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A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

"All recently used clothing, bedding, and towels must be washed in hot water." Rationale:Pediculosis capitis is commonly referred to as head lice. All recently used clothing, bed sheets, and towels need to be washed in hot water. Anything that cannot be washed should be sealed in a plastic bag for 10 to 14 days. Unwashable items can include jackets, sweaters, hats, pillows, bicycle helmets, and stuffed animals. Furniture, carpets, and car seats can be

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?

"Bring your baby in to the clinic today." Rationale:Projectile vomiting followed by hunger are characteristic of pyloric stenosis. The infant needs to be examined in the clinic by a provider as soon as possible.

A nurse is providing teaching about lice to the parents of a school-age child at a well-child visit. Which of the following information should the nurse include in the teaching?

"Encourage your child to avoid sharing hats with other children." Rationale:Lice are transmitted from person to person on personal items, such as hats, hair ornaments, scarves, combs, and brushes.

A nurse receives a call from a parent of a child who has von Willebrand disease and has having a nosebleed. Which of the following instructions should the nurse give to the parent?

"Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes."

A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following?

"I will give my son the enzymes between meals." Rationale: The parent should give the child pancreatic enzymes with every meal and snack.

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

"I will keep my baby in an upright position after feedings." Rationale: The infant should be maintained in an upright position for 1 hr after feedings.

A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make

"It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." Rationale:A recently learned skill, such as toilet training, is often temporarily lost due to the stress of hospitalization. The nurse should reassure the parents that regression is an expected behavior in children who are hospitalized and that her child will regain bladder control when she is feeling better

A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse to say to the child?

"It is not your fault that this happened." Rationale: The nurse should reinforce to the child that the abuse is not his fault

A nurse is teaching new parents the proper way to use an infant safety seat. Which of the following should indicate to the nurse a need for further teaching?

"My baby will be able to watch me drive while sitting in the back seat." Rationale: The safest area for a car seat is in the back seat. Infants should travel in a rear-facing position for the best protection from airbags and neck and head injury. While in a rear-facing position, the back of the car seat supports the infant's weak neck muscles, soft fontanels, and spine in the event of a frontal motor vehicle crash.

A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?

"I should eat a snack half an hour before playing soccer." Rationale:Exercise lowers blood glucose levels. The child should eat a snack half an hour prior to physical activity. If the exercise is prolonged, the child might require a snack during the activity.

A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching?

"I will add Polycose to each of my baby's bottles." Rationale: The parent should add Polycose to the formula to increase the number of calories per ounce, allowing the infant to consume more calories in less volume.

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

"I will apply heat." Rationale:Supportive measures to control a minor bleeding episode include applying cool compresses.

A nurse is caring for a 7-year-old child who has an upper respiratory infection and type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?

"I will continue to check his blood sugar two times every day." Rationale:A client who has type 1 diabetes mellitus and is ill is at risk of developing DKA. DKA results in the breakdown of body fat for energy and the presence of ketones in the blood and urine. Because acute illness increases glucose levels, the child's glucose levels and the urine ketones should be checked every 3 hr. Checking the child's blood glucose two times per day is not enough to adequately monitor glucose levels

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching?

"My child will take the enzymes to help digest the fat in foods." Rationale:Pancreatic enzymes help the body to digest fat in foods.

A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates an understanding of the teaching

"My son might complain of feeling shaky when he has a low blood glucose level." Rationale:A shaky feeling is a consistent finding of hypoglycemia.

.A nurse is providing teaching to the parents of a child who has iron deficiency anemia and is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching?

"Our child's blood count will need to be monitored routinely for several weeks." Rationale: The child's response to treatment will be determined by monitoring hemoglobin and hematocrit levels through routine blood tests. Treatment can take up to 3 months to be effective.

.A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?

"The teacher says my child has to squint to see the board." Rationale:Squinting to see the board can indicate a vision problem. It is essential to assess children for hearing and vision problems. If not caught early, they lead to frustration and decreased ability to learn

A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

"We will give our child pancreatic enzymes with snacks and meals." Rationale: CF interferes with the availability of pancreatic enzymes necessary for digestion and absorption of nutrients. Therefore, pancreatic enzymes must be taken with all meals and snacks

A nurse is providing teaching to the parents of a 1 week old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

"We will rotate the probe of the pulse oximeter every 24 hours." Rationale:Pulse oximeters are a noninvasive method of monitoring oxygen saturation in the blood. The measurement is obtained by the application of a probe around a hand, foot, finger, toes, or earlobe, which is then connected to a machine that provides continuous oxygen saturation levels. The probe should be rotated every 3 to 4 hr to prevent pressure necrosis from occurring.

A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching?

"Your need for sleep will increase during periods of growth." Rationale: The nurse should inform the adolescent that sleep needs increase during growth spurts. Adequate sleep and rest during the adolescent period is important for optimal health.

A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take?

. Wrap the arm of the child's doll or toy prior to the procedure. Rationale: The nurse should consider the developmental age before the cast is applied. A preschooler might fear bodily harm and fantasize about the loss of an extremity. Using a doll or stuffed animal helps to explain the procedure. During this stage of development, the child is a "magical thinker" and might believe stuffed animals are alive. This action shows the child that it does not hurt the doll or stuffed animal, and, in turn, will not hurt the child

A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?

Meningococcal polysaccharide vaccine Rationale: Recent studies have shown that college students, especially freshmen living in dormitories, are at an increased risk for meningococcal meningitis. The Centers for Disease Control and Prevention and the American Academy of Pediatrics now recommend that college students and parents be educated about meningococcal disease and consider vaccination.

A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care

Modify the environment. Rationale: Using the safety and risk reduction priority-setting framework, maintaining safety is the highest priority for this client. Modification of the environment includes making the child's home accessible and safe from hazards that could cause injury.

A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following

Negative behaviors characterized by the need for autonomy Rationale:Assertion of autonomy is seen in toddlers as they begin their language and social development.

A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make?

Normal bone growth can be affected." Rationale:A fracture of the epiphyseal plate can affect growth in a child.

A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?

Observe for indications of hypokalemia. Rationale: The nurse should observe the child for indications of hypokalemia. Diuresis can result in electrolyte loss, leading to hypokalemia.

A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?

Obtain a detailed history. Rationale: The nurse should obtain a detailed history in order to assess for other indicators of abuse.

A nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first?

Offer mother private time with the newborn. Rationale:It is critical for the nurse to help the client acknowledge the loss and begin the grieving process. Providing private time with the newborn provides an opportunity for the client to overcome feelings of powerlessness and actualize the loss in a safe and supportive environment.

.A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client?

On the unoperated side Rationale: The nurse should position the child flat on the unoperated side to prevent a rapid reduction of intracranial fluid and to protect the child for injuring the operative site.

A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?

Oral electrolyte solution Rationale:After gastrointestinal surgery, infants should receive clear liquids that contain glucose and electrolytes, such as an oral electrolyte or rehydration solution. They should then advance to formula or breast milk as they demonstrate tolerance.

A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid?

Oral rehydration solution Rationale: Oral rehydration solution is the fluid of choice for infants and children who have dehydration

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

Orthopnea Rationale:A toddler who has heart failure has increased venous return to the heart and lungs, which leads to pulmonary congestion. The congestion causes orthopnea, or difficulty breathing, while lying down. Having the toddler sit up decreases venous return, as well as pressure the abdominal organs have on the diaphragm. This decrease in pressure improves breathing and oxygenation.

A nurse is educating new parents about risk factors for sudden infant death syndrome (SIDS). Which of the following statements should indicate to the nurse the need for additional teaching?

Our baby will sleep in our bed because I am breastfeeding."

A nurse is teaching a parent of a 6-month-old infant about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?

Our car seat is an infant model and is anchored in the car." Rationale: This statement by the parent indicates correct use of the infant care seat.

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

Pain Rationale:A client who is in sickle cell crisis has severe pain resulting from tissue hypoxia and necrosis.

A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse include as being expected of a preschooler?

Participates in imaginary play Rationale:By 5 years of age, a preschooler should participate in imaginary and creative play, play cooperatively with peers, and speak in complete sentences.

A school nurse is assessing a school-age child and notices white flakes that don't brush off the hair and a rash on the back of the child's neck. The nurse should suspect which of the following disorders?

Pediculosis capitis Rationale:Pediculosis capitis is head lice, and its nits (eggs) are cemented to the hair shaft. The nits are silvery to white in color, similar to dandruff. They are typically seen on hair on the back of the head near the nape of the neck. A papular rash might be present at the nape of the neck secondary to scratching

A nurse is planning care for a client who ingested a large amount of acetylsalicylic acid. Which of the following actions should the nurse take?

Perform gastric lavage with activated charcoal. Rationale: The nurse should plan to perform gastric lavage with activated charcoal, which acts to adsorb drugs and other chemicals in the gastrointestinal tract to prevent absorption into the bloodstream.

.A nurse is obtaining the length and weight of a 6-month-old infant. Which of the following actions should the nurse take? (Select all that apply.)

Place a disposable covering on the scale. . Measure the infant from crown of the head to the heels of feet. Balance the scale to 0 prior to use.

A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take?

Place the child in an upright position. Rationale:Placing the child in an upright position will assist in maintaining a patent airway.

A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?

Place the child on droplet precautions. Rationale: Using the greatest risk framework, the nurse should first place the child on droplet precautions to prevent spread of the infection to other clients and staff.

. A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings?

Place the infant in an infant seat. Rationale:An infant seat provides elevation and decreases the risk of aspiration.

A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?

Placing your child on her back when sleeping will decrease the risk of SIDS." Rationale: The nurse should instruct the mother to position in the infant on her back during sleep to prevent SIDS. The incidence of SIDS has declined since the Back to Sleep campaign started in the 1990s.

. A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Position the child laterally

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Position the child laterally. Rationale:Positioning the child laterally facilitates airway patency

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Position the child side-lying. Rationale: This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.

.A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention?

Positive Moro reflex Rationale: The Moro reflex disappears at approximately 3 to 4 months of age. Therefore, a 9-month-old who has a positive Moro reflex is a finding that requires further intervention

A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority?

Prepare for nasotracheal intubation

A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client's history, the nurse should determine that which of the following is the priority risk factor for suicide completion?

Previous suicide attempt Rationale:A prior suicide attempt is found in as many as half of the adolescents who attempt suicide

A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

Projectile vomiting Rationale:Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine. The narrowing does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting.

A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

Provide a latex-free environment.

A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions should the nurse take to promote sleep?

Provide bedtime rituals. Rationale:Establishing a bedtime routine is important. Reading a familiar book or providing a favorite stuffed toy or blanket will help decrease the child's insecurity and fears.

.A school nurse is performing a routine health assessment for a school-age child. Which of the following findings indicates the nurse should investigate further for pediculosis capitis?

Pruritus of the scalp Rationale:Pediculosis capitis is an infestation of head lice. Generally, the only manifestation is scalp itchiness.

.A nurse is planning care for a 4-year-old child who requires airborne precautions. Which of the following activities should the nurse plan for child?

Putting a large-piece puzzle together Rationale:A child who requires airborne precautions must remain in her room. Appropriate activities for a 4-year old child include putting together large-piece puzzles, using paints and crayons, playing ball, riding tricycles, playing pretend and dress up, sewing cards and beads, and reading books.

A nurse is teaching car seat safety to a parent of an infant who weighs 4.5 kg (10 lb). Which of the following car seat positions should the nurse include in the teaching?

Rear-facing in the middle of the back seat Rationale: The safest position for infants is rear facing in the center of the back seat. Infants should ride rear-facing until age 2 or until the child outgrows the height or weight limits of a rear-facing seat. Studies have shown that children who ride properly restrained in the middle of the back seat have a 43% decreased risk for injury compared to children who are placed near a window

A nurse is providing teaching to a parent of a child who has acute group A ß-hemolytic streptococci. Which of the following information should the nurse include in the teaching?

Replace the child's toothbrush after 24 hr on antibiotics. Rationale: The child's toothbrush should be replaced after 24 hr on antibiotics to prevent the spread of infection or re-infection.

A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck extension traction. Which of the following actions should the nurse take?

Reposition the child every 2 hr. Rationale: The nurse should reposition the child should be repositioned every 2 hr to prevent skin breakdown

A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

Respiratory rate Rationale: Using the airway, breathing, circulation approach to client care, the nurse should prioritize assessing the client's respiratory rate. Small amounts of kerosene can enter the lungs and damage them directly, causing a severe aspiration pneumonia. Because the pneumonia is caused by chemical irritation rather than bacteria, antibiotics aren't useful for prevention or treatment. Breathing becomes rapid and gasping, and vomiting and persistent coughing ca

A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.

Sensitive to touch Wound blanches with pressure Blisters

A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse expected of a toddler?

Separates easily from primary care giver for short periods of time Rationale:By 3 years of age, a toddler's psychosocial development should include the ability to accept separating from a primary care giver for short periods of time. A toddler should also be able to express likes and dislikes and begin to play with children and others outside the family.

. A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?

Sits with pillow props Rationale:Infants who have cerebral palsy require support when sitting upright.

A nurse is teaching about neural tube defects to a group of females who are pregnant. Which of the following disease processes should the nurse include as an example of a neural tube defect?

Spina bifida Rationale: Neural tube defects, such as spina bifida, occur when the neural tube fails to close. In spina bifida, the osseous spine fails to close.

A nurse is assessing a 3 year-old-child at a routine wellness checkup. Which of the following findings should the nurse expect?

Stands on one foot for a few seconds Rationale: The nurse should expect a 3 year-old-child to be able to stand on one foot for a few seconds, ascend stairs on alternate feet, and jump off of the bottom step.

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

Sudden pain relief Rationale:Accumulation of exudate caused by otitis media with effusion increases pressure behind the tympanic membrane. The pressure releases when the tympanic membrane ruptures, which results in sudden pain relief

A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis?

Sweat chloride test Rationale: Clients who have cystic fibrosis have an increase of sodium and chloride in both saliva and sweat. Therefore, a sweat chloride test can definitively confirm a diagnosis of cystic fibrosis.

A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?

Tachycardia Rationale:A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to have tachycardia due to increased circulating catecholamines and increased adrenergic activity.

A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?

Takes an axillary temperature Rationale: Rectal temperatures should be avoided in infants who have spina bifida due to the risk for irritation and rectal prolapse.

A nurse is teaching the parents of a toddler about temper tantrums. Which of the following statements should the nurse include in the teaching?

Temper tantrums are the toddler's attempt to gain control of a situation." Rationale: Temper tantrums are a result of the toddler's frustration over his inability to control his environment. Temper tantrums occur because toddlers have not learned to control their emotions.

A nurse is caring for a toddler who has a fractured right femur and is in Bryant traction. When determining that the traction is appropriately assembled, the nurse should observe which of the following?

The buttocks is elevated slightly off of the bed. Rationale: Having the buttocks elevated slightly off of the bed is appropriate for Bryant traction. The child's hips are flexed at a 90° angle with the legs suspended by pulleys and weights. The weights must hang freely from the bed to maintain alignment.

A nurse is preparing to administer the first measles, mumps, and rubella (MMR) immunization to a 15-month-old toddler. Which of the following findings is a contraindication for this immunization?

The child has a congenital immunodeficiency. Rationale:A diagnosis of a congenital immunodeficiency is a contraindication to receiving the MMR immunization.

.A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?

The fever is causing an increase in your baby's heart rate." Rationale: The expected reference range for the temperature of an infant from birth to 1 year is 36.5° C (97.7° F) to 37.2° C (98.9° F). This infant has a fever that is causing the infant's heart rate to increase. The expected reference range for heart rate in a 2 month-old infant is 121 to 179/min.

A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider?

The infant does not sit steadily without support. Rationale:An 8-month-old infant should be able to sit steadily without support. A 10-month-old infant should be able to change from a prone to sitting position, stand while holding onto furniture, and lift one foot while standing.

A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply.)

The preschooler mispronounces words. E. The preschooler speaks in a nasally tone

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.)

The reason why the child is taking the medication Written information about the medication The adverse effects of the medication

A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider?

The toddler cannot stand upright without support. Rationale: The nurse should expect a 15-month-old toddler to be able to stand upright without support. The nurse should report this finding to the provider as this can indicate a developmental delay.

A nurse is administering ear drops to a toddler and pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following explanations should the nurse provide?

This technique opens the ear canal, allowing medication to reach the inner ear region." Rationale: For children younger than 3 years old, the auricle should be pulled down and back to fully open the ear canal. This technique allows the correct dose of medication to enter the ea

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?

This test will confirm if your child had a recent streptococcal infection." Rationale:An ASO titer is a blood test that measures anti-streptolysin O antibodies in the blood. The test determines if the client has recently been infected with Group A streptococcus. The ASO antibody can be detected in the blood for weeks or months after the primary source of the infection has been eradicated

A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant?

Trendelenburg Rationale:Infants who have cystic fibrosis are placed in various positions to allow gravity to facilitate the removal of tenacious secretions. The nurse should identify the Trendelenburg position (head lower than body) as being contraindicated for the infant because infants do not have autonomic regulation of blood flow to the head. This position is also contraindicated for children who have head injuries.

A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

Tugging on the affected ear lobe Rationale: Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear.

A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?

Use a moisturizer to wipe urine from the skin. Rationale:It is appropriate for the nurse to use a moisturizer to wipe urine from the skin. This will prevent further breakdown of the skin.

A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?

Varicella (VAR) Rationale: The child should have received the first dose between 12 to 15 months of age. The child should then receive a second dose between 4 and 6 years of age.

A nurse is caring for an infant who has gastroesophageal reflux. The nurse should recognize that which of the following findings are associated with this condition? (Select all that apply.

Vomiting Weight loss Wheezing

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's laboratory values?

WBC 17,000/mm3 Rationale: The expected reference range for a WBC count for a child is 5,000 to 10,000/mm3. A WBC count of 17,000/mm3 is elevated. The nurse should expect to see an elevated WBC count because appendicitis is an acute bacterial infection.

.A nurse is preparing to teach a parent how to care for a child who has impetigo contagiosa. Which of the following information should the nurse plan to include in the teaching

Wash clothing in hot water. Rationale: The nurse should teach the parent to ensure the child changes her clothes every day and to wash all clothing in hot water.

A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching?

We'll discard his toothbrush and buy another." Rationale: Children who have positive throat cultures for streptococcal infection should replace their toothbrush after they have been taking antibiotics for 24 hr. Using a contaminated toothbrush can re-introduce the bacteria and spread it to others if others handle the toothbrush.

A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names?

Whooping cough Rationale: Whooping cough is the common name for pertussis

A nurse is assessing a 1-year-old toddler notices a large abdominal mass and pink-tinged urine on the diaper. Which of the following disorders should the nurse suspect?

Wilms' tumor Rationale: Manifestations of Wilms' tumor include an abdominal mass, hematuria, fatigue, weight loss, and fever

.A nurse is caring for a child on the oncology unit. The child's parents are asking the nurse about the cancer diagnosis. Which of the following information should the nurse provide the parents about the most common malignant renal and intra-abdominal tumor of childhood?

Wilms' tumor Rationale: Wilms' tumor, or nephroblastoma, is the most common malignant renal and intra-abdominal tumor of childhood. 28.A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expecte

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to take to prevent aspiration?

Withhold fluids until the client demonstrates a gag reflex.

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? (Select all that apply.

coughing apnea cyanosis frothy saliva

A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching?

will be sure my child aspirates before injecting the insulin." Rationale:It is not necessary to aspirate before injecting the insulin

A nurse is administering vaccines at a county health immunization clinic. Which of the following clients should the nurse plan to administer the meningococcal conjugate (MCV4) vaccine?

An 11-year-old school-age child Rationale:A school-age child between the ages of 11 to 12 years should receive a single dose of the MCV4 vaccine and a booster shot at 16 years of age.

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.

Daytime symptoms occur more than twice a week. Minor limitations occur with normal activity Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.

A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings indicates that the treatment has been effective?

Decreased stridor Rationale:Laryngotracheobronchitis, or croup, is a condition caused by an infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The direct purpose of a cool mist tent is to humidify the inspired air, which decreases respiratory effort.

A nurse is caring for a pre-school age child who has epiglottitis with a barking cough. Which of the following actions should the nurse take?

Monitor oxygen saturation. Rationale: The nurse should monitor the child's oxygen saturation levels to check for indications of respiratory distress or a decline child's condition.

A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?

Muscle tremors Rationale:A serum calcium level of 8.0 mg/dL is below the expected reference range. A preschooler who has hypocalcemia is likely to have muscle tremors and cramps that can progress to tetany and convulsions

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

The rate and rhythm of breath are irregular in newborns." Rationale: Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

increased sleeping Rationale: Following a head injury, an infant's level of consciousness can deteriorate, show signs of excessive sleeping, and eventually go into a coma.

A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?

instruct the parent to avoid pressing on the abdominal area. Rationale: The priority action is to instruct the parent to avoid pressing on the child's abdomen. These symptoms are associated with Wilms' tumor, and trauma to the mass should be avoided to prevent movement of cancer cells into other sites.

A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.)

management of tantrums dental care

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance?

2 mL/kg/hr Rationale:The expected urinary output for infants up to the age of 1 year is 2 mL/kg/hr. An infant who is not dehydrated should produce this amount of urine.

.A nurse participating in lead screening at a community center. The nurse should instruct parents to bring their children back for rescreening in a year for which of the following laboratory values

4 mcg/dL Rationale:A child who has a lead blood level of 4 mcg/dL should return in a year for rescreening

A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately?

A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing Rationale:Vital sign ranges for adolescents are similar to those for adults. A drop in the systolic blood pressure of more than 20 mm Hg or a drop in the diastolic of more than 10 mm Hg after standing is considered to be orthostatic hypotension. One of the most common causes of orthostatic hypotension is hypovolemia. The client likely will feel lightheaded and dizzy. This finding should be reported to the provide

A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

A sibling who had a sore throat 3 weeks ago Rationale: Rheumatic fever typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. If the sibling had a respiratory infection, it is likely the client also has a streptococcal respiratory infection

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

A. Inspection D. Auscultation B. Superficial palpation C. Deep palpation

.A nurse is collecting data from an adolescent. Which of the following should the nurse identify as the greatest risk for suicide?

Active psychiatric disorder Rationale:An active psychiatric disorder represents the greatest risk for suicide. An active psychiatric disorder is present in 90% of those who complete suicide.

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take?

Administer albuterol prior to CPT. Rationale:Albuterol is a bronchodilator that relaxes and dilates the airway to promote air exchange. The nurse should administer the medication prior to implementing CPT to improve airway clearance. Albuterol facilitates the removal of the secretions as the chest wall is being percussed.

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Administer antibiotics when available. Rationale: The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS. Antibiotic therapy has a marked effect on the course and prognosis of the illness

A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?

Administer opioids for pain. Rationale:Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.

A nurse is providing discharge instructions to a parent and his school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include?

Administer prednisone on an alternate-day schedule. Rationale:Prednisone is an effective anti-inflammatory agent that can have serious adverse effects. Taking prednisone on an alternate-day schedule can help maintain joint mobility and minimize adverse effects.

.A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse initiate?

Airborne Rationale: The nurse should initiate airborne precautions for a child who has measles, which is transmitted via droplet nuclei smaller than 5 microns. The nurse should place the child in a negative-pressure airflow room and wear a mask when providing client care.

A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse initiate

Airborne Rationale: The nurse should initiate airborne precautions for a child who has measles, which is transmitted via droplet nuclei smaller than 5 microns. The nurse should place the child in a negative-pressure airflow room and wear a mask when providing client care.

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development?

Allow the infant to stand in the crib. Rationale:Allowing the child to participate in normal developmental activities promotes growth and development. The infant can be held and allowed to walk in a cast or orthotic device.

A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions

An anxiety reaction Rationale: Hospitalization is stressful, regardless of the age of the client. However, for an 18-month-old toddler, separation from parents adds to that stress. The toddler's behavior indicates an anxiety reaction to the stress of hospitalization. Separation anxiety initially causes demonstrations of protest. Remaining sad and quiet when a parent leaves indicates the second response to separation anxiety, which is despair

A nurse is assessing a toddler who has suspected lead poisoning. Which of the following findings should the nurse expect the client to manifest with acute lead poisoning?

Anorexia Rationale: Manifestations of acute lead poisoning include anorexia, nausea, vomiting, abdominal pain, and constipation.

A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?

Avoid triggers that cause an attack." Rationale: The nurse should emphasize that the ability to prevent asthma attacks can be improved by avoiding allergens that the child is sensitive to. Triggers can include animals, dust, certain foods, pollen, and grass. Clients who have asthma manifestations throughout the year should receive allergy testing to determine specific triggers.

A nurse is reviewing the laboratory results of an adolescent who has chronic glomerulonephritis. Which of the following findings should the nurse expect?

BUN 50 mg/dL Rationale: The nurse should expect the adolescent to have a BUN above the expected reference range due to kidney injury and the inability to filter and excrete urea nitrogen from the blood.

A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation?

Babbles one-syllable sounds Rationale:A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds; therefore, this finding indicates a need for further evaluation.

A nurse is teaching a parent of a 2-year-old child about safe food choices. Which of the following foods should the nurse recommend?

Bananas Rationale:Bananas are a safe choice for a 2-year-old child because they are easy to chew and swallow.

.A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

Bleeding

A nurse is caring for an adolescent who was admitted with anorexia nervosa. Which of the following finding should the nurse expect?

Bloating Rationale: Bloating is a finding associated with anorexia nervosa.

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Blood pressure 92/50 mm Hg Rationale: The expected reference range for blood pressure in an adolescent is 110/65 to 120/80 mm Hg. A blood pressure 92/50 mm Hg indicates the adolescent is hypotensive and unstable. Therefore, this finding is the priority. Blunt abdominal trauma can cause internal hemorrhage that leads to hypotension.

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Body weight Rationale:Body weight is the most reliable indicator of fluid loss for infants and young children.

A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection?

Bulging fontanel Rationale:A CNS infection causes increased intracranial pressure. Therefore, a bulging fontanel is a manifestation of a CNS infection.

.A nurse is caring for a school-age child who has a systemic disorder and is receiving antibiotics, immunosuppressants, and corticosteroids. Both of the child's parents have a smoking history. The child reports soreness in his mouth and refuses to eat. Inspection of his mouth reveals a white, milky plaque that does not come off with rubbing. The nurse should suspect which of the following conditions?

Candidiasis Rationale: Manifestations of oral candidiasis include white patches that adhere to the inner cheeks, tongue, and palate that are painful and can cause the child to refuse to eat.

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

Clear breath sounds Rationale: Clear breath sounds indicate that there are no remaining secretions obstructing or potentially obstructing the client's airway.

A nurse is preparing to teach about communicable diseases. During which of the following stages is the period in which a disease is contagious?

Communicability period Rationale: The communicability period is the time when a disease is contagious and can be transmitted to others.

A nurse is providing health promotion teaching to the parents of an infant. Which of the following conditions should the nurse identify as the leading cause of death among this age group?

Congenital anomalies Rationale: Congenital anomalies are the leading cause of infant mortality in the U.S

A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time

Crushed ice Rationale: Cold, clear liquids are well-tolerated following a tonsillectomy. Liquids that are brown or red should be avoided in order to tell the difference between the liquid and fresh or old blood.

A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of the following warnings over the child's bed?

Do not palpate abdomen. Rationale: Wilms' tumor is a neoplasm of the kidney (nephroblastoma). This tumor is encapsulated, and palpation can cause it to rupture, which would allow seeding of the tumor into the pelvic cavity.

A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The provider prescribes restraints. The nurse should apply which of the following types of restraints for this infant?

Elbow Rationale:It is essential to apply elbow restraints immediately after surgery to keep the infant from rubbing the operative site. The nurse should remove the restraints periodically to inspect the skin and allow the infant arm exercise.

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

Encourage the client to complete school work. Rationale:Erikson's stage of psychosocial development for a 10-year-old child is industry vs. inferiority. By providing school-age children the opportunity to keep up with their school work, they can continue to develop skills and knowledge and maintain a sense of accomplishment

A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

Establish a reward system for positive behavior. Rationale: Children who have autism spectrum disorder benefit from a reward system for positive behavior.

A nurse in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching?

Expect that food consumption might not decrease significantly.

.A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level?

FLACC Rationale: The FLACC pain scale is appropriate to use with infants and children between the ages of 2 months and 7 years.

A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain?

FLACC scale Rationale: The FLACC scale is used for children 2 months to 7 years. It uses facial expressions, leg movement, activity, cry, and consolability to assess the client's level of pain.

A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect?

Facial edema Rationale: The glomerular membrane is permeable to albumin, which is excreted and changes the colloidal osmotic pressure. Therefore, facial edema is a manifestation of nephrotic syndrome

2. A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include?

Fetal heart tones detected by ultrasound Rationale: Fetal heart tones are a positive sign of pregnancy because the presence of fetal heart tones can only be explained by pregnancy

A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this condition?

Firmly attached white particles on the hair Rationale:Pediculus capitis, or head lice, are tiny parasitic insects that live on the scalp and can be spread by close contact with other people. Their eggs (nits) appear much like flakes of dandruff but stick firmly to the hair shaft instead of flaking off of the scalp

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

Frequent swallowing Rationale: Children who exhibit frequent swallowing should be evaluated for hemorrhage.

A nurse is caring for a 6-month-old infant. Which of the following findings indicates to the nurse that the infant may be experiencing pain?

Furrowed brow Rationale:A furrowed brow may indicate that the infant is in pain or distress. Pain indicators for an infant include a change in facial expressions, such as a furrowed brow and grimacing. The nurse should assess the infant for pain using an age-appropriate scale and provide appropriate pain relief as prescribed.

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

Give the child acetaminophen for discomfort. Rationale: The child might have minor discomfort at the puncture site. The parent should offer either acetaminophen or ibuprofen due the risk of Reye syndrome associated with taking aspirin

A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?

Give with orange juice. Rationale:Citrus fruit or juice aids absorption of this medication.

A nurse is developing a health program for the parents of school-age boys. Which of the following information about pubescent changes should the nurse include in the program?

Growth spurts in height occur toward the end of midpuberty. Rationale: Growth spurts in height occur toward the end of midpuberty. Boys grow an average of 10 to 30 cm (4 to 12 inches) during this period.

A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?

Has your son had a sore throat recently?" Rationale: Rheumatic fever typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. It is appropriate to determine whether the child previously had a sore throat.

6.A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.)

Have a parent stay with the child during procedures. Perform the procedure as quickly as possible Allow the child to keep a toy from home with her

.A nurse is assessing an adolescent who has an exacerbation of Graves' disease. Which of the following findings should the nurse expect?

Heat intolerance Rationale:An exacerbation of Graves' disease can cause heat intolerance due to an increased metabolic rate, which leads to warm flushed moist skin and extreme diaphoresis

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?

Hirschsprung's disease

.A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care

Hold the infant's chin to his chest and knees to his abdomen during the procedure. Rationale: During the procedure, the infant is positioned on her side in a fetal position (knees curled to abdomen and chin tucked to chest) to open up the subarachnoid space.

A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect?

Hyporeflexia Rationale: The nurse should expect a child who has a brain tumor to exhibit hyporeflexia and hyperreflexia

A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.

Hypotension Weak pulses Murmur

A nurse is caring for a child who has influenza. The nurse should identify that which of the following statements by the parent indicates the child has an increased risk for Reye syndrome?

I give my child aspirin to reduce his fever." Rationale: The administration of aspirin for fever associated with a viral illness increases the child's risk for Reye syndrome. Reye syndrome is a metabolic encephalopathy with manifestations of cerebral edema and fatty changes in the liver.

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

I only need to catheterize myself twice every day." Rationale: The client has paralysis from the level of the defect down. In the majority of cases, this condition affects bladder and bowel continence. Catheterization should be performed every 4 hr. Infrequent emptying of the bladder can result in stasis and urinary tract infections

A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

I'm glad that my child's ostomy is only temporary." Rationale: Hirschsprung disease is also known as aganglionic megacolon and is characterized by an area of the large intestine without nerve innervation. The child will probably require two surgeries over an 18- to 24-month period before normal bowel function is obtained. The initial surgery creates an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest.

A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider?

Inability to raise head when in prone position Rationale:A 3-month-old infant should be able to raise her head and shoulders from prone position; therefore, the nurse should report this finding to the provider

A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure?

Increased crying episodes Rationale:Infants and children younger than 7 years of age may exhibit certain behavior that suggests pain. Some of the behavioral indicators include facial expressions, legs drawn, increased activity, and excessive crying with inability to be consoled. The FLACC (faces, legs, activity, cry, and consolability) pain scale is frequently used to monitor postoperative pain.

A nurse is providing care to a child who has an allergy to eggs. The nurse should question a prescription for which of the following immunizations?

Influenza, live attenuated (LAIV) Rationale:An egg allergy is a contraindication for receiving the LAIV vaccine. Severe anaphylactic reactions can occur and pose life-threatening conditions for the child.

A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?

Initiate droplet precautions. Rationale: Mumps is a contagious infection transmitted by large droplets. Therefore, initiating droplet precautions is appropriate for the nurse to include in the plan of care.

A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings?

Intussusception Rationale: These findings are associated with a diagnosis of intussusception. Other associated findings include vomiting, lethargy, periods of screaming and drawing the knees to the chest followed by periods of normal behavior, and eventual fever and signs of peritonitis

A nurse is reviewing the laboratory results of four children. Which of the following values should the nurse report to the provider?

Iron 38 mcg/dL Rationale: This iron level is below the expected reference range for children and should be reported to the provider.

A parent tells a nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk for which of the following disorders?

Iron deficiency anemia Rationale: Children between the ages of 12 and 36 months are at risk for iron deficiency anemia when cow's milk, which is poor in iron, is a major component of the diet.

A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect?

Irritability Rationale:An infant who is dehydrated will exhibit irritability

A nurse is admitting a toddler who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

Keep thermometer in the toddler's room. Rationale: The nurse should keep and use dedicated equipment, such as blood pressure monitor, stethoscope, and thermometer in the client's room to prevent the spread of infection from client to client.

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client?

Large building blocks Rationale:Large building blocks are age-appropriate toys for a 12-month-old toddler.

A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?

Lethargy Rationale:A blood glucose of 280 mg/dL is above the expected reference range indicating hyperglycemia. The nurse should expect the child to appear lethargic, leading to a decreased level of consciousness and confusion

A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?

Low-sodium, fluid-restricted Rationale:A low-sodium, fluid-restricted diet will prevent complications.

.A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care

Measure head circumference every shift. Rationale: The head circumference of a 6-year-old can't increase since the fontanels and sutures have been closed since the child was 18 months old. Therefore, it is unnecessary to measure the child's head circumference.

A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis?

Cardiovascular Rationale: Cardiovascular changes occur in children who have Kawasaki disease due to inflammation of the arterioles, venules, and capillaries.

A nurse is providing nutritional teaching to the mother of a preschooler and is recommending food options to provide 1 oz of grains. Which of the following foods should the nurse recommend

1 cup ready-to-eat cereal flakes Rationale: The child should eat 1 cup of ready-to-eat cereal flakes to consume 1 oz of grains.

. A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

13% weight loss Rationale:A weight loss greater than 10% is a manifestation of severe dehydration in an infant.

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

260 ml

A nurse is assessing a child in an area struck by an earthquake. The child, who is crying, walks well, can state their first name, and repeatedly says "All done" and "Go bye-bye now" during the assessment. The child has 20 deciduous teeth and their anterior fontanel is closed. Based on these observations, the nurse should estimate that the child is how many months old?

30 Rationale: The nurse should estimate that the child is at least 30 months old because the child has completed their primary dentition (20 deciduous teeth), which occurs by 30 months of age. In addition, the nurse should recognize that the child is at least 18 months old because the anterior fontanel is closed and should recognize that the child is at least 24 months old because the child speaks in two- and three-word phrases.

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

90 /min

A nurse is reviewing data for four children. Which of the following children should the nurse assess first

A 10-year-old child who has sickle cell anemia who reports severe chest pain Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the 10-year-old child who has sickle cell anemia and reports severe chest pain should be assessed first. This finding is a medical emergency because it is a manifestation of acute chest syndrome

.A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

A child who has nephrotic syndrome Rationale:A child who has leukemia is at risk for infection. Nephrotic syndrome is not an infectious disorder poses no risk to a child who has leukemia.

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

A child whose parents answer questions for the child Rationale: Often the perpetrator of abuse is controlling and will talk for the child to avoid the risk of the child saying something that could expose the abuse. A school-age child should be able to answer most questions. The nurse should gather information when the parents are absent and to determine if the child interacts differently

A nurse is assessing a toddler who has acute nephrotic syndrome. Which of the following findings should the nurse report to the provider?

A. Yellow nasal discharge Rationale:Yellow or green nasal discharge is an indication of an upper respiratory infection. Children who have nephrotic syndrome are at constant risk for infection. The nurse should report this manifestation to the provider so the child can receive appropriate and prompt treatment.

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?

Apex of the heart Rationale: The most effective way to assess an infant's heart rate is to auscultate at the apex of the heart.

.A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching?

Apply a topical corticosteroid ointment to the affected area. Rationale: The child might require a topical corticosteroid ointment to use during flare-ups to decrease inflammation

A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Apply and release elbow restraints every hour. Rationale:It is essential to apply elbow restraints after surgery to keep the infant from placing her hands in and around her mouth. The nurse should remove them periodically to inspect the skin and allow the infant to exercise her arms.

A home health nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching

Apply suction for less than 10 seconds. Rationale:Prolonged suctioning can cause damage to tissues and induce hypoxia. Hypoxia can interfere with stages of respiration, cellular absorption, and blood transport

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?

Ask the parents what caused the bruises. Rationale: The nurse should gather additional data. Inconsistencies between the history and the injury are the most important criterion on which to base the decision to report suspected abuse

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.

Assess the client's airway patency. Remove objects from the client's bed. Place the client in a side-lying position

A nurse is caring for a child who has red marks across his cheeks. Which of the following actions should the nurse take?

Assess the rest of the child's body for a rash. Rationale: Fifth disease presents with erythema on the face, which resembles slap marks. The nurse should further assess the child's body and extremities to determine if the child has Fifth disease

.A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?

At the end Rationale: When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows

.A nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names?

Athlete's foot Rationale:Athlete's foot is the common name for tinea pedis

A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?

Auscultating the rate and characteristics of the child's heart sounds Rationale: Using the airway, breathing, circulation approach to client care, the nurse should place priority on auscultating the client's heart rate and heart sounds. Rheumatic fever is an inflammatory disease that begins with a strep throat from a streptococcal infection and can progress to rheumatic heart disease, which is a condition in which the heart valves are damaged by rheumatic fever. Auscultating heart sounds is the priority assessment because tachycardia and cardiac murmur indicate cardiac involvement, which can result in serious, life-threatening, and life-long complications.