Pediatrics Assignment Exam
An infant with developmental dysplasia of the hip is placed in a Pavlik harness. What instructions should the nurse include in a teaching plan for the parents? Apply lotion or powder to minimize skin irritation. Put clothing over harness for maximum effectiveness. Check for red areas under the straps three times a day. Use a thin absorbent disposable diaper over the harness.
Check for red areas under the straps three times a day.
The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents? A child is insecure because trust is not fostered and developed during infancy. A toddler should be exposed to different routines to promote adapting to new experiences. Children of this age are comfortable with ritualism and display global thinking. Objects should be frequently moved in the environment to teach the child to acclimate to change.
Children of this age are comfortable with ritualism and display global thinking.
A newborn who is breastfeeding is diagnosed with galactosemia. What action should the nurse implement? Stop the infant breastfeeding. Add amino acids to breast milk. Give galactokinase with breast milk. Substitute a lactose-containing formula.
Stop the infant breastfeeding. Galactosemia is a rate genetic disorder that involves an inborn error of carbohydrate metabolism in which a hepatic enzyme, galactokinase, involved in the conversion of galactose to glucose is absent.
How should the nurse measure the length of a 14-month-old child ? Side-lying position Prone recumbent position. Supine recumbent position. Standing height.
Supine recumbent position. Children younger than 24 to 36 months of age should be measured for length in the supine potion from crown to heel, known as recumbent length. Standing height measurements begin after 36 months or older depending on the ability and cooperation of the child
The nurse calculates a 4 ml dose of prescribed digoxin a 9-month-old infant. What action should the nurse implement? Mix dose with juice to disguise its taste. Suspect dosage error and do not give dose. Check heart rate and administer dose by placing it to the back and side of mouth. Check heart rate and administer dose by letting the infant suck it through a nipple.
Suspect dosage error and do not give dose. Digoxin narrow margin of safety for an infant should not excess 1 ml (50 mcg) in one dose
When conducting a hygiene class for adolescent girls, it is important for the nurse to include which instruction about preventing toxic shock syndrome? Wash your hands before inserting a tampon. Use super absorbent tampons. Wear cotton underwear. Douche every month following menstruation.
Wash your hands before inserting a tampon.
The nurse determines the daily caloric need for a six-month old weighs 15 pounds. Considering an infant requires 108 calories/kg/day, how many calories should the infant be provided throughout the day? (Round at the end of the calculation to the nearest whole number.) 420 calories per day. 575 calories per day. 650 calories per day. 735 calories per day.
735 calories per day.
The mother of a 2-month-old reports that she often lets the baby cry in the middle of the night instead of going to pick up or sooth the infant. What information should the nurse provide the mother? Picking up the infant in the middle of the night fosters dependency on the mother. A sense of trust is developed in an infant when others respond to the infant's cry. An infant is learning to manipulate others when the infant is picked up unnecessarily. A 2-month-old who does not sleep through the night should be evaluated further.
A sense of trust is developed in an infant when others respond to the infant's cry.
The nurse is collecting a blood sample from a newborn for a screening test for phenylketonuria (PKU). When should the nurse obtain the blood sample? At birth from cord blood. Fourteen days after birth. Before oral feedings are initiated. After ingestion of a source of protein.
After ingestion of a source of protein.
A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement? Remove the object impaled in the eye and then apply a regular eye patch. Place an ice bag over the eye until the healthcare provider is seen. Irrigate the affected eye copiously with a cool sterile saline solution. Apply a Fox shield to the affected eye and any type of patch to the other eye.
Apply a Fox shield to the affected eye and any type of patch to the other eye.
Which research finding provides evidence-based practice for an infant's risk for sudden infant death syndrome (SIDS)? Breastfeeding reduces the risk for and the incidence of SIDS. Infants should be positioned supine or supported laterally to sleep. The prone position should be used when an infant sleeps after feeding. The peak incidence occurs between the ages of 1 and 2 months.
Infants should be positioned supine or supported laterally to sleep.
The nurse at the well-child clinic is advising the parents of an 8-month-old child about health and safety. What information should the nurse provide? Install stair guards or gates in the home. Use of a car seat is optional if a lap/shoulder belt is in place. Start toilet training with a child-sized potty. Give syrup of ipecac in case of accidental ingestion or poisoning.
Install stair guards or gates in the home.
A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority? Insert an orogastric tube for gastric lavage. Prepare a set-up for an endotracheal intubation. Draw blood for stat chemistries and blood gases. Insert a Foley catheter to monitor renal functioning.
Prepare a set-up for an endotracheal intubation.
The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention? Prolonged exhalations. Thick yellow rhinorrhea. Frequent nonproductive cough. Oxygen saturation is 95% by pulse oximeter.
Prolonged exhalations.
A mother expresses concern to the nurse about the behavior of her 15-year-old adolescent who is frequently finding fault and criticizing her. What information should the nurse provide? The family value system may need to be changed to meet the teen's changing needs. Teens create psychological distance from parents in order to separate from them. Parents should relinquish their relationship with their teen to the teen's peers. Conflicts in the parent-teen relationship are to be expected during adolescence.
Teens create psychological distance from parents in order to separate from them.
The nurse observes the interactions of a 2-year-old child who says, "No," even when "Yes" is what the child really wants to say. The parent says to the nurse, "We, as parents, are such positive people, why is our child so negative?" How should the nurse respond? A 2-year-old often acts in the opposite way to get attention. This age child is testing the limits of the parent's patience. The toddler is exhibiting an example of ritualistic behavior. The child is trying to assert autonomy through negativism.
The child is trying to assert autonomy through negativism.
A nurse who is working in the Poison Control Center receives a telephone call from a parent of a 16-month old child who drank 2 ounces of acetaminophen (Children's Tylenol) elixir. What action should the nurse recommend to the parent? Administer oral syrup of ipecac. Give the child a glass of whole milk. Transport to emergency center for gastric decontamination. Obtain oral activated charcoal tablets from the pharmacy.
Transport to emergency center for gastric decontamination.
Which clinical finding should the nurse expect a child with nephrosis to exhibit? Elevated blood pressure. Blood-tinged urine. Elevated temperature. Urine protein 3+ to 4+.
Urine protein 3+ to 4+.
A 4-year-old boy is brought to the emergency department by his parent, who reports that the child has been pointing at his stomach and saying, "It hurts so bad." Which pain-assessment tool should the nurse use? Descriptor Scale. Brief Pain Inventory. A numeric rating scale. Wong-Baker FACES Scale.
Wong-Baker FACES Scale.
The parents of a child with Asperger's disorder asks the nurse to explain the differences between Asperger's and autism. Which information should the nurse share with the parents about Asperger's disorder that is not characteristic in autism? Obsession with moving objects. Repetitive patterns of behavior. Age-appropriate language development. Stereotypic movements and speech patterns.
Age-appropriate language development
Which neurological test should the nurse implement to assess cerebellar function in a 5-year-old with symptoms of hyperactivity? Finger-to-nose. Quadriceps reflex. Two-point discrimination. Ability to follow directions.
Finger-to-nose. The cerebellum controls balance and coordination and is significant in children with symptoms of interactivity or learning difficulty, so difficulty in performing a "Finger to Nose" Test.
During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the block. which normal growth and development is milestone is the baby developing? Associative play Object prehension Object permanence Separation anxiety
Object permanence
During the well-child assessment, the parents of a 4-year-old express concern that their child often chatters while playing alone. What information should the nurse provide the parents? The child is attempting to formulate a secondary language. This is an attempt by the child to form an imaginary social base. "Private speech" is normal at this age and serves as a problem-solving tool. Concern for psychological development is warranted so further testing is required.
"Private speech" is normal at this age and serves as a problem-solving tool
The nurse is caring for a female client with scoliosis who had a posterior spinal fusion and is in a body jacket cast. Which assessment finding indicates to the nurse the client is developing cast syndrome? Abdominal distention. "Hot spot" felt on cast. Diminished pulses in the foot. Musty, unpleasant odor to cast.
Abdominal distention.
The parents of a 14-year-old girl tell the nurse that their daughter dresses as a tomboy and plays baseball one day and the next day dresses in feminine clothes and becomes a teenage "drama queen." What information should the nurse use to respond to the parents? Teenagers need a strong role mode to emulate. Adolescents try on different roles while seeking their identity. Such erratic behavior needs further investigation. Forteen-year-olds often try to please parents with their role choices.
Adolescents try on different roles while seeking their identity.
A 6-year-old child is admitted in the emergency department with a systolic blood pressure of 58 mm Hg. What action should the nurse take first? Comfort the child. Assess responsiveness. Alert the healthcare provider. Initiate IV fluid replacement.
Alert the healthcare provider. The lower limit for systolic BP for a child older than 1 year of age is 70 plus 2x the child's age in years
When assessing the breath sounds of an 18-month-old child who is crying, what action should the nurse take? Ask the parent to quiet the child so breath sounds can be auscultated. Auscultate and document breath sounds, noting that the child was crying at the time. Document that the assessment is not available because the child is crying. Allow the child to initially play with the stethoscope, and distract during auscultation.
Allow the child to initially play with the stethoscope, and distract during auscultation.
A 4-year-old is brought to the emergency room for a laceration on the right foot. What action should the nurse implement to help the child in coping with the emergency room experience? Avoid the use of bandages to keep wounds open to air. Remind the preschooler how big children should act. Give the child some time after explaining procedures. Avoid using jargon, such as "shot," when giving care.
Avoid using jargon, such as "shot," when giving care
A nurse reviews the methods for preventing recurring urinary tract infections (UTI) with the parent of a female child. Which response by the parent indicates that further teaching is needed in caring for the child? Bathes the child nightly with liquid bubbles added. Increases oral fluids and encourages the child to void frequently. Provides the child with cotton underwear for daily use. Teaches the child to cleanse perineal area from front to back.
Bathes the child nightly with liquid bubbles added.
The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client? Anemia. Cardiac arrhythmias. Gastrointestinal reflux. Heightened neurologic reflexes.
Cardiac arrhythmias.
A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child's growth and development, which intervention is most important for the nurse to implement? Encourage the parents to participate in a planned program of play with the infant. Refer the parents for psychological counseling to identify parental detachment. Demonstrate feeding strategies and infant cues that indicate hunger and satiation. Provide instructions about formula preparation and feeding schedules.
Demonstrate feeding strategies and infant cues that indicate hunger and satiation.
The nurse is assessing the coping behaviors of the parents whose child has been recently diagnosed with a chronic illness. What reaction by the parents is a positive step in the ability to cope with this new situation? Endowing the illness with meaning. Refusing to believe the child is ill. Entertaining an unrealistic future plan for the child. Placing complete faith in religion to the point of relinquishing own responsibility.
Endowing the illness with meaning.
The nurse is preparing to catheterize an 8-year-old child. Before starting the procedure, which action should the nurse take first? Obtain the parent's cooperation before initiating the procedure. Explain to the child and the parents that the procedure needs to be done. After talking with the parents about the procedure, ask them to leave the room. Provide the child with privacy by conducting the procedure in the treatment room.
Explain to the child and the parents that the procedure needs to be done.
A mother brings her 6-month-old infant to the clinic for a well-baby routine exam. Which vaccine(s) should the nurse verify the infant has received? (Select all that apply.) Meningococcal polysaccharide vaccine (MPSV4). Haemophilus influenzae type b conjugate vaccine (Hib). Inactivated poliovirus vaccine (IPV). Hepatitis B virus vaccine (HepB). Diphtheria, tetanus toxoids, and acellular pertussis (DTaP). Measles, mumps, and rubella vaccine (MMR).
Inactivated poliovirus vaccine (IPV). Hepatitis B virus vaccine (HepB). Diphtheria, tetanus toxoids, and acellular pertussis (DTaP). Haemophilus influenza type B Conjugate vaccine (Hib)
An 8-year-old boy who is recently diagnosed with diabestes mellitus is admitted to the intensive care unit with diabetic ketoacidosis (DKA). Which nursing action has the highest priority? Place on cardiac monitor. Initiate an intravenous infusion. Collect specimen for serum electrolytes. Obtain fingerstick glucose.
Initiate an intravenous infusion.
A 5-year-old child who is one day postoperative has bilateral eye patches in place and should be out of bed. What nursing intervention should be implemented first before leaving the bedside? Speak to the child when entering the room. Allow the child to assist in feeding himself. Orient the child to the immediate surroundings. Allow the parents to stay in the room with the child.
Orient the child to the immediate surroundings.
A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. What action should the nurse implement? Postpone the abdominal palpation until the next examination. Place the child's hand under the examiner's hand while palpating. Touch the abdomen firmly as the child takes short, quick breaths. Press the abdomen with the child bearing down and holding the breath.
Place the child's hand under the examiner's hand while palpating.
The nurse is developing the plan of care for a school-aged boy with a chronic disability. The child frequently cries about being different from his siblings and wants others to do things for him that he is capable of doing for himself. To assist the family in coping with this child's chronic illness, which intervention is most important for the nurse to implement? Recommend the use of consistent discipline and reward for acceptable behavior. Encourage the parents to role model ways to act when one is disappointed. Suggest that all the children are included in family decision making. Evaluate the proper use of equipment that is provided to improve the child's lifestyle.
Recommend the use of consistent discipline and reward for acceptable behavior.
After discussing the introduction of solid foods with the mother of a 6-month-old infant, the nurse determines that the mother understands the information when she states that the first food she gives the infant is from which food group? Fruits. Egg yolks. Rice cereal. Yellow vegetables.
Rice cereal.
A child is brought to the emergency department with sweating, chills, and snake fang-like puncture marks on the calf. What action should the nurse implement after the type of snake is identified? Secure the antivenin. Ambulate the child. Apply a tourniquet to the leg. Reassure the child and parent.
Secure the antivenin.
What sign of malignant hyperthermia should the nurse assess for during the perioperative period in a child receiving general anesthesia? Apnea. Tachypnea. Bradycardia. Decreased blood pressure.
Tachypnea.
A 15-year-old girl tells the school nurse that she wants to have a baby. How should the nurse respond? "Will you be able to support the baby?" "Do you have plans to continue school?" "Have you talked with your parents about this?" "Can you tell me how your life will be if you have an infant?"
"Can you tell me how your life will be if you have an infant?"
The nurse is examining a neonate at age 10 minutes. Which site should the nurse expect to see nonpathologic cyanosis? Feet and hands. Bridge of nose. Circumoral area. Mucus membranes
Feet and hands.
What is a priority nursing diagnosis for a child in the subacute stage of Kawasaki disease? Alterations in skin integrity. High risk for altered tissue perfusion, cardiopulmonary. Risk for imbalanced body temperature, hyperthermia. High risk for fluid volume deficit.
High risk for altered tissue perfusion, cardiopulmonary.
The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority? Potential for fluid volume deficit. Alteration in bowel elimination. Pain related to postoperative condition. Anxiety of parents related to newborn's condition.
Potential for fluid volume deficit.
A 14-year-old is brought to the emergency room after a biking accident. How should the nurse interact with the adolescent? Furnish rewards for cooperation during procedures. Have the parents remain with the adolescent at all times. Provide clear explanations while encouraging questions. Limit the number of choices to be made by the adolescent.
Provide clear explanations while encouraging questions.
When caring for a child who has pertussis that is in the paroxysmal stage, which intervention should the nurse implement to support the child's nutritional needs? Provide small, frequent meals. Increase protein intake. Maintain a liquid diet. Offer the child a regular diet.
Provide small, frequent meals.
An infant weighs 7 lb (3.18kg)at birth. How much should the nurse expect the infant to weigh at age 6-months? 12 lb (5.44kg). 14 lb (6.35kg) 17 lb (7.71kg). 21 lb (9.53).
14 lb (6.35kg) Infancy growth spurts double the birth weight by 4 to 6 months and triple it by one year
Which site should the nurse assess to obtain the pulse rate for a 1-year-old child? Radial. Apical. Carotid. Femoral.
Apical.
The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose? Syrup. Applesauce. Orange juice. Formula or milk.
Applesauce.
The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching? "Excessive amounts of fluoride will make teeth turn brittle and yellow." "Having our children brush with fluoride toothpaste is not effective." "Use of fluoride in water is mostly effective during initial tooth formation." "Dental caries can be prevented through fluoridation of public water."
"Dental caries can be prevented through fluoridation of public water." A. Large Amounts produces yellow and discolored teeth (not brittle teeth)
A 2-year-old is receiving care in the emergency department (ED) for a deep laceration on the head. What action should the nurse implement to facilitate the child's cooperation? Allow the child to hold a favorite toy or blanket. Direct the parents to remain outside the treatment room. Keep the child physically restrained during nursing care. Let the child decide whether to sit up or lie down for procedures.
Allow the child to hold a favorite toy or blanket
A 12-year-old male client tells the nurse that he is happy to be taking growth hormones because now he can expect to grow and be just as tall as all of his friends. What response is best for the nurse to provide? "You must remember that this treatment regimen is not always effective." "Although being tall is important to you, remember there are far more important characteristics than height." "You will grow with this medicine, and are likely to be taller than anyone in your family." "Being taller is important to you and taking your injections will help achieve that goal."
"Being taller is important to you and taking your injections will help achieve that goal."
When plotting a 20-week-old infant's weight on a standardized growth chart, the nurse determines that the child's weight is between the 2 nd and 3 rd percentile. Based on this finding, which action should the nurse take? Teach the parents about interventions for failure to thrive syndrome. Compare this weight with previous weights recorded in the child's record. Evaluate the parent's body build in relation to the infant's weight. Obtain a 24-hour nutritional history before making any conclusions.
Compare this weight with previous weights recorded in the child's record.
An adolescent female's susceptibility to vulvitis is most likely related to which causative factor? Contact with fabric dyes. Frequent sexual activity. Urinary incontinence. Menarche.
Contact with fabric dyes.
While assessing the apical pulse of a 13-year-old, the nurse determines that the rate is 88 beats/minute, and the rhythm is irregular. The heart rate is phasic with respirations, increasing during inspiration and decreasing with expiration. What action should the nurse take? Continue the cardiac examination. Inquire about daily caffeine intake. Re-assess the apical pulse in 15 minutes. Schedule a consultation with a cardiologist.
Continue the cardiac examination.
The parents of an adolescent male with Ewing sarcoma ask the nurse what is the most significant factor contributing to their son's prognosis. Which factor should the nurse include when answering the parent's concern? Age of onset. Gender of child. Appearance on X-ray. Degree of metastasis.
Degree of metastasis.
While assessing an 18-month-old during a well-child visit, the nurse notes that the toddler has a rounded "pot-belly" abdomen, marked lordosis or swayback, short, slightly bowed legs, and a large head. Based on these findings, what action should the nurse implement? Refer the findings to the healthcare provider for diagnostic studies for hydrocephalus. Document general physical appearance of a normally developed toddler. Plot the findings on the growth chart within the parameters of delayed physical maturation. Review the dietary intake for indications of a vitamin deficiency or malnutrition.
Document general physical appearance of a normally developed toddler.
What intervention should the nurse implement to help keep a 6-month-old infant calm during a physical assessment? Give the infant a soft cuddly toy to hold. Remove the pacifier from the infant's mouth. Encourage the parent to hold the infant. Distract the infant with noise or bright lights.
Encourage the parent to hold the infant.
A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? Experiencing culture shock. Lacks the maturity needed in school. Refuses to participate in school activities. Going through minority group discrimination.
Experiencing culture shock.
What is the best action for the nurse to take when initiating contact with a toddler for the first time? Ask the toddler to point to where it hurts. Tell the child your name and that you are the nurse. Call the child by name while picking up the toddler. Kneel in front of the toddler and speak softly to the child.
Kneel in front of the toddler and speak softly to the child.
A mother brings her 6-month-old infant to the clinic for a well-child checkup. She comments, "I want to go back to work, but I don't want my baby to suffer because I'll have less time at home." How should the nurse respond to the mother? Stay home until the child starts school. Find a good baby-sitter close to the house. Let's talk about the child care options that are best for the child. Go back to work now so the infant will get used to being with others.
Let's talk about the child care options that are best for the child.
The low-birth-weight (LBW) infant requires a neutral thermal environment. What action should the nurse implement? Use wool blankets for covers. Avoid using disposable diapers. Maintain a high-humidity atmosphere. Continue cool oxygenation via a hood.
Maintain a high-humidity atmosphere.
The mother of a 2-month-old infant who just received the first DTaP asks the nurse what symptoms to expect. What is the best response for the nurse to provide? Most children do not experience any reaction. Seizures are common and require anticonvulsant medication. Mild reactions are common and most frequently include low-grade fever. The most common reaction is a whole-body rash that develops into itchy vesicles.
Mild reactions are common and most frequently include low-grade fever.
The nurse is developing a plan of care for a 10-year-old who is scheduled for a cardiac catheterization. Which intervention should the nurse implement to prepare the child for the procedure? Reassure the parents that 10-year-olds are cooperative and are less likely to be anxious. Obtain a video film of a cardiac catheterization to show to the child prior to the procedure. Have another child the same age explain the procedure in "child" language. Ask the parents to explain the procedure to influence the child's behavior.
Obtain a video film of a cardiac catheterization to show to the child prior to the procedure.
The father of an 8-year-old child tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father? The father should decrease his expectations to give the son a chance to succeed. The child has an introverted personality and should be encouraged to play isolated games. The father should encourage the son to participate in team sports instead of less physical activities. The child should be given opportunities to achieve a sense of competency in an area he chooses.
The child should be given opportunities to achieve a sense of competency in an area he chooses.
Which finding should the nurse in the emergency department identify as an indicator that a 3-year-old child has been mistreated? The toddler does not remember how the injury occurred. The parents are extremely calm in the emergency room. The injury sustained is highly unusual for 3-year-old children. The child was doing something unsafe when the injury occurred.
The injury sustained is highly unusual for 3-year-old children.
What should the nurse assess last when examining a 5-year-old child? Heart. Lungs. Throat. Abdomen.
Throat
A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding? Milk allergy. Failure to thrive. Inadequate milk supply in mother. Normal growth curve of a breast-fed infant.
Normal growth curve of a breast-fed infant.
A 14-year-old returns to the pediatric unit after corrective surgery for scoliosis. In the immediate postoperative period, the nurse should include which action(s) in this client's plan of care? (Select all that apply.) Record intake and output every 8 hours. Elevate the head of the bed 30 degrees. Assess bowel sounds every 4 hours. Initiate a logrolling schedule every 2 hours. Ambulate for 5 minutes 12 hours postoperative. Give morphine sulfate 2 mg IV every 4 hours PRN.
Record intake and output every 8 hours. Assess bowel sounds every 4 hours. Initiate a logrolling schedule every 2 hours. Give morphine sulfate 2 mg IV every 4 hours PRN.
During the well-child assessment of an 18-month-old male toddler, the nurse determines the child does not walk while holding on to furniture but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which nursing diagnosis should the nurse formulate? Alteration in nutrition. Alteration in parenting. Delayed growth and development. Alteration in health maintenance.
Delayed growth and development.
The nurse is caring for a 9-year-old male child who frequently speaks about sex and uses correct sexual vocabulary. What action should the nurse implement with this child? Ask the child whether he was sexually abused. Ascertain what the child understands about sex. Inquire where the child got this important information. Involve the child in teaching sex information to peers.
Ascertain what the child understands about sex.
The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding? Adequate hydration. Poor skin turgor. Normal skin elasticity. Assessment inconclusive.
Poor skin turgor.
When assessing a preschooler, which finding warrants further assessment by the nurse? Able to ride a tricycle. Talks about an imaginary friend. Dresses independently. Gains 2 pounds (0.9kg) in 12 months.
Gains 2 pounds (0.9kg) in 12 months. Preschool children gain an average of 5 pounds per year, so gain of 2 pounds is less than half of the expected weight gain and should be investigated further are expected development milestone during preschool years
The nurse is assessing a child for neurological "soft" signs. Which finding is most likely demonstrated in the child's behavior? Presence of vertigo. Loss of visual acuity. Poor coordination and sense of position. Inability to move tongue in all directions.
Poor coordination and sense of position.
When administering a gavage feeding to a school-age child, which action should the nurse implement? Administer feedings over 5 to 10 minutes. Position the child on the right side after administering the feeding. Check the placement of the tube by inserting 20 ml of sterile water. Lubricate the tip of the feeding tube with petroleum jelly to facilitate passage.
Position the child on the right side after administering the feeding. The child should be positioned on the right side after administering the feeding to facilitate gastric emptying and prevent gastric reflex, should be given over 15-30 minutes
A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement? Notify the healthcare provider of the measurement. Quiet the child and retake the blood pressure. Ask the parent if the child has a history of hypertension. Document the finding and recheck in 4 hours.
Quiet the child and retake the blood pressure.
The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? Tachycardia. Bradycardia. Dry mucous membranes. Increased skin turgor.
Tachycardia.
The nurse notices that the hem of a skirt on a per-adolescent girl is uneven when she comes to the clinic. What procedure should the nurse follow to examine the girl for scoliosis? (Arrange the examination process from first on top to last on the bottom.) 1. Ask the girl to remove her shirt but leave on her bra or swimsuit top 2. Examine the scapular prominence 3. Look for asymmetry in the hip area 4. Instruct the girl to bend at the waist so back is parallel to the floor
1. Ask the girl to remove her shirt but leave on her bra or swimsuit top 2. Look for asymmetry in the hip area 3. Instruct the girl to bend at the waist so back is parallel to the floor 4. Examine the scapular prominence
A mother tells the nurse that her children are asking questions about divorce, but one male child tells her that he is sorry that he caused the divorce of the parents. Which age group is most likely to experience feelings of punishment or responsibity for the divorce of parents? 1 year. 4 years. 8 years. 13 years.
4 years.
What is the priority nursing intervention for a 12-year-old client newly diagnosed with bacterial meningitis? Continue pain management and provide comfort measures. Maintain seizure precautions to protect the client from injury. Monitor for increased intracranial pressure and do frequent neural vital sign checks. Administer broad-spectrum antibiotics before results of culture and sensitivity tests are returned.
Administer broad-spectrum antibiotics before results of culture and sensitivity tests are returned. Although culture and sensitivity results identify the most effective treatment, prescribed antibiotic therapy should be initiated once the culture is obtained to provide an immediate antiinfectant regimen against the risk of mortality due to bacterial meningitis.
The nurse is caring for an irritable, lethargic 18-month-old child who swallowed several over-the-counter (OTC)antihistamine tablets an hour ago. What intervention should the nurse implement? Initiate gastric lavage. Administer naloxone. Give a dose of ipecac syrup. Encourage oral intake of water or milk.
Initiate gastric lavage.
The nurse is caring for a premature infant who needs an IV access restarted. What action should the nurse take when using adhesive tape? Remove adhesives with water, mineral oil, or petrolatum. Avoid using tape and adhesives until skin is more mature. Use scissors carefully to remove tape instead of pulling tape off. Employ solvents to remove adhesives instead of pulling on skin.
Remove adhesives with water, mineral oil, or petrolatum.
A 4-year-old child who is ventilator-dependent is receiving tube feedings in the home setting. The family wants to begin oral feeding of the child, and asks the home health nurse to feed the child baby food orally. After explaining the risks for aspiration to the family, list in order which actions the nurse should implement. (Rank in the priority order from first action to last action.) 1. Refuse to feed the child orally, because the risk is too high. 2. Ask the parents to negotiate a change in feeding methods with the healthcare provider. 3. Set additional goals for feeding the child with the parents. 4. Acknowledge the request and then explore with the family the available options for care.
1. Acknowledge the request and then explore with the family the available options for care. 2. Set additional goals for feeding the child with the parents. 3. Refuse to feed the child orally, because the risk is too high. 4. Ask the parents to negotiate a change in feeding methods with the healthcare provider.
