Peds Exam#3
A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A. maintain the child in a side-lying position B. loosen the child's restrictive clothing C. reorient the child to the environment D, note the time & characteristics of the child's seizure
A
At a well-child visit, a urine specimen is obtained from a child for testing. The nurse is reviewing the results which reveal positive leukocytes. The nurse interprets this as indicating which of the following? A. Possible urinary tract infection B. Diabetes C. Renal disease D. Bleeding
A
The nurse is teaching the parent of a child with chronic renal failure on high-potassium foods that should be restricted. Which foods will the nurse include in this teaching? . A. Bananas, carrots, nuts, and milk B. Peaches, broccoli, and red meat C. Oranges, potatoes, wheat, and bran D. Spinach, chicken, fish, and green beans
A
A nurse is reviewing the lab values for a 6mo who has acute renal failure. Which of the following findings should the nurse expect? A. BUN 5 mg/dL B. Creatinine 0.2 mg/dL C. Sodium 125 mEq/L D. Potassium 4.2 mEq/L
C
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A. .measure the pt's Wt daily B. check for tears C. palpate the fontanel D. assess skin turgor
A
A nurse is developing a teaching plan for the parents of an 8-year-old experiencing nocturnal enuresis. The nurse determines that additional teaching is needed when the parents identify what as an appropriate measure? A. Encouraging fluid intake after dinner B. Practicing bladder-stretching exercises C. Giving desmopressin intranasally D. Engaging the child in stress reduction measures
A
A child who was Dx w/ Hirschsprung's Dz has a fever & watery explosive diarrhea. Which of the following would the nurse do first? A. administer an antidiarrheal B. notify the physician immediately C. monitor the child every 30 mins D. nothing these are common findings
B
A nurse is providing discharge teaching to the parents whose infants had a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching? A. "We will check his abdomen daily for signs of fluid accumulation" B. "We will notify the doctor right away if he has a fever." C. "We should keep a helmet on him when he's awake." D. "We can expect him to have occasional seizure episodes."
B
A nurse is reviewing the lab report of a 2yo who has diarrhea & has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider? A. Hct 40% B. potassium 2.5 C. serum creatinine 0.4 D. BUN 6
B
The nurse is caring for a 2-month-old with a cleft palate. The child will undergo corrective surgery at age 3 months. The mother would like to continue breastfeeding the baby after surgery and wonders if it is possible. How should the nurse respond? A. "There is a good chance that you will be able to breastfeed almost immediately." B. "Breastfeeding is likely to be possible, but check with the surgeon." C. "After the suture line heals, breastfeeding can resume." D. "We will have to wait and see what happens after the surgery."
B
The nurse performing an admission assessment on a 2yo who has be Dx w/ nephrotic syndrome notes that which most common characteristic is associated w/ this syndrome? A. hypertension B, generalized edema C. increased UOP D. frank, bright red blood in urine
B
A nurse is caring for an infant who has gastroenteritis & is dehydrated. Which of the following characteristics places the infant at higher risk of electrolyte imbalances compared to an adult client? A. less extracellular fluid B. reduced body surface area C. longer intestinal tract D. decreased rate of metabolism
C
A nurse is reviewing the lab reports of a child w/ acute nephrotic syndrome who has been receiving prednisone by mouth for the past wk. Which of the following findings should the nurse report to the provider? A. serum sodium 142 B. serum potassium 4 C. WBC count 3,000 D. platelet count 298,000
C
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? A. prone B. on the stomach C. left lateral D. right lateral
C
An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the father would indicate to the nurse that additional teaching should be done? A. "I have ibuprofen available in case it's needed." B. "My child will likely outgrow these seizures by age 5." C. "I always keep phenobarbital with me in case of a fever." D. "The most likely time for a seizure is when the fever is rising."
C
The nurse instructs a hearing-impaired school-age child on to how self-inject a prescribed medication. Which observation indicates to the nurse that additional teaching is required? A. The child pinches the skin together before inserting the needle. B. The child injects the appropriate amount of air into the vial before withdrawing medication. C. The child places the filled syringe and uncapped needle on the bed to open the alcohol wipe. D. The child slowly pushes on the plunger to inject the medication before withdrawing the needle
C
The nurse is caring for a female preschool-aged patient with a urinary tract infection. What measures should the nurse teach the mother to prevent future infections? A. Suggest the child drink less fluid daily to concentrate urine. B. Encourage the child to be more active to increase urine output. C. Teach the child to wipe the perineum front to back after voiding. D. Teach the child to take frequent tub baths to clean the perineal area.
C
The nurse is providing postop care for an infant who has cleft palate; she should position the child in which of the following? A. in an infant seat B. in the supine position C. in the prone position D. on his side
C
A 7yo was Dx w/ minimal-change nephrotic syndrome; which of the following Sxs are characteristics of this? A. hypertension, edema, hematuria B. hypertension, edema, proteinuria C. gross hematuria, fever, proteinuria D. poor appetiie, edema, proteinura
D
A nurse is assessing a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect? A. hypokalemia B. decreased BP C. increased urine vol D. periorbital edema
D
The clinic nurse reviews the record of an infant and notes that the PCP has documents a Dx of suspected Hirschusprung's disease. The nurse reviews the assessment findings documented, knowing that which sign most likely led the mom to seek health care for the infant? A. diarrhea B. projectile vomiting C. regurgitation of feedings D. foul-smelling ribbon-like sttols
D
The nurse is assessing a child w/ pyloric stenosis; she is likely to note which of the following? A. "currant jelly" stools B. regurgitation C. steatorrhea D. projectile vomiting
D
The nurse is preparing an 18-month-old for discharge following treatment for dehydration secondary to diarrhea. What instruction would the nurse most likely include in the discharge teaching? A. "Encourage a bland diet." B. "Implement clear liquids." C. "Provide plenty of 100% fruit juice." D. "Offer flavored gelatin if hungry."
A
The nurse is providing education to the parents of a female with hydrocephalus who has just had a shunt inserted. When discussing the child's condition with the parents, which of the following would be most appropriate? A. "Tell me your concerns about your child's shunt." B. "Be sure to call the doctor if she gets a persistent headache." C. "Her autoregulation mechanism to absorb spinal fluid has failed." D. "Always keep her head raised 30 degrees."
A
The nurse is taking a health history for a 9-year-old with conjunctivitis. Which statement by the parents leads the nurse to suspect that the child is experiencing allergic conjunctivitis? A. "He recently helped clean the basement. B. "He was exposed to several family members with an infection. C. He just recovered from an upper respiratory infection. D. We have a family history of conjunctivitis
A
The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet? A. rice B. oatmeal C. rye toast D. wheat bread
A
A 4-month-old infant is seen at the ambulatory care clinic and diagnosed with nasolacrimal duct obstruction. The mother asks what can be done. What information should be included in the information provided to the parent? A. Once the child is 6 to 9 months old a specialist will be able to drain the duct. B. Most of these conditions will spontaneously resolve. C. Antiviral therapy can be prescribed to manage this condition. D. Over-the-counter drops can be used sparingly
B
A nurse is teaching the parents of a 3yo who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching? A. my child should not play around others who have ear infections B. we should not smoke around our child C. my child should not swim this summer D. I will encourage my child to blow his nose forcefully when he has a cold
B
In diagnosing seizure disorder, which of the following is the most beneficial? A. skull radiographs B. EEG C. Brain scan D. lumbar puncture
B
The most common assessment finding in a child w/ ulcerative colitis is: A. intense abdominal cramps B. profuse diarrhea C. anal fissures D. abdominal distention
B
The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this Dx? A. his pediatrician said his kidneys are working well B. I noticed his urine was the color of cola lately C. I'm so glad they didn't find any protein in his urine D. the nurse who admitted my child said his BP was low
B
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? A. diarrhea B. metabolic acidosis C. metabolic alkalosis D. hyperactive bowel sounds
C
A nurse is assessing a 6mo infant who was recently admitted w/ acute vomiting & diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. bulging anterior fontanel B. bradycardia C. tachypnea D. polyuria
C
A nurse is obtaining a urine sample from a 5mo by applying a urine collection bag. Which of the following actions should the nurse take first? A. apply the collection bag to the skin at the area of the symphysis pubis B. apply the collection bag to the skin at the area of the perineum C. wash & dry the genitalia, perineum & surrounding skin D. stroke the muscles on either side of the infant's spine
C
A panicked mother calls the health care provider's office and reports that her 5-year-old has a high fever and just had a seizure. The mother asks the nurse what she should do. Which is the nurse's best response? A. Report to the emergency room for medical evaluation B. Immerse the child in a bathtub of tepid water C. Administer oral acetaminophen per package directions D. Remove any heavy clothing and cover with a thin sheet
A
An 8-year-old boy and his father visit the pediatrician's office with reports of a sudden onset of abdominal pain and reddish-brown urine. A urinalysis shows 4+ protein. On taking the boy's health history, the nurse learns that he had strep throat a little over a week ago. Which condition should the nurse suspect? A. Acute glomerulonephritis B. Kidney agenesis C. Polycystic kidney D. Nephrosis
A
An 8-year-old child is being treated for tonic-clonic seizures. What should the nurse emphasize when teaching the parents about this disorder? A. The child should maintain an active lifestyle. B. Immediately provide medication if a seizure begins. C. Have the child carry a padded tongue blade with her at all times. D. Ensure quiet time late in the day, when seizure activity is most likely to occur.
A
The nurse is working with a child with altered genitourinary status. Which intervention would be included in the plan of care for the client with excess fluid volume? A. Weigh the child daily on the same scale. B. Hold all medication until the fluid retention is improving. C. Avoid administering IV therapies. D. Measure the amount of nitrates present in the urine
A
A nurse is caring for an infant following the surgical repair of a cleft lip & palate. Which of the following actions should the nurse take? A. keep the infant's mouth open by using a tongue blade for 4 hr following surgery B. suction the infant gently w/ a bulb syringe PRN C. place the infant in a prone position D. clean the infant's incision w/ chlorhexidine
B
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. assign an assistive personnel to feed the child B. explain the sounds the child is hearing C. have the child use a cane when ambulating D. rotate nurses caring for the child
B
A nurse is obtaining the history from a parent of a child who experiences absence seizures. Which of the following would the nurse expect the mother to describe? A. Brief, sudden onset with muscles that become tense B. Loss of motor activity accompanied by a blank stare C. Sudden, brief jerking motions of a muscle group D. Loss of muscle tone and loss of consciousness
B
A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following lab values should the nurse expect? A. platelets 120,000 B. sodium 160 C. Hgb 9 D. cholesterol 700
D
The nurse is preparing to care for a child with a Dx 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
A nurse is caring for a toddler who is postop following a cleft palate repair. Which of the following actions should the nurse take? A. restrain the toddler's arms at the elbows B. feed the toddler w/ a spoon C. monitor the toddler's oral temp D. weigh the toddler every 48 hrs
A
A nurse is discussing the causes of chronic diarrhea w/ a pt. Which of the following conditions is caused by malabsorption? A. celiac disease B. ulcerative colitis C. Hirschsprung's disease D. Crohn's disease
A
A nurse is planning care for a 4yo who has nephrotic syndrome. Which of the following actions should the nurse take? A. provide through skin care B. test for blood type & cross-match C. allow ample hydrating fluids D. maintain a low-carbohydrate diet
A
A nurse is planning care for a toddler who has acute gastroenteritis & was recently admitted. Which of the following should the nurse plan to provide for the child? A. oral rehydration solution B. bananas/applesauce C. chicken/beef broth D. hypertonic IV soultion
A
A 10-year-old girl is experiencing acute renal failure due to dehydration. The nurse is preparing to administer IV fluid. Which of the following interventions should the nurse take in caring for this child? A. Administer the IV fluid slowly B. Make sure the IV fluid contains potassium C. Increase oral intake of fluid D. Provide a diet high in protein and sodium
A
A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A. burp the infant at least 2-3 times during the feeding B. remove the nipple from the infant's mouth if swallowing becomes audible C. stop the feeding if formula appears in the nasal cavity of the infant D. discourage the parents from participating in the feeding prior to a surgical repair
A
A nurse is providing teaching to the parent of a child who is having an EEG. Which of the following responses should the nurse include in the teaching? A. "decaffinated beverages should be offered on the morning of the procedure" B. "don't wash your child's hair the night before the procedure" C. "withhold all foods the morning of the procedure" D. "give your child an analgesic the night before the procedure"
A
A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia? A. patch the unaffected eye B. administer mydriatic eye drops daily C. obtain prescription eyeglasses D. administer antihistamines
A
During the assessment of a preschooler, the nurse notes that the child has abnormal dryness and thickening of the conjunctiva and dry and scaly skin. Which vitamin deficiency does the nurse suspect this child is experiencing? A. Vitamin A B. Vitamin B C. Vitamin D D. Vitamin E
A
A nurse is teaching the parents of a toddler who has enterobiasis about managing this parasitic disease. Which of the following pieces of information should the nurse include in the teaching? A. you should encourage your child to take a tub bath daily B. you should keep your child's fingernails trimmed short C. you should dress your child in a 2-piece outfit at bedtime D. you should expect your child not to have a recurrence of the parasitic disease
B
A school-aged girl with Crohn's disease will receive total parenteral nutrition (TPN) for the next 6 weeks. Which would best help her accept the treatment plan? A. Help her ambulate with the bottles. B. Provide some time to talk to her several times a day. C. Help her give the bottles nicknames and personalities. D. Explain that TPN substitutes for normal food.
B
The school nurse is educating the parents of a child with infectious conjunctivitis. Which of the following statements by the nurse would be most helpful for the parents related to prevention? A. "Use all the medication as directed." B. "Don't use anything that touches her face." C. "This could have started with a head cold." D. "Place the ointment inside the lower eyelid."
B
Which is most likely the underlying physiology of primary enuresis? A. psychogenic stress B. delayed bladder maturation C. UTI D. vesicoureteral reflux
B
Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant w/ gastroesophageal reflux? A. urine B. vomiting C. weight D. stools
B
A nurse is caring for a school-age child who has glomerulonephritis. The child has decreased UOP & a BP of 160/78 & is receiving hydralazine. Which of the following lunch choices should the nurse recommend? A. 1 hot dog, 22 potato chips, 120 ml (4oz) of oj B. 1 sandwich w/ lettuce, tomato & 4 slices of bacon, a small apple and 240 mL (8oz) of milk C. 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4oz) of apple juice D. 1 cup of cottage cheese, a small banana & 240 mL (8 oz) of soda
C
A nurse is planning care for a 3mo who has an ileostomy. Which of the following interventions should the nurse include in the plan? A. avoid laying the infant on his abdomen B. avoid tucking the appliance into the infant's diaper C. check the bag for stool every 4 hrs D. replace the appliance every 3 days
C
A nurse is providing discharge teaching to the parent of an infant following a hypospadias repair. Which of the following instructions should the nurse include? A. clamp the infant's catheter for 30 mins each day B. give the infant a tub bath once per day C. apply antibacterial ointment to the infant's penis once per day D. decrease the infant's fluid intake for 3 days
C
A nurse is providing postoperative teaching to the parent of a 3mo infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching? A. I will expect the site to bulge when my baby cries B. I will place a belly band around my baby's abdomen C. I will fold my baby's diaper away from the incision D. I will bathe my child in the bathtub daily
C
A nurse is providing teaching to the parent of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to the facilitate communication w/ the child? A. exaggerate the pronunciation of each word B. keep hands still when speaking C. speak at the child's eye level D. avoid using facial expressions when speaking
C
A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. absence of bowel sounds B, neck contortions C. barking cough D. projectile vomiting
C
A nurse is teaching the parents of an infant who has mild gastroesophageal reflux (GER). Which of the following instructions about feeding therapies should the nurse recomment? A. apply the infant's diaper snugly prior to feedings B. administer nasogastric feedings C. thicken feedings w/ rice cereal D. place the infant in a lateral position for 1 hr after feedings
C
An infant failed to pass meconium w/in the 1st 24hrs after birth; this may indicate which of the following? A. celiac disease B. intussusception C. Hirschsprung's disease D. abdominal-wall defect
C
A clinic nurse is providing teaching to the parent of a 1mo who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. I will give lansoprazole 30 min after my baby's feedings B. I will lay my baby on her side after feedings C. I will give my baby a bottle just before bedtime D. I will add rice cereal to my baby's feedings
D
A nurse is caring for a 12mo infant following the surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? A. spoon B. straw C. firm nipple D. cup
D
A nurse is caring for a 4mo infant who has meningitis. Which of the following findings is associated w/ this Dx? A. depressed anterior fontanel B. constipation C. presence of the rooting reflex D. high-pitched cry
D
A nurse is caring for a 5yo child who has a fever & begins to have a seizure. Which of the following actions should the nurse take? A. give acetaminophen 240 mg PO immediately following the seizure B. sponge the child's skin w/ a mixture of cold water & rubbing alcohol C. administer rectal diazepam if the seizure lasts longer than 2 mins D. place the child in a side-lying position
D
A nurse is caring for a 6mo infant & has moderate dehydration. Which of the following findings should the nurse expect? A. absent tears B. Wt loss >10% C. lethargy D. dry mucous membranes
D
A nurse is teaching the parent of a school-age child who has celiac disease. Which of the following foods selected by the parent indicates an understanding of the teaching? A. corn tortilla w/ black beans B. pizza C. canned soup D hot dogs
A
A 12yo has recurring nephrotic syndrome; which of the following areas of potential disturbances should be a prime consideration when planning ongoing nursing care? A. body image B. sexual maturation C. muscle coordination D. intellectual development
A
A 7yo has cystits; which of the following would the nurse expect when assessing the child? A. dysuria B. costovertebral tenderness C. flank pain D. high fever
A
A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? A. abdominal distention B. unequal peripheral pulses C. pinpoint pupils D. frontal bossing
A
A nurse is assessing an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing? A. high-pitched cry B. sunken fontanel C. tachycardia D. increased awake time
A
A nurse is caring for a 2yo who has frequent UTIs. When educating the parents about the prevention of UTIs, which of the following instructions should the nurse include? A. teach the child to wipe from front to back B. give the child frequent bubble baths C. urge the child to urinate every 6 hr D. administer oxybutyin daily
A
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is determined. Which of the following responses should the nurse make? A. an abdominal ultrasound will confirm the pocket in the intestine B. genotyping will be done to identify this condition C. a biopsy will be done on a small amt of tissue from the colon D. an upper GI series should identify the area involved
A
A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take? A. perform a tape test B. collect stool specimen for culture C. test the stool for occult blood D. initiate IV fluids
A
A nurse is caring for a female adolescent who is being treated for frequent UTIs. Which of the following statements by the adolescent indicates a possible cause of the UTIs? A. I have BMs every 4-5 days B. My mom taught me to wipe from front to back after going to the bathroom D. I urinate every 2-3 hr during the day D. I don't wear nylon underwear
A
A nurse is caring for a pt who has suspected meningitis & a decreased LOC. Which of the following actions by the nurse is appropriate? A. Place the pt on NPO status B. Prepare the pt for a liver biopsy C. Position the pt dorsal recumbent D. Put the pt in a protective environment
A
A nurse is caring for a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse perform first? A. position the child on his side B. measure the child's VS C. loosen any restrictive clothing D. check the child for head injuries
A
A nurse is teaching the parents of an infant about Tx options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants? A. they provide direct stimulation of auditory nerve fiber B. they conduct sound waves through the mastoid bone to the cochlea C. they process digital sound to amplify several sound frequencies D. they convert vibrations in the ear's structure to electrical signals
A
The nurse is assessing a 7-year-old with a hearing aid. His mother says he is losing his hearing again. Which finding would the nurse identify as contributing to this current complaint? A. Overproduction of cerumen B. Soreness of the outer ear C. History of a normal term birth D. The eardrum responds to a puff of air
A
The nurse is caring for a 12-year-old girl with nephrotic syndrome. The girl confides that she feels like a "freak" compared to her peers because of her weight, edema, and moon face. Which response by the nurse would be most appropriate? A. "Let's put you in touch with some other girls who are also having the same body changes." B. "Luckily, this is just a temporary, unfortunate part of your condition; you need to accept it." C. "Your real friends do not care about your appearance and just want you to get well." D. "You are beautiful in your own way; what matters is what is on the inside."
A
The nurse is caring for a child diagnosed with a urinary tract infection. The caregiver asks the nurse why it is so important for the child to have so much fluid. What is the most important reason the child needs increased fluids? A. To dilute the urine and flush the bladder B. To fill the bladder so a specimen can be obtained C. To prevent the child from developing a fever D. To decrease the pain of urination
A
A nurse is assessing an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority? A. decreased skin turgor B. capillary refill 5 seconds C. heart rate 150/min D. dry mucous membranes
B
A nurse is caring for a 6wo infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure? A. bottle formula w/ added protein B. small, frequent bottle feedings of electrolyte solution C. continuous nasoduodenal tube feedings D. bolus feedings via gastrostomy tube
B
A nurse is caring for a child who has a ruptured appendix. Which of the following positions should the nurse encourage the child to maintain? A. supine B. semi-Fowler's C. Sims' D. orthopneci
B
A 7-month-old is scheduled for surgical correction of strabismus. The child's mother says to the nurse, "I'm glad my child will never have to wear that patch again." Which of these responses would be most appropriate for the nurse to make? A. "Your child will never need to wear the patch again." B. "Your child will need to wear the patch for a few days to keep him/her from rubbing or putting pressure on the eye." C. "Your child will need to wear the patch for several months to keep the eye in alignment." D. "Your child will have to be in restraints for a week to keep him/her from rubbing the eye."
B
A child is having their urine checked for complaints of polyuria. When analyzing the results, what would positive glucose indicate? A. This may indicate a urinary tract infection. B. This determines the presence of sugar in the urine. C. This indicates renal disease. D. This determines the presence of bacteria in the urine.
B
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. perform nasotracheal suctioning B. test the nasal secretions for glucose C. maintain direct lighting on the child D. lower the head of the bed
B
A nurse is assessing a school-age child who has celiac disease. Which of the following findings should the nurse expect? A. elevated sweat chloride B. steatorrhea C. clubbing of the fingers D. jaundice
B
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? A. upper right quadrant abdominal pain B. rigid abdomen C. hyperactive bowel sounds D, bradycardia
B
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. maintain the child on strict bed rest B. check the child's BP every 4 hr C. administer albumin to the child every 8 hr D. provide the child w/ a low-carbohydrate diet
B
A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an appropriate action for the nurse to take? A. offer chicken broth B. initiate oral rehydration Thx C. start hypertonic IV solution D. keep NPO until the diarrhea subsides
B
A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. obtain a portable suction machine & suction tubing B. ease the child to the floor in Sims' position C. time the length of the sizure D. notify the child's parents
B
A nurse is caring for a toddler who has gastroenteritis caused by Salmonella. Which of the following is the priority action for the nurse? A. weight the child B. initiate contact precautions C. establish a skin care routine D. obtain a recent food history
B
A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recomment? A. 1/2 cup whole milk B. 1/2 cup cooked pinto beans C. 1 cup green leaf lettuce D. 1 cup apple juice
B
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room? A. A room with a 12-month-old infant with a urinary tract infection B. A room with an 8-month-old infant with failure to thrive C. A private room near the nurses' station D. A two-bed room in the middle of the hall
C
A lumbar puncture is performed on a child suspected to have bacterial meningitis & CSF is obtained for analysis. The nurse reviews the results of the CSF analysis & determines that which results would verify the Dx? A. clear CSF, decreased pressure, elevated protein level B. clear CSF, elevated protein, decreased glucose levels C. cloudy CSF, elevated protein, decreased glucose levels D. cloudy CSF, decreased protein, decreased glucose levels
C
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. slight thirst B. capillary refill of 3 seconds C. deep, rapid respirations D. decreased tear production
C
A nurse is caring for a 13-year-old boy with end-stage renal disease who is preparing to have his hemodialysis treatment in the dialysis unit. Which nursing action is appropriate? A. Administer his routine medications as scheduled B. Take his blood pressure measurement in extremity with AV fistula C. Withhold his routine medication until after dialysis is completed D. Assess the Tenckhoff catheter site
C
A nurse is caring for a 6mo infant who has intussusception. Which of the following actions should the nurse take? A. prepare to administer high-dose steroids B. give the child magnesium hydroxide PO C. prepare the child for a barium enema D. inform the parents that the child will need a colostomy
C
A nurse is caring for a 6yo child who is experiencing encopresis. Which of the following actions should the nurse take? A. instruct the child's guardian to limit stool softener use to no more than twice a week B. encourage the child to attempt to have a bowel movement 4 times a day C. determine if there are any recent stressors in the child's environment D. urge the child's guardian to provide negative consequences when the child has a bowel accident
C
A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? A. monitor the child's BP twice a day B. maintain the child on bed rest for 3 days C. weigh the child once each day D. increase the child's daily intake of sodium
C
The parents of a child with a history of seizures who has been taking phenytoin (Dilantin) ask the nurse why it's difficult to maintain therapeutic plasma levels of this medication. Which statement by the nurse would be most accurate? A. "A drop in the plasma drug level will lead to a toxic state." B. "The capacity to metabolize the drug becomes overwhelmed over time." C. "Small increments in dosage lead to sharp increases in plasma drug levels." D. "Large increments in dosage lead to a more rapid stabilizing therapeutic effect."
C
A nurse is caring for a school-aged child who has acute post-streptococcal glomerulonephritis. Which of the following manifestations should the nurse expect? A. hypotension B. elevated serum lipid levels C. decreased serum potassium levels D. hematuria
D
A nurse is performing an assessment on a child. What would be indicative of a potential for a urinary tract infection? A. Washing the genital area with water daily B. Not using cleansing towelettes routinely C. Not using soap when cleaning the urethral area D. Holding urine while at school
D
A nurse is planning care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. airborne precautions B. contract precautions C. protective environment D. droplet precautions
D
A nurse is planning to perform a peripheral vision test on a child. Which of the following actions should the nurse take? A. place the child 10 feet away from a Snellen chart B. show a set of cards to the child one at a time C. cover the child's eye while performing the test on the other eye D. have the child focus on an object while performing the test
D
A nurse is preparing to administer an enema to a 10mo infant. Which of the following actions should the nurse plan to take? A. administer the enema using room-temperature tap water B. insert the tubing 7.5 cm (3in) into the rectum C. position the infant sitting upright on a bedpan while administering the enema D. hold the infant's buttocks together after administering the fluid
D
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse provide? A. the test determines the level of antibiotics in your child's blood B. the test tells us if your child ever had measles C. the test verifies the amount of albumin in your child's blood D. the test shows us if your child had a recent strep infections
D
A nurse is reviewing lab findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. hypokalemia B. hypercalcemia C. decreased plasma creatinine level D. metabolic acidosis
D
The nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A. restrict the child's potassium intake B. administer acetaminophen to the child twice daily C. weigh the child once each week D. keep the child away from people who have an infection
D
A nurse is performing a visual acuity screening for a school-aged child using the Snellen letter chart. Which of the following actions should the nurse take? A. position the child 5 ft away from the letter chart B. have the child wear his glasses during the vision screening C. observe for pupillary constriction while shining a light into the child's eye D. instruct the child to point in the directions the letters are facing
B
A nurse is planning care for a preschooler who is immediately postop following the placement of a ventriculoperitoneal (VP) shunt. Which of the following interventions should the nurse include in the plan? A. monitor the preschooler's pupils every 8 hrs B. lay the preschooler on the nonoperative side C. keep the HOB elevated to 30 degrees D. check bowel sounds once per day
B
A nurse is reviewing the lab results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005
B
The nurse is conducting a physical examination of a child with suspected Crohn disease. Which finding would be the most suspicious of Crohn disease? A. Normal growth patterns B. Perianal skin tags or fissures C. Increased hunger D. Abdominal tenderness
B