Peds exam 2 NCLEX
For which complication would the nurse assess an infant with GI reflux? a) bowel obstruction b) abdominal distention c) increased hematocrit d) respiratory problems
D
Which assessment would the nurse perform to assess the magnitude of an infant's fluid loss from diarrhea? a) tissue turgor b) hematocrit value c) moistness of mucous membranes d) weight compared with prior weight
D
What information should be considered before replying to the parents of a child with cystic fibrosis who ask why he needs a glucose tolerance test? a) pancreatic scarring predisposes the child to diabetes b) the thickened mucus blocks the insulin secreting glands c) the test reveals the degree to which the child adheres to the diet d) adjustments of the dosage of pancreatic enzymes are based on the results of the test
A
A school aged child with a fracture of the femur near the epiphyseal plate is admitted to the hospital. Which physiological characteristic of the femur would the nurse consider when teaching the family about the injury? a) growth of that leg may be affected b) risk for infection at this location is increased c) fracture repair will necessitate prolonged traction d) long bones contain marrow, which increases the risk for anemia
A
After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? a) turn the child to the side B) administer the prescribed antiemetic c) maintain NPO d) notify the Dr
A
In which position would the nurse place an infant with tetralogy of Fallot who begins to cry and exhibits worsening cyanosis and dyspnea? a) knee chest b) orthopedic c) lateral sims d) semi-Fowler
A
The nurse analyzes the lab values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500. On the basis of this result, which intervention should the nurse include in the plan of care? a) initiate bleeding precautions b)monitor closely for signs of infection c) monitor temperature every 4 hours d) initiate protective isolation precautions
A
The nurse is monitoring a 3 year old child for signs of increased ICP. The nurse plans to monitor for which EARLY sign? a) vomiting b) bulging anterior fontanel c) increasing head circumference d) complains of frontal headache
A
The nurse is teaching a 12 year old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family? a) polyuria and polydipsia b) lethargy and fatigue c) increased facial hair d) facial bone structure changes
A
Which explanation would the nurse provide the mother of an infant who vomits the first feeding after corrective surgery for hypertrophic pyloric stenosis? a) this often occurs after the first feeding b) the baby is ridding postoperative mucus c) your feeding technique may need to be changed d) feedings will have to be stopped until peristalsis improves
A
Which would the nurse include when educating and adolescent about herpes simplex virus 2 ( HSV-2)? SATA a) illness or stress can result in outbreaks b) use lubricant during sexual encounters c) treatment is intended to prevent outbreaks d) a one time dose of oral azithromycin is curative e) condoms should be used to decrease transmission
A, B, D, E
While providing care to a pediatric patient with acute glomerulonephritis, you note the urine output to be 10mL/hr. The patient weighs 30 lbs. As the nurse, you will want to limit what type of foods from the patient's diet? a) calcium b) potassium c) purine d) none
B
During a 2 month well visit with a patient and her mother you educate the parent on the most common cause of epiglottis. What do you explain to her that causes this and what can help prevent most cases? a) RSV, palivizumab b) influenza virus, annual flu shot c) haemophilus influenzae type B, Hib vaccine d) rotavirus, RV vaccine
C
In which position would the nurse place a 5 week old infant who has difficulty breathing and feeding related to a suspected congenital heart defect? a) supine, with knees flexed b) orthopedic, with pillows for support c) side lying, with upper body elevated d) prone, with the head supported by pillows
C
The nurse is assisting a primary health care provider examine a 3 week old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PHCP to assess? a) Babinski's sign b) The Moro reflex c) ortolani's maneuver d) the palmar plantar grasp
C
Which nursing action would the nurse perform for an infant who develops mottling in the leg used for cardiac catheterization? a) elevate the leg b) cover the leg with a blanket c) check the pulse in the extremity d) call the DR
C
A dehydrated 15 month old toddler is admitted to the pediatric unit. Which finding indicates the child's hydration status has improved? a) increased heart rate b) decreased blood pressure c) increased capillary refill time d) decreased urine specific gravity
D
In which position would the nurse place a 1 year old infant with a distended abdomen admitted with Hirschsprung disease? a) prone b) sitting c) supine d) lateral
D
Which early sign of heart failure would the nurse recognize in an infant who has congenital heart defect with left to right shunting of blood? a) cyanosis b) restlessness c) decreased heart rate d) increased respiratory rate
D
preoperative nursing care for a child with Wilm's tumor should include which intervention? a) gently percuss the abdomen for evidence of trapped air b) observe the abdomen for any noticeable discolorations c) apply cold compresses to the abdomen to reduce edema d) put a sign on the bed reading "DO NOT PALPATE ABDOMEN"
D
The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? a) meningitis b) spinal cord injury c) intracranial bleeding d) decreased cerebral blood flow
A
The nurse recognizes that belly binding is a common cultural practice for the mother of a 9 month old infant with extrusion of the umbilicus. Which variation of belly binding would the nurse discourage? a) coin in the umbilicus b) tight diaper over the umbilicus c) binder that encircles the umbilicus d) adhesive tape across the umbilicus
A
Which treatment would the nurse expect for a newborn with developmental dysplasia of the hip? a) a fitted Pavlik harness b) tight swaddling in blankets c) periodic strapping to a cradle board d) placement in an infant seat on a set schedule
A
A 30 month old toddler is brought to the emergency department in acute respiratory distress, and a diagnosis of laryngotracheobronchitis (viral croup) is made. Which is the most important equipment for the nurse to have available when the child is admitted to the pediatric unit? a) intravenous set B) tracheotomy set c) nasal cannula for oxygen d) crib with padded side rails
B
After a tonsillectomy, the nurse reviews the surgeon's post op prescriptions. Which ones should the nurse question? a) monitor for bleeding b) suction every 2 hours c) give no milk or milk products d) give clear liquids only
B
Which parent education would the nurse include about the cause of most cases of otitis media? a) virus b) bacteria c) fungus d) rickettsia
B
The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? a) supine b) side lying c) high fowlers d) trendelenburg
B ( drainage)
On assessment of a child admitted with a diagnosis of acute stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? a) cracked lips b) normal appearance c) conjunctival hypermedia d) desquamation of the skin
C
Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? a) a trial of adrenocorticotrophic hormone injections b) frequent stimulation of the cremasteric reflex c) a trial of human chorionic gonadotrophic hormone d) frequent warm baths to gently dilate the scrotal area
C
When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children? a) hyperactive behavioral traits b) delay in the eruption of permanent teeth c) slow sexual development but within normal range d) cessation of growth i a child that had been normal
D
After the nurse feeds and burps an infant with a cardiac defect, the infant has a bowel movement and almost immediately becomes cyanotic, diaphoretic, and limp. Which activity most likely caused this response? a) burping b) feeding c) position change d) bowel movement
D ( tet spell )
Which clinical findings would the nurse expect to find during the assessment of a child with acute glomerulonephritis? Select all that apply a) flank pain b) periorbital edema c) intermittent fever d) increased urine volume e) decreased joint mobility
A, B
Which information would the nurse provide to decrease the incidence of further infections in a 17 year old female who has experienced multiple non-sexually transmitted genitourinary infections? Select all that apply? a) dry off after swimming b) select cotton underwear c) wear loose fitting clothes d) avoid taking bubble baths e) refrain from scented toilet tissue
All of the above
Which predominant change occurs in the GI system of the toddler? a) food is rejected due to texture b) voluntary control of elimination increased c) capacity of the stomach decreases d) acidity of gastric contents increases
B
Which precursor would the nurse recognize as common in children who develop reye syndrome? a) body rash b) high fever c) viral infection d) allergic reactions
C
To take the vital signs of a 4 month old child, which order will give the most accurate results? a) respiratory rate, heart rate, rectal temperature b) heart rate, rectal temp, respiratory rate c) rectal temp, heart rate, respiratory rate d) rectal temp, respiratory rate, heart rate
A
Which foods should the nurse recommend for a toddler with newly diagnosed celiac disease? Select all that apply a) oatmeal b) ice cream c) rice cakes d) corn crisps e) whole wheat toast
A, B, C, D
A child losses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes that the child is displaying the oculocephalic reflex. Which would the nurse conclude about the presence of the oculocephalic reflex in an unconscious child? a) unusual b) expected c) suppressed d) hyperactive
B
Which parent teaching would the nurse provide to minimize regurgitation in an infant with a cleft lip? a) offer a thickened formula b) burp frequently during a feeding c) place the child in an infant seat during feedings d) position the child on the side with bottle propped
B
Which strategy would the nurse provide CNA when caring for a child admitted to the hospital with severe diarrhea? a) limiting fluid intake b)counting the number of wet diapers c) weighing the child at the same time every day d) encouraging BRAT diet
C
Which clinical finding would the nurse recognize as a sign that an infant's intracranial pressure has increased? a) hypoactive reflexes b) increased pulse rate c) decreased blood pressure d) tension of the anterior fontanel
D
A toddler who has undergone cleft palate repair is now able to tolerate fluids. Which would the nurse use to offer the toddler fluids? a) small cup b) soft nipple c) bulb syringe d) teflon-coated spoon
A
Which condition would the nurse suspect when assessing an 11 month old infant sitting on the parent's lap crying and tugging at the right ear? a) child abuse b) otitis media c) hearing impairment d) upper respiratory infection
B
Select all the signs and symptoms that can present with epiglottitis? a) slow onset b) difficulty swallowing c) drooling d) high fever e) barking cough f) stridor g) exudate on tonsils h) crackles
B, C, D, F
The nurse reviews the lab results for a child with a suspected diagnosis of rheumatic fever, knowing that which lab study would assist in confirming the diagnosis? a) immunoglobulin b) red blood cell count c) white blood cell count d) anti-streptolysin O titer
D
A parent tells the nurse in the ER that her 3 year old has had a fever for several days and has been vomiting. After prescribed measures to reduce the fever have been instituted, which nursing action is most important? a) preventing shivering b) restricting oral fluids c) measuring output hourly d) taking vital signs hourly
A
A pregnant adolescent reports painful vesicles in the labia minors. The adolescent is diagnosed with a herpes simplex virus infection. Which medication would the nurse expect the primary health care provider to prescribe? a) acyclovir b) peniciclovir c) famciclovir d) valacyclovir
A
Which action would the nurse take when assessing an infant on digoxin who has an apical pulse of 88 beats per minute? a) notify the health care provider immediately b) tell the mother to continue giving the digoxin c) expect the health care provider to lower the dose d) ask the mother whether this is the infant's usual heart rate
A ( less than 90 is sign of toxicity)
A 3 year old client with sickle cell anemia is admitted to the ED with abdominal pain. The nurse palpates an enlarged liver, an X-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis? a) aplastic b) sequestration c) hyperhemolytic d) vaso-occlusive
B
A child is admitted to the pediatric ICU with acute bacterial meningitis. Which intervention would the nurse include in the plan of care? a) offering clear fluids whenever the child is awake b) checking the child's LOC hourly c) assessing the child's blood pressure every 4 hours d) administering the prescribed oral antibiotic medication
B
A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents? a) studies have shown that handing a sick newborn is not good for the baby and upsets the parents b) the oxygen hood is holding the baby's oxygen level just as the point which is needed. You may stroke and talk to her c) since your baby has been doing well under oxygen for 24 hours, I can let you hold the baby without oxygen d) you can hold the baby with the oxygen blowing in the baby's face since the level is very close to room air
B
Which class of anti infective drugs is contraindicated for use in children under 8 years of age? a) aminoglycosides b) tetracyclines c) penicillins d) quinolones
B
Which nursing intervention would the nurse implement for an infant with a myelomeningocele awaiting surgical correction of the defect? a) using disposable diapers b) placing the infant in the prone position c) performing neurological checks above the site of the lesion d) washing the area below the defect with a nontoxic antiseptic
B
Which nursing intervention would the nurse provide an infant exhibiting signs of increased ICP? a) initiating clear fluid diet b) elevating the infant's head higher than the hips c) checking the infant's reflexes every 15 minutes d) stimulating the infant frequently while assessing the level of consciousness
B
Which parent education would the nurse provide the parents of a 9 month old about the cause of diaper dermatitis? a) use of disposable diapers b) prolonged contact with an irritant c) decreased pH of the infant's urine d) too-early introduction of solid foods
B
Which parental statement would the nurse recognize as a knowledge deficit when discussing the care of an infant with severe diaper rash? a) "I expose the buttocks to the air" b) " I direct a heat lamp at the buttocks" c) " I dont use soap to clean the diaper area" d) " I apply medicated ointment to the diaper area
B
Which assessment finding in a newborn is suggestive of cystic fibrosis? a) rapid heart rate b) excessive crying c) sternal retractions d) abdominal distention
D
How would the nurse expect the urine of a child with acute glomerulonephritis with hematuria to appear? a) cola colored b) orange c) bright red d) straw colored
A
The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which action should the nurse perform immediately? a) notify the surgeon b) reinforce the dressing c) document the findings and continue to monitor d) circle the area of drainage and continue to monitor
A
Which family history would the nurse recognize as a risk factor for an infant developing hypertrophic pyloric stenosis? a) a first cousin underwent surgery for HPS b) the birth was preterm, and the birth weight was 4 lb c) an older brother had idiopathic vomiting during infancy d) the older sister experienced an intestinal obstruction during early infancy
A
Which nursing intervention would the nurse provide for a 6 month old infant with bronchiolitis? a) discouraging prenatal visits to conserve energy b) monitoring skin color, anterior fontanel, and VS c) wearing gown and gloves when providing care d) promoting stimulating activities to meet developmental needs
B
An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognized that surgical correction is designed to achieve which outcome? a) stop the flow of unoxygenated blood into systemic circulation b) increase the flow of unoxygenated blood to the lungs c) prevent the return of oxygenated blood to the lungs d) reduce peripheral tissue hypoxia and nailbed clubbing
C
The nurse is caring for an infant with bacterial meningitis. Which etiology would the nurse consider as the most likely route of transmission to the central nervous system? a) GU tract b) GI tract c) Skin or mucous membranes d) cranial apertures or sinuses
D
Which assessment finding would the nurse expect for a 2 month old infant admitted to the pediatric unit with gastroenteritis and dehydration? a) bulging fontanels b) marked restlessness c) resilient tissue turgor d) tachycardia
D
Which clinical finding would the nurse expect when assessing an infant with a tentative diagnosis of hypertrophic pyloric stenosis? a)visible peristaltic waves across the lower abdomen b) palpable mass in the epigastric area to the right of the umbilicus c) tenderness over the epigastric region not relived by heat application d) lower abdominal distention with vomiting of bile stained gastric contents
B
An 18 month old is admitted to the hospital with possible Hirschprung's disease. WHen obtaining a nursing history, the nurse asks about bowel habits. What description of the disease? a) foul smelling and fatty b) bile colored and watery c) semi solid and yellow d) ribbon like and brown
D
Which assessment finding would the nurse recognize as the ortolani sign? a)unilateral droop of the hip b) broadening of the perineum c) apparent shortening of one leg d) audible click on hip manipulation
D
Which education would the nurse provide the parents of a 6 month old infant with a hip spica cast about cast cleanliness? a) the entire cast should be wrapped in plastic b) special precautions are unnecessary for diapering c) baby powder should be sprinkled lightly around the diaper area d) the cast edges in the perineal area should be covered with plastic wrap
D
The nurse is reviewing the lab results for a child scheduled for a tonsillectomy. The nurse determines that which lab value is most significant to review? a) creatinine level b) prothrombin time c) sedimentation rate d) BUN
B
The nurse is caring for an infant with a myelomeningocele. Which clinical manifestation helps distinguish a myelomeningocele from a meningocele? a) enlarged head b) sac over lumbar area c) affected lower extremities d) infection of the spinal fluid
C
Antibiotic prophylaxis is prescribed for a 2 year old child with a cardiac malformation who is awaiting corrective surgery. Which condition is likely to be prevented? a) bacterial pneumonia b) laryngotracheobronchitis c) upper respiratory infections d) subacute bacterial endocarditis
D
The nurse is providing pre op teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is which? a) viral b)fungal c) bacterial d) rickettsial
C
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? a) watery diarrhea b) ribbon like stools c) profuse projectile vomiting d) bright red blood and mucus in the stools
D
Which description of myelomeningocele is accurate? a) it is fusion failure of the vertebral arches without herniation of cord or meninges b) there is a defect in the base of the skull through which the brain and meninges have herniated c) a membrane covered sac of meninges, filled with spinal fluid, is protruding through a defect in the spine d) a saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine
D
A 2 year old child is brought to the emergency department with fever, drooling, and agitation. The child is not coughing and is sitting upright and leaning forward. Which intervention is the priority? A) IV fluids and antibiotics b) immediate removal of the parents from the room to keep the child calm c) maintenance of the child in a prone position during transport to radiology d) procurement of a crash cart and emergency airway management tools to be kept on hand during examination of the throat
D (epiglottis obstruction)
A family member, who is caring for a 2 year old with tetralogy of fallot, asks why the child will periodically squat when playing with other children. Your response is: a) squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels b) Squatting helps to decrease systemic vascular resistance, which will decrease the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels. c) Squatting helps to decrease systemic vascular resistance, which will increase the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels.
A
A child is weak and lethargic, has headaches, has no appetite, and has dark, cloudy urine. The nurse suspects acute poststreptococcal glomerulonephritis. Which question would the nurse ask the mother? a) has your child lost weight recently? b) did your child have a sore throat during the past 3 weeks? c) does your child have migratory pains in the shoulders and knees? d) has your child had a rash on their palms in the last two weeks?
B
A child sitting on a chair starts having a tonic-clinic seizure with a clenched jaw. Which would be the initial action by the nurse? a) trying to open the jaw b) placing the child on the floor c) calling out for assistance from staff d) placing a pillow under the child's head
B
A newborn with a diaphragmatic hernia has impaired gas exchange. Which would the nurse identify as the cause of the infant's decreased gas exchange? a) incarcerated hernia b) decreased oxygen intake c) increased basal metabolic rate d) excessive respiratory secretions
B
During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing? a) hearing tests b) eye exams c) chest X-rays d) fasting blood glucose tests
B
The nurse is assessing a 13 year old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? a) have you lost any weight in the last month? b) are you experiencing any type of nervousness? c) when was the last time you took your synthroid? d) are you having any problems with your vision?
B
The nurse is assigning care for a 4 year old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that a) only an RN should be assigned to monitor this child's temperature b) a tympanic measurement of temperature will providing the most accurate reading c) the licensed practical nurse should be instructed to obtain rectal temps d)the Dr should be asked to prescribe the method for measurement of the child's temp
B
The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? a) The femur is the most common site of this sarcoma b) the child does not experience pain at the primary tumor site c) limping, if a weight bearing lumb is affected, is a clinical manifestation d) the symptoms of the disease in the early stage are almost always attributed to normal growing pains
B
Which intervention would the nurse provide a 3 month old infant hospitalized with RSV? a) Administering an antiviral agent b) clustering care to conserve energy c) administering a bronchodilator every 4 hours d) providing an antitussives agent whenever necessary
B
Which is the priority nursing intervention for a child with severe burns and extensive eschar formation on the arms? a) removing blisters b) checking radial pulses c) maintaining respiratory isolation d) ROM
B
Which preoperative goal would the nurse establish while caring for an infant born with myelomeningocele? A) keeping the infant sedated b) keeping the infant infection- free c) ensuring the maintenance of leg movement d) ensuring development of a strong sucking reflex
B
Which would the nurse avoid in an infant with a congenital heart defect after cardiac catheterization? a)offering fluids as tolerated b) performing ROM c) monitoring the apical pulse for rate and rhythm d) assessing the pulses distal to the Catherine's ion site
B
Why is the vomit of an infant with pyloric stenosis white? a) the pyloric sphincter obstructs the bile duct b) there in an obstruction above the opening of the common bile duct c) the bile duct sphincter is connected to the hypertrophied pyloric muscle d) there is a constriction of the cardiac sphincter that obstructs bile flow
B
You're caring for a 2 day old infant with a large patent ductus arteriosus. The mother of the infant is anxious and asks you to explain her child's condition to her again. Which statement below best describes this condition? a) The vessel connecting the aorta and pulmonary vein has closed prematurely, which is leading to increased blood flow to the lungs b) the vessel connecting the aorta and pulmonary artery has failed to close at birth, which is leading to a left to right shunt of blood
B
The nurse is reviewing a record of a child with increased ICP and notes the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? a) flaccid paralysis of all extremities b) abduction of the arms at the shoulders c) rigid extension and pronation of the arms and legs d) abnormal flexion of the upper extremities and extension of the lower extremities
C
Which schedule would the nurse follow for chest percussion and postural drainage for a toddler with cystic fibrosis? a) after suctioning b) before aerosol therapy c) one hour before meals d) fifteen minutes after meal
C
Why are children with cystic fibrosis often small and underdeveloped compared with children without CF? a) there is muscle atrophy from lack of motor activity b) there is decreases secretion of pituitary growth hormone c) these children digest little food because pancreatic enzymes are blocked d) these children have anorexia with minimal amounts of nutritional intake
C
Which parental statements would the nurse recognize as signs that an infant may need to be evaluated for cerebral palsy? Select all that apply a) my baby doesn't make eye contact b) my baby seems to have a voracious appetite c) my baby was able to turn from front to back by 2 months of age d)I've noticed that this baby clings to me more than other children of the same age e) all of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone
C, E
A mother arrives at the ED with her 5 year old and states that he fell off bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased ICP. Which is a LATE sign of increased ICP? a) nausea b) irritability c) headache d) bradycardia
D
The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? a) stress b) trauma c) infection d) fluid overload
D
The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the vaccine schedule for the child. Which statement should the nurse make to the parents? a) the vaccine schedule will need to be altered b) the child will receive all vaccines except for polio c) the child should not get the hepatitis vaccine d) the child will receive the recommended basic series of vaccines along with a yearly influenza vaccine
D
The nurse is assessing a 5 year old child using the Glasgow coma scale after surgery. Which rating would the nurse assign if the child shows a confused verbal response? a) 1 b) 2 c) 3 d) 4
D
The nurse is assessing an 8 month old child who is a medical diagnosis of Tetrology of Fallot. Which symptom in this client most likely to exhibit? a) bradycardia b)machinery murmur c) weak pedal pulses d) clubbed fingers
D
The nurse must prevent a 2 year old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis? a) obtain gloves for the child's hands b) apply finger cots on the child's fingers c) place elbow restraints on the child's arms d) apply to soft restraints to the child's wrists
D
What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? a) monitor for signs of metabolic acidosis b) estimate the quantity of diarrhea stools c) place in a supine position after feeding d) observe for projectile vomiting
D
Which assessment would the nurse choose for a 4 week old boy whose mother reports "He cries all the time and always acts hungry, but he throws up everything?" a) inspecting the anus for rectal prolapse b) obtaining the elimination history for celiac disease c) noting the color of vomitus for a bile duct obstruction d) palpating the abdomen for hypertrophic pyloric stenosis
D
Which are signs and symptoms that indicate cerebral involvement of acute glomerulonephritis in a child? a) headache, drowsiness, vomiting b) edema, anorexia, restlessness c) Anura, fever, confusion d) cardiac decompensation, increased heart rate, vomiting
A
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next? a) no action required, as this is an expected finding for a school aged child b) ask the child if he/ she has a cold, runny nose, or any ear pain lately c) send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible d) call the parents and have them take the child home from school for the day
B
The nurse is caring for an infant whose vomiting is intractable. Which complication is likely to occur? a) acidosis b) alkalosis c) hyperkalemia d) hypernatremia
B
A lumbar puncture is performed on a child suspected to have bacterial meningitis, and CSF is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? a) clear CSF, decreased pressure, elevated protein level b) clear CSF, elevated protein, decreased glucose level c) cloudy CSF, elevated protein, decreased glucose level d) cloudy CSF, decreased protein, decreased glucose level
C
After a tonsillectomy, which early clinical finding would alert the nurse to suspect a possible hemorrhage? a) noisy snoring b) asking for water c) frequent swallowing d) gradual onset of pallor
C
After returning from surgery an infant suddenly becomes cyanotic. Which is the nurse's priority intervention? a) checking vital signs b) administering oxygen c) suctioning the nasopharynx d) placing infant in side lying position
C
An infant is being admitted to a PICU with bacterial meningitis. Which is the priority nursing action? a) assessing the infant's neuro status b) beginning IV fluids and antibiotics c) implementing respiratory isolation precautions d) educating parents on quiet environment
C
The home care nurse for a 3 month old infant with developmental dysplasia of the hips sees the infant sleeping without the Pavlik harness. Which education would the nurse provide the parents? a) assure the parent that the harness may be removed for a short nap b) encourage the parent to reapply the harness after the baby falls asleep c) explain to the parent the importance of wearing the harness continuously d) instruct them to eliminate one of the infant's daily naps
C
The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure. The nurse should assess the infant for which early sign? a) pallor b) cough c) tachycardia d) slow and shallow breathing
C
The nurse is counseling the parents of a 12 year old child with Duchenne muscular dystrophy about problems that may develop during adolescence. Which body system will the nurse expect to be affected? a) neurological b) integumentary c)genitourinary d) cardiopulmonary
D
Which physiological alteration would the nurse expect when assessing a 6 month old infant with bronchiolitis (RSV)? a) decreased heart rate b) inspiratory stridor c) increased breath sounds d) prolonged expiratory phase
D
A 6 month old infant with congestive heart failure is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? a) apical heart rate of 60 b) sweating across the forehead c) doesn't suck well d) respiratory rate of 30 bpm
A
A child is admitted to the PICU with a diagnosis of thalassemia major ( Cooley anemia). The parents are told that there is no cure, but that the anemia can be treated with frequent blood transfusions. how do blood transfusions treat children with this diagnosis? a) correct the anemia, but they may cause other problems b) reverse the anemia, but they also present a risk of hepatitis c) are a supportive treatment, fewer will be needed as the child grows older d) are a replacement for defective red blood cells, they are like giving insulin to a person with diabetes
A
The nurse would notify the health care provider with which finding in a child being observed following a closed head injury? a)vomiting b) pupils measuring 3 mm c) respiratory rate of 24 breaths/min d) systolic blood pressure falling below 110mmHg
A
The parents of a 3 week old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? a) description of vomiting episodes in the past 24 hours b) number of wet diapers in last 24 hours c) feeding and sleep schedule d) amount of formula consumed during the past 24 hours
A
When assessing a child with asthma, the nurse should expect intercostal retractions during a) inspiration b) coughing c) apneic episodes d) expiration
A
Which education would the nurse provide about the occurrence of febrile seizures? a) they may occur in minor illnesses b) the cause is usually readily identified c) they usually do not occur during the toddler years d) the frequency of occurrence is greater in females than males
A
Which education would the nurse provide the parents of a 3 year old child who has recurrent acute spasmodic laryngitis (spasmodic croup) about why this is a disorder of young children? a) they have small airways b) they are mouth breathers c) they have immature immune systems d) they are prone to upper respiratory infections
A
Which electrolyte if found on urinalysis, would alert the nurse to the possibility of kidney damage? a) protein b) calcium c) potassium d) phosphate
A
Which nursing intervention would the nurse provide an infant during the immediate postoperative period after surgical repair of a cleft lip? a) minimize crying b) restrain continuously c) oxygenate frequently d) handle as little as possible
A
Which parent teaching would the nurse provide for a 4 month old infant with a spica cast? a) obtain a specially designed car seat b) keep diapers on to prevent soiling of the cast c) be sure to change the infant's position every 8 hours d) use the bar between the infant's legs to change positions
A
Which pathophysiology Al process would the nurse expect to account for growth failure in a 4 year old child with newly diagnosed cystic fibrosis? a) impaired digestion and absorption because of the lack of pancreatic enzymes b) dyspnea and shortness of breath, which cause anorexia and disinterest in food c) increased bowel motility and diarrhea, which lead to inadequate absorption of nutrients d) pulmonary obstruction, which causes an oxygen deficit and inadequate tissue nourishment
A
Which would the nurse plan to offer the parents of a child who was treated for acute glomerulonephritis in preparation for the discharge? a) samples of no salt added diets for the child to continue at home b) suggestions about activities to keep the child Mobile for longer periods c) instructions about when the child should return for a work up for a kidney transplant d) phone numbers to reach the nurse on the unit for questions
A
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is the newborn likely to have exhibited? a) choking, coughing, and cyanosis b) projectile vomiting cyanosis c) apneic spells and grunting d) scaphoid abdomen and anorexia
A ( 3 C's)
The nurse is obtaining the health history of a 7 month old infant who has had repeated episodes of otitis media. Which question is most important to ask? a) please describe how you position your child during feedings b) tell me how often your child has ear infections c) what medicine do you give them for the infection d) please describe your oral health practices
A ( position in recumbent position can lead to pooling of fluid into pharyngeal cavity, impairing ear drainage )
As the nurse you know which statements below are correct about the ductus arteriosus? SATA a) it is a structure that should be present in all babies in utero b) it normally closes about 3 days after birth or sooner c) its purpose is to help carry blood that is entering the left side of the heart to the rest of the body d) it connects the aorta to the pulmonary vein
A, B
The nurse is caring for a child with a diagnosis of meningitis. Which clinical findings indicate an increase in intracranial pressure? Select all that apply a) irritability b) bradycardia c) hyperalertness d) decreased pulse pressure e) decreased systolic blood pressure
A, B
Which clinical indicators are consistent with the diagnosis of hyperthyroidism? SATA a) emotional lability b) Dyspnea on exertion c) abdominal distention D) decreased bowel sounds e) hyperactive deep tendon reflexes
A, B, E
Which clinical manifestations would the nurse expect to assess in an infant diagnosed with hypertrophic pyloric stenosis? SATA a) white vomit b) abdominal pain c) peristaltic waves d) insatiable hunger e) abdominal distention
A, C, D
The nurse obtains a health history from the parents of a toddler who is admitted with acute lymphocytic leukemia (ALL). Which problems would the nurse expect the parents to report? SATA a) loss of appetite b) sores in the mouth c) paleness of the skin d) inability to fall asleep e) purplish spots on the skin
A, C, E
A child has been diagnosed with acute otitis media in the right ear. Which interventions should the nurse include in the plan of care? SATA a) provide a soft diet b) position the child on the left side c) administer antihistamines twice daily d) administer ibuprofen for fever every 4 hours As prescribed and prn e) instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy
A, D, E
The nurse is performing an assessment on a 10 year old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? SATA a) abdominal pain b) fever and malaise c) anorexia and weight loss d) painful, enlarged inguinal lymph nodes e) painless, firm, and movable adenopathy in the cervical area
A, E
The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? SATA a) restrict fluid intake b) position for comfort c) avoid strain on painful joints d) apply nasal oxygen at 2L/min e) give meperdine, 25 mg IV q4hr
A, E
A 1 year old has been admitted with a tentative diagnosis of bacterial meningitis. Which CSF lab finding would support this diagnosis? a) decreased cell count b) increased protein level c) increased glucose level d) low spinal fluid pressure
B
A 3 year old boy has X linked Duchenne muscular dystrophy, but neither of his parents has muscular dystrophy. Which statement indicates that the parents understand how the disorder is transmitted? a) our sons or daughters may have the disease b) our daughters may be carriers of the disease c) we each contributed a gene that gave our son the disease d) we know that our other son probably wont get the disease
B
A 4 year old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which lab result confirms this diagnosis? a) lumbar puncture showing no blast cells b) bone marrow biopsy showing blast cells c) platelet count of 350,000 d) WBC count of 4500
B
All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20 month old child? a) weighing diapers b) assessing fontanel c) checking skin turgor d) observing mucous membranes for moisture
B
Which assessment finding alerts the nurse to suspect increasing intracranial pressure in an infant? a) sunken eyes b) projectile vomiting c) depressed fontanel d) narrowing pulse pressure
B
Which assessment would the nurse perform while caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis? a) quality of the cry b) signs of dehydration c) coughing up feedings d) characteristics of stool
B
Which procedure would the nurse anticipate to confirm the diagnosis of Hirschprung disease in a 1 month old? a) colonoscopy b) rectal biopsy c) multiple saline enemas d) fiber optic nasoenteric tube
B
Which teaching would the nurse provide the parents of a 6 week old infant recently diagnosed with GI reflux? a) feeding cereal with a spoon B) providing formula thickened with cereal c) placing the infant supine immediately after feedings d) explaining changes in care after surgical repair of the esophageal defect
B
Which would the nurse expect to see when reviewing the results of a CBC for an infant with tetralogy of fallot? a) anemia b) polycythemia c) agranulocytosis d) thrombocytopenia
B ( from hypoxia)
An adolescent reports uncomfortable genital warts. Which interventions would reduce the discomfort? SATA a) take imiquimod b) consider cryotherapy c) bathe with an oatmeal solution d) wear loose fitting cotton clothes e) use less water to clean the genitals
B, C, D
An infant is admitted to the PICU with bronchiolitis caused by RSV. Which interventions would the nurse provide? SATA a) limiting fluid intake b) instilling saline nose drops c) maintaining droplet precautions d) nasal suctioning to remove mucus e) administering inhaled bronchodilators
B, C, D
A 5 year old male is admitted with acute glomerulonephritis. On assessment, you note mild edema predominately in the face and tea colored urine. The patient's blood pressure is 165/110, hear rate 95, o2 98% on room air, and temp 98.9/ In your nursing care plan, what nursing interventions will you include in this patient's plan of care? SATA a) initiate and maintain a high sodium diet daily b) monitor intake and output hourly c) encourage patient to ambulate every 2 hours d) assess color of urine after each void e) weigh patient every day on a standing scale
B, D, E
A child is admitted to the pediatric unit with a diagnosis of acute glomerulonephritis. Which would the nurse expect the admission urinalysis to reveal? a) polyuria b) ketonuria c) hematuria d) bacteriuria
C
A nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which of the following? a) hematuria b) proteinuria c) bacteriuria d) glucosuria
C
Assessment findings of an infant admitted to the hospital reveal a machinery like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac analogies and identifies that the infant's condition as which disorder? a) aortic stenosis b) atrial septal defect c) patent ductus arteriosus d) ventricular septal defect
C
The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoeseophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? a) incessant crying b) coughing at nighttime c) choking with feedings d) severe projectile vomiting
C
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of what? a) an infectious disease of the CNS b) an inflammation of the brain as a result of illness c) a chronic disability characterized by impaired muscle movement and posture d) a congenital condition that results in moderate to severe intellectual disabilities
C
Which assessment finding would the nurse report to the primary health care provider because it likely indicates pyloric stenosis? a) loud bowel sounds b) sudden expulsion of diarrheal stool c) peristaltic waves that traverse the epigastrium d) regurgitation of a portion of the feeding when burped
C
Which clinical finding is associated with acute glomerulonephritis? a) polyuria b) dehydration c) periorbital edema d) decreased blood pressure
C
Which clinical finding would the nurse expect when assessing a 3 week old infant with pyloric stenosis who is severely dehydrated? a) weight loss b) severe allergies c) depressed anterior fontanel d) urine specific gravity of 1.014
C
Which education would the nurse provide the parent of a preschool child with atopic dermatitis? a) scratching causes lesions to become more contagious b) scratching spreads dermatitis to other areas of the body c) scratching results in skin breaks that can lead to infection d) scratching produces changes that are precursors to skin cancer
C
Which education would the nurse provide the parents of a child diagnosed with atopic dermatitis (eczema)? a) it is easily treated b) it is highly contagious c) it is most common in infants d) it is associated with respiratory infections
C
Which findings would the nurse expect when examining the lab report of a preschooler with rheumatic fever? a) negative C reactive protein b) increased reticulocyte count c) positive antistreptolysin titer d) decreased sedimentation rate
C
Which intervention would be included in the plan of care for a child immediately after the application of a spica cast? a) using the crossbar to turn the child b) logrolling the child until the cast is dry c) performing a neurovascular assessment of the legs d) drying the cast with a hair dryer on the cool setting
C
Which manifestation of hypertrophic pyloric stenosis in an infant would the nurse expect when palpating the abdomen? a) a distended colon b) marked tenderness around the umbilicus c) an olive sized mass in the RUQ d) rhythmic peristalsis waves in the lower abdomen
C
Which parent teaching would the nurse provide for an infant who has eczema? a) ensuring physical growth b) identifying causative factors c) providing adequate hydration d) applying daily topical corticosteroids
C
Which pathophysiology Al abnormality is present in cystic fibrosis? a) dysfunction of sweat glands b) inactivity of respiratory tract cilia c) dysfunction of mucus secreting glands d) overproduction of endocrine gland activity
C
Which positioning would the nurse use for a newborn with a diagnosis of tracheoesophageal fistula? a) prone to reduce aspiration risk b) Trendelenburg to drain stomach contents c) semi Fowler to reduce risk of chemical pneumonia d) supine to reduce SIDS
C
A 4 year old child is found to have Hirschprung disease. Which diet recommendations would the nurse provide to the parents? a) high fat b) high fiber c) low calorie d) low residue
D
A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding? a) diarrhea b) rhinorrhea c) galactorrhea d) steatorrhea
D
A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of this disease? a) has the child complained of any back pain? b) Has the child complained of headaches? c) Has the child had any nausea or vomiting? d) Did the child have a sore throat or fever within the last 2 months?
D
A topical corticosteroid is prescribed by the health care provider for a child with contact dermatitis ( eczema). Which instruction should the nurse give the parent about applying the cream? a) apply the cream over the entire body b) apply a thick layer of cream to affected areas only c) avoid cleansing the area before application of the cream d) apply a thin layer of cream and rub it into the area thoroughly
D
After several episodes of intermittent abdominal pain and vomiting, a 5 month old infant is admitted to PICU. Which nursing assessment helps confirm the diagnosis of intussusception? a) auscultating for bowel sounds b) listening for high pitched crying c) measuring fluid intake and output d) observing characteristics of stools
D
The nurse knows that which symptom of croup requires immediate intervention? a) irritability b) hoarseness c) barking cough d) rapid respiration
D
Which education would the nurse provide the parents of an infant being discharged after surgical correction of a myelomeningocele? a) they need to limit the infant's fluid intake to formula b) the need to provide a quiet environment to limit external stimuli c) the positions to be avoided to help prevent the infant from turning d) How to perform range of motion exercises for the lower extremities
D
Which is the primary cause of otitis media in young children? a) sinusitis b) recurrent tonsillitis c) an inflamed mastoid process d) an obstructed eustachian tube
D
Which nursing care would the nurse provide an 8 month old infant with tetralogy of fallot? a) restriction of fluid intake to conserve energy b) provision of iron-fortified formula to prevent anemia C) administration of coagulants to control bleeding tendencies d) prevention of increased respiratory effort to promote oxygenation
D
Which position would the nurse place a 1 year old infant with a distended abdomen admitted with Hirschsprung disease? a) prone b) sitting c) supine d) lateral
D
Which procedure would the nurse use to elevate the head of an infant in a spica cast? a) use of a donut head pad b) inserting pillows under the shoulders c) padding the edge of the cast with folded diapers d) raising the entire mattress at the head of the crib
D
Which treatment would the nurse anticipate when caring for an infant with heart failure? a) open heart surgery b) cardiac stress test c) aggressive IV infusions d) medications that are prescribed for both children and adults
D
The nurse is caring for a 3 month old infant whose abdomen is distended and whose vomitus is bile stained. Which clinical manifestations support the suspicion of intestinal obstruction? SATA a) weak pulse b) hypotonicity c) high pitched cry d) paroxysmal pain e) grunting respirations
D, E ( obstruction)