Pediatric HESI Practice Questions
A child with leukemia is being discharged after beginning chemotherapy. Which of the following instructions will the nurse include when teaching the parents of this child? A. Provide a diet low in protein and high carbohydrates. B. Avoid fresh vegetables that are not cooked or peeled. C. Notify the doctor if the child's temperature exceeds 101 F (39C). D. Increase the use of humidifiers throughout the house.
B. Avoid fresh vegetables that are not cooked or peeled.
Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery? A. Crying that is unrelieved by comforting measures B. Presence of an inguinal bulge after gentle palpation C. Refusal to take oral feedings D. Straining during defecation
B. Presence of an inguinal bulge after gentle palpation
When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions? A. Supine B. Prone C. In an infant seat D. On the side
B. Prone
The nurse is preparing a child with an intussusception for a prescribed barium enema. What is the main purpose of conducting this procedure prior to surgical intervention? A. Evacuate the bowel of impacted feces. B. Reduce the invaginated bowel segment. C. Locate the presence of diverticula. D. Identify the area of esophageal atresia.
B. Reduce the invaginated bowel segment.
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. What nursing intervention should be included in this child's plan of care? A. Keep restraints on at all times to prevent unplanned extubation. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities. D. Document the reason for application of the restraints q 72 hours
B. Remove restraints one at a time and provide range-of-motion exercises.
Which of the following health teachings regarding sickle cell crisis should be included by the nurse? A. It results from altered metabolism and dehydration B. Tissue hypoxia and vascular occlusion cause the primary problems C. Increased bilirubin levels will cause hypertension D. There are decreased clotting factors with an increase in white blood cells
B. Tissue hypoxia and vascular occlusion cause the primary problems
A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother? A. Give another dose. B. Withhold this dose. C. Administer a half dose now. D. Mix the next dose with food.
B. Withhold this dose.
When developing a care plan for an adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on: A. becoming industrious. B. establishing an identity. C. achieving intimacy. D. developing initiative.
B. establishing an identity.
A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need? A. 400 calories/day B. 500 calories/day C. 600 calories/day D. 700 calories/day
C. 600 calories/day
The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs? A. Place the child's head flat with the knees on pillows above the level of the heart. B. Have the child lie on his right side with his head elevated on one pillow. C. Allow the child to assume a knee-chest position with head and chest slightly elevated. D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths.
C. Allow the child to assume a knee-chest position with head and chest slightly elevated.
The nurse observes a 4-year-old boy in a daycare setting. Which behavior should the nurse expect this child to exhibit? A. Throws a temper tantrum when told he must share the toys B. Plays by himself for most of the day C. Boasts aggressively when telling a story D. Cries and is fearful when separated from his parents
C. Boasts aggressively when telling a story
After teaching the parents of a preschooler who has undergone T and A (Tonsillectomy and Adenoidectomy) about appropriate foods to give the child after discharge, which of the following, if stated by the parents as appropriate foods, indicates successful teaching? A. Meatloaf and uncooked carrots B. Pork and noodle casserole C. Cream of chicken soup and orange sherbet D. Hot dog and potato chips
C. Cream of chicken soup and orange sherbet
A client and her husband are positive for the sickle cell trait. The client asks the nurse about chances of her children having sickle cell disease. Which of the following is appropriate response by the nurse? A. One of her children will have sickle cell disease. B. Only the male children will be affected. C. Each pregnancy carries a 25% chance of the child being affected. D. If she had four children, one of them would have the disease.
C. Each pregnancy carries a 25% chance of the child being affected.
When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information? A. Stool inspection B. Pain pattern C. Family history D. Abdominal palpation
C. Family history
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first? A. Obtain a scale to weigh the infant's diapers. B. Instruct the mother to offer Pedialyte regularly. C. Insert an intravenous (IV) line and begin IV fluids. D. Obtain a stool specimen for analysis.
C. Insert an intravenous (IV) line and begin IV fluids.
A 16 month old child diagnosed with Kawasaki Disease (KD) is very irritable,refuses to eat, and exhibits peeling skin on the hands and feet. Which of the following would the nurse interpret as the priority? A. Applying lotions to the hands and feet B. Offering foods the toddler likes C. Placing the toddler in a quiet environment D. Encouraging the parents to get some rest
C. Placing the toddler in a quiet environment
An 8 year old child has been diagnosed to have iron deficiency anemia. Which of the following activities is most appropriate for the child to decrease oxygen demands on the body? A. Dancing B. Playing video games C. Reading a book D. Riding a bicycle
C. Reading a book
Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A. Adjustment of orthodontic appliances or braces B. Loss of deciduous teeth (baby teeth) C. Urinary catheterization D. Insect bites
C. Urinary catheterization
Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux(GER)? A. Fluid volume deficit B. Risk for aspiration C. Altered nutrition: less than body requirements D. Altered oral mucous membranes
D. Altered oral mucous membranes
A client with hemophilia has a very swollen knee after falling from bicycle riding. Which of the following is the first nursing action? A. Initiate an IV site to begin administration of cryoprecipitate. B. Type and cross-match for possible transfusion. C. Monitor the client's vital signs for the first 5 minutes. D. Apply ice pack and compression dressings to the knee.
D. Apply ice pack and compression dressings to the knee.
The nurse is caring for a 14-year-old whose fractured femur is immobilized using 90-90 skeletal traction. What intervention is most important for the nurse to implement daily? A. Give skin and back care with each linen change. B. Encourage adequate bulk and liquids in the diet. C. Provide opportunities for diversion and peer interaction. D. Cleanse pin sites using topical antiseptic an antibiotic.
D. Cleanse pin sites using topical antiseptic an antibiotic.
In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses
D. Diminished femoral pulses
A 4-year-old has cystic fibrosis. Which stage of Erikson's theory of psychosocial development is the nurse addressing when teaching inhalation therapy? A. Autonomy vs. Shame and Doubt B. Industry vs. Inferiority C. Trust vs. Mistrust D. Initiative vs. Guilt
D. Initiative vs. Guilt
A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained.The child's color becomes blue and respiratory rate increases to 44 bpm.Which of the following actions would the nurse do first? A. Obtain an order for sedation for the child B. Assess for an irregular heart rate and rhythm C. Explain to the child that it will only hurt for a short time D. Place the child in knee-to-chest position
D. Place the child in knee-to-chest position
Which of the following would the nurse perform to help alleviate a child's joint pain associated with rheumatic fever? A. Maintaining the joints in an extended position B. Applying gentle traction to the child's affected joints C. Supporting proper alignment D. Using a bed cradle to avoid the weight of bed lines on the joints
D. Using a bed cradle to avoid the weight of bed lines on the joints
An adolescent receives a prescription for an injection of S-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.)
0.33 ml
A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available and 25 mg/ml ampules. How many ml should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
0.4 ml
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
0.4 ml
The HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divides doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given weekly? (Enter the numeric value only. If rounding is required, round to the nearest tenth.)
2.5 mg
Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed? A. "I will give her a baby aspirin every 4 hours as needed for fever." B. "I will call the clinic if her cry becomes high-pitched or unusual." C. "I know I can expect her to be irritable over the next 2 days." D. "I will exercise her legs regularly to decrease the soreness."
A. "I will give her a baby aspirin every 4 hours as needed for fever."
A child with iron deficiency anemia is ordered ferrous sulfate (Ferralyn), an oral iron supplement. When teaching the child and parent how to administer this preparation, the mother asks why she needs to mix the supplement with citrus juice. Which response by the nurse is best? A. "The vitamin C in the citrus juice helps with iron absorption." B. "Having food and juice in the stomach helps with iron absorption." C. "The citrus juice counteracts the unpleasant taste of the iron." D. "There isn't a specific reason for it."
A. "The vitamin C in the citrus juice helps with iron absorption."
Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant? A. A thin stratum corneum that increases topical absorption. B. A lower sensitivity reactions to skin irritants. C. A smaller percentage of muscle mass. D. A greater body surface area that requires larger dosages.
A. A thin stratum corneum that increases topical absorption.
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement? A. Assess the child's mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child's food likes and dislikes. D. Ask the parents about the child's recent dietary intake.
A. Assess the child's mucous membranes and skin turgor.
After diagnosis and initial treatment of a 3-year-old with cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary function? A. Chest physiotherapy should be performed twice a day before a meal. B. Administer a cough suppressant every 6 hours. C. Maintain supplemental oxygen at 4 to 6 L/minute. D. Energy should be conserved by scheduling minimally strenuous activities.
A. Chest physiotherapy should be performed twice a day before a meal.
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? A. Describes life without purpose. B. Complains of nausea and loss of appetite. C. States is often fatigued and drowsy. D. Exhibits in increase in sweating.
A. Describes life without purpose.
A newborn's failure to pass meconium within the first 24 hours after birth may indicate which of the following? A. Hirschsprung disease B. Celiac disease C. Intussusception D. Abdominal wall defect
A. Hirschsprung disease
At what point during the physical exam should a child with asthma be assessed for the presence or absence of intercostal retractions? A. Inspiration B. Coughing C. Apneic episodes D. Expiration
A. Inspiration
Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea? A. Notify the physician immediately B. Administer antidiarrheal medications C. Monitor child ever 30 minutes D. Nothing, this is characteristic of Hirschsprung disease
A. Notify the physician immediately
The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider? A. Pale bluish coloration of the toes. B. Skin is warm and dry to the touch. Toes are wiggled upon command. Capillary refill less than 3 seconds.
A. Pale bluish coloration of the toes.
A 3-month-old infant returns from surgery with elbow restraints and a Logan's bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning. D. Apply water-soluble lubricant to the suture line.
A. Place the infant upright in an infant seat position.
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. What assessment finding suggests the presence of a common complication often experienced by those with Down syndrome? A. Presence of a systolic murmur B. New onset of patchy alopecia C. Complaints of long bone pain D. Recent projectile vomiting
A. Presence of a systolic murmur
A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take? A. Send the child home with a note to the parents about how to care for the lesions. B. Send the child home and report the occurrence to the health department. C. Cover the lesion with a gauze dressing and send the child back to class. D. Wash the lesion with antimicrobial soap and send the child back to class.
A. Send the child home with a note to the parents about how to care for the lesions.
The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further assessment reveals that he is concerned about his edematous facial features. Based on these assessment findings, the nurse should plan interventions related to the nursing diagnosis of A. Social isolation. B. Altered health maintenance. C. Knowledge deficit. D. Ineffective coping.
A. Social isolation.
Which assessment finding(s) should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) A. Steatorrhea B. Obesity C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion
A. Steatorrhea C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion
While assessing a newborn with cleft lip,the nurse would be alert that which of the following will most likely be compromised? A. Sucking ability B. Respiratory status C. Locomotion D. GI function
A. Sucking ability
Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease? A. Susceptibility to respiratory infection B. Bleeding tendencies C. Frequent vomiting and diarrhea D. Seizure disorder
A. Susceptibility to respiratory infection
The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP? A. Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care. D. Report any pain the child experiences.
A. Use designated isolation precautions.
Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)? A. Vomiting B. Stools C. Uterine D. Weight
A. Vomiting
Ampicillin 75 mg/kg is prescribed for a 22-lb child. It is available in a solution that contains 250 mg/5 ml. How many milliliters should the nurse administer in one dose? A. 10 B. 15 C. 20 D. 25
B. 15
In determining the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has flaccid muscle tone with slight flexion and slight resistance to straightening. He has a loud cry with stimulation, and his color is acrocyanotic. What is the correct Apgar score for this infant? A. 7. B. 8. C. 9. D. 10.
B. 8.
Which nursing intervention(s) is (are) therapeutic when caring for a hospitalized toddler? (Select all that apply.) A. Require parents to leave the room when performing invasive procedures. B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures. D. Insert a urinary catheter if bedwetting occurs during hospitalization. E. Do not allow any toys to be brought in from the child's home.
B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures.
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take? A. No action required, as this is an expected finding for a school-aged child. B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately. C. Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible. D. Call the parents and have them take the child home from school for the rest of the day.
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
When assessing a child for impetigo, the nurse expects which assessment findings? A. Small, brown, benign lesions B. Honey-colored, crusted lesions C. Linear, threadlike burrows D. Circular lesions that clear centrally
B. Honey-colored, crusted lesions
The nurse is palpating the lymph nodes of an 18-month-old. Which findings should the nurse call to the attention of the healthcare provider? A. Small, firm, mobile nodules in the axilla. B. Enlarged, warm, tender preauricular node. C. Enlarged, nontender, movable occipital node. D. Small, discrete, mobile, nontender, inguinal node.
C. Enlarged, nontender, movable occipital node.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? A. Hypoglycemia. B. Fluid balance. C. Heat loss. D. Bleeding tendencies.
C. Heat loss.
When planning the care for a child who has had a cleft lip repair the nurse knows that crying should be minimized because it A. Increases salivation. B. Increases the respiratory rate. C. Stresses the suture line. D. Leads to vomiting.
C. Stresses the suture line.
A nurse is assessing a severely depressed adolescent. Which finding indicates a risk of suicide? A. Excessive talking B. Excessive sleepiness C. A history of cocaine use D. A preoccupation with death
D. A preoccupation with death
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide? A. Antibiotics take two weeks to become effective against infections such as athlete's foot. B. Continue using the ointment for a full week, even after the symptoms disappear. C. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. D. Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
D. Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? A. Have partners screened for human immunodeficiency virus. B. Report a sudden onset arthralgia to the healthcare provider. C. Decrease intake of high-fat foods, caffeine, and alcohol. D. Use two forms of contraception while taking this drug.
D. Use two forms of contraception while taking this drug.
The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) - Start chest compressions with assisted manual ventilations. - Apply pads and prepare for transthoracic pacing. - Administer epinephrine 0.01 mg/kg intraosseous (IO). - Review the possible underlying causes for bradycardia
1. Start chest compressions with assisted manual ventilations. 2. Administer epinephrine 0.01 mg/kg intraosseous (IO). 3. Apply pads and prepare for transthoracic pacing. 4. Review the possible underlying causes for bradycardia
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hours. The pharmacy delivers 10 million units/ liter of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
83 ml/hr
The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which finding(s)? (Select all that apply.) A. Restlessness. B. Clenched fists. C. Increased pulse rate. D. Increased temperature. E. Peripheral pallor of the skin. F. Increased respiratory rate.
A. Restlessness. B. Clenched fists. C. Increased pulse rate. F. Increased respiratory rate.
A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? A. Sitting up and leaning forward. B. Standing with the head leaning backward. C. Side-lying with the head slightly elevated. D. Supine with the legs raised.
A. Sitting up and leaning forward.
A 6-year-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% of personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first? A. Administer a prescribed bronchodilator. B. Report finding to the healthcare provider. C. Encourage the child to cough and deep breath. D. Determine what trigger precipitated this attack.
A. Administer a prescribed bronchodilator.
Which restraint should be used for a toddler after a cleft palate repair? A. Elbow. B. Clove hitch. C. Mummy. D. Jacket.
A. Elbow.
An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? A. LDH or LD, SGOT or ALT, SGPT or AST. B. White blood count, hemoglobin, hematocrit. C. BUN, creatinine, specific gravity. D. pH, PCO2, HCO3.
A. LDH or LD, SGOT or ALT, SGPT or AST.
The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching? A. Ask the adolescent to describe his level of comfort with injecting himself with insulin. B. Observe him as he demonstrates the self-technique to another diabetic adolescent. C. Have the adolescent list the procedural steps for safe insulin administration. D. Review his glycosylated hemoglobin level 3 months after his diabetic teaching.
B. Observe him as he demonstrates the self-technique to another diabetic adolescent.
A nurse is developing a plan to teach a mother how to reduce her infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan? A. Administer antibiotics whenever the infant has a cold. B. Place the infant in an upright position when giving a bottle. C. Avoid getting the infant's ears wet while bathing or swimming. D. Clean the infant's external ear canal daily.
B. Place the infant in an upright position when giving a bottle.
A child is admitted with a tentative diagnosis of clinical depression. Which assessment finding is most significant in confirming this diagnosis? A. Irritability B. Sadness C. Weight gain D. Fatigue
B. Sadness
If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6°F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? A. The intravenous fluid replacement contains a hypertonic solution of sodium chloride, B. Urinary and gastrointestinal fluid loss reduce blood viscosity and stimulate thirst. C. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes. D. Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat.
C. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes.
In assessing an infant 10 hours after birth, the nurse notes that the infant is slightly cyanotic and has a large amount of mucus. Which intervention should the nurse implement first? A. Begin oxygen at 2 L/minute. B. Insert a nasogastric tube. C. Suction the infant as needed. D. Assess the heart rate.
C. Suction the infant as needed.
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? A. Cleanse the foot with soap and water and apply an antibiotic ointment. B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. Have the mother check the child's temperature q4h for the next 24 hours. D. Transfer the child to the emergency department to receive a gamma globulin injection.
A. Cleanse the foot with soap and water and apply an antibiotic ointment.
The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply.) A. Close car windows and use air conditioner. B. Decrease the raw sugars in the diet. C. Avoid sudden changes in temperature. D. Keep away from pets with long hair. E. Stay indoors when grass is being cut.
A. Close car windows and use air conditioner. C. Avoid sudden changes in temperature. D. Keep away from pets with long hair. E. Stay indoors when grass is being cut.
The parents of a 4-week-old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitating and pyloric stenosis, which is most important for the nurse to obtain? A. Degree of forcefulness of vomiting episodes. B. Level of infant's distress after vomiting. C. Odor and texture associated with emesis. D. Position of the infant when vomiting occurs.
A. Degree of forcefulness of vomiting episodes.
The nurse asks the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? A. Examine the genitalia as the last part of the total exam. B. Use soothing statements to facilitate cooperation. C. Allow the child to keep underpants on to examine genitalia. D. Work slowly and methodically so not to stress the child.
A. Examine the genitalia as the last part of the total exam.
A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? A. Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%. B. Administer diuretics via secondary infusion in the morning only. C. Evaluate heart rate for effectiveness of cardiotonic medications. D. Use high energy formula 30 calories/ounce at q3 hour feeding via soft nipples. E. Ensure uninterrupted and frequent rest periods between procedures.
A. Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%. C. Evaluate heart rate for effectiveness of cardiotonic medications. D. Use high energy formula 30 calories/ounce at q3 hour feeding via soft nipples. E. Ensure uninterrupted and frequent rest periods between procedures.
The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take? A. Pass the information on in the report. B. Notify the healthcare provider because the value is high. C. Repeat the lab study because the value is too high. D. Hold the next dose of theophylline.
A. Pass the information on in the report.
After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child's urine output is 50 mL/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement? A. Perform a fingerstick glucose test. B. Obtain arterial blood gases. C. Increase the IV fluid flow rate. D. Review 24 hour intake and output.
A. Perform a fingerstick glucose test.
A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? A. Place the ID bands on the infant and mother. B. Obtain the infants vital signs. C. Administer vitamin K injection. D. Observe the infant latching onto the breast.
A. Place the ID bands on the infant and mother.
A nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity is most appropriate for the nurse to schedule in the care plan? A. Playing ping-pong B. Reading books C. Climbing on play equipment in the playroom D. Ambulating without restrictions
B. Reading books
The nurse is planning care for a newborn infant scheduled for a cardiac catheterization. Which occurrence poses the greatest risk for this child? A. Allergic response to the plastics in the catheter used for catheterization. B. Acute hemorrhage from the entry site of the catheter after the procedure. C. Loss of pulses proximal to the entry site of the cardiac catheter. D. Fever associated with nausea and vomiting after the procedure.
B. Acute hemorrhage from the entry site of the catheter after the procedure.
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction? A. Tell children they should not taste anything but food. B. Store all toxic agents and medicines in locked cabinets. C. Provide special play areas in the house and restrict play in other areas. D. Punish children if they open cabinets that contain household chemicals.
B. Store all toxic agents and medicines in locked cabinets.
A 3-year-old boy is brought to the emergency department after the mother found the child in the back yard holding a piece of a toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement? A. Obtain a pulse oximetry reading and arterial blood gases. B. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver. C. Request a stat chest x-ray and prepare medications for an asthmatic episode. D. Determine if the child ingested a toxic substance and if vomiting occurred.
B. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver.
The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? A. Perform CPT after meals to increase appetite and improve food intake. B. CPT should be performed more frequently, but at least an hour before meals. C. Stop using CPT during the daytime until the child has regained an appetite. D. Perform CPT only in the morning, but increase frequency when appetite improves.
B. CPT should be performed more frequently, but at least an hour before meals.
The nurse is caring for a 12 year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication? A. Poor skin turgor resulting from dehydration. B. Changes in level of consciousness. C. Premature aging as the disease progresses. D. Severe edema from an excess of water and sodium.
B. Changes in level of consciousness.
A newborn infant is receiving positive pressure ventilation after delivery. Based on which assessment findings should the nurse initiate chest compressions? A. Apgar Score 7. B. Heart rate 54. C. Central cyanosis. D. Limp muscle tone.
B. Heart rate 54.
During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings incidence of otitis media? A. Pneumococcal vaccine. B. Hemophilus Influenza type B (HiB) vaccine. C. Palivizumab vaccine for RSV. D. Varicella Virus Vaccine Live.
B. Hemophilus Influenza type B (HiB) vaccine.
A 10-month-old is choking. The nurse observes a rescue or administer back blows, but the infant continues to choke. The rescuer prepares to administer chest thrusts as seen in the picture. What instructions should the nurse provide? A. Use the heel of the hand rather than fingers. B. Move the fingers to the middle of the breast bone. C. Keep the head supported in an upward position. D. Begin five upward thrusts immediately.
B. Move the fingers to the middle of the breast bone.
A nurse is conducting an infant nutrition class for parents. Which foods are appropriate to introduce during the first year of life? Select all that apply. A. Sliced beef B. Pureed fruits C. Whole milk D. Rice cereal E. Strained vegetables F. Fruit juice
B. Pureed fruits D. Rice cereal E. Strained vegetables
The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift? A. An RN should be assigned to take temperatures frequently. B. Tympanic and oral temperatures are equally accurate. C. The PN should take rectal temperatures on this child. D. The pediatrician should decide how to assess the temperature.
B. Tympanic and oral temperatures are equally accurate.
A mother tells the nurse that her preschool-age daughter with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently she had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to: A. bananas. B. latex. C. kiwifruit. D. color dyes.
B. latex.
A mother who is HIV positive asks the nurse about her infant's positive ELISA test. What information should the nurse provide to the mother? The infant has A. converted to HIV positive status. B. received HIV maternal antibody transmission. C. developed CMV (cytomegalovirus). D. been infected with congenital syphilis.
B. received HIV maternal antibody transmission.
The nurse is teaching a mother, who is a RN, care about her 4-year-old child who was recently diagnosed with acute lymphocytic leukemia. Based on this mother's nursing background, how should the nurse introduce the teaching plan? A. "I know you are a registered nurse, so I will skip the pathophysiology." B. "Even though you are a nurse, we need to go over the basics of care." C. "Your nursing education should be helpful to you as we begin care." D. "As a nurse, you know that the staff will need your complete cooperation."
C. "Your nursing education should be helpful to you as we begin care."
The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? A. A young adult with Crohn's disease who reports having diarrheal stools. B. An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late. C. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. D. A teenager who reports continued pain 30 minutes after receiving an oral analgesic.
C. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping.
A kindergarten child who is very drowsy and has a generalized rash and fever comes to the school nurse's office. After reviewing the child's past medical history, the nurse is alerted to a risk for viral meningitis. Which finding is most important for the nurse to report to the healthcare provider? A. Past history of exacerbated asthma. B. Febrile seizures before one year of age. C. A recent exposure to mumps at school. D. Known to share silverware with classmates.
C. A recent exposure to mumps at school.
A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client's social interaction, what intervention is best for the nurse to initiate? A. Encourage the client to use a hand-held video game that is popular with all his friends. B. Assign a 25-year-old female nursing student to offer support to the client. C. Arrange for an Internet connection in the client's room for email communication. D. Encourage the client's mother to arrange a surprise get together in the cafeteria.
C. Arrange for an Internet connection in the client's room for email communication.
The nurse is counseling a family whose 5-year-old daughter was killed by a hit and run driver. The 10-year-old daughter child tells the nurse that she should have been watching her sister better. After the nurse tells the child she did not cause the accident, which response is best for the nurse to provide? A. Explain to the child that the accident was the fault of the person driving. B. Inquire if the parents or others were watching when the accident occurred. C. Ask the child to share what could have been done to stop this from happening. D. Question the parents if the child had the duty to watch her sister often.
C. Ask the child to share what could have been done to stop this from happening.
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? A. Immunosuppressive therapy. B. Chemotherapy. C. Bone marrow transplantation. D. Blood transfusions.
C. Bone marrow transplantation.
A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102° F. He is drooling and becoming increasingly more restless. What action should the nurse take first? A. Put a cold cloth on his head and administer acetaminophen. B. Listen to Long sounds in place him in a mist tent. C. Notify the healthcare provider and obtain a tracheostomy tray. D. Assist a child to lie down and examine his throat.
C. Notify the healthcare provider and obtain a tracheostomy tray.
The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats/minute. Which action should the nurse take? A. Continue the insertion since this is a typical response. B. Insert the feeding tube into the infant's nasal passage. C. Pause and monitor for a continued drop of the heart rate. D. Postpone the feeding until the infant's vital signs and stable.
C. Pause and monitor for a continued drop of the heart rate.
The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is the best for the nurse to implement? A. Give the child syringes or hospital mask to play it at home prior to hospitalization. B. Include the child in pay therapy with children who are hospitalized for similar surgery. C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. D. Provide dolls and equipment to re-enact feeling associated with painful procedures.
C. Provide a family tour of the preoperative unit one week before the surgery is scheduled.
When checking a third grader's height and weight, the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement? A. Report findings to the parents. B. Document findings in the child's school file. C. Refer child to the family healthcare provider. D. Encourage child to get more sleep.
C. Refer child to the family healthcare provider.
The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? A. An adolescent who works part time in a paint factory. B. A 10-year-old who is an insulin-dependent diabetic (Type 1). C. An 8-year-old who lives in a housing project. D. A 2-year-old who plays on aging outdoor playground equipment.
D. A 2-year-old who plays on aging outdoor playground equipment.
A 13-year-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? A. Administer antiemetic agents. D. Bivalve the cast for distal compromise. C. Provide high- calorie, high-protein diet. D. Begin parenteral antibiotic therapy.
D. Begin parenteral antibiotic therapy.
The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings? A. Squeeze the nipple base to introduce milk into the mouth. B. Position the baby in the left lateral position after feeding. C. Alternate milk with water during feeding. D. Hold the newborn in an upright position.
D. Hold the newborn in an upright position.
A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant? A. Give ampicillin 25 mg/kg slow IV push. B. Deliver 1:10,000 epinephrine 0.1 ml/kg per endotracheal tube. C. Administer digoxin 20 mcg/kg IV. D. Instill beractant 100 mg/kg in endotracheal tube.
D. Instill beractant 100 mg/kg in endotracheal tube.
What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? A. Monitor for signs of metabolic acidosis. B. Estimate the quantity of diarrhea stools. C. Place in a supine position after feeding. D. Observe for projectile vomiting.
D. Observe for projectile vomiting.
An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? A. Tell the client that the vaccine for HPV is not indicated. B. Inform the client that warts do not return following cryotherapy. C. Recommend the use of latex condoms to prevent HPV transmission D. Reinforce the importance of annual papanicolaou (Pap) smears.
D. Reinforce the importance of annual papanicolaou (Pap) smears.
A female adolescent client refuses to allow male nurses to care for her while she's hospitalized. Which of these health care rights is this adolescent exerting? A. Right to competent care B. Right to have an advance directive on file C. Right to confidentiality of her medical record D. Right to privacy
D. Right to privacy
A 6-month-old is admitted to the hospital with diarrhea. The mother is feeding the infant a bottle of tap water and tells the nurse that the baby has taken three 8-ounce bottles of water in the last four hours. Which laboratory finding is most important for the nurse to monitor? A. Creatinine clearance. B. White blood cell count. C. Serum potassium levels. D. Serum sodium levels.
D. Serum sodium levels.
When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A. Crying. B. Straining on stool. C. Vomiting. D. Sitting upright.
D. Sitting upright.
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? A. Sweating across the forehead. B. Doesn't suck well. C. Apical heart rate of 60. D. Respiratory rate of 30 breaths per minute.
C. Apical heart rate of 60.
A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and that she is going to take him home when he is discharged. Which action should the nurse implement next? A. Report the incident to the local child protective services. B. Find a home health agency that specializes in brain injuries. C. Determine the mother's basic skill level in providing care. D. Consult the ethics committee to determine how to proceed.
C. Determine the mother's basic skill level in providing care.
The nurse is preparing to administer 1.6 ml of medication IM to a 4-month-old infant. Which action should the nurse include? A. Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection. B. Administer into the deltoid muscle while the parent holds the infant securely. C. Divide the medication into two injections both with volumes under 1 ml. D. Use a quick dart-like motion to inject into the dorsogluteal site.
C. Divide the medication into two injections both with volumes under 1 ml.
A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? A. Evaluate postural blood pressure measurements. B. Obtain specimen for uranalysis. C. Encourage popsicles and fluids of choice. D. Assess bowel sounds in all quadrants.
C. Encourage popsicles and fluids of choice.
A nine-day-old infant with congenital adrenal hyperplasia (CAH) develops dehydration and is admitted to the hospital for aldosterone replacement therapy. The healthcare provider prescribes fludrocortisone acetate (Florinef) 0.05 mg PO daily. Which finding indicates the newborn is experiencing a therapeutic response? A. Resting blood pressure of 62/41 mmHg. B. Plasma glucose 45 mg/dl. C. Serum sodium 142 mEq/L. D. Capillary refill greater than 3 seconds.
C. Serum sodium 142 mEq/L.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child? A. Use a diluted commercial mouthwash with mouth care. B. Obtain any childhood vaccination that is not up-to-date. C. Use sunblock or protective clothing when outdoors. D. Include the child on regular outings with the family.
C. Use sunblock or protective clothing when outdoors.
A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? A. Tachycarcia. B. Muscle cramps. C. Vomiting. D. Dyspnea.
C. Vomiting.
The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? (Select all that apply.) A. Poor feeding and vomiting. B. Leakage of CSF from the incisional site. C. Hyperactive bowel sounds. D. Abdominal distention. E. WBC count of 10,000/mm3.
A. Poor feeding and vomiting. B. Leakage of CSF from the incisional site. D. Abdominal distention.
The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? A. Reposition the infant every 2 hours. B. Perform diaper changes under the light. C. Feed the infant every 4 hours. D. Cover with a receiving blanket.
A. Reposition the infant every 2 hours.
During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. What action should the nurse implement next? A. Take the blood pressure two more times during the visit and determine the average of the three readings. B. Measure the child's blood pressure three times during the visit and determine the highest of the three readings. C. Refer child to the healthcare provider and schedule evaluation of blood pressure in two weeks. D. Conduct a head to toe assessment and omit repeated blood pressures during the examination.
A. Take the blood pressure two more times during the visit and determine the average of the three readings.
The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? A. Talk directly to the adolescent while providing care. B. Monitor vital signs and neuro status every 2 hours. C. Inquire about food allergies and food likes and dislikes. D. Initiate open communication with the teen's parents.
A. Talk directly to the adolescent while providing care.
A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide? A. This hernia is a normal variation that resolves without treatment. B. Restrictive clothing will be adequate to help the hernia go away. C. An abdominal binder can be worn daily to reduce the protrusion. D. The quarter should be secured with an elastic bandage wrap.
A. This hernia is a normal variation that resolves without treatment.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take? A. Dispense a tetanus antitoxin. B. Prepare human tetanus immune globulin. C. Administer tetanus toxoid booster. D. Delay the tetanus toxoid booster until due.
C. Administer tetanus toxoid booster.
A 4- year- old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? A. Role conflict is a common problem of children this age. She is just wondering where she fits into society. B. Children need to retain a sense of initiative without impinging on the rights and privileges of others. C. Negative feelings of doubt and shame are characteristic of 4-year-old children. D. At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.
B. Children need to retain a sense of initiative without impinging on the rights and privileges of others.
A nurse is assessing a 2-year-old child with left-sided heart failure. Which assessment finding should the nurse report to the healthcare provider immediately? A. An apical heart rate of 120 beats per minute. B. Crackles heard in the lower lobes of lungs bilaterally. C. Periorbital edema noted bilaterally after napping. D. Liver palpated 2 cm below right coastal margin.
B. Crackles heard in the lower lobes of lungs bilaterally.
A 15-year-old male is attending an after school, adolescent group session because he frequently loses his temper, argues with his teachers, and refuses to comply with classroom rules. During the group session, the adolescent repeatedly blames others regardless of the situation. To help modify the adolescent's behavior, what action should the nurse implement. A. Encourage the client to ventilate his feelings of anger. B. Describe the consequences of his behavior in concrete terms. C. Ignore blaming behavior and praise the client's appropriate behavior. D. Explain that blaming others limits his psychological growth.
B. Describe the consequences of his behavior in concrete terms.
The mother of a preschool aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he has a "tummy ache" After reminding the mother to check the label of all OTC drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? A. If the child's tongue darkens, discontinue the Pepto Bismol immediately. B. Do not give if the child has chickenpox, the flu, or any other viral illness. C. Avoid the use of Pepto Bismol until the child is at least 16 years old. D. Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache."
B. Do not give if the child has chickenpox, the flu, or any other viral illness.
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? A. Wheat products. B. Foods sweetened with aspartame. C. High fat foods. D. High calorie foods.
B. Foods sweetened with aspartame.
The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits? A. Is able to name four colors. B. Half of child's speech is understandable. C. Can count five blocks. D. Is capable of making a three word sentence.
B. Half of child's speech is understandable.
Which class of antiinfective drugs is contraindicated for use in children under 8 years of age? A. Aminoglycosides. B. Tetracyclines. C. Penicillins. D. Quinolones.
B. Tetracyclines.
During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement? A. Start another IV of dextrose solution and stay with the child. B. Continue the transfusion and monitor the child's vital signs. C. Slow the transfusion and assess for cessation of symptoms. D. Stop the infusion immediately and notify the healthcare provider.
D. Stop the infusion immediately and notify the healthcare provider.
The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother? A. Paddle him gently as soon as the behavior is initiated. B. Immediately put him in "time-out." C. Quietly remind him that others are watching him. D. Walk away from him and ignore the behavior.
D. Walk away from him and ignore the behavior.
The nurse is interviewing a 18-year-old female client who was released 3 weeks ago following two months of treatment for anorexia nervosa. Which statement is characteristic of a young woman who has been successfully treated for anorexia nervosa? A. "My parents attempt to smother me, but I will not allow them to make my decisions." B. "If I don't get a college scholarship my parents will be very disappointed in me." C. "I know that I am fat and I plan to lose at least 10 more pounds." D. "I will not binge eat, vomit after I eat, or take laxatives or diuretics."
A. "My parents attempt to smother me, but I will not allow them to make my decisions."
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned about this regression in toileting. Which information should the nurse provide the parents? A. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers. C. Children usually resume their toileting behaviors when they leave the hospital. D. A potty chair will be brought from home so he can maintain his toileting skills.
C. Children usually resume their toileting behaviors when they leave the hospital.
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first? A. Turn off the infusion pump. B. Position the child on the side. C. Clamp the catheter. D. Flush the catheter with heparin.
C. Clamp the catheter.
A mother brings her 2-month-old infant to the clinic for a well baby appointment. The nurse obtains a history and conducts a physical assessment. Which finding requires the most immediate intervention? A. History of poor feeding and vomiting. B. A positive Ortolani maneuver. C. Mother describes infant as irritable. D. Bilateral retinal hemorrhages.
D. Bilateral retinal hemorrhages.
When taking the health history of a child, the nurse know what which finding is an early indication of hypothyroidism in children? A. Hyperactive behavioral traits. B. Delay in the eruption of permanent teeth. C. Slow sexual development, but within normal range. D. Cessation of growth in a child that had been normal.
D. Cessation of growth in a child that had been normal.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A. Invite other children home to share meals B. Accept that he will eat when he is hungry. C. Reward the child with a nap after eating. D. Consistently follow a set mealtime routine.
D. Consistently follow a set mealtime routine.
The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's repeated hospitalizations. Which is the best response that the nurse should offer? A. Inform the parent that the child is too young to visit the hospital. B. Suggest that the child visit a grandmother until the sibling returns home. C. Ask the mother if the child asks when the sibling will be discharged. D. Encourage the mother to have the children visit the hospitalized sibling.
D. Encourage the mother to have the children visit the hospitalized sibling.
