Peds 2

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? ANS: Difficulty concentrating:

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 reviews dietary choices of adolescent with iron deficiency anemia. Nurse should ID which menu items has highest amount of nonheme iron?

½ cup raisins: - The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron.

Nurse in ED cares for school age child with epiglottis. Which actions should the nurse take?

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.

Nurse assesses infant with PNA. Which findings is priority for nurse to report to HCP?

ANS: Nasal flaring: R: 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.

Nurse planning developmental activities for newly admitted 10 y/o child with neutropenia. Which actions should the nurse plan to take?

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.

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?

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.

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?

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.

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?

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.

Nure gives discharge teaching to guardian of school age child who's undergone tonsillectomy. Which statements by guardian indicates understanding of teaching?

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. - 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.

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."

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 receiving change of shift report for 4 children. Which children should the nurse assess first?

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.

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?

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 teaching parents of toddler with cognitive impairment about toilet training. Which instructions should the nurse include in teaching?

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 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 teaching school age child and parent about postop care following cardiac catheterization. Which instructions should the nurse include?

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.

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?

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.

Nurse performs hearing screenings for children at community health fair. Which children should the nurse refer to HCP for more extensive hearing evaluation? An 8-month-old infant who is not yet making babbling sounds

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.

Nurse in ED is caring for school age child with sustained minor superficial burn from fireworks on forearm. Which actions should the nurse take?

ANS: Apply an antimicrobial ointment to the affected area: - The nurse should apply an antimicrobial ointment to the burned area to prevent infection.

Nurse creating POC (plan of care) for preschooler with Wilms' tumor and scheduled for surgery. Which interventions should the nurse include?

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.

School nurse is caring for child following tonic-clonic seizure. Which actions should the nurse take first?

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.

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?

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. - The nurse should expect decreased abdominal girth with prednisone therapy. - Increased, rather than decreased, appetite is an expected manifestation of corticosteroid therapy. - The nurse should expect decreased protein in the urine with prednisone therapy.

Charge nurse prepares to make room assignment for newly admitted school age child. Which considerations is the nurse's priority?

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.

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?

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. - the use of a cooling blanket is indicated for the treatment of hyperthermia, but not a fever. - the use of a tepid bath is indicated for the treatment of hyperthermia, but not a fever. - 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 planning care for newly admitted school-age child with generalized seizure disorder. Which interventions should the nurse plan to include?

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 admitting a 4 month old infant with heart failure. Which findings is the nurse's priority?

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.

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?

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 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?

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 creating POC for newly-admitted adolescent with bacterial meningitis. How long should the nurse plan to maintain adolescent in droplet precautions? For 24 hr following initiation of antimicrobial therapy

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 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 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.

Nurse is admitting infant with intussusception. Which findings should the nurse expect? (SATA) Vomiting Lethargy

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.

Nurse in ED auscultates lungs of adolescent experiencing dyspnea. Nurse should ID sound as what?

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 planning care to address nutritional needs for preschooler with cystic fibrosis. Which interventions should the nurse include in plans? ANS: 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 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? Potassium chloride

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 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 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 teaches parents of preschooler with heart failure and new prescription for digoxin 2x daily. Which instructions should the nurse include in teaching?

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.

Nurse creates POC for child with varicella. Which interventions should the nurse include?

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 caring for school age child with DM was admitted with Dx of diabetic ketoacidosis. When performing resp assessment, which findings should the nurse expect?

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.

Nurse gives discharge teaching to parents of 3 month old infant following cheiloplasty. Which instructions should the nurse include? 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.

-instruct the parents to clean the infant's sutures with sterile water or diluted hydrogen peroxide. -notify the provider of excessive swallowing because this can indicate bleeding and the infant's swallowing of the blood. -avoid placing objects, such as tongue depressors, in the infant's mouth to prevent injury to the suture line.

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."

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. -recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort. - Necklaces can result in suffocation and choking. Therefore, the nurse should instruct the guardian to avoid placing these on the infant. -eruption of an infant's teeth begins with the lower central incisors.

Nurse gives anticipatory guidance to parent of toddler. Which expected behavior characteristics should the nurse include?

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 teaches family of school age child with juvenile idiotpathic arthritis. Which instructions should the nurse include in teaching?

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.

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?

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.

Nurse assesses 6 month old during well-child visit. Which findings should the nurse report to HCP?

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.

Nurse is planning educational program to teach parents about protecting children from sunburns. Which instructions should the nurse plan to include?

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.

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?

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 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? IV access

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.

Nurse cares for school age child with peripheral edema. Nurse should ID which assessments should be performed to confirm peripheral edema?

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 is planning educational program for school age children and parents about bicycle safety. Which info should the nurse plan to include?term-54

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.

Nurse planning care for school age child with tunneled CVA device. Which interventions should the nurse include in plan?

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. - The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter. - The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. - The nurse should use a noncoring angled or straight needle when accessing an implanted port.

Nurse teaches adolescent about how to manage tinea pedis. Which statements by adolescent indicates understanding of teaching?

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. - The use of plastic shoes increases the occurrence of tinea pedis. The nurse should instruct the adolescent to avoid wearing plastic shoes. - Permethrin 5% cream is a scabicide used to treat scabies. This treatment is not indicated for tinea pedis. - 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 school age child with moderate persistent asthma. Which instructions should the nurse include?

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 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?

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.

Nurse provides dietary teaching to guardian of school age child with cystic fibrosis. Which statements should nurse make?

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.

Nurse assesses pain level of 3 y/o toddler. Which pain assessments should the nurse use?

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.

Community health nurse assesses 18 month old toddler in community day care. Which findings should the nurse ID as potential indication of physical neglect?

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.