse makes a home visit to a disabled 13-year-old client who has a 6-month-old infant sister. The infant lies quietly in her crib and rarely smiles or vocalizes; it appears that the infant barely has her basic needs met. Which is the nurse's most appropriate action? o Advise the parent that the infant will be delayed developmentally if not stimulated. o Ask the disabled client to spend more time playing with the sister. o Encourage purchasing toys that are appropriate for the infant's age level. o Determine whether there is anyone who can help with chores and the infant's care.

o Determine whether there is anyone who can help with chores and the infant's care. · Recruiting someone to help with chores and infant care will allow the parent time to rest and will provide the infant with care and attention. Making the parent feel guilty is not therapeutic and will increase anxiety. The disabled sibling requires attention, and this responsibility may cause jealousy, rivalry, and resentment. Toys need not be employed for sensory stimulation; household objects and quality human contact can serve as well.

Which intervention would the nurse implement for an infant with increased intracranial pressure? o Weighing daily before feedings o Elevating the head higher than the hips o Checking the reflexes at regular intervals o Monitoring alertness with frequent stimulation

o Elevating the head higher than the hips · Elevation of the head helps decrease intracranial pressure by way of gravity. The infant is weighed daily before feedings after the insertion of a shunt; if the infant is in the intensive care unit, this is done routinely. Checking reflexes at regular intervals may be disturbing to the infant and impair the infant's ability to rest. Frequent stimulation may cause further irritability to an already traumatized central nervous system.

Which strategies would the nurse use when communicating with a child with a hearing deficit when the child's hearing aids were forgotten at home? Select all that apply. o Speaking slower and louder than normal o Facing the child directly when talking to the child o Avoiding chewing gum while communicating with the child o Avoiding using hand expressions that could interfere with lip reading o Moving from side to side while talking to the child to keep the child looking at the nurse

o Facing the child directly when talking to the child o Avoiding chewing gum while communicating with the child · Many hearing-impaired children have some degree of lip-reading skills. This will help the child understand what is being said. Chewing gum alters speech sounds and may alter lip movement, adding to the child's confusion. The nurse would speak slowly but not excessively, because this modifies speech. Speaking louder than normal may distort speech. Hand expressions can add meaning to the spoken words. Standing still while speaking to the child ensures that the speaker's face remains clearly visible.

The nurse in the pediatric clinic is reviewing the health history of a 6-year-old child with celiac disease who has been on the dietary regimen for 6 months. Which evaluation criterion would the nurse use to assess the child's adherence to the diet? o Formed bowel movements o Ability to handle stressful situations o Understanding of the disease process o Knowledge of foods allowed on the diet

o Formed bowel movements · Steatorrhea disappears, replaced by formed bowel movements, when the child adheres to the diet. The ability or inability to cope with stressful situations is not a cause of celiac disease; it is caused by a toxic reaction to gluten. Even when the child understands the disease process, adherence to the diet may be relaxed; as a result of this relaxation, signs and symptoms may recur. Although it is important to assess what the child knows about the diet, knowledge does not guarantee that the child will select the foods on the diet.

Which are differences between the pubertal growth of girls and boys? Select all that apply. o Girls tend to begin their physical changes 2 years before boys. o Girls grow until the age of 17 years whereas boys grow until the age of 20 years. o Girls gain weight at an increased rate whereas boys gain height at an increased rate. o Girls show alteration in the width of hips whereas boys show alteration in shoulder width. o Girls who mature early are less happy with their body appearance whereas boys who mature early are satisfied.

o Girls tend to begin their physical changes 2 years before boys. o Girls grow until the age of 17 years whereas boys grow until the age of 20 years. o Girls who mature early are less happy with their body appearance whereas boys who mature early are satisfied. · The physical changes in girls start 2 years before that in the boys. The growth spurt in girls occurs around 12 years of age whereas in boys, the growth spurt occurs at about 14 years. Girls grow till the onset of menarche (16 or 17 years old) whereas boys continue to grow until 18 to 20 years of age. Girls who mature early are shorter and heavy compared with girls who mature late. Because of this, girls are less satisfied with their body appearance. Boys who mature early are more athletic compared with boys who mature late; boys who mature earlier are more satisfied with their appearance. The proportion of weight and height gain is almost the same in boys and girls. Sex-specific changes such as changes in shoulder and hip width are seen in both girls and boys.

Which is the priority of care for a child who was recently diagnosed with celiac disease? o Preventing celiac crisis and resulting problems o Minimizing complications of respiratory involvement o Teaching the parents to establish a diet that promotes optimal growth o Helping the parents and child adjust to the long-term dietary restrictions

o Helping the parents and child adjust to the long-term dietary restrictions · Adherence to dietary restrictions can prevent future complications and celiac crisis. Celiac crisis usually develops as a result of nonadherence to the diet, so adherence to the diet, rather than preventing celiac crisis, is the primary objective. Respiratory involvement is not a primary problem with celiac disease. Teaching the parents to establish a growth-encouraging diet is incorrect because, regardless of adherence to the diet, the disease may interfere with the expected growth rate.

Which parent education would the nurse provide to decrease the workload of a baby's heart for an infant with a cardiac defect? o How to organize care to support periods of rest o Reasons that the infant should not be held or cuddled o Reasons that a regular feeding schedule should be maintained o How to stimulate the infant periodically to promote respiratory excursion

o How to organize care to support periods of rest · Long periods of rest must be promoted; activities should be organized to minimize interruptions. Parents should be encouraged to cuddle their infants, both for emotional development and to induce sleep. The feeding plan should be flexible to accommodate the infant's sleep and wake needs and patterns. Stimulation should be minimized to decrease the workload of the heart.

An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. Which physiologic imbalances would the nurse most likely encounter? Select all that apply. o Hypovolemia o Hyperkalemia o Hypercalcemia o Metabolic acidosis o Decreased hematocrit

o Hypovolemia o Metabolic acidosis · Fluid loss causes hypovolemia. Loss of bicarbonate and sodium in the stools causes metabolic acidosis. Potassium will be lost with diarrhea. Sodium may be increased, decreased, or unchanged. Hypercalcemia does not occur. The hematocrit is increased because of fluid loss (hemoconcentration).

Which action would the nurse recommend to the parents of a toddler-age client who has a difficult temperament when disciplining the child? Select all that apply. o Ignoring the child's behavior o Implementing a time-out with the child o Using physical containment with the child o Making sustained eye contact with the child o Allowing the child an appropriate time to adjust to a new situation

o Implementing a time-out with the child o Using physical containment with the child · A toddler-age child who has a difficult temperament should be disciplined with time-outs and physical containment. Ignoring the child's behavior is not effective for any type of temperament. Making sustained eye contact is more appropriate for a child with an easy temperament. Allowing the child adequate time to adjust to a new situation before implementing discipline is appropriate for the child with a slow-to-warm-up temperament.

A child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. Which clinical finding would the nurse expect? o Proteinuria o Peripheral edema o Increased hematocrit o Absence of pedal pulses

o Increased hematocrit · Polycythemia, reflected in an increased hematocrit reading, is a direct attempt by the body to compensate for the decrease in oxygen to all body cells caused by the mixture of oxygenated and deoxygenated circulating blood. Proteinuria is not a characteristic of heart malformations that cause right-to-left shunting of blood; nor is edema. An absence of pedal pulses is characteristic of coarctation of the aorta, an obstructive malformation.

Which is the priority nursing action for a school-aged child admitted for surgery? o Allowing a favorite toy to remain with the child o Documenting the child's antistreptolysin O (ASO) titer and C-reactive protein (CRP) level o Inspecting the child's mouth for loose teeth and reporting the findings o Encouraging a parent to stay until the child leaves for the operating room

o Inspecting the child's mouth for loose teeth and reporting the findings · School-aged children lose their primary teeth, which may be aspirated during surgery. Special precautions must be taken to maintain safety. Allowing a favorite toy to remain with the child is a comforting gesture, but it is not essential. There is no reason to obtain an ASO titer or a CRP level. Encouraging a parent to stay until the child leaves for the operating room is important but not always possible.

The nurse determines that a 22-month-old child uses two- or three-word phrases (telegraphic speech), has a vocabulary of about 20 words, and often uses the word "me." Which would the nurse conclude about the child's language development? o It is delayed. o It is advanced. o It is appropriate. o It is pathologic.

o It is appropriate. · Brief messages, with only essential words included (telegraphic speech), a vocabulary of 20 words, and frequent use of the word "me" are expected assessment findings in a child of 18 months to 2 years. A child with a developmental delay has a smaller vocabulary than 20 words and does not use phrases. A child who is advanced for this age will have a vocabulary of more than 20 words and will use three- or four-word sentences rather than telegraphic speech. This speech pattern is age appropriate, not pathologic.

According to the principles of developmental direction, in which order does a child develop the following fine motor skills? Begin with the skill that is accomplished first. o Kicks a ball o Turns a doorknob o Uses scissors o Copies a square on a piece of paper

o Kicks a ball o Turns a doorknob o Uses scissors o Copies a square on a piece of paper · At 2 years, a toddler can coordinate the legs and feet to kick a ball. At 3 years, children can coordinate fingers, hands, and wrists to turn doorknobs. At 4 years, children can manipulate fingers to use scissors effectively. At 5 years, children's fine motor coordination improves, enabling them to copy a square and other geometric shapes.

Which explanation would the nurse provide to parents regarding a toddler's higher risk of falling from heights? o Sensory perception o Cognitive perception o Lack of motor coordination o Immature visual depth perception

o Lack of motor coordination · A lack of motor coordination places a toddler at risk of falling from heights. The toddler's cognitive and sensory perception are not the primary factors that place the toddler at risk of falling from heights. Although the toddler's visual depth perception continues to develop, this is not the primary factor that places the toddler at risk of falling from heights.

A critically ill 5-year-old child exhibits Kussmaul respirations. Which would the nurse suspect may be causing an increasing acid-base imbalance? o Metabolic alkalosis caused by an increase in base bicarbonate o Respiratory alkalosis caused by excess carbon dioxide (CO2) output o Respiratory acidosis caused by an accumulation of CO2 o Metabolic acidosis caused by a concentration of cations in body fluids

o Metabolic acidosis caused by a concentration of cations in body fluids · Metabolic acidosis results from an excess concentration of hydrogen cations. The kidneys cannot convert ammonium to ammonia, and there is inadequate base bicarbonate to maintain an appropriate acid-base balance. With Kussmaul respirations there is an excess of hydrogen ions, the opposite of an excess of base bicarbonate. Carbonic acid blown off as CO2 is a compensatory mechanism to counter the present metabolic acidosis. There is an excess of hydrogen ions from a metabolic problem rather than an excess of carbonic acid resulting from retained CO2.

The parents of a 3-year-old tell the nurse that their child is afraid to sleep alone because of monsters under the bed. They ask for suggestions. Which would the nurse recommend? o Tell the child that monsters do not exist. o Allow the child to sleep with the parents temporarily. o Look under the bed and say, "I don't see any monsters." o Leave a small light on at night and state, "Monsters aren't allowed in the house."

o Leave a small light on at night and state, "Monsters aren't allowed in the house." · Leaving a light on and announcing that monsters aren't allowed in the house may reduce the toddler's level of stress without damaging self-esteem. A light allows the toddler to see familiar objects in the room and reduces fears associated with a dark environment. Toddlers see their parents as capable of all things and will be accepting of this house rule. Telling the child that monsters do not exist denies the toddler's concerns and is beyond the concrete thinking of a toddler. Sleeping with the parents may interfere with their ability to get a restful night's sleep. With additional emotional support, the child should be encouraged to remain in his or her own bed. A toddler thinks in concrete terms, and telling the child that there are no monsters under the bed may not relieve the fear of monsters; it also denies the toddler's concerns.

The nurse is caring for an adolescent admitted to the hospital after taking an acetaminophen overdose. Which result is most important for the nurse to monitor at this time? o Blood gas level o Liver function tests o Complete blood count o Glycosylated hemoglobin

o Liver function tests · Acetaminophen is metabolized by the liver, and an excess may result in increased aspartate aminotransferase and bilirubin levels and prothrombin time. Hepatic involvement may last as long as 7 days, and liver damage may be permanent. Blood gas results are not the priority at this time. They will become important if hepatic failure or respiratory distress develops. The hematologic components measured in a complete blood count are not profoundly affected by an acetaminophen overdose. Glycosylated hemoglobin is a measure of diabetic control, not a measure of response to an acetaminophen overdose.

Which family members would the nurse anticipate receiving a prescription for Mebendazole after a preschooler is diagnosed and treated for pinworms? o The child's infant sibling o People using the same toilet facilities as the child o Members of the child's family after they test positive o The child's immediate family members, even if they are free of symptoms

o Members of the child's family after they test positive · All household members should be treated at the same time unless they are younger than 2 years of age or pregnant. Mebendazole is not recommended for children under the age of 2 years. The use of the same toilet facilities as the child is not a significant criterion for the administration of medication because the eggs are not transmitted in water. Positive testing of each family member is not a criterion for the administration of medication to family members.

Which nursing intervention would the nurse implement for an infant during the first 24 hours after surgery to place a ventriculoperitoneal shunt for hydrocephalus? o Placing in the high Fowler position o Administering the prescribed sedative o Positioning on the same side as the shunt o Monitoring for increasing intracranial pressure

o Monitoring for increasing intracranial pressure · The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid in the head; the accumulated fluid causes an increase in intracranial pressure, which in turn leads to brain stem hypoxia. Positioning the infant flat helps prevent complications resulting from too-rapid reduction of intracranial fluid. Although pain management is essential to minimize an increase in intracranial pressure, sedation is contraindicated because it will mask the infant's level of consciousness. The infant is positioned on the side opposite the shunt to prevent pressure on the valve and incision area.

A 4-year-old child is fluid-restricted to 600 mL/24 hr. Which intervention would the nurse use to help the child cope with this limitation? o Dividing the fluids equally throughout the 24 hours o Allowing the child to drink fluids as desired until the 600-mL limit is reached o Providing the 600 mL from 7:00 AM to 7:00 PM and then withholding fluids again until 7:00 AM o Offering the child at least 1 oz (30 mL) of fluid, served in a 1-oz (30-mL) medicine cup, each waking hour

o Offering the child at least 1 oz (30 mL) of fluid, served in a 1-oz (30-mL) medicine cup, each waking hour · Providing at least 1 oz (30 mL) of fluid per hour, served in a 1-oz (30-mL) medicine cup, allows the child to drink 30 mL of fluid (1-oz medicine cup) without going long periods between drinks. This approach will provide a total of 480 mL with leeway to offer another ounce four times during waking hours, either at meal or snack times or if the child awakens during the night. When fluid is limited, a smaller amount should be apportioned to the sleeping hours. If the child is allowed to drink as much as is desired until the limit is reached, 15 to 20 hours might elapse before fluids will be permitted again. Although fluids can be limited more easily during sleeping hours, 12 hours without fluid is too long for a young child to tolerate.

The nurse is caring for a client who is diagnosed with syphilis. Which medication is the nurse administering to the client? o Acyclovir o Penicillin G o Ceftriaxone o Azithromycin

o Penicillin G · Penicillin G is used to treat clients in all stages of syphilis; this medication should be administered once a day. Acyclovir is used to treat herpes simplex virus. Ceftriaxone is used to treat a gonorrheal infection. Azithromycin is used to treat a chlamydia infection.

Which is the first action of the nurse when a parent expresses concern about a child's diet? o Perform a nutritional assessment. o Provide a referral for a nutritionist. o Encourage the parent to decrease juice intake. o Speak to the physician about ordering blood testing.

o Perform a nutritional assessment. · Before taking any action, the nurse first performs a nutritional assessment, including a dietary history. The child may need blood testing, but the nutritional assessment should be performed first. Once the nurse has the appropriate data, nursing diagnoses can be identified and a plan established. Providing a referral for a nutritionist or encouraging the decreased intake of juice are potential interventions, depending on the outcome of the assessment.

Which nursing plan of care best meets the needs of a neglected 6-month-old infant? o Arrange to have staff members pick up and play with the infant whenever possible. o Design a program that provides activities geared to a 6-month-old's developmental level. o Provide consistent caregivers who will provide purposeful stimulation. o Schedule care that allows for stimulation and physical contact by a variety of staff members.

o Provide consistent caregivers who will provide purposeful stimulation. · A consistent caregiver enhances formation of a trusting and mutually satisfying relationship between infant and caregiver. Overstimulation should be avoided. Activities geared to a 6-month-old's developmental level may cause overstimulation. A consistent caregiver, rather than multiple caregivers, enhances the development of trust.

Which strategy would the nurse use to teach the parents of a 3-year-old child requiring complex care? o Provide information in short sessions. o Schedule a whole evening for teaching. o Offer explanations when the parents visit. o Require that both parents attend the sessions.

o Provide information in short sessions. · The parents will probably be anxious and will benefit most from short teaching sessions and written material that they may review at their leisure. A whole evening of teaching would be overwhelming; the parents might not be able to retain everything presented. The most effective teaching and learning sessions occur in an area with minimal distractions. Being in the room with their child at this time will present a major distraction to the parents. The nurse may recommend, but not insist, that both parents attend the teaching sessions.

A child is admitted to the pediatric unit with nephrotic syndrome. Which measures would the nurse expect to include in the plan of care for this child? Select all that apply. o Maintaining bed rest o Administering antibiotics o Providing symptomatic care o Eliminating high-sodium foods o Monitoring response to steroids

o Providing symptomatic care o Eliminating high-sodium foods o Monitoring response to steroids · Examples of symptomatic care are treating azotemia with a low-protein diet, encouraging bed rest if there is gross edema, restricting fluids if there is oliguria, and treating infection if it should occur. Foods that are high in sodium are restricted when there is gross edema; although restricting foods that are high in sodium does not lessen the edema, it seems to prevent it from worsening. A steroid is given to children with nephrotic syndrome because of its anti-inflammatory properties. It is essential that the nurse monitor the child's response to steroids to determine the medication's effectiveness. Bed rest for children with nephrotic syndrome is generally no longer prescribed. When there is gross edema, children usually prefer to remain in bed to conserve energy, but there are no ill effects of ambulating if they wish to do so. Nephrotic syndrome is a noninfectious disorder; however, these children are prone to infection, and if they contract an infection it is treated accordingly.

Which foods would the nurse determine are appropriate for an 8-month-old infant? Select all that apply. o Whole milk o Pureed pears o Pureed carrots o Soft-boiled eggs o Mashed sweet potatoes

o Pureed pears o Pureed carrots o Soft-boiled eggs o Mashed sweet potatoes · Pureed pears, pureed carrots, and mashed sweet potatoes are easily digested foods that are usually introduced after 6 months of age. Recent evidence shows that eggs are safe to introduce to infants as long as there is not an egg allergy in the family. If there is an egg allergy, it is recommended to wait until after 12 months to introduce eggs. Breast milk or formula, not whole milk, is recommended for the first year of life.

Which type of discipline would the nurse include in the teaching plan that can lower the risk for accidents? o Realistic rigidity o Rational consistency o Guarded indifference o Surreptitious overprotection

o Rational consistency · Unwavering adherence to the same principles and regulations promotes safe, firm limits (rational consistency). Realistic rigidity stifles children's natural development in learning to explore. Injuries are promoted when there is lack of attention (guarded indifference). Overprotection, whether open or hidden, hinders children's freedom to explore and enjoy their surroundings.

Which common foods would the nurse expect to cause of an outbreak of Salmonella? Select all that apply. o Ice cream o Raw carrots o Hamburgers o Soft-boiled eggs o Toasted cheese sandwich

o Raw carrots o Hamburgers o Soft-boiled eggs · Salmonella is present in animal sources such as meat and poultry but is destroyed when these foods are cooked adequately. Dairy products carry many microorganisms, but not specifically Salmonella. This type of infection usually is not associated with vegetables. Salmonella is not associated with processed products such as cheese or with grain-based foods such as bread.

The parents of a preschooler with a congenital heart defect asks the nurse why their child squats after exertion. Which rationale would the nurse provide the parents? o Decreases the number of muscle aches o Improves walking capacity and hip mobility o Reduces how hard the heart must work o Helps more blood return to the heart

o Reduces how hard the heart must work · When the child squats, blood pools in the lower extremities because of hip and knee flexion, which causes less blood to return to the heart and reduces how hard the heart must work (cardiac workload). For this young child, squatting after exertion does not reduce muscle aches, it is unrelated to walking capacity and hip mobility, and it decreases (not increases) blood return to the heart.

In which part of the cardiovascular system would the nurse expect an increase in pressure in a toddler with pulmonic stenosis? o Left atrium o Right ventricle o Pulmonary vein o Pulmonary artery

o Right ventricle · Pulmonic stenosis increases resistance to blood flow, causing right ventricular hypertrophy; with right ventricular failure there is an increase in pressure on the right side of the heart. Pressure in the left side of the heart is decreased with pulmonic stenosis. Pressure in the pulmonary vein is decreased with pulmonic stenosis. Pressure in the pulmonary artery is decreased with pulmonic stenosis.

The nurse reviews the history to find an adolescent has a tattoo on the neck and piercings on the ear and eyebrow. During the next visit, the nurse finds a new tattoo on the right upper arm and another piercing on the nose. Which would be priority nursing interventions in this situation? Select all that apply. o Prepare a proper diet plan for the adolescent. o Instruct the adolescent to get an electrocardiogram. o Instruct the adolescent to perform regular exercises. o Screen the adolescent for human immunodeficiency virus (HIV). o Schedule an appointment for administering the hepatitis vaccine.

o Screen the adolescent for human immunodeficiency virus (HIV). o Schedule an appointment for administering the hepatitis vaccine.

Which would the nurse do first if an allergic reaction to a blood transfusion occurs? o Shut off the infusion. o Slow the rate of flow. o Administer an antihistamine. o Call the health care provider (HCP).

o Shut off the infusion. · The child is experiencing an allergic reaction, and the infusion must be stopped immediately to prevent serious complications. Slowing the rate of infusion will not halt the allergic reaction to the transfused blood. Administering an antihistamine is dangerous as an initial action because the degree of allergic reaction cannot be determined at this time. Also, it requires an HCP's prescription. The HCP should be notified after the infusion has been stopped.

Which is the difference between the social contract orientation and the universal ethical principle orientation stages? o Social contract orientation involves following laws without question, whereas universal ethical principle orientation involves civil disobedience. o Social contract orientation is a part of conventional reasoning, whereas universal ethical principle orientation is a part of postconventional reasoning. o Social contract orientation focuses on expanded societal concerns in an individual, whereas universal ethical principle orientation focuses on basic rights and laws. o Social contract orientation demonstrates moral decisions based on societal view, whereas universal ethical principle orientation stage outlines an individual's response based on physical punishment.

o Social contract orientation involves following laws without question, whereas universal ethical principle orientation involves civil disobedience. · The social contract orientation stage relies on following laws without question, whereas an individual under the universal ethical principle orientation stage may show civil disobedience. Both the social contract orientation stage and the universal ethical principle orientation stage are part of postconventional reasoning. Both stages are related to basic rights and laws. The society-maintaining orientation stage demonstrates moral decisions based on societal laws, whereas the punishment and obedience orientation stage outlines an individual's response based on the threat of physical punishment.

Which nutrients would the nurse list as restricted for the child with the diagnosis of acute glomerulonephritis? Select all that apply. o Fats o Sodium o Glucose o Potassium o Lipids

o Sodium o Potassium · Sodium is restricted, in that salt is not added to foods, and processed meat and salty snacks are avoided. Potassium is always restricted in the presence of oliguria to prevent cardiac dysrhythmias associated with hyperkalemia. Potassium is found in fruits such as bananas, oranges, and apples and in white potatoes. Lipids are not restricted; usually fats are a prime source of calories. Glucose is not restricted; it is also a prime source of calories.

An adolescent is admitted to the burn unit with partial-thickness burns of both arms and the chest. Which information about burns would guide the nurse's plan of care? o Burns are extremely painful and disfiguring. o Some grafting of the burned area is necessary. o Pressure dressings and prolonged hydrotherapy are required. o Spontaneous epithelial regeneration occurs within several weeks.

o Spontaneous epithelial regeneration occurs within several weeks. · If there is no subsequent infection of the burned areas, wound healing should be uneventful. Although partial-thickness burns are painful, they usually heal with little or no scarring. Regeneration will occur unless there is further insult to the burn injury, such as infection; grafting should not be necessary. Occlusive dressings may be applied to minimize the discomfort of frequent dressing changes; hydrotherapy is not required for partial-thickness burns.

Which behavior would the nurse know is important to avoid in a 5-month-old child who had heart surgery to repair the defects associated with tetralogy of Fallot? o Crying o Coughing o Straining at stool o Unnecessary movement

o Straining at stool · Forceful evacuation involves taking a deep breath, holding it, and straining (Valsalva maneuver). This increases intrathoracic pressure, which puts excessive strain on the heart sutures. Crying is not a problem after cardiac surgery; it may, in fact, help prevent respiratory complications. Coughing and deep breathing are essential for the prevention of postoperative respiratory complications. Activity is gradually increased.

Which clinical finding would the nurse expect when assessing a 4-year-old child with suspected mucocutaneous lymph node syndrome (Kawasaki disease)? o Strawberry tongue o Copious discharge from the eyes o Insidious onset of low-grade fever o Maculopapular rash on the extremities

o Strawberry tongue · The characteristic "strawberry tongue" is a result of sloughing of the normal coating of the tongue that leaves the papillae exposed. There is bilateral conjunctivitis without an exudate. The fever associated with Kawasaki disease is high and is abrupt in onset; it is unresponsive to antibiotics and antipyretics. A maculopapular rash on the extremities does not occur; peripheral edema and erythema occur with desquamation of the palms and soles.

An adolescent sustains an ankle injury while playing soccer. Crutches and no weight-bearing are prescribed by the primary health care provider. Which would the nurse ensure when adjusting the crutches? o That they reach to 1 inch (2.5 cm) below the axillae o That they extend to 6 inches (15.2 cm) from the side of each foot o That the elbows are extended when the crutches are held by the crossbars o That the shoulders are slightly stooped when the crutches are bearing body weight

o That they extend to 6 inches (15.2 cm) from the side of each foot · Having the crutches extend to 6 inches (15.2 cm) from the sides of the feet ensures the maximal base of support when the adolescent ambulates. Having the crutches reach to 1 inch (2.5 cm) below the axillae may cause trauma to the brachial plexus; the crutches should be 2 inches (5 cm) below the axillae. The elbows should be flexed, not extended, when the client holds the crossbars. Hunched shoulders indicate that the crutches are too short, which could result in trauma to the brachial plexus.

A child with type 2 diabetes is scheduled for abdominal surgery. Which factors are most important for the nurse to consider during the postoperative period? Select all that apply. o Infection will likely occur at the surgical site. o Ketoacidosis frequently occurs later in the postoperative period. o The blood glucose level will increase because of the stress of surgery. o Urine test results are the most useful gauge of diabetic control after surgery. o Diabetic control is usually maintained with insulin after surgery.

o The blood glucose level will increase because of the stress of surgery. o Diabetic control is usually maintained with insulin after surgery. · The stress of surgery causes the release of epinephrine and glucocorticoids, which increase the blood glucose level. Most individuals with type 2 diabetes who control their diabetes through diet and exercise require insulin during the recovery period. Although the child with diabetes is at risk for infection, surgical aseptic technique should prevent infection. Ketoacidosis is associated with type 1, not type 2, diabetes. Urine test results are affected by many variables and are not reliable indicators of the blood glucose level.

According to Erikson's theory, which behavior would a toddler exhibit? o The child is casual about body appearance. o The child starts performing self-care activities. o The child suppresses feelings of the superego. o The child becomes dependent on his or her siblings.

o The child starts performing self-care activities. · According to Erikson's theory, a toddler between 1 and 2 years of age becomes involved in self-care activities like walking, feeding, and toileting. During the identity versus role confusion stage, an adolescent can be seen having a preoccupation with appearance and body image. The child moves to the next stage and develops superego, or conscience, during the initiative versus guilt stage. During the autonomy versus shame and doubt stage, the toddler develops his or her autonomy by making choices and does not depend on siblings.

Which would the nurse emphasize when teaching insulin self-administration to a child with recently diagnosed diabetes? o The need to wash the hands before preparing the insulin injection o The need to shake the bottle of insulin thoroughly before drawing up the dose o The need to alternate the sites of the insulin injections among the four extremities o The need to rub the injection site briskly for half a minute after giving the injection

o The need to wash the hands before preparing the insulin injection · Thorough hand washing is the best infection-prevention technique and should always precede preparation of an injection. Shaking insulin causes air bubbles, which can interfere with preparation of an accurate dose; the bottle should be rolled gently between the palms. Although injection sites should be rotated, the abdomen, not the extremities, is the preferred site for self-administration of insulin. The injection site should not be rubbed, because this will affect absorption of the insulin and cause a reaction at the site.

A student nurse developed a chart comparing the characteristic features of nightmares with sleep terrors in young children. Which chart entry reflects accurate characteristics of nightmares and sleep terrors? o Return to sleep o Time of distress o Time of occurrence o Description of dream

o Time of distress · In the case of nightmares, the child wakes and cries or calls after the dream is over. The child does not do this during the nightmare itself. In contrast, the child expresses distress by screaming and thrashing during the night terror; afterward, the child is calm and may have no recollection of the event. In the case of nightmares, the return to sleep may be considerably delayed because of persistent fear, whereas in the case of sleep terrors, not only does the child rapidly return to sleep, but it is often difficult to keep the child awake after an episode. Nightmares occur in the second half of the night, when dreams are most intense. Sleep terrors usually occur 1 to 4 hours after falling asleep, when non-REM sleep is deepest. For nightmares, the child is able to describe the nightmare if he or she is old enough to do so. For sleep terrors, the child has no memory of a dream or of yelling or thrashing.

While interacting with parents of children ranging in ages from 6 to 12 years, the nurse suggests that the parents avoid imposing too many expectations on their children. Which statement provides the rationale for this suggestion? o To prevent role confusion in the children o To reduce the feelings of guilt in the children o To prevent inferiority complexes in the children o To improve the decision-making abilities of the children

o To prevent inferiority complexes in the children · Erikson's lifespan approach in the development of children is categorized into eight stages relating to childhood. In the stage of industry versus inferiority, development is attained by children between 6 and 12 years of age. Children at this stage act as workers and producers; they initiate and complete work aiming at real achievement. The child may feel inferior if parents impose many expectations on him or her. Identity versus role confusion is seen in children between 12 and 18 years of age and is the stage in which rapid and marked physical changes occur. Adolescents struggle to fit the roles they have played and those they expect to play. When the ability to solve these conflicts fails, it leads to role confusion. Initiative versus guilt is seen in children between 3 and 6 years old; children in this stage explore the physical world with all their senses and powers and may feel guilty when parents make them feel as though their behaviors are bad. Children in the age group of 1 to 3 years are in the stage of autonomy versus shame and doubt. Children in this stage increase their ability to develop, control their bodies and their environment, and use their mental powers for decision-making. However, avoiding imposing too many expectations does not prevent role confusion or guilt and does not improve the children's decision-making abilities.

The nurse is providing care to a preschool-age client of Asian descent whose family speaks fluent English. Which assessment strategies would the nurse implement with the child and family? Select all that apply. o Using open-ended questions o Avoiding prolonged eye contact o Phrasing questions in a neutral manner o Asking all questions directly to the interpreter o Asking several questions for time management purposes

o Using open-ended questions o Avoiding prolonged eye contact o Phrasing questions in a neutral manner · Open-ended questions should be used as frequently as possible during a health history interview. This is especially important for a family of Asian descent who tend to answer "yes" or anticipate the answer the nurse wants to hear. Direct or prolonged eye contact is often seen as a sign of disrespect when assessing a family of Asian descent. Phrasing questions in a neutral manner decreases the risk of the family anticipating the answer the nurse wants to hear, which often occurs for clients of Asian descent. Because the family speaks fluent English, there is no need to engage the services of an interpreter unless the family requests it. If an interpreter were used, the nurse would direct the questions directly to the family. One question should be asked at a time during the assessment process.

Which play activities are appropriate for a 6-year-old child who is in the acute phase of nephrotic syndrome? Select all that apply. o Hula hoop o Video games o Large puzzles o Stuffed animal o Children's books

o Video games o Children's books · Age-appropriate video games do not require excessive energy to play and will help a 6-year-old child avoid boredom. Children's books are appropriate for 6-year-old children because at this age they are beginning to read. Also, the parents may read to the child. This activity does not require energy. Playing with a hula hoop requires energy that a child in the acute phase of nephrotic syndrome does not have. Large puzzles are more appropriate for toddlers, who are developing fine motor skills. A stuffed animal is more appropriate for an infant or toddler. It is a passive toy that will not be stimulating for a 6-year-old child.

Which precursor would the nurse recognize as common in children who develop Reye syndrome? o Body rash o High fever o Viral infection o Allergic reactions

o Viral infection · Although the cause is unknown, there is a strong relationship between Reye syndrome and an antecedent viral infection, such as varicella and the use of aspirin as an analgesic. A rash is not specific to Reye syndrome; a rash may have other causes. A fever may also have other causes. Allergic reactions have no relationship to Reye syndrome.

Which clinical finding would the nurse expect when assessing an infant with pyloric stenosis? Select all that apply. o Boardlike abdomen o Visible peristaltic waves o Decreased bowel sounds o Cramping movements in the lower abdomen o Olive-shaped mass in the right upper quadrant

o Visible peristaltic waves o Olive-shaped mass in the right upper quadrant · Gastric peristaltic waves are visible because the stomach is attempting to propel its contents through the stenotic pyloric sphincter. The hypertrophied muscle becomes elongated and is palpable as an olive-shaped mass. Because of its anatomic location, it is felt in the upper right quadrant of the abdomen. The upper abdomen may be distended, not boardlike, because food is unable to leave the stomach and progress through the remainder of the gastrointestinal tract. Transmission of ingested food is interrupted, but digestive processes are intact; therefore bowel sounds are heard. Gastric peristaltic waves, not cramping movements in the lower abdomen, may be observed.

Which clinical manifestations would the nurse expect to assess in an infant diagnosed with hypertrophic pyloric stenosis (HPS)? Select all that apply. o White vomitus o Abdominal pain o Peristaltic waves o Insatiable hunger o Abdominal distention

o White vomitus o Peristaltic waves o Insatiable hunger · The vomitus is white (color of milk) because the obstruction is above the ampulla of Vater, and the feedings are expelled before digestion and absorption take place. Vomiting usually occurs shortly after a feeding. Visible peristaltic waves are typical of infants with HPS because of gastric hypermotility. Hunger is evidenced by crying and vigorous suckling that are not diminished after a feeding. The infant will eagerly accept a second feeding after a vomiting episode. The crying is caused by hunger, not abdominal pain. Infants with HPS do not have abdominal distention, as evidenced by the visible peristaltic waves.