Peds 2
Nurse teaches adolescent about how to manage tinea pedis. Which statements by adolescent indicates understanding of teaching? "I should buy plastic shoes to wear at the swimming pool." "I should wear sandals as much as possible." "I should place the permethrin cream between my toes twice daily." "I should seal my nonwashable shoes in plastic bags for a couple of weeks."
"I should buy plastic shoes to wear at the swimming pool.": - The use of plastic shoes increases the occurrence of tinea pedis. The nurse should instruct the adolescent to avoid wearing plastic shoes. ANS: "I should wear sandals as much as possible.": - Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection. "I should place the permethrin cream between my toes twice daily.": - Permethrin 5% cream is a scabicide used to treat scabies. This treatment is not indicated for tinea pedis. "I should seal my nonwashable shoes in plastic bags for a couple of weeks.": - Sealing nonwashable items in plastic bags for 14 days is a recommended practice for clients who have pediculosis. This practice is not indicated for tinea pedis.
Nurse gives discharge teaching to parent of 18 month old toddler with dehydration due to acute diarrhea. Which statements by parents indicate understanding of teaching? "I will offer my child small amounts of fruit juice frequently." "I will avoid giving my child solid foods until the diarrhea has stopped." "I will monitor my child's number of wet diapers." "I will give my child polyethylene glycol daily for 7 days."
"I will offer my child small amounts of fruit juice frequently.": - Children recovering from dehydration should not be encouraged to drink frequent, small amounts of fruit juice because it is high in carbohydrates, low in electrolytes, and has a high osmolality value. "I will avoid giving my child solid foods until the diarrhea has stopped.": - The nurse should teach the parent to encourage solid foods as soon as the toddler is rehydrated to provide adequate nutrient intake. ANS: "I will monitor my child's number of wet diapers.": - The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. "I will give my child polyethylene glycol daily for 7 days.": - Polyethylene glycol is an osmotic agent that will pull fluid into the bowel, increasing the frequency of stools, which will increase the level of dehydration.
School nurse provides in service for faculty about improving education for students with ADHD. Which statements by faculty member indicates understanding of teaching? "I will plan to increase the amount of homework I assign to students who have ADHD." "I will give students who have ADHD the same amount of time as other students to complete tests." "I will allow students who have ADHD one rest break throughout the day." "I will teach challenging academic subjects to students who have ADHD in the morning."
"I will plan to increase the amount of homework I assign to students who have ADHD.": - Faculty should decrease the amount of school work and homework given to a child who has ADHD to maintain their attention. "I will give students who have ADHD the same amount of time as other students to complete tests.": - Students who have ADHD should be given additional time to take tests due to decreased attention. "I will allow students who have ADHD one rest break throughout the day.": - Faculty should allow frequent breaks throughout the day for students who have ADHD to modify their learning environment. ANS: "I will teach challenging academic subjects to students who have ADHD in the morning.": - Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective.
Nurse teaches family of school age child with juvenile idiotpathic arthritis. Which instructions should the nurse include in teaching? "Limit movement of the child's large joints." "Encourage the child to perform independent self-care." "Provide the child with a soft mattress for sleeping." "Schedule a 2-hour daily nap for the child in the afternoon."
"Limit movement of the child's large joints.": - Large joints should be exercised regularly to maintain mobility and strengthen muscles. ANS: "Encourage the child to perform independent self-care.": - The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem. "Provide the child with a soft mattress for sleeping.": - Children who have juvenile idiopathic arthritis should sleep on a firm mattress to provide support in maintaining joints in a functional position. "Schedule a 2-hour daily nap for the child in the afternoon.": - Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity, and naps can interfere with nighttime sleeping.
Nure gives discharge teaching to guardian of school age child who's undergone tonsillectomy. Which statements by guardian indicates understanding of teaching? "My child can resume usual activities since this was just an outpatient surgery." "My child will be able to drink the chocolate milkshake I promised to get for them tonight." "I will notify the doctor if I notice that my child is swallowing frequently." "I will have my child gargle with warm salt water to relieve their sore throat."
"My child can resume usual activities since this was just an outpatient surgery.": - Activity should be limited following a tonsillectomy to decrease the risk of hemorrhage. "My child will be able to drink the chocolate milkshake I promised to get for them tonight.": - Milk products should be avoided because they coat the child's throat, which can initiate a cough response and increase the risk of bleeding. Brown and red foods should be avoided during the immediate postoperative period so that food and fresh or old blood are distinguishable in the child's emesis. ANS: "I will notify the doctor if I notice that my child is swallowing frequently.": - The nurse should instruct the parent that frequent swallowing is an indication of bleeding and, if it is observed, to notify the provider immediately. "I will have my child gargle with warm salt water to relieve their sore throat.": - Gargles are likely to cause irritation and discomfort and can increase the risk of bleeding following a tonsillectomy. The child should receive adequate pain medication following the procedure and can wear an ice collar if tolerated.
Nurse provides discharge teaching to parents of 6 month old infant postop following hypospadias repair with stent placement. Which instructions should the nurse include in teaching? "You may bathe your infant in an infant bathtub when you go home." "Apply hydrocortisone cream to your infant's penis daily." "You should clamp your infant's stent twice daily." "Allow the stent to drain directly into your infant's diaper."
"You may bathe your infant in an infant bathtub when you go home.": - Submerging the stent in water can cause infection at the operative site. The parents should avoid placing the infant in an infant bathtub until after the provider removes the stent. "Apply hydrocortisone cream to your infant's penis daily.": - Following surgical repair of a hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection. "You should clamp your infant's stent twice daily.": - The stent in place following hypospadias repair allows urine to drain from the body. The nurse should instruct the parents to avoid blocking the stent to prevent urinary stasis and potential injury to the infant. ANS: "Allow the stent to drain directly into your infant's diaper.": - The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow.
Nurse gives discharge teaching to parent of school age child with moderate persistent asthma. Which instructions should the nurse include? "You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy." "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." "When using the peak expiratory flow meter, record your child's average of three readings."
"You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing.": - The nurse should inform the parent that long-acting beta2 agonists are to be used in conjunction with a low- or medium-dosage inhaled corticosteroid, and never used alone. Using this medication alone on an as-needed basis during an acute asthma attack is dangerous and can lead to worsening of the child's condition. "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy.": - The nurse should instruct the parent that the use of inhaled corticosteroids has not been shown to have any negative effects on growth. The provider might monitor the child's growth for systemic absorption; however, it is not necessary for the parent to weigh the child weekly. ANS: "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy.": - The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly. "When using the peak expiratory flow meter, record your child's average of three readings.": - The nurse should instruct the parent to measure the child's airflow using a peak expiratory flow meter. This should be done twice daily, taking three measurements each time and waiting 30 seconds between each measurement. The parent should record the highest of the three readings, rather than the average.
Nurse provides dietary teaching to guardian of school age child with cystic fibrosis. Which statements should nurse make? "You should offer your child high-protein meals and snacks throughout the day." "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." "You should restrict your child's calorie intake to 1,200 per day." "You should give your child a multivitamin once weekly."
ANS: "You should offer your child high-protein meals and snacks throughout the day.": - The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake.": - Children who have cystic fibrosis need a diet that is unrestricted in fat. They also require 35% to 40% of their calories to come from fats due to decreased absorption from the intestines. "You should restrict your child's calorie intake to 1,200 per day.": - Children who have cystic fibrosis require a high-calorie diet and should consume at least 2,000 calories per day. "You should give your child a multivitamin once weekly.": - Children who have cystic fibrosis should be given a multivitamin once daily.
Nurse teaches guardian of 6 month old infant about teething. Which statements should the nurse make? "Your baby might pull at their ears when they are teething." "Rub your baby's gums with an aspirin to decrease discomfort." "Place a beaded teething necklace around your baby's neck." "Your baby's upper middle teeth will erupt first."
ANS: "Your baby might pull at their ears when they are teething.": - The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness. "Rub your baby's gums with an aspirin to decrease discomfort.": - The guardian should avoid using aspirin or teething powders due to the risk of aspiration, infection, or irritation of the gum tissues. The nurse should recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort. "Place a beaded teething necklace around your baby's neck.": - Necklaces can result in suffocation and choking. Therefore, the nurse should instruct the guardian to avoid placing these on the infant. "Your baby's upper middle teeth will erupt first.": - The nurse should inform the guardian that the eruption of an infant's teeth begins with the lower central incisors.
Nurse receiving change of shift report for 4 children. Which children should the nurse assess first? A toddler who has a concussion and an episode of forceful vomiting An adolescent who has infective endocarditis and reports having a headache An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 A school-age child who has acute glomerulonephritis and brown-colored urine
ANS: A toddler who has a concussion and an episode of forceful vomiting: - When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of IICP in a toddler who has a concussion. An adolescent who has infective endocarditis and reports having a headache: - A report of a headache is nonurgent because it is an expected finding for a child who has infective endocarditis. An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10: - A report of moderate pain is nonurgent because it is an expected finding for a child who has a new halo traction device. A school-age child who has acute glomerulonephritis and brown-colored urine: - Brown-colored urine is nonurgent because it is an expected finding for a school-age child who has acute glomerulonephritis.
Nurse creating POC (plan of care) for preschooler with Wilms' tumor and scheduled for surgery. Which interventions should the nurse include? Avoid palpating the abdomen when bathing the child before surgery. Refrain from auscultating the child's bowel sounds during the postoperative assessment. Encourage the child to play with other children on the unit prior to surgery. Explain to the child that their pain will be managed after the surgery.
ANS: Avoid palpating the abdomen when bathing the child before surgery: - The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site. Refrain from auscultating the child's bowel sounds during the postoperative assessment: - Auscultation of the child's bowel sounds to monitor for an obstruction is an important part of the postoperative assessment. Therefore, the nurse should auscultate bowel sounds following the surgery. Encourage the child to play with other children on the unit prior to surgery: - The child's risk for injury increases with physical activity. Therefore, the nurse should not encourage the child to play with other children on the unit. Explain to the child that their pain will be managed after the surgery: - Telling the child about pain prior to surgery will likely increase their fear and anxiety level. Therefore, the nurse should not explain to the child that pain will be managed after surgery.
Nurse caring for school age child with primary nephrotic syndrome and taking prednisone. Following 1 week of txt, which manifestations indicates to nurse that med is effective? Decreased edema Increased abdominal girth Decreased appetite Increased protein in the urine
ANS: Decreased edema: - A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema. Increased abdominal girth: - The nurse should expect decreased abdominal girth with prednisone therapy. Decreased appetite: - Increased, rather than decreased, appetite is an expected manifestation of corticosteroid therapy. Increased protein in the urine: - The nurse should expect decreased protein in the urine with prednisone therapy.
Nurse caring for school age child with DM was admitted with Dx of diabetic ketoacidosis. When performing resp assessment, which findings should the nurse expect? Deep respirations of 32/min Shallow respirations of 10/min Paradoxic respirations of 26/min Periods of apnea lasting for 20 seconds
ANS: Deep respirations of 32/min: - The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis. Shallow respirations of 10/min: - The nurse should expect shallow respirations in a child who has respiratory depression related to opioid administration. Paradoxic respirations of 26/min: - The nurse should expect paradoxic respirations in a child who has flail chest. Periods of apnea lasting for 20 seconds: - The nurse should expect periods of apnea lasting 20 seconds or more in a child who has sleep apnea.
Nurse admitting a 4 month old infant with heart failure. Which findings is the nurse's priority? Exhibit: Temperature 37.5° C (99.5° F) Heart rate 70/min Respiratory rate 30/min Birth weight 3.2 kg (7 lb) Current weight 5.9 (13 lb) 3 episodes of vomiting 6 wet diapers in 24 hr Consumed 3 oz concentrated formula every 3 hr Digoxin 0.5 mcg PO Q12H Furosemide 20 mg PO Q12H Episodes of vomiting Formula consumption Weight Temperature
ANS: Episodes of vomiting: - When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. Formula consumption: - A 4-month-old infant who has heart failure requires 3 to 4 oz of formula every 3 hr to adequately address caloric needs. A feeding schedule of every 2 hr does not allow sufficient rest time between feedings, and a feeding schedule of every 4 hr requires consumption of a higher volume, which is often not tolerated by the infant. An intake of 3 to 4 oz of formula every 3 hr indicates that the infant is tolerating the current feeding schedule. Therefore, there is another finding that is the nurse's priority. The infant who has heart failure is at risk for inadequate nutrition; therefore, the nurse should closely monitor the infant's intake. Weight: - A weight of 5.9 kg (13 lb) is an expected finding for a 4-month-old infant who weighed 3.2 kg (7 lb) at birth. Therefore, there is another finding that is the nurse's priority. The infant should gain 680 g (1.5 lb) per month until the age of 5 months. Temperature: - A temperature of 37.5º C (99.5º C) is within the expected reference range of 37º to 37.5º C (98.6º to 99.5º F) for a 4-month-old infant. Therefore, there is another finding that is the nurse's priority.
Nurse is reviewing lab results of a school age child 1 week postop following an open fracture repair. Which findings should nurse ID as indication of potential complication? Erythrocyte sedimentation rate 18 mm/hr WBC count 6,200/mm3 C-reactive protein 1.4 mg/L RBC count 4.7 million/mm3
ANS: Erythrocyte sedimentation rate 18 mm/hr: - above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis. WBC count 6,200/mm3: - within the expected reference range of 5,000 to 10,000/mm3. An elevated WBC count is an indication of osteomyelitis. C-reactive protein 1.4 mg/L: - within the expected reference range of <10.0 mg/L. An elevated C-reactive protein level is an indication of osteomyelitis. RBC count 4.7 million/mm3: - within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC count can indicate hemorrhage.
Nurse assesses pain level of 3 y/o toddler. Which pain assessments should the nurse use? FACES Numeric CRIES Visual analog
ANS: FACES: - The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management. Numeric: - The nurse should use the numeric pain rating scale when assessing the need for pain management in pediatric clients who are 8 years old and older. The nurse should identify that a 3-year-old toddler does not yet possess a concept of numbers and numerical value to effectively use this pain rating scale. CRIES: - The nurse should use the CRIES pain assessment scale when assessing the need for pain management in infants who are less than 40 weeks of age. Visual analog: - The nurse should use the visual analog scale to assess pain for a child who is greater than 8 years of age. The visual analog scale allows the child to mark their pain on a centimeter ruler.
Nurse in ED assesses toddler with Kawasaki disease. Which findings should the nurse expect? (SATA) Increased temperature Gingival hyperplasia Xerophthalmia Bradycardia Cervical lymphadenopathy
ANS: Increased temperature is correct: - Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics. ANS: Cervical lymphadenopathy is correct: - A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size. ANS: Xerophthalmia is correct: - Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Gingival hyperplasia is incorrect: - Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Bradycardia is incorrect: - Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction.
Nurse assesses infant with PNA. Which findings is priority for nurse to report to HCP? Nasal flaring WBC count 11,300/mm3 Diarrhea Abdominal distension
ANS: Nasal flaring: - When using the ABC approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress. WBC count 11,300/mm3: - The nurse should report a WBC count of 11,300/mm3 because it is above the expected reference range of 5,000 to 10,000/mm3 and indicates infection. However, there is another finding that is the priority for the nurse to report. Diarrhea: - The nurse should report diarrhea because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report. Abdominal distension: - The nurse should report abdominal distension because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report.
Nurse planning developmental activities for newly admitted 10 y/o child with neutropenia. Which actions should the nurse plan to take? Provide the child with a book about adventure. Arrange frequent visits from family members and peers. Give the child a large-piece puzzle. Use puppets to entertain the child.
ANS: Provide the child with a book about adventure: - The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read. Arrange frequent visits from family members and peers: - The nurse should limit visitors for a child who has neutropenia because this places the child at an increased risk for infection. Give the child a large-piece puzzle: - The nurse should provide a large-piece puzzle to a preschooler. School-age children tend to be challenged mentally with complex board and video games. Use puppets to entertain the child: - The nurse should use puppets to entertain toddlers. School-age children are not typically entertained for very long or challenged mentally with puppets. Instead, they tend to prefer complex board and video games.
Nurse is planning educational program for school age children and parents about bicycle safety. Which info should the nurse plan to include? The child should be able to stand on the balls of their feet when sitting on the bike. The child should ride their bike 2 feet to the side of other bike riders. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. The child should ride the bike facing traffic when it is necessary to ride in the street.
ANS: The child should be able to stand on the balls of their feet when sitting on the bike: - To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar. The child should ride their bike 2 feet to the side of other bike riders: - To decrease the risk for injury, children should ride their bikes single file rather than side by side. The child should wear dark-colored clothing with a fluorescent stripe when riding at night: - To decrease the risk for injury when riding a bike at night, children should wear light-colored clothing that has fluorescent material attached. This measure, along with fluorescent material on the bike itself, makes bike riders more visible to motor vehicle drivers and other bike riders. The child should ride the bike facing traffic when it is necessary to ride in the street: - To decrease the risk for injury, bike riders should ride in the direction of the flow of traffic.
Nurse is admitting infant with intussusception. Which findings should the nurse expect? (SATA) Steatorrhea Vomiting Lethargy Constipation Weight gain
ANS: Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. ANS: Lethargy is correct: - The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake. Steatorrhea is incorrect: - The nurse should expect an infant who has intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis. Constipation is incorrect: - The nurse should expect an infant who has intussusception to have mucus-filled and red jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen. Weight gain is incorrect: - The nurse should expect an infant who has intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.
Nurse planning care for newly admitted school-age child with generalized seizure disorder. Which interventions should the nurse plan to include? Ensure that a padded tongue blade is at the child's bedside. Allow the child to play video games on a tablet computer. Allow the child to take a tub bath independently. Ensure the oxygen source is functioning in the child's room.
Ensure that a padded tongue blade is at the child's bedside.: - Nothing should be placed in the child's mouth during or after a seizure. Allow the child to play video games on a tablet computer: - Bright or flashing lights from video games can trigger seizure activity. The nurse should decrease environmental stimuli and offer other play activities, such as reading a book or playing with a stuffed animal. Allow the child to take a tub bath independently: - The nurse should allow the child to take a tub bath with supervision, but not independently. There should be someone available to assist the child if they experience a seizure. ANS: Ensure the oxygen source is functioning in the child's room.: - The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure.
Nurse creates POC for child with varicella. Which interventions should the nurse include? Maintain the child's room temperature at 80° F. Prepare the child for a lumbar puncture. Administer aspirin to the child for a temperature greater than 38.3° C (101° F). Initiate airborne precautions for the child.
Maintain the child's room temperature at 80° F: - The nurse should ensure that a child who has varicella remains cool. Cooler temperatures decrease pruritis. Maintaining the child's room at a warm temperature will increase the child's discomfort. Prepare the child for a lumbar puncture: - The nurse should prepare a child who has bacterial meningitis for a lumbar puncture. Administer aspirin to the child for a temperature greater than 38.3° C (101° F): - Guardians should be instructed to avoid the administration of aspirin when the child has a viral varicella infection due to the possibility of causing the development of Reye syndrome, which can be fatal. ANS: Initiate airborne precautions for child: - The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear.
Nurse in ED cares for school age child with epiglottis. Which actions should the nurse take? Obtain a throat culture from the child. Monitor the child's oxygen saturation. Put a warm mist humidifier in the child's room. Place the child in the supine position.
Obtain a throat culture from the child: - Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing. ANS: Monitor the child's oxygen saturation: - The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. Put a warm mist humidifier in the child's room: - The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room. Place the child in the supine position: - Placing the child in the supine position increases the child's risk for complete airway obstruction. The nurse should allow the child to be in whatever position they feel provides the most help with breathing. This is usually an upright position, and sometimes it is helpful for the child to lean forward to help with breathing.
Nurse assesses 6 month old during well-child visit. Which findings should the nurse report to HCP? Presence of a central incisor tooth Presence of strabismus Presence of an open anterior fontanel Presence of external cerumen
Presence of a central incisor tooth: - The nurse should recognize that the presence of a central incisor tooth is an expected finding for a 6-month-old infant and is not necessary to report to the provider. ANS: Presence of strabismus: - Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider. Presence of an open anterior fontanel: - The nurse should recognize that the presence of an open anterior fontanel is an expected finding for a 6-month-old infant and is not necessary to report to the provider. The anterior fontanel generally closes around 12 months of age. Presence of external cerumen: - The nurse should recognize that the presence of cerumen, which is a soft, yellow-brown waxy substance found in the ear, is an expected finding for a 6-month-old infant and is not necessary to report to the provider.
Community health nurse assesses 18 month old toddler in community day care. Which findings should the nurse ID as potential indication of physical neglect? Resists having an axillary temperature taken Exhibits withdrawal behaviors when their parent leaves Has multiple bruises on their knees Poor personal hygiene
Resists having an axillary temperature taken: - A toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Exhibits withdrawal behaviors when their parent leaves: - Separation anxiety is an expected finding for a toddler. Toddlers can become fearful and exhibit regressive behaviors when left alone with strangers and separated from their parents. Has multiple bruises on their knees: - An 18-month-old toddler has typically accomplished the gross motor skills of standing and walking, and has likely started trying to run, which can result in them falling and bruising their knees. ANS: Poor personal hygiene: - A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision.
Nurse caring for newly admitted school age child with hypopituitarism. Which meds should the nurse expect the HCP to prescribe? Desmopressin Luteinizing hormone-releasing hormone Recombinant growth hormone Levothyroxine
Desmopressin: - used to treat hyposecretion of ADH. Luteinizing hormone-releasing hormone: - used in the treatment of precocious puberty to slow prepubertal growth in children and in the treatment of advanced prostate cancer in adult clients. ANS: Recombinant growth hormone: - used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment. Levothyroxine: - used to treat various hypothyroid conditions.
Nurse assesses school age child with infratentorial brain tumor. Which findings should the nurse ID as manifestation of IICP? Hypotension Reports insomnia Difficulty concentrating Tachycardia
Hypotension: - HTN is a late manifestation of IICP due to compression of the brain vessels. Reports insomnia: - somnolence and lethargy are manifestations of IICP. ANS: Difficulty concentrating: - The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of IICP due to decreased blood flow within the brain and pressure on the brainstem. Tachycardia: - bradycardia is a late manifestation of IICP.
Nurse gives discharge teaching to guardians of toddler with lower leg cast applied 24 hrs ago. Nurse should instruct guardians to report which findings to HCP? Capillary refill time less than 2 seconds Restricted ability to move the toes Swelling of the casted foot when the leg is dependent Pedal pulse +3 bilateral
Capillary refill time < 2 seconds: - Capillary refill time is assessed to determine circulatory status by pressing lightly on the tips of the toes until the skin has blanched. A capillary refill time that is > 2 seconds indicates circulatory compromise and should be reported to the provider ASAP. ANS: Restricted ability to move the toes: - The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours. Swelling of the casted foot when the leg is dependent: - an expected finding. The nurse should instruct the guardians that frequent rest is needed for the next several days, and that the casted foot should not be in a dependent position for more than 30 min. When the toddler is resting, the casted extremity should be elevated on a pillow at chest level to minimize swelling. Pedal pulse +3 bilateral: - A pulse that is not easily obliterated with pressure is graded as a +3 and is an expected finding that indicates adequate circulation of the extremity. An absent pulse indicates circulatory compromise and should be reported to the provider ASAP.
Nurse is planning educational program to teach parents about protecting children from sunburns. Which instructions should the nurse plan to include? "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." "Choose a waterproof sunscreen with a minimum SPF of 15." "Dress your child in loose weave polyester fabric prior to sun exposure." "Reapply sunscreen every 4 hours."
"Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m.": - The nurse should instruct parents to avoid allowing their children to play outside during the hours between 1000 and 1400 because the child is at greatest risk for developing a sunburn during this time. ANS: "Choose a waterproof sunscreen with a minimum SPF of 15.": - The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. "Dress your child in loose weave polyester fabric prior to sun exposure.": - The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun exposure to protect the skin from the sun. "Reapply sunscreen every 4 hours.": - The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.
Nurse gives discharge teaching to parents of 3 month old infant following cheiloplasty. Which instructions should the nurse include? "Clean your baby's sutures daily with a mixture of chlorhexidine and water." "Expect your baby to swallow more than usual over the next few days." "Inspect your baby's tongue for white patches using a tongue depressor every 8 hours." "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."
"Clean your baby's sutures daily with a mixture of chlorhexidine and water.": - The nurse should instruct the parents to clean the infant's sutures with sterile water or diluted hydrogen peroxide. "Expect your baby to swallow more than usual over the next few days.": - The nurse should instruct the parents to notify the provider of excessive swallowing because this can indicate bleeding and the infant's swallowing of the blood. "Inspect your baby's tongue for white patches using a tongue depressor every 8 hours.": - The nurse should instruct the parents to avoid placing objects, such as tongue depressors, in the infant's mouth to prevent injury to the suture line. ANS: "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days.": - The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.
Nurse teaching group of parents about infectious mononucleosis. Which statements by parent indicates understanding of teaching? "Mononucleosis is caused by an infection with the Epstein-Barr virus." "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." "A Monospot is a throat culture used to diagnosis mononucleosis." "Children who get mononucleosis will need to refrain from sports for 6 months."
ANS: "Mononucleosis is caused by an infection with the Epstein-Barr virus.": - The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics.": - No known specific treatment is available for mononucleosis. "A Monospot is a throat culture used to Dx mononucleosis.": - The nurse should identify that a Monospot is a blood test that uses a special piece of paper to assist in diagnosing mononucleosis. "Children who get mononucleosis will need to refrain from sports for 6 months.": - The nurse should identify that a child who has mononucleosis should adjust their activities according to their level of fatigue. It is recommended that contact sports be avoided for about 4 weeks, or until splenomegaly has resolved.
Nurse is monitoring SpO2 level of an infant using pulse ox. Nurse should secure sensor to which areas on the infant? Wrist Great toe Index finger Heel
Wrist: - The nurse should avoid placing the sensor on the wrist because this placement will result in an inaccurate reading. ANS: Great toe: - The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse. Index finger: - The nurse should secure the sensor to the index finger of a child and then use a self-adhering bandage to hold the sensor in place; however, this site is not recommended for pulse ox of an infant. Heel: - The nurse should avoid placing the sensor on the heel of the infant's foot because this placement will result in an inaccurate reading.
Nurse cares for infant receiving IV fluids for tx of Tetralogy of Fallot and begins to have hypercyanotic spell. Which actions should the nurse take? Place the infant in a knee-chest position. Administer a dose of meperidine IV. Discontinue administration of IV fluids. Apply oxygen at 2 L/min via nasal cannula.
ANS: Place the infant in a knee-chest position: - The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance. Administer a dose of meperidine IV: - The nurse should administer morphine IV to the infant, instead of meperidine, to decrease infundibular spasms that cause a decrease in pulmonary blood flow and right-to-left shunting. Discontinue administration of IV fluids: - The nurse should continue the administration of IV fluids during a hypercyanotic spell to decrease the viscosity of the infant's blood, which decreases the risk of a cerebrovascular accident. Apply oxygen at 2 L/min via nasal cannula: - The nurse should apply oxygen at 100% via face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brain.
Nurse planning care for school age child with tunneled CVA device. Which interventions should the nurse include in plan? Use sterile scissors to remove the dressing from the site. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use Access the site using a noncoring angled needle Use a semipermeable transparent dressing to cover the site
Use sterile scissors to remove the dressing from the site: - The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use: - The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. Access the site using a noncoring angled needle: - The nurse should use a noncoring angled or straight needle when accessing an implanted port. ANS: Use a semipermeable transparent dressing to cover the site.: - The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.
Nurse performs hearing screenings for children at community health fair. Which children should the nurse refer to HCP for more extensive hearing evaluation? An 18-month-old toddler who has unintelligible speech A 3-month-old infant who has an exaggerated startle response A 4-year-old preschooler who prefers playing with others rather than alone An 8-month-old infant who is not yet making babbling sounds
An 18-month-old toddler who has unintelligible speech: - The nurse should refer a toddler who does not possess intelligible speech by the age of 24 months to a provider for a more extensive evaluation of hearing. A 3-month-old infant who has an exaggerated startle response: - The nurse should refer infants who are under the age of 4 months and lack a startle response to a provider for a more extensive evaluation of hearing. A 4-year-old preschooler who prefers playing with others rather than alone: - The nurse should refer a preschooler who prefers playing alone and avoids interaction with others to a provider for a more extensive evaluation of hearing. ANS: An 8-month-old infant who is not yet making babbling sounds: - The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing.
Charge nurse prepares to make room assignment for newly admitted school age child. Which considerations is the nurse's priority? Length of stay Treatment schedule Disease process Self-care ability
Length of stay: - some client rooms might be larger, and thus more comfortable for families during long hospitalizations. However, this is not the nurse's priority consideration. Treatment schedule: - children requiring frequent monitoring and treatment should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration. ANS: Disease process: - The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration. Self-care ability: - children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration.
Nurse caring for 10 y/o following head injury. Which findings should the nurse ID as an indication that the child is developing diabetes insipidus? Urine specific gravity 1.045 Sodium 155 mEq/L Blood glucose 45 mg/dL Urine output 35 mL/hr
Urine specific gravity 1.045: - above the expected reference range of 1.005 to 1.030. A child who has diabetes insipidus is more likely to have diluted urine and a urine specific gravity below the expected reference range. ANS: Sodium 155 mEq/L: - A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of ADH. Under-excretion of ADH leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. Blood glucose 45 mg/dL: - below the expected reference range of 70 to 110 mg/dL. A child who has diabetes insipidus is expected to have a blood glucose level within the expected reference range. Urine output 35 mL/hr: - within the expected reference range of 33 to 58 mL/hr for a 10-year-old child. A child who has diabetes insipidus is expected to have polyuria.
Nurse cares for school age child with peripheral edema. Nurse should ID which assessments should be performed to confirm peripheral edema? Palpate the dorsum of the child's feet. Weigh the child daily using the same scale Assess the child's skin turgor Observe the child for periorbital swelling
ANS: Palpate the dorsum of the child's feet: - The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema. Weigh the child daily using the same scale: - Weighing the child daily might indicate that the child has retained fluid. Assess the child's skin turgor: - Assessing the child's skin turgor measures the elasticity and mobility of the skin. Observe the child for periorbital swelling: - Observing the child for periorbital swelling is a method used to assess for generalized edema.
Nurse assesses adolescent who received sodium polystyrene sulfonate enema. Which findings indicates effectiveness of med? Reports an absence of nausea and vomiting Reports experiencing an onset of loose stools within 15 min of administration Serum potassium level 4.1 mEq/L Blood pressure 86/52 mm Hg
Reports an absence of nausea and vomiting: - Absence of nausea and vomiting indicates effectiveness of an antiemetic medication. Sodium polystyrene sulfonate is an antidote, which exchanges sodium ions in the intestine. Reports experiencing an onset of loose stools within 15 min of administration: - The nurse should monitor the adolescent for diarrhea because it is an adverse effect of sodium polystyrene sulfonate. ANS: Serum potassium level 4.1 mEq/L: - The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication. Blood pressure 86/52 mm Hg: - below the expected reference range of 90 to 110 mm Hg systolic and 60 to 80 mm Hg diastolic for an adolescent and does not indicate effectiveness of the medication. The nurse should continue to monitor BP as an indicator of fluid and electrolyte imbalance.
Nurse teaching school age child and parent about postop care following cardiac catheterization. Which instructions should the nurse include? "Stay home from school for 1 week following the procedure." "Follow a diet that is low in fiber for 1 week." "Wait 3 days before taking a tub bath." "Apply a pressure dressing to the site for 3 days."
"Stay home from school for 1 week following the procedure.": - The child can attend school the next day but they should avoid strenuous activities to prevent bleeding at the insertion site. "Follow a diet that is low in fiber for 1 week.": - The child can resume their regular diet after the procedure. ANS: "Wait 3 days before taking a tub bath.": - The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. "Apply a pressure dressing to the site for 3 days.": - The parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.
Nurse in HCP office is caring for school age child with varicella. Parent asks nurse when their child will no longer be contagious. Which response should the nurse make? "When your child no longer has an increased temperature." "Three days after you first noticed the rash appear on your child." "When your child's lesions are crusted, usually 6 days after they appear." "Two to three weeks, when your child's lesions completely disappear."
"When your child no longer has an increased temperature.": - The nurse should inform the parent that an absence of a fever does not indicate the child is no longer contagious. "Three days after you first noticed the rash appear on your child.": - The nurse should inform the parent that the child will remain contagious longer than 3 days after the rash appears. ANS: "When your child's lesions are crusted, usually 6 days after they appear.": - The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days. "Two to three weeks, when your child's lesions completely disappear.": - The incubation period of varicella is two to three weeks. However, this is not related to the appearance and disappearance of the lesions.
Nurse teaches parents of preschooler with heart failure and new prescription for digoxin 2x daily. Which instructions should the nurse include in teaching? "Use a kitchen teaspoon to measure the medication." "Brush the child's teeth after giving the medication." "Double the next dose if the child misses a dose." "Repeat the dose if the child vomits."
"Use a kitchen teaspoon to measure the medication.": - The nurse should instruct the parents to use the calibrated device that comes with the medication when measuring the medication to avoid accidental overdose. ANS: "Brush the child's teeth after giving the medication.": - The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste. "Double the next dose if the child misses a dose.": - The parent should administer digoxin at regular intervals, usually twice daily, or every 12 hr. The nurse should instruct the parents not to double the medication amount if they miss a dose because this can result in digoxin toxicity. "Repeat the dose if the child vomits.": - N/V, and decreased appetite are common manifestations of digoxin toxicity in children. The nurse should instruct the parents not to administer a second dose if the child vomits and to notify the provider.
Nurse is planning care to address nutritional needs for preschooler with cystic fibrosis. Which interventions should the nurse include in plans? Administer pancreatic enzymes 2 hr after meals. Discontinue the use of pancreatic enzymes if steatorrhea develops. Limit fluid intake to 750 mL per day. Increase fat content in the child's diet to 40% of total calories.
Administer pancreatic enzymes 2 hr after meals: - The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis. Discontinue the use of pancreatic enzymes if steatorrhea develops: - A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves. Limit fluid intake to 750 mL per day: - The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration. ANS: Increase fat content in the child's diet to 40% of total calories: - A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.
Nurse in ED is caring for school age child with sustained minor superficial burn from fireworks on forearm. Which actions should the nurse take? Administer the tetanus toxoid vaccine if more than 1 year since the prior dose. Apply an antimicrobial ointment to the affected area. Leave the burn area open to air. Place an ice pack on the affected area.
Administer the tetanus toxoid vaccine if more than 1 year since the prior dose: - The nurse should administer the tetanus toxoid vaccine if it has been more than 5 years since the prior dose. ANS: Apply an antimicrobial ointment to the affected area: - The nurse should apply an antimicrobial ointment to the burned area to prevent infection. Leave the burn area open to air: - The nurse should apply a clean-dry dressing of fine mesh gauze and a light gauze dressing that restricts movement to prevent injury to the wound. Place an ice pack on the affected area: - Applying ice to the affected area can impair circulation to the area and increase tissue damage.
Nurse gives anticipatory guidance to parent of toddler. Which expected behavior characteristics should the nurse include? Controls impulsive feelings Understands right from wrong Easily separates from parents for long periods of time Expresses likes and dislikes
Controls impulsive feelings: - an expected behavior of school-age children. A toddler is more likely to have difficulty controlling strong and impulsive feelings as they try to assert their independence and gain control of situations. Understands right from wrong: - Understanding right from wrong and modifying their behavior in response to others' expectations is an expected behavior of preschoolers. Toddlers tend to have a great deal of curiosity and ask many questions but are not able to fully understand what behaviors are right or wrong. Easily separates from parents for long periods of time: - A toddler might be able to separate from their parents for a short period of time, but the toddler is more likely to experience acute separation anxiety when separated from their parents for an extended period of time. The toddler might offer resistance if they are left with a new babysitter or at a new day care center. ANS: Expresses likes and dislikes: - The nurse should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions.
Nurse caring for preschooler has congestive heart failure. Nurse observes wide QRS complexes and peaked T waves on cardiac monitor. Which prescriptions should the nurse clarify with HCP? Furosemide Captopril Regular insulin Potassium chloride
Furosemide: - A child who has congestive heart failure might need a diuretic to prevent fluid overload from heart failure. Furosemide is a loop diuretic that excretes potassium. Since the child is exhibiting manifestations of hyperkalemia, this medication is safe to administer. Captopril: - A child who has congestive heart failure will require medications that cause vasodilation, such as ACE inhibitors, to reduce cardiac afterload. Regular insulin: - A child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and that insulin should be administered to facilitate the movement of potassium into the cells. Potassium chloride: - The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia.
Nurse in health department is caring for emancipated adolescent with STI and unaccompanied by guardian. Which actions should the nurse take? Have the adolescent sign a consent form for treatment. Instruct the adolescent to return with a guardian. Obtain consent from the adolescent's guardian over the phone Treat the adolescent without a consent form
ANS: Have the adolescent sign a consent form for treatment: - The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent. Instruct the adolescent to return with a guardian: - *Adolescents or emancipated minors can provide their own consent for any medical treatment. Obtain consent from the adolescent's guardian over the phone: - * Treat the adolescent without a consent form: - *
Nurse in ED assesses 3 month old infant with rotavirus and experiences acute vomiting and diarrhea. Which manifestations should nurse ID as indication that infant has moderate to severe dehydration? Heart rate 124/min Increased tear production Sunken anterior fontanel Cap refill 2 secs
Heart rate 124/min: - within the expected reference range of 106 to 186/min for a 3- to 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia. Increased tear production: - An infant who has moderate to severe dehydration is more likely to have absence of tears rather than increased tear production. ANS: Sunken anterior fontanel: - The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. Capillary refill 2 sec: - within the expected reference range of 2 seconds or less for a 3-month-old infant. An infant who has moderate to severe dehydration is more likely to have delayed capillary refill of greater than 2 seconds.
Nurse creating POC for newly-admitted adolescent with bacterial meningitis. How long should the nurse plan to maintain adolescent in droplet precautions? Until the adolescent is afebrile For 7 days following admission to the facility Until the adolescent has a negative blood culture For 24 hr following initiation of antimicrobial therapy
Until the adolescent is afebrile: - A temperature within the expected reference range for an adolescent can be achieved with acetaminophen. Therefore, this is not a determinant factor for removing a client from droplet precautions. For 7 days following admission to the facility: - The adolescent is not contagious for 7 days. Therefore, it is not necessary for the nurse to maintain droplet precautions for that length of time. Until the adolescent has a negative blood culture: - Blood cultures should be drawn before the first dose of antibiotics. It usually takes 48 to 72 hr for the organism to grow enough for identification. The test should be repeated after the entire antibiotic regimen is completed to determine if the infection is still present. Therefore, blood cultures are not a determinant factor for removing a client from droplet precautions. ANS: For 24 hr following initiation of antimicrobial therapy: - The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.
Nurse caring for 1 month old infant who's breastfeeding and requires heel stick. Which actions should the nurse take to minimize infant's pain? Use a manual lancet to obtain the heel blood sample. Apply an ice pack to the infant's heel prior to obtaining the sample Allow the mother to breastfeed while the sample is being obtained. Apply a topical lidocaine cream prior to obtaining the sample
Use a manual lancet to obtain the heel blood sample: - The use of a manual lancet should be avoided because it can cause more discomfort. EBP recommends using an automatic lancet to obtain heel samples because it is safer and less traumatic. Apply an ice pack to the infant's heel prior to obtaining the sample: - The nurse should apply a heating pad to the infant's heel prior to obtaining the sample. This will increase blood flow to the site, which will make the sample easier to obtain. ANS: Allow the mother to breastfeed while the sample is being obtained: - The nurse should allow the mother to breastfeed the infant prior to or during the procedure. EBP indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmalogical pain management in infants. Apply a topical lidocaine cream prior to obtaining the sample: - The use of topical lidocaine is not an effective pain management technique for a heel stick.
Nurse reviews dietary choices of adolescent with iron deficiency anemia. Nurse should ID which menu items has highest amount of nonheme iron? ½ cup whole milk 1 cup orange juice 1/2 cup raisins 1 cup raw carrots
½ cup whole milk: - Whole milk does not contain the highest amount of nonheme iron. However, it does contain high amounts of calcium. 1 cup orange juice: - Orange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body. ANS: ½ cup raisins: - The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. 1 cup raw carrots: - Raw carrots do not contain the highest amount of nonheme iron.
School nurse is caring for child following tonic-clonic seizure. Which actions should the nurse take first? Check the child for a head injury. Observe for oral bleeding. Check the child's respiratory rate. Observe for extremity weakness.
Check the child for a head injury: - A tonic-clonic seizure is characterized by symmetric contraction and intense jerking movements of the child's body. If the child is standing or sitting in a chair, they will fall to the ground and a head injury can potentially occur. Therefore, it is important to check for a head injury following a tonic-clonic seizure; however, this is not the first action the nurse should take. Observe for oral bleeding: - During a tonic-clonic seizure, a child can lose muscle control and bite down on their tongue. It is important to check for oral bleeding following a tonic-clonic seizure; however, this is not the first action the nurse should take. ANS: Check the child's respiratory rate: - When using the ABC approach to client care, the nurse should determine the priority action is to assess the child's RR. If the child is not breathing, the nurse should administer rescue breaths. Observe for extremity weakness: - The client might experience extremity weakness due to intense jerking movements following a tonic-clonic seizure; however, this is not the first action the nurse should take.
Nurse teaching parents of toddler with cognitive impairment about toilet training. Which instructions should the nurse include in teaching? "Scold your child when they have a toileting accident." "Award your child with a sticker when they sit on the potty chair." "Play your child's favorite song while teaching them to use the potty chair." "Teach multiple steps of the skill at the same time."
"Scold your child when they have a toileting accident.": - The parents should use positive reinforcement when teaching their child a new task. Reinforcing positive behaviors, such as remaining dry through the night, will have a greater effect on the child than the negative reinforcement of scolding. ANS: "Award your child with a sticker when they sit on the potty chair.": - A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair. "Play your child's favorite song while teaching them to use the potty chair.": - A child who has a cognitive impairment has difficulty discriminating between two or more cues or stimuli. The nurse should instruct the parents to eliminate all other stimuli when teaching the child the task of toilet training. "Teach multiple steps of the skill at the same time.": - Children who have a cognitive impairment have difficulty remembering multiple steps. The nurse should instruct the parents to teach one step at a time to the child. The child should master each step before the parents introduce the next step.
Nurse in ED auscultates lungs of adolescent experiencing dyspnea. Nurse should ID sound as what? Wheezes Crackles Pleural friction rub Rhonchi
ANS: Wheezes: - high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. Crackles: - high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted. Pleural friction rub: - a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together. Rhonchi: - low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed.
Nurse is caring for toddler with acute otitis media and temp of 40 C (104 F). After admin acetaminophen, which actions should the nurse plan to take to reduce toddler's temp? Apply a cooling blanket to the toddler. Dress the toddler in minimal clothing. Give the toddler a tepid bath. Administer diphenhydramine to the toddler.
Apply a cooling blanket to the toddler: - Applying a cooling blanket can cause shivering and discomfort, which increases metabolic requirements. The nurse should be aware that the use of a cooling blanket is indicated for the treatment of hyperthermia, but not a fever. ANS: Dress the toddler in minimal clothing: - The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature. Give the toddler a tepid bath: - A tepid bath is lukewarm, which can cause discomfort to the toddler. The nurse should be aware that the use of a tepid bath is indicated for the treatment of hyperthermia, but not a fever. Administer diphenhydramine to the toddler: - Diphenhydramine is an antihistamine indicated for the treatment of an allergic reaction. The nurse should identify that antipyretics, such as acetaminophen, are indicated for the treatment of a fever.
Nurse discussing organ donation with parents of school age child who has sustained brain death due to bicycle crash. Which actions should the nurse take first? Inform the parents that written consent is required prior to organ donation. Provide written information to the parents about organ donation. Ask the provider to explain misconceptions of organ donation to the parents. Explore the parents' feelings and wishes regarding organ donation.
Inform the parents that written consent is required prior to organ donation: - The nurse should inform the parents that written consent is required prior to organ donation to document that the parents have consented to organ donation and that the provider has addressed any questions or concerns the parents might have. However, there is another action the nurse should take first. Provide written information to the parents about organ donation: - The nurse should provide written information to the parents to enhance their understanding about organ donation. However, there is another action the nurse should take first. Ask HCP to explain misconceptions of organ donation to the parents: - The nurse should ask the provider to explain misconceptions of organ donation to the parents, because it is important that they have accurate information before making a final decision. However, there is another action the nurse should take first. ANS: Explore the parents' feelings and wishes regarding organ donation: - The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family.
Nurse assesses 8 y/o child with early indications of shock. After establishing airway and stabilizing child's resp, which actions should the nurse take next? Insert an indwelling urinary catheter. Measure weight and height. Initiate IV access. Maintain ECG monitoring.
Insert an indwelling urinary catheter: - The nurse should insert an indwelling urinary catheter for a child who has early indications of shock. Strict intake and output monitoring is needed because UO decreases during shock due to reduced blood flow to the kidneys as the body attempts to conserve body fluids. However, there is another action that the nurse should take first. Measure weight and height: - The nurse should measure weight and height of a child who has early indications of shock to calculate weight-based medication dosages. However, there is another action that the nurse should take first. ANS: Initiate IV access: - After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the ABC approach to client care is to establish IV access to maintain the child's circulatory volume. Maintain ECG monitoring: - The nurse should maintain ECG monitoring for a child who has early indications of shock to continually assess for changes in cardiac status. However, there is another action that the nurse should take first.
