PATIB

A nurse is assessing a school-age child who has appendicitis with possible perforation. The nurse should identify which of the following as a manifestation of peritonitis

abd distention

A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching

"Allow the stent to drain directly into your infant's diaper: The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow

A nurse is caring for a 2-week-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain

Administer sucrose to the infant prior to the procedure

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney

Serum creatinine 3.0 mg/dt: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the normal reference range and may indicate rejection of the kidney.

A nurse is preparing to suction an infant who has a tracheostomy. Which of the following actions should the nurse take

Suction for 5 seconds or less

A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include

The child should be able to stand on the balls of her feet when sitting on the bike

A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss

The toddler received tobramycin during a hospitalization 2 weeks ago: The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.

A nurse is preparing to administer a hep B vaccine to a 1-month-old. The nurse should plan to inject the medication at which location?

Thigh

A nurse is teaching a school-age child who has a severe allergy to bee venom and his parent about epinephrine. Which of the following instructions should the nurse include in the teaching

Use a second dose if the first dose of epinephrine does not completely reverse the symptom: A biphasic response, in which the child will appear to recover and then experience a recurrence of symptoms, is possible with some allergic reactions. The nurse should instruct the parent and child to use a second dose if the first dose does not resolve all the symptoms.

A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan

Use a semipermeable transparent dressing to cover the site

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect

a unilateral rib hump: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.

A nurse is reviewing the laboratory report of a 6-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider

hgb: The child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range for a 6-year-old child and should be reported to the provider.

A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis

increased protein concentration: The nurse should recognize that an increased protein concentration in the spinal fluid is a finding associated with bacterial meningitis.

A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first

epinephrine: This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction

flank pain

A nurse is teaching a school-age child and his parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include

"Wait 3 days before taking a tub bath: The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. He should not take a tub bath for 3 days to avoid immersion of the incision in water.

A nurse is teaching the mother of a 6-month-old infant about teething. Which of the following statements should the nurse make

"Your baby may pull at her ears when she is teething

A nurse in an emergency department suspects that a toddler has epiglottitis. Which of the following actions should the nurse take

Prepare the toddler for nasotracheal intubation: When epiglottitis is suspected the nurse should prepare for nasotracheal intubation or a tracheostomy, which might be required if the toddler begins to experience severe respiratory distress.

A nurse is assessing a 6-month-old infant at a well-infant visit. Which of the following findings should the nurse report to the provider

Presence of strabismus: Strabismus, or crossing of the eyes, disappears at 3 to 4 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is providing discharge teaching to the parents of a Caucasian toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the parents to report which of the following findings to the provider

Restricted ability to move the toe

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first

tachypnea: When using the airway, breathing, circulation approach to client care, the first finding the nurse should address is the toddler's tachypnea, which results when the kidneys are unable to excrete hydrogen ions and produce bicarbonate leading to metabolic acidosis.

A nurse is assessing a toddler who has leukemia and is receiving his first round of chemotherapy. Which of the following findings is the priority for the nurse to report to the provide

urticaria

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take

Screen the child's visitors for indications of infection

A nurse is providing teaching to the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent should the nurse identify as understanding the teaching

"I should keep my child indoors when I mow the yard

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. The nurse should identify which of the following statements by the child as understanding the teaching

"I will give myself a shot of regular insulin 30 minutes before I eat breakfast

A nurse is providing discharge teaching to the parent of a school-age child who has undergone a tonsillectomy. Which of the following statements by the parent should the nurse identify as understanding the teaching

"I will notify the doctor if I notice that my child is swallowing frequently: The nurse should instruct the parent that frequent swallowing is a sign of bleeding and, if it is observed, to notify the primary care provider immediately.

A nurse is teaching the parent of an infant who has a Pavlik harness to treat developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching

"I will place my infant's diapers under the harness straps

A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make

"Let's talk about some of the ways you have handled previous stressors in your life

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent should the nurse identify as understanding the teaching

"Mononucleosis is caused by an infection with the Epstein-Barr virus

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero

1

A nurse is providing anticipatory guidance to the parents of a 2-week-old infant about risk factors for sudden infant death syndrome (SIDS). Which of the following risk factors should the nurse include in the teaching

Covering the sleeping infant with a blanket

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe

Cuts a shape using scissor

A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Decreased attention span

A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect

Deep respirations of 32/min: The nurse should expect deep and rapid respirations in a child who has diabetic ketoacidosis. This respiratory rhythm is the body's attempt to blow off excess carbon dioxide and achieve a state of homeostasis.

A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse's priority when making a room assignment

Disease proces

A nurse is caring for a toddler who has acute otitis media and a temperature of 40º C (104º F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature

Dress the toddler in minimal clothing

A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data

Episodes of vomit: When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention; therefore, this is the priority finding.

A nurse is reviewing laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following values should the nurse identify as an indication of a potential complication

Erythrocyte sedimentation rate 18 mm/hr: An erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range and is an indication of osteomyelitis.

A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycling accident. Which of the following actions should the nurse take first

Explore the parents' feelings and wishes regarding organ donation

A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following findings should the nurse expect

Facial rash: Erythema on the face, predominantly on the child's cheeks, is a manifestation of erythema infectiosum (fifth disease). The erythema causes the child to have the appearance of a "slapped face." The rash lasts from 1 to 4 days.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates his abdominal pain at 7 on a 0 to 10 scale. Which of the following actions should the nurse take

Give morphine 0.05mg/kg IV

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant

Great toe: he nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for pulses, temperature, and color.

A nurse is planning care for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan

Increase fat content in the child's diet to 40% of total calories :A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to equal 40% of total caloric intake.

A nurse is caring for a newly-admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to recommend to the parents for treating the child's condition

Recombinant growth hormone: Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to recommend this treatment to the child's parents. The nurse's role is to provide emotional support for the parents as they make a decision about the treatment they feel is best for their child.

A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next

Initiate IV access

A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take

Initiate droplet precautions for the child

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan

Initiate seizure precautions for the child: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions in order to maintain the child's safety.

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect

Loud, harsh murmur

A nurse is caring for a school-age child who has acute rheumatic fever. Which of the following actions should the nurse take

Maintain the child on bed rest

A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler

Oral rehydration solution

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period

Place the child in a lateral position

A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take

Place the infant in a knee-chest position: The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.

A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect

Poor personal hygiene

A nurse is providing anticipatory guidance to the parents of an 8-month-old infant during a well-child visit. Which of the following statements should the nurse make

"Your baby should be able to sit unsupported

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan

Provide small, frequent meals to the child

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should teach the parent to apply which of the following to the affected area

Zinc oxide: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.

A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply

vomiting, lethargy: Steatorrhea is incorrect. The nurse should expect the infant with intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis. Vomiting is correct. The nurse should expect the infant with intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. Lethargy is correct. The nurse should expect the infant with intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably leading to exhaustion and decreased nutritional intake. Constipation is incorrect. The nurse should expect the infant with intussusception to have mucus-filled and currant jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen. Weight gain is incorrect. The nurse should expect the infant with intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.

A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip

wheezes

A nurse in an emergency department is caring for a school-age child who has sustained a superficial minor burn from fireworks on his forearm. Which of the following actions should the nurse take

Use an antimicrobial ointment on the affected area

A nurse in the emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply

increased temperature is correct. Kawasaki disease is an acute illness associated with a fever lasting more than 4 days that is unresponsive to antipyretics or antibiotics. Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction. Cervical lymphadenopathy is correct. The child who has Kawasaki disease may develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.