Peds B 2023 W Explanation
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?
increase the fat connect to 40% of total cals
A nurse is planning an educational program to teach caregivers about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?
choose a waterproof sunscreen with a minimum of spf of 15 The nurse should instruct caregivers 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. The nurse should instruct caregivers to reapply sunscreen every 2 to 3 hr.
A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take?
cleanse the affected area with mild soap and water The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.
A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take?
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.
A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?
white rice The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and that sometimes lactose deficiency can be secondary to this disease.
A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make?
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.
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
give morphine 0.05
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
1
A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?
rest of 45 per min The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.
A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperatures above 38.0º C (100.5º F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100 mg/5 mL. How many mL should the nurse administer to the infant per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2ml per dose (17.6Ib in kg is 8kg bc its divided by 2.2.) 5 divided by 100 times 8 times 5
A nurse is receiving change of shift report for four children. Which of the following children should the nurse assess first?
A toddler who has a concussion and is experiencing 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 increased intracranial pressure in a toddler who has a concussion.
The nurse is caring for the child 14 days after admission. The child has returned to the unit following the procedure. Which of the following actions should the nurse take? Select all that apply.
CORRECT: provide 100% oxygen check anterior neck and chest dressing for bleeding place a warm blanket on the child keep the Childs head in a neutral position
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?
Capillary refill less than 2 sec The nurse should identify that a capillary refill less than 2 seconds indicates the current treatment regimen the infant is receiving for dehydration is effective.
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?
denies discomfort during assessment of injuries The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?
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 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.
A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
difficulty concentrating
A toddler who has a concussion and is experiencing an episode of forceful vomiting
difficulty concentrating The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem. The nurse should identify that hypertension is a late manifestation of increased intracranial pressure due to compression of the brain vessels. The nurse should identify that somnolence and lethargy are manifestations of increased intracranial pressure. The nurse should identify that bradycardia is a late manifestation of increased intracranial pressure.
A nurse is caring for a toddler who has acute otitis media and a temperature of 40º C (104º F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature?
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.
A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should the nurse include?
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.
For each assessment finding, click to specify if the finding is consistent with nightmares, sleep terrors, or insomnia. Each finding may support more than 1 disease process.
When analyzing cues, the nurse should recognize that manifestations of nightmares include awakening during the night after a scary dream. Nightmares are sleep disturbances that cause distress after the dream is over. The child might be crying, fearful of returning to sleep, and believe the dream is real. Sleep disturbances cause interruptions in the sleep-wake cycle and can cause impaired concentration, daytime fatigue, and impulsive behaviors. When analyzing cues, the nurse should recognize that manifestations of sleep terrors include partial awakening during a deep sleep. Sleep terrors are sleep disturbances that cause a child to exhibit behaviors such as thrashing, screaming, moaning, and diaphoresis that disappear once the child awakens. The child does not remember the episode and is not comforted by others during the disturbance. The child usually falls asleep easily afterwards. Sleep terrors cause interruptions in the sleep-wake cycle and can cause impaired concentration, daytim
The nurse is caring for the child 4 days after admission. After reviewing the child's assessment, which of the following findings should the nurse address first? Complete the following sentence by using the lists of options.
dropdown 1- temperature dropdown 2- pain Temperature is correct. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an increased temperature is a priority finding, because it can indicate an infection and sepsis. Wound sepsis is most likely to occur between the third and fifth day after a burn. Therefore, the nurse should first address the child's temperature. Pain is correct. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing. Sensorium, nutrition, drainage on dressing, and fluid status are
A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first?
a toddler who has a concussion and an episode of forceful vomiting
school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?
a unilateral rib hump When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.
A nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect?
abdominal distention The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness.
nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?
nasal flaring When using the airway, breathing, and circulation 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.
A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?
I should secure the car seat using lower anchors and testers instead to the seat belt Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used. The car seat harness in rear-facing car seats should be positioned at or just below the infant's shoulders. The car seat should be positioned at a 45° angle to prevent slumping and injury to the infant.
A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching?
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.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
middle- cystic fibrosis educate the parents on sweat chloride testing and prepare for chest physiotherapy monitor the oxygen saturation and stools Upon recognizing and analyzing client findings, the nurse's priority hypothesis is that the toddler is most likely experiencing cystic fibrosis and that is it important to generate solutions and take actions by planning to educate the guardian about sweat chloride testing for the toddler and prepare the toddler for chest physiotherapy. The toddler is most likely experiencing cystic fibrosis, as evidenced by reports of recurring respiratory infections, wheezing, coughing, tachypnea, tachycardia, labored respirations, decreased oxygen saturation, nasal congestion, inability to gain weight, loose fatty stool, salty tasting sweat, and hyponatremia. To evaluate the toddler's response to these interventions, the nurse should monitor the toddler's oxygen saturation level and stools. These are parameters that indicate if the toddler is further experiencing respiratory distress, inadequate intake, and dehydration, which can lead to further complications, including pneumothorax, respiratory failure, and failure to thrive.
My child will need to use a compression garment to decrease blood supply to the scarred tissue"
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.
A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first?
check the Childs resp. rate When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths.
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?
perform a finger stick The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?
epi This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta-adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?
petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.
Nurses' Notes 1000, 1 week ago: Parent presents to primary care provider's office with 13-month-old. Parent states the toddler is having trouble passing stool. States this has been happening on and off for the last few months. Toddler is awake and alert. S1 and S2 auscultated, no murmur. Respirations unlabored. Hypoactive bowel sounds. Provider recommended over-the-counter stool softener and encouraged hydration and increasing fruits and vegetables in diet.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again highlight: When recognizing cues, the nurse should identify that the assessment findings of lethargy, disinterest in eating, hypoactive bowel sounds, distended abdomen, palpable fecal mass, ribbon-like, foul-smelling stools and elevated blood pressure require follow-up. These findings indicate the toddler's constipation has worsened and the toddler needs further evaluation for suspected Hirschsprung's disease. When recognizing cues, the nurse should identify that the assessment findings of lethargy, disinterest in eating, hypoactive bowel sounds, distended abdomen, palpable fecal mass, ribbon-like, foul-smelling stools and elevated blood pressure require follow-up. These findings indicate the toddler's constipation has worsened and the toddler needs further evaluation for suspected Hirschsprung's disease.
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?
place the child in a side lying position The nurse should place the child in a side-lying position to prevent aspiration.
a nurse is teaching a school- age child who has a new dx of type one db, which of the following statements indicated undetsanding of teaching
I will give myself a shot of regular insulin 30 min before I eat my breakfast The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.
A nurse is caring for an infant who is receiving IV fluids for the treatment of tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take?
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.
A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child.
Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas- contraindicated. Insert an indwelling urinary catheter- anticipated Provide 100% oxygen via face mask.- anticipated Weigh the child-anticipated. Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas is contraindicated. Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. The nurse should cover the burn with a clean, dry cloth to prevent contamination and hypothermia. Insert an indwelling urinary catheter is anticipated. Inserting an indwelling urinary catheter is essential and allows for accurate measurement of urine output. Urine output is an indicator of the fluid status of the child. A child who has major burns will lose a significant amount of fluid due to increased capillary permeability, which increases the risk for hypovolemic shock. It is important to maintain accurate hourly I&O to manage fluid replacement. Provide 100% oxygen via face mask is anticipated. Upon admission to the emergency department, the nurse should recognize the need to provide 100% oxygen via face mask as an essential prescription. The child's SaO2 is below the expected reference range and their respiratory rate is increased. Weigh the child is anticipated. The nurse should recognize the need to weigh the child as essential. Children of the same age weigh different amounts. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight.
The nurse is providing discharge teaching to the child and their parent 36 days after admission. Select 6 statements by the parent that indicate an understanding of the discharge teaching.
CORRECT: I should apply a moisturizer to the scar tissue" I will use a measured spoon or medicine cup to give my child hydroxyzine" "I can give my child hydroxyzine every 6 hours as needed" "Puppet play can be helpful for my child" "I need to assess for any redness or open skin areas before applying my child's left arm splint" My child will need to use a compression garment to decrease blood supply to the scarred tissue" "I will give my child hydroxyzine to prevent bacterial infection" is incorrect. Hydroxyzine is an antihistamine, not an antibiotic, and is prescribed for pruritus. Scar tissue can cause intense itching while it is healing. It is important the child does not scratch the healing wounds. "I should apply a moisturizer to the scar tissue" is correct. Frequent application of a non-perfume moisturizer should be applied to the scar tissue to help reduce itching the child might experience. "I will use a measured spoon or medicine cup to give my child hydroxyzine" is correct. All liquid medications should be administered with a measured spoon or cup to provide an accurate amount of the prescribed dose of medication. "I can give my child hydroxyzine every 6 hours as needed" is correct. Hydroxyzine is administered every 6 to 8 hr each day as needed. "Puppet play can be helpful for my child" is correct. Preschoolers engage in imaginative play. The use of puppets will encourage the child to express their feelings through imaginary play. "I should avoid giving hydroxyzine at bedtime" is incorrect. Giving hydroxyzine at bedtime can help reduce scratching while sleeping. An adverse effect of hydroxyzine is drowsiness. Therefore, administering it at bedtime will not interfere with the child's sleep. "I will avoid massaging the scar tissue" is incorrect. Massage therapy is beneficial in helping to stretch the sca
the nurse is continuing care for the child After examining the child during hydrotherapy, the provider enters prescriptions into the child's medical record. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child.
Change the morphine route to family-controlled analgesia via a PCA pump.- ANTICIPATED Obtain a wound culture.- ANTICIPATED Place the child on a pressure-reduction mattress.- ANTICIPATED Limit daily protein intake.- CONTRAINDICATED Change the morphine route to family-controlled analgesia via a PCA pump is anticipated. A pain rating of 8 indicates severe pain. The use of a PCA pump should increase the effectiveness of pain management during movement and procedures. The nurse should teach the child's primary caregiver about the use of the PCA pump. Obtain a wound culture is anticipated. The child has an elevated temperature and malodorous green wound drainage. The nurse should obtain a wound culture to determine the causative organism and an antibiotic should be administered. Place the child on a pressure-reduction mattress is anticipated. The child has developed a stage 1 pressure injury on their occiput. A pressure-reduction mattress can help prevent further tissue injury. Limit daily protein intake is contraindicated. Children who have major burns require a high-protein, high-calorie diet to help with wound healing. The nurse should provide high-protein snacks to the child between meals.
A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?
administer the imms using a 24 gauge needle The nurse should administer an immunization for a 4-year-old child using a 22- to 25-gauge needle to minimize the amount of pain the child experiences.
Which of the following statements by a guardian indicate that the discharge teaching was effective? Select all that apply.
apply skin emollient keep the fingernails trimmed short use a mild detergent for laundry "We should apply a skin emollient immediately after bathing our child" is correct. An emollient is an oil that moisturizes the skin and should be applied immediately after bathing, while the skin is damp, to prevent drying. Therefore this statement by the guardian indicates the teaching has been effective. "We should keep our child's fingernails trimmed short" is correct. The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. Therefore this statement by the guardian indicates the teaching has been effective. "We should use a mild detergent for our laundry" is correct. The use of mild detergents for laundry helps prevent allergens and itching. Therefore this statement by the guardian indicates the teaching has been effective. "We should allow our child to take a bubble bath prior to bed" is incorrect. The use of bubble baths and powders should be avoided because they can cause skin irritation. Therefore this statement by the guardian indicates the need for further teaching.
0830:Child is alert and responsive to stimuli. Skin is warm and dry. Capillary refill less than 3 seconds. Respirations regular and shallow. Mild intercostal retractions noted. Expiratory wheezes auscultated in the anterior and posterior lung bases. Abdomen is soft, flat, and non-distended.
arterial blood gases, WBC, oxygen sat, respiratory assessment Arterial blood gases is correct. The child's arterial blood gases (ABGs) indicate respiratory alkalosis, which is associated with complications of asthma, such as hyperventilation and hypoxia. Therefore, the nurse should report these findings to the provider. WBC count is correct. The child's WBC count is above the expected reference range, which could be an indication of infection or inflammation. Therefore, the nurse should report this finding to the provider. Oxygen saturation level is correct. The child's oxygen saturation level has decreased below the expected reference range despite the use of supplemental oxygen. Therefore, the nurse should report this finding to the provider. Respiratory assessment is correct. The child's respiratory assessment indicates increased respiratory distress, as evidenced by the presence of tachypnea, retractions, and increased wheezing. Therefore, the nurse should report these findings to the provider.
A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?
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.
A nurse on a pediatric unit is admitting a preschooler.After reviewing the information in the medical record, the nurse should identify that the child is at risk for developing which of the following conditions? Complete the following sentence by using the list of options.
dropdown 1: splenomegaly dropdown 2: positive mononucleosis rapid test Splenomegaly is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Positive mononucleosis rapid test is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis.
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. Laryngeal edema is an indication of an allergic reaction to the blood transfusion. Distended neck veins are an indication of circulatory overload, which is a complication of a blood transfusion. Muscle weakness is an indication of an electrolyte disturbance, which is a complication of a blood transfusion.
nurse is teaching the parent of an infant about ways to prevent sudden unexplained infant death (SUID). Which of the following instructions should the nurse include?
give the infant a pacifier at bedtime The nurse should inform the parent that protective factors against SUID include breastfeeding and the use of a pacifier when the infant is sleeping.
A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant?
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.
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control?
have a designated stethoscope in the infants room The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions.Therefore, designated equipment, such as a blood pressure cuff and stethoscope, should be placed in the infant's room.
A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
hgb A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels.
A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?
increase protien concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis. Increased cerebrospinal fluid pressure is a finding associated with bacterial meningitis. An increased WBC count in the spinal fluid is a finding associated with bacterial meningitis. A decreased glucose level in the spinal fluid is a finding associated with bacterial meningitis.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?
initiate seize precautions for the child A decreased sodium level indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make?
lets talk about some of the ways you have handled previous stressors in your life This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.
nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
loud harsh murmer The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?
oral rehydration solution A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.
A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?
palpate the dorsum of the Childs 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.
nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). The nurse should identify that which of the following findings require immediate follow-up? Select the 3 findings that require immediate follow-up.
partial and full thickness burns to the left upper anterior neck sao2 89% on room air heart rate of 150 Partial- and full-thickness burns to the left upper anterior chest and anterior neck is correct. Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate follow-up due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. Non-productive cough is incorrect. Airway, breathing, and circulation are the immediate concerns. A non-productive cough does not require immediate follow-up. The nurse should assess for signs of inhalation burns or injury. One of the manifestations of inhalation injury the nurse should assess for is carbonaceous secretions, which indicate burned saliva. SaO2 89% on room air is correct. Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the low oxygen saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. Heart rate 150/min is correct. Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the child's increased heart rate. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock due to fluid loss.
A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider
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.
A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following findings to the provider?
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.
A nurse is providing discharge teaching to the guardian of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral?
speech therapist The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.
nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?
substernal retractions When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure. RESP FAILURE B4 CARDIAC FAILURE
A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan?
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.
A nurse in a provider's office is caring for a school-age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make?
when your Childs 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.
