NURSING CARE OF CHILDREN 2
A nurse is teaching the parents of a 4-month-old infant who has gastroesophageal reflux. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." B. "I will place my baby on her side when sleeping." C. "I will decrease the number of feedings my baby receives per day." D. "I will give my baby loperamide with each feeding."
A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula."
A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). Which of the following pieces of information should the nurse include in the teaching? A. Add fortified rice cereal to the infant's formula B. Alternate feedings between several family members C. Offer the infant juice between feedings D. Provide feedings on demand rather than on a schedule
A. Add fortified rice cereal to the infant's formula
A nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include? A. Begin after the extrusion reflex has diminished. B. Introduce solids between 2 and 3 months of age. C. Wait until the infant's first tooth erupts. D. Add a sweetener such as light corn syrup to bland foods.
A. Begin after the extrusion reflex has diminished.
A nurse is assessing a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction? A. Chills and flank pain B. Pruritus and flushing C. Rales and cyanosis D. Bradycardia and diarrhea
A. Chills and flank pain
A nurse is assessing an infant who has untreated congenital hypothyroidism. Which of the following manifestations should the nurse expect? A. Constipation B. Hyperreflexia C. Oily skin D. Hyperthermia
A. Constipation
A nurse is teaching the parent of an infant about food allergens. Which of the following is the most common food allergy in children? A. Cow's milk B. Wheat bread C. Corn syrup D. Eggs
A. Cow's milk
A nurse is assessing an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing? A. High-pitched cry B. Sunken fontanel C. Tachycardia D. Increased awake time
A. High-pitched cry
A nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately? A. Slurred speech B. Hemoglobin level of 9 g/dL C. Hematuria D. Pain level of 7 on FACES scale
A. Slurred speech
A nurse is assessing a 3-year-old preschooler. Which of the following developmental milestones should the nurse expect the preschooler to demonstrate? A. Stacking 10 blocks B. Printing 1 letter C. Tying shoelaces D. Using 7-word sentences
A. Stacking 10 blocks
A nurse is performing a physical assessment on a 12-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant's current weight is double his birth weight. B. The infant's posterior fontanel is closed. C. The infant is unable to walk without support. D. A total of 6 teeth are present.
A. The infant's current weight is double his birth weight.
A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I can take my brace off to sleep every night at bedtime." B. "I can take my brace off for about an hour daily to shower." C. "I should loosen the straps on my brace if it is rubbing against my skin." D. "I should place the pads of the brace against my skin with a t-shirt over them."
B. "I can take my brace off for about an hour daily to shower."
A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A. "Your child's immunizations today will be half-doses." B. "The pneumococcal and influenza vaccines are recommended for your child." C. "Immunizations will be delayed until your child tests HIV-negative." D. "Your child will need to restart the immunization schedule once your child's laboratory values are within the reference range."
B. "The pneumococcal and influenza vaccines are recommended for your child."
A nurse is providing discharge teaching to parents whose infant had a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching? A. "We will check his abdomen daily for signs of fluid accumulation." B. "We will notify the doctor right away if he has a fever." C. "We should keep a helmet on him when he's awake." D. "We can expect him to have occasional seizure episodes."
B. "We will notify the doctor right away if he has a fever."
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005
B. 1.035
A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend? A. 1/2 cup whole milk B. 1/2 cup cooked pinto beans C. 1 cup green leaf lettuce D. 1 cup apple juice
B. 1/2 cup cooked pinto beans
A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor? A. Preeclampsia B. Alcohol consumption C. Placenta previa D. Late prenatal care
B. Alcohol consumption
A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following examples should the nurse use to illustrate a suggestive finding? A. Bruising of both knees with sutures on 1 B. Arm cast for a spiral fracture of the forearm C. Consistent bedwetting at nap time D. Frequent, vague reports of a stomachache or a headache
B. Arm cast for a spiral fracture of the forearm
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find? A. Stepping B. Babinski C. Extrusion D. Moro
B. Babinski
A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child? A. Jump rope B. Coloring book and crayons C. Checkers game D. Jack-in-the-box
B. Coloring book and crayons
A nurse is providing discharge teaching to the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider? A. Nasal secretions containing dark brown blood B. Constant clearing of the throat C. Unpleasant odor from the oral cavity D. Temperature of 37.7°C (99.8°F) at 48 hr postoperative
B. Constant clearing of the throat
A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. Obtain a portable suction machine and suction tubing B. Ease the child to the floor in Sims' position C. Time the length of the seizure D. Notify the child's parents
B. Ease the child to the floor in Sims' position
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head-to-toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical terminology D. Stop the assessment if the child becomes uncooperative
B. Minimize physical contact with the child initially
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? A. Maintain the child on bed rest B. Monitor the child for increased temperature C. Administer oxygen to the child D. Monitor the child for bleeding
B. Monitor the child for increased temperature
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? A. Brightly colored mobile B. Plastic stethoscope C. Small-piece jigsaw puzzle D. Book of short stories
B. Plastic stethoscope
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? A. Upper right quadrant abdominal pain B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia
B. Rigid abdomen
A nurse is evaluating the outcome of surgery for an infant who had a bile duct obstruction. Which of the following findings should indicate to the nurse that the surgery was successful? A. The infant's stool becomes fatty B. The color of the infant's stool is yellowish-brown C. The infant's direct bilirubin level has increased D. A palpable mass is noted in the infant's right upper quadrant
B. The color of the infant's stool is yellowish-brown
A nurse is caring for a 4-week-old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful? A. The infant has lost 2.2 kg (1 lb) since the surgery. B. The infant has a total bilirubin level of 0.3 mg/dL. C. The infant has an aspartate aminotransferase (AST) level of 120 units/L. D. The infant's stools are gray in color.
B. The infant has a total bilirubin level of 0.3 mg/dL.
A nurse is teaching the guardian of an 18-month-old toddler about otic medication administration. Which of the following statements should the nurse make? A. "Administer the drops immediately after removing the medication from the refrigerator." B. "Place the child in a seated position with the head tilted to the side for administration." C. "Gently pull the ear cartilage down and back when administering the medication." D. "Position the medication bottle so the drops do not touch the side of the ear canal."
C. "Gently pull the ear cartilage down and back when administering the medication."
A nurse is providing education to the parent of a toddler who is about to receive an MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should not play with other children for 2 days." B. "I will need to return in 2 weeks for my child to receive the varicella immunization." C. "I will help my child to blow bubbles during the injection." D. "My child may have some drainage from the injection site."
C. "I will help my child to blow bubbles during the injection."
A nurse is present at the time of a child's death following a terminal illness. Which of the following statements should the nurse make to the child's parent? A. "If you'll excuse me, I'll go call the funeral home to have them pick up your child." B. "Your child is no longer suffering." C. "I will miss your child's infectious laugh; it always made me smile." D. "You should consider how to share the news of your child's death with her siblings."
C. "I will miss your child's infectious laugh; it always made me smile."
A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety? A. Provide privacy B. Give the child a thorough explanation before providing care C. Encourage rooming-in D. Tell the child you will help fix her
C. Encourage rooming-in
A nurse is planning care for a preschooler who is scheduled for a surgical procedure. The nurse should identify that the preschooler is in which of the following of Erikson's psychosocial stages of development? A. Industry vs. inferiority B. Trust vs. mistrust C. Initiative vs. guilt D. Identity vs. role confusion
C. Initiative vs. guilt
During a well-child visit, the guardian of a toddler reports that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make? A. Vary the time the toddler goes to bed each night. B. Allow the toddler to watch television before bedtime. C. Provide the toddler with a favorite stuffed animal at bedtime. D. Increase the toddler's activity prior to bedtime.
C. Provide the toddler with a favorite stuffed animal at bedtime.
A nurse is assessing a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggests a possible delay in development? A. Inability to tie shoes B. Adding 3 parts to a stick figure C. Speaking using 2- or 3-word sentences D. Inability to walk backward
C. Speaking using 2- or 3-word sentences
A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will give lansoprazole 30 min after my baby's feedings." B. "I will lay my baby on her right side after feedings." C. "I will give my baby a bottle just before bedtime." D. "I will add rice cereal to my baby's feedings."
D. "I will add rice cereal to my baby's feedings."
A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? A. "My child has frequent mood swings." B. "My child has a very messy bedroom." C. "My child takes 1 to 2 showers per day." D. "My child spends 4 hours per day using online chat rooms."
D. "My child spends 4 hours per day using online chat rooms."
A nurse is teaching the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine. Which of the following instructions should the nurse include? A. "Common sites for an injection of epinephrine are the fatty tissue found in the upper arm and in the lower abdomen." B. "Administer epinephrine prior to giving your child peanut products in the future." C. "No further treatment is needed after injecting the epinephrine." D. "You will need to increase the dosage as your child gains weight."
D. "You will need to increase the dosage as your child gains weight."
A nurse is providing anticipatory nutritional guidance for the caregivers of a 5-month-old infant. Which of the following points should the nurse include in the teaching? A. Switch the infant from formula to low-fat cow's milk at 6 months of age. B. Heat fruit juice before offering it to the infant. C. Introduce a new food every other day. D. Allow the infant to try finger foods, such as crackers, after 6 months of age.
D. Allow the infant to try finger foods, such as crackers, after 6 months of age.
A nurse is assessing an adolescent who is receiving fentanyl via epidural. Which of the following assessments should the nurse identify as the priority? A. Skin around the catheter site B. Blood pressure C. Pain level D. Oxygen saturation
D. Oxygen saturation
A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take? A. Administer 81 mg of aspirin to the toddler B. Give the toddler a cold bath C. Place the toddler in a supine position D. Pad the rails of the toddler's bed
D. Pad the rails of the toddler's bed
A nurse is teaching a group of parents and guardians about otitis media. Which of the following should the nurse identify as a risk factor for this illness? A. Summer months B. Breastfeeding C. Ages 7 to 10 years D. Passive smoking
D. Passive smoking
A nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse. Which of the following actions should the nurse take? A. Ask the child if his parents are responsible for the abuse B. Notify the facility's risk manager C. Interview the child with his parents present D. Report the suspected abuse to local authorities
D. Report the suspected abuse to local authorities
A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room? A. Pulse oximeter B. Oxygen therapy C. Bag valve mask D. Suction equipment
D. Suction equipment
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying B. Semi-recumbent C. Flexed sitting D. Supine
D. Supine
A nurse is assessing a 10-month-old infant at a well-infant checkup. Which of the following assessment findings should the nurse report to the provider? A. The infant is unable to walk independently B. The infant's Moro reflex is absent C. The infant's anterior fontanel is open D. The infant needs assistance to sit up
D. The infant needs assistance to sit up
A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved? A. Sitting alone B. Attempting to stack objects C. Picking up small objects with a crude pincer grasp D. Turning from back to stomach
D. Turning from back to stomach
A nurse is caring for a child with a vesicular rash that has been present for 6 days. The nurse should expect that the child has which of the following conditions? A. Measles B. Fifth disease C. Tetanus D. Varicella
D. Varicella
A nurse is caring for a child who has electrical burns on the lower arms and hands. Which of the following findings indicate the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20/min D. Minimal pain
A. Dark urine
A nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? A. Increased blood pressure B. Lanugo over the back C. Oily skin with acne D. Elevated body temperature
B. Lanugo over the back
A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia? A. Patch the unaffected eye B. Administer mydriatic eye drops daily C. Obtain prescription eyeglasses D. Administer antihistamines
A. Patch the unaffected eye
A nurse in the emergency department is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as an indication of digoxin toxicity? A. Irritability B. Diaphoresis C. Vomiting D. Tachycardia
C. Vomiting
A nurse is providing teaching to a school-aged child who just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hr? A. "Use a toothbrush to scratch under the cast if your skin itches." B. "Avoid moving your leg and the joints above and below the cast." C. "Keep the cast above the level of your heart." D. "Clean soil from the cast with soapy water."
C. "Keep the cast above the level of your heart."
A nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? A. Administer IV morphine B. Administer topical antimicrobials C. Administer IV fluid replacement D. Administer tetanus prophylaxis
C. Administer IV fluid replacement
A nurse is caring for a 3-year-old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to improve these manifestations? A. Orthopneic B. Knee-chest C. Sims' D. Semi-Fowler's
B. Knee-chest
A nurse is assessing the gross and fine motor behaviors of a toddler. Which of the following behaviors should the nurse identify as an expected achievement for a 3-year-old child? A. Walking backward while moving heel to toe B. Standing on 1 foot for several seconds C. Using scissors to cut out shapes D. Printing letters with a pencil
B. Standing on 1 foot for several seconds
A nurse is providing teaching about disease-management strategies to a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? A. "Thorough and effective pulmonary clearance can help prevent the need for a lung transplant when you get older." B. "You should eat these kinds of foods because they will help you grow big and strong." C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." D. "Your medication follows a certain schedule to help you sleep better."
C. "Your mucus is thick because cystic fibrosis interferes with how your glands work."
A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? A. Wash and dry the infant's genitalia and perineum thoroughly B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area C. Avoid placing the scrotum inside the collection bag D. Wait several hours after positioning the device before checking it
A. Wash and dry the infant's genitalia and perineum thoroughly
A nurse is caring for a 16-year-old client who reports dysmenorrhea and asks about alternative therapies for treatment. Which of the following statements should the nurse make? A. "Herbal medication can be effective but should be monitored by your provider." B. "You should place a cold compress on your lower abdomen to decrease inflammation." C. "You should limit exercise, which can increase the pain." D. "Avoid touching the painful areas because this can increase your discomfort."
A. "Herbal medication can be effective but should be monitored by your provider."
A nurse is teaching the parent of a school-age child who has celiac disease. Which of the following foods selected by the parent indicates an understanding of the teaching? A. Corn tortilla with black beans B. Pizza C. Canned soup D. Hot dogs
A. Corn tortilla with black beans
A nurse is planning to teach a 9-year-old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-age children are attempting to master which of the following developmental tasks? A. Initiative vs. guilt B. Industry vs. inferiority C. Trust vs. mistrust D. Identity vs. role confusion
B. Industry vs. inferiority
A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the nurse administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen
C. Amoxicillin
A nurse is assessing the gross motor skills of a 4-year-old preschooler. The nurse should expect the preschooler to perform which of the following activities? A. Hopping on 1 foot B. Skipping on alternate feet C. Jumping rope D. Roller skating
A. Hopping on 1 foot
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I will breathe in through the mouthpiece, hold my breath for 5 sec, and then exhale." B. "If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10 sec interval." D. "I will record the highest reading of three attempts."
D. "I will record the highest reading of three attempts."
A nurse is assessing a toddler who has AIDS. Which of the following findings is an indication of an opportunistic infection? A. Koplik spots B. Peripheral neuropathy C. Chancre D. Candidiasis
D. Candidiasis
A nurse is planning preoperative teaching for a 5-year-old child. Which of the following interventions should the nurse include? A. Explain the long-term benefits of the procedure. B. Provide diagrams and pictures while explaining the procedure. C. Use correct medical terminology during the teaching session. D. Explain the procedure in terms of what the child will feel, see, hear, and taste.
D. Explain the procedure in terms of what the child will feel, see, hear, and taste.
A nurse is caring for a school-age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hr during the night B. Ensure the child's meal tray contains no high-fiber foods C. Perform passive range-of-motion exercises on the child's involved joints every 4 hr D. Place the child on a pressure-reduction mattress
D. Place the child on a pressure-reduction mattress
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A. Head lagging when the infant is pulled from a lying to a sitting position B. Absence of startle and crawl reflexes C. Inability to pick up a rattle after dropping it D. Rolling from back to side
A. Head lagging when the infant is pulled from a lying to a sitting position
A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? A. Koplik spots B. Parotitis C. Strawberry tongue D. Paroxysmal coughing
A. Koplik spots
A nurse is caring for a 2-day-old infant who has myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference B. Position the infant supine C. Place the infant under a radiant warmer D. Tape a piece of plastic over the protruding membranes
A. Monitor the infant's head circumference
A nurse is planning care for a toddler who has acute gastroenteritis and was recently admitted. Which of the following should the nurse plan to provide for the child? A. Oral rehydration solution B. Bananas or applesauce C. Chicken or beef broth D. Hypertonic IV solution
A. Oral rehydration solution
A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following? A. Olfaction B. Visual acuity C. Speech patterns D. Hand-eye coordination
C. Speech patterns
A nurse is teaching the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following pieces of information should the nurse include in the teaching? A. "Crush the medication and mix it in your child's food." B. "Administer the medication 1 hour before bedtime." C. "Expect your child to have cloudy urine while he is taking this medication." D. "Weigh your child twice per week while he is taking this medication."
D. "Weigh your child twice per week while he is taking this medication."
A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include? A. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." B. "A toddler first shows interest in looking at pictures at 20 months of age." C. "A toddler should have daytime control of his bowel and bladder by 24 months of age." D. "Your child should be able to scribble spontaneously using a crayon at 15 months of age."
D. "Your child should be able to scribble spontaneously using a crayon at 15 months of age."
A nurse is providing teaching to the parents of an infant who is breastfeeding. When should the nurse instruct the parents to introduce solid foods in the infant's diet? A. After the rooting reflex disappears B. At 2 to 3 months of age C. After the infant's first tooth erupts D. At 4 to 6 months of age
D. At 4 to 6 months of age
A nurse is planning care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. Airborne precautions B. Contact precautions C. Protective environment D. Droplet precautions
D. Droplet precautions
A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss >10% C. Lethargy D. Dry mucous membranes
D. Dry mucous membranes
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? A. Platelets 150,000/mm^3 B. Hgb 6 g/dL C. WBC 6,000/mm^3 D. Potassium 4.5 mEq/L
B. Hgb 6 g/dL
A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria
C. Tachypnea
A nurse is providing immediate postoperative care for a preschooler who had a tonsillectomy. Which of the following actions should the nurse take? A. Offer ice cream or pudding when the child is fully awake B. Eliminate the use of a straw when offering fluids C. Apply a heating pad to the neck area D. Instruct the child to blow his nose to clear bloody secretions
B. Eliminate the use of a straw when offering fluids
A nurse is assessing a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypokalemia B. Decreased blood pressure C. Increased urine volume D. Periorbital edema
D. Periorbital edema
A nurse is performing a visual acuity screening for a school-aged child using the Snellen letter chart. Which of the following actions should the nurse take? A. Position the child 5 ft away from the letter chart B. Have the child wear his glasses during the vision screening C. Observe for pupillary constriction while shining a light into the child's eye D. Instruct the child to point in the direction the letters are facing
B. Have the child wear his glasses during the vision screening
A nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion D. Autonomy vs. shame and doubt
B. Industry vs. inferiority
A nurse is providing teaching to the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include? A. Instruct the child to ride against the flow of traffic B. Instruct the child to walk the bike through intersections C. Provide a larger bike that the child will be able to grow into D. Ensure the child's helmet covers the ears
B. Instruct the child to walk the bike through intersections
A nurse is assessing a school-age child who has celiac disease. Which of the following findings should the nurse expect? A. Elevated sweat chloride B. Steatorrhea C. Clubbing of the fingers D. Jaundice
B. Steatorrhea
A nurse is caring for an infant following the surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? A. Keep the infant's mouth open by using a tongue blade for 4 hr following surgery B. Suction the infant gently with a bulb syringe PRN C. Place the infant in a prone position D. Clean the infant's incision with chlorhexidine
B. Suction the infant gently with a bulb syringe PRN
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. Perform nasotracheal suctioning B. Test the nasal secretions for glucose C. Maintain direct lighting on the child D. Lower the head of the bed
B. Test the nasal secretions for glucose
A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL. C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32%
C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL
A nurse is assessing the fine motor skills of a 3-year-old preschooler. Which of the following findings should the nurse expect? A. The preschooler can draw a stick figure that has 7 parts B. The preschooler can print her first name C. The preschooler can cut out a picture using scissors D. The preschooler builds a tower of 9 cubes
D. The preschooler builds a tower of 9 cubes
A nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take? A. Offer the infant water before feedings B. Discontinue amoxicillin C. Administer an antifungal medication after feedings D. Give the infant formula instead of breast milk
C. Administer an antifungal medication after feedings
A nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing. Which of the following findings is the priority for the nurse to report to the provider? A. The child's temperature is 39°C (102°F) B. The child's skin is sallow C. The child is drooling D. The child's voice is hoarse
C. The child is drooling
A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before the child can have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months for surgery to prevent which of the following outcomes? A. Repeated ear infections B. Nutritional deficits C. Immune system deficits D. Difficulty with language acquisition
D. Difficulty with language acquisition
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero B. Administer a folic acid supplement to the child each day C. Give pancreatic enzymes to the child with meals and snacks D. Ensure the child's dietary intake of calcium and iron is adequate
D. Ensure the child's dietary intake of calcium and iron is adequate
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child B. Explain the sounds the child is hearing C. Have the child use a cane when ambulating D. Rotate nurses caring for the child
B. Explain the sounds the child is hearing
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeping on hands and knees B. Inability to vocalize vowel sounds C. Using a crude pincer grasp D. Standing by holding onto a support
B. Inability to vocalize vowel sounds
A nurse is providing teaching to the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include? A. "The doctor will replace the tubes routinely about every 2 years." B. "If your child gets water in her ears will not cause any further problems." C. "The tubes should stay in place until they fall out on their own." D. "Now that the tubes are in place, she should not have any further problems with hearing."
C. "The tubes should stay in place until they fall out on their own."
A nurse on a pediatric unit is caring for a child who is not eating well. Which of the following suggestions should the nurse offer to the parents to promote the child's food intake? A. "Make dietary selections for your child." B. "Offer foods that have strong flavors or smells." C. "Let your child eat with others when possible." D. "Make sure your child eats most of the food on his plate."
C. "Let your child eat with others when possible."
A nurse working on a maternal-newborn unit is teaching a group of newly licensed nurses about assisting new mothers with breastfeeding. The nurse should include which of the following infant conditions as a contraindication for breastfeeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism
A. Galactosemia
A nurse on a pediatric unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? A. Age 10 years B. Frequent hospitalizations C. Parent bonding with child D. Calm, quiet demeanor
B. Frequent hospitalizations
A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile for height. Which of the following findings should the nurse report to the provider? A. Heart rate 175/min B. Respiratory rate 26/min C. Blood pressure 88/40 mmHg D. Temperature 37.6°C (99.7°F)
A. Heart rate 175/min
A nurse is performing a well-child assessment on a 4-year-old child. Which of the following findings should the nurse expect? A. The child is able to hop on 1 foot. B. The child is able to build a tower of up to 6 blocks. C. The child is able to name the days of the week. D. The child is able to identify left and right.
A. The child is able to hop on 1 foot.
