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A nurse is providing education for the family of a 6-month-old infant about ways to stimulate language development. Which of the following instructions should the nurse include? A. "Explain what you are doing to the infant while providing care." B. "Promote fine-motor development of the tongue by offering a pacifier several times each day." C. "Exercise jaw muscles with foods that require chewing, such as hot dogs and carrots." D. "Leave a television playing in the child's room during nap time."

Correct Answer: A. "Explain what you are doing to the infant while providing care." The nurse should instruct the family that exposing the infant to expressive speech is the foundation for the development of expressive skills (the ability to make others understand needs and thoughts) and receptive skills (the ability to understand spoken words).

A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will lock my medications in the medicine cabinet." B. "I will keep my child's crib mattress at the highest level." C. "I will turn pot handles to the side of my stove while cooking." D. "I will give my child syrup of ipecac if she swallows something poisonous."

Correct Answer: A. "I will lock my medications in the medicine cabinet." Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow further exploration of the environment and possible access to hazardous substances.

A nurse is teaching the family of a child about hospice care. Which of the following statements should the nurse include in the teaching? A. "The hospice staff will be the primary caregivers for the child." B. "Hospice staff members consider the family's needs to be just as important as those of the child." C. "Hospice care will end with the death of your child." D. "The priority of hospice care is to provide curative treatment for the child."

Correct Answer: B. "Hospice staff members consider the family's needs to be just as important as those of the child." The nurse should inform the family that part of the philosophy of hospice care is to provide care for the family's needs as well as those of the child. Assisting with respite care, counseling, spiritual needs, and care of the family following the child's death are all part of hospice care.

A nurse is providing teaching about disease management to the parent of a preschooler who has a new diagnosis of asthma. Which of the following parent statements indicates an understanding of the teaching? A. "My child should not receive live virus vaccines." B. "I will encourage my child to participate in sports." C. "I will give my child aspirin when she has a fever." D. "My child will outgrow asthma by adulthood."

Correct Answer: B. "I will encourage my child to participate in sports." The parent should encourage the child to remain physically active because this promotes lung expansion and air exchange.

A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor? A. Preeclampsia B. Alcohol consumption C. Placenta previa D. Late prenatal care

Correct Answer: B. Alcohol consumption Alcohol consumption is a maternal risk factor for the development of congenital heart disease.

A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? A. Brightly colored mobile B. Plastic stethoscope C. Small-piece jigsaw puzzle D. Book of short stories

Correct Answer: B. Plastic stethoscope Preschool play centers on imitative activities. Providing a stethoscope allows the child to engage in therapeutic play. Imitating health care personnel may ease the child's fear of unfamiliar equipment.

A nurse in a provider's office is observing children playing in the waiting room. The nurse should expect to identify parallel behavior in which of the following age groups? A. Infants B. Toddlers C. Preschoolers D. School-age children

Correct Answer: B. Toddlers Toddlers demonstrate parallel play.

A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I will breathe in through the mouthpiece, hold my breath for 5 sec, and then exhale." B. "If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10 sec interval." D. "I will record the highest reading of three attempts."

Correct Answer: D. "I will record the highest reading of three attempts." After establishing a personal best, the client should routinely check the PEFM by performing 3 attempts and recording the highest reading of the 3.

A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? A. Hypotension B. Stomatitis C. Bloody diarrhea D. Periorbital edema

Correct Answer: D. Periorbital edema Periorbital edema is an expected finding in a child who has glomerulonephritis.

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? "I will puncture the pad of my finger when I am testing my blood glucose." "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." "I will decrease the amount of fluids I drink when I am sick."

"I will give myself a shot of regular insulin 30 minutes before I eat breakfast." The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.

A nurse is teaching about skin care to the parent of an infant who has diaper dermatitis. Which of the following statements by the parent indicates an understanding of the teaching? "I will use a heat lamp to dry my baby's rash." "I should avoid using superabsorbent diapers." "I will leave the diaper off my baby several times during the day." "I should use a disposable diaper wipe containing detergent."

"I will leave the diaper off my baby several times during the day." Allowing the perineal skin to remain open to air several times during the day helps the skin and rash area dry. Changing the diaper as soon as it becomes wet will also help improve the skin integrity.

A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? "I will offer my child small amounts of fruit juice frequently." "I will avoid giving my child solid foods until the diarrhea has stopped." "I will monitor my child's number of wet diapers." "I will give my child polyethylene glycol daily for 7 days."

"I will monitor my child's number of wet diapers." The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status.

A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? "Shake the medication prior to administration." "Provide the medication through a straw." "Rinse the child's mouth with water immediately after giving the medication." "Mix the medication with applesauce if the child dislikes the taste."

"Shake the medication prior to administration." The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension.

A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? "You should offer your child high-protein meals and snacks throughout the day." "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." "You should restrict your child's calorie intake to 1,200 per day." "You should give your child a multivitamin once weekly."

"You should offer your child high-protein meals and snacks throughout the day." The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection.

A nurse is teaching an adolescent who has sickle cell disease about prevention of vaso-occlusive crisis. Which of the following statements should the nurse include in the teaching? "You should receive the pneumococcal vaccine." "You should apply cold compresses to painful areas." "You should avoid using narcotic pain medication." "You should limit your daily fluid intake."

"You should receive the pneumococcal vaccine." The nurse should instruct the client that they should receive the pneumococcal vaccine because infections are a major cause of death in clients who have sickle cell disease.

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return? "Your daddy will be back at 7 p.m." "Your daddy will be back after he takes care of your brother." "Your daddy will be back in the morning." "Your daddy will be back after you eat."

"Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first? A school-age child who has sickle cell anemia and reports decreased vision in the left eye A school-age child who has cystic fibrosis and a frequent nonproductive cough A preschooler who has asthma and a peak flow meter reading in the green zone An adolescent who has meningitis and reports a sensitivity to lights and noise

A school-age child who has sickle cell anemia and reports decreased vision in the left eye When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first? A toddler who has a concussion and an episode of forceful vomiting An adolescent who has infective endocarditis and reports having a headache An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 A school-age child who has acute glomerulonephritis and brown-colored urine

A toddler who has a concussion and an episode of forceful vomiting When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.

A nurse is performing a developmental assessment for a 2-year-old toddler. Which of the following findings should the nurse report to the provider? Inability to build a tower with more than 10 blocks Ability to participate in parallel play Inability to draw a three-part stick figure Ability to speak with a vocabulary of less than 50 words

Ability to speak with a vocabulary of less than 50 words The nurse should recognize that a 2-year-old toddler should have a vocabulary of approximately 300 words. Therefore, the nurse should report this finding to the provider.

A nurse is developing a plan of care for a child who is experiencing status asthmaticus. Which of the following interventions should the nurse include? Maintain oxygen saturation greater than 87%. Administer salmeterol via a nebulized aerosol. Measure the child's peak expiratory flow rate. Administer an intravenous corticosteroid.

Administer an intravenous corticosteroid. The nurse should administer an intravenous corticosteroid to a child who is experiencing status asthmaticus. Corticosteroids decrease inflammation quickly due to rapid onset, which improves oxygenation until bronchodilators take effect.

A nurse in an emergency department is assessing a 2-year-old child who has a temperature of 39º C (102.2º F), is drooling, and maintains an upright tripod position. The nurse suspects the client has epiglottitis. Which of the following actions should the nurse take? Obtain a throat culture. Assign an assistive personnel to accompany the client to radiology. Administer humidified oxygen via blow-by. Perform oropharyngeal suctioning.

Administer humidified oxygen via blow-by. Oxygen is humidified and administered to the child via mask or blow-by to correct hypoxia and ease respirations. The nurse should monitor the child's breath sounds and the presence of substernal or suprasternal retractions.

A school nurse is assessing a school-age child who has asthma and whose peak expiratory flow rate is in the red zone. Which of the following interventions should the nurse take? Administer salmeterol via a metered-dose inhaler. Allow the child to participate in physical education. Quarantine the child from other students. Administer levalbuterol nebulizer treatment.

Administer levalbuterol nebulizer treatment. The child whose peak expiratory flow rate is in the red zone is in immediate danger of respiratory compromise and needs immediate treatment with a short-acting beta agonist, such as levalbuterol, used for acute exacerbations of asthma. Following administration of the medication, the child should complete the test again. The nurse should notify the parent and the child's provider if the peak expiratory flow rate does not return to the yellow or green zones.

A nurse is reviewing the laboratory results of a school-age child who recently had a group A beta hemolytic streptococcal infection. Which of the following findings should the nurse report to the provider? BUN 30 mg/dL Potassium 3.9 mEq/L Cholesterol 180 mg/dL Sodium 144 mEq/L

BUN 30 mg/dL The nurse should report a BUN of 30 mg/dL because it is above the expected reference range of 15 to 18 mg/dL for a school-age child. An elevated BUN following a group A beta hemolytic streptococcal infection is an indication of acute glomerulonephritis.

A nurse is evaluating the growth and development skills of a 3-year-old preschooler during a well-child visit. Which of the following findings should the nurse expect? Names four colors Builds a tower using 9 to 10 blocks Catches a ball well Draws a stick figure with seven parts

Builds a tower using 9 to 10 blocks The nurse should expect a 3-year-old preschooler to be able to build a tower using 9 to 10 blocks. The child should also be able to ride a tricycle, walk up steps using alternating feet, and jump off a bottom step.

A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? Check the child for a head injury. Observe for oral bleeding. Check the child's respiratory rate. Observe for extremity weakness.

Check the child's respiratory rate. When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths.

A nurse is performing a developmental assessment on a 3-year-old child. Which of the following commands should the nurse expect the child to complete successfully? A. "Put your shoes on." B. "Name the days of the week." C. "Cut out this picture with a pair of scissors." D. "Balance on 1 foot with your eyes closed."

Correct Answer: A. "Put your shoes on." Children should be able to pull on their shoes when they are 3 years old. They typically cannot tie their shoes until they are 5 years of age.

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

Correct Answer: A. Abdominal distention A VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus.

A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure

Correct Answer: A. Bulky stools The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools.

A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include as an expected finding for this age group? A. Copying a circle B. Cutting foods using a table knife C. Beginning to write in cursive D. Printing the first and last name clearly

Correct Answer: A. Copying a circle The nurse should explain that copying a circle is a skill achieved by the age of 4 years.

A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring the child's stuffed animal B. Give the child choices when planning daily activities C. Administer phenytoin 3 times per day D. Provide a shared room with another child his age

Correct Answer: A. Encourage the parents to bring the child's stuffed animal Encouraging parents to bring in a child's favorite stuffed animal may lessen the disruptiveness of hospitalization.

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

Correct Answer: A. High-pitched cry The nurse should identify that an infant's high-pitched cry is an indication of increased ICP. Other indications include a bulging fontanel, a high-pitched cry, and increased sleeping.

A nurse is assessing the gross motor skills of a 4-year-old preschooler. The nurse should expect the preschooler to perform which of the following activities? A. Hopping on 1 foot B. Skipping on alternate feet C. Jumping rope D. Roller skating

Correct Answer: A. Hopping on 1 foot The nurse should expect a 4-year-old preschooler to hop on 1 foot.

A nurse is teaching a newly hired nurse about caring for an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? A. Hydrocephalus B. Congenital hypotonia C. Otitis media D. Osteomyelitis

Correct Answer: A. Hydrocephalus In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered. Therefore, the infant is at risk of hydrocephalus, and the nurse should monitor the infant for this condition.

A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the child's protein intake B. Decrease the child's calorie intake C. Increase the child's fiber intake D. Decrease the child's salt intake

Correct Answer: A. Increase the child's protein intake The nurse should recommend an increased protein intake for the child who has cystic fibrosis. These children require up to 150% of the recommended daily allowance to meet their nutritional needs.

A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include? A. Initiate protective-environment isolation for the child B. Apply pressure for 1-2 min at the puncture site following blood specimen collection C. Mix the child's ferrous sulfate elixir twice per day into a glass of milk for administration D. Check the child's blood glucose level every 4 hr

Correct Answer: A. Initiate protective-environment isolation for the child The nurse should suggest protective-environment isolation for the child, which consists of a private room with positive air pressure and no live flowers; nurses must don a respirator mask, gloves, and gown prior to entering the child's room. A child who has aplastic anemia has decreased RBCs, platelets, and WBCs, causing immune suppression and increasing susceptibility to infection.

A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry

Correct Answer: A. Provide a high-fat diet for the toddler Children who have cystic fibrosis have impaired intestinal absorption of fat. Therefore, the toddler will require an increased intake of fat.

A nurse is performing a well-child assessment on a 4-year-old child. Which of the following findings should the nurse expect? A. The child is able to hop on 1 foot. B. The child is able to build a tower of up to 6 blocks. C. The child is able to name the days of the week. D. The child is able to identify left and right.

Correct Answer: A. The child is able to hop on 1 foot. The nurse should expect a 4-year-old child to have the gross motor ability to hop on 1 foot.

A nurse on a pediatric unit is caring for a preschooler who is prescribed an IV medication. Which of the following actions should the nurse take to prepare the child for the procedure? A. Use role-play activities with the child B. Provide the child with a detailed explanation of the procedure C. Implement interactive sessions of 30 min each with the child D. Give the child identical IV supplies to play with

Correct Answer: A. Use role-play activities with the child Using role-play activities with the child will decrease the child's anxiety about the procedure. This will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure.

A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg (4 lb) B. Heart rate of 125/min C. Soft, flat fontanel D. Systemic murmur

Correct Answer: A. Weight gain of 1.8 kg (4 lb) A 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider.

A nurse is providing discharge teaching to parents whose infant 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."

Correct Answer: B. "We will notify the doctor right away if he has a fever." Infection is a risk after ventriculoperitoneal shunt insertion, especially 1 to 2 months after placement. The parents should report fevers, vomiting, seizure activity, and decreased responsiveness, as these findings can indicate infection.

A nurse is reviewing the laboratory 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

Correct Answer: B. 1.035 1.035 is a concentrated specific gravity, which is an expected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hours.

A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan to offer which of the following benefits? A. Decrease the child's fear of the dark B. Allow the child to manipulate toy medical equipment C. Provide an opportunity to analyze the child's emotions D. Encourage parents to engage with their child

Correct Answer: B. Allow the child to manipulate toy medical equipment A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging the child to touch the equipment, the nurse is helping decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people.

A nurse is instructing a group of parents and guardians about child development. Which of the following recommendations should the nurse make to promote the developmental task of industry in the school-age child? A. Have an after-school snack ready for the child each day B. Assign the child several small chores C. Talk with the child about what future goals as an adult D. Talk openly about the family's value system

Correct Answer: B. Assign the child several small chores The nurse should recommend assigning the child several small chores. The completion of each chore in a short amount of time offers the child a sense of accomplishment and promotes the achievement of the developmental task of industry.

A nurse is assessing the fine motor skill development of a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Tying shoelaces into a bow B. Copying a square C. Drawing a person with at least 8 parts D. Printing the letters of her name

Correct Answer: B. Copying a square The nurse should expect a 3-year-old child to have the fine motor ability to copy a circle. A 4-year-old child should have the ability to copy a square.

A nurse is observing the behavior of a 2-year-old child. Which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers? A. Playing a simple game with another child B. Engaging in play near other children C. Sharing crayons with another toddler D. Jumping on 1 foot without help

Correct Answer: B. Engaging in play near other children The nurse should identify that toddler play happens in parallel to that of other children. As socialization begins, the child plays alongside other children, not with them.

A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeping on hands and knees B. Inability to vocalize vowel sounds C. Using a crude pincer grasp D. Standing by holding onto a support

Correct Answer: B. Inability to vocalize vowel sounds The infant should begin vocalizing vowel sounds at the age of 7 months. By the age of 10 months, the infant should be able to say at least 1 word

A nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion D. Autonomy vs. shame and doubt

Correct Answer: B. Industry vs. inferiority The developmental task of industry vs. inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years (ages 6 to 12 years).

A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEq/L

Correct Answer: B. Oxygen saturation 85% The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should report this finding to the provider immediately.

A nurse is assessing the gross and fine motor behaviors of a toddler. Which of the following behaviors should the nurse identify as an expected achievement for a 3-year-old child? A. Walking backward while moving heel to toe B. Standing on 1 foot for several seconds C. Using scissors to cut out shapes D. Printing letters with a pencil

Correct Answer: B. Standing on 1 foot for several seconds Standing on 1 foot for several seconds is an expected behavior for a toddler.

A nurse is providing teaching to a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding of the teaching? A. "Impetigo is caused by a virus." B. "Impetigo is contagious for 48 hours after vesicles rupture." C. "I will wash my child's clothes in hot water." D. "My child now has immunity against impetigo."

Correct Answer: C. "I will wash my child's clothes in hot water." The parent should wash the child's clothes in hot water to kill bacteria. The parent should also keep the child's towels and washcloths separate from those of other members of the household.

A nurse is providing teaching about oxycodone to an adolescent who is experiencing a vaso-occlusive crisis. Which of the following pieces of information should the nurse include? A. "This medication can cause diarrhea." B. "This medication can cause an increase in blood pressure." C. "This medication might cause nausea." D. "This medication can cause an increase in salivation."

Correct Answer: C. "This medication might cause nausea." The nurse should instruct the adolescent that nausea is an adverse effect of oxycodone. Other adverse effects include dizziness, sedation, and confusion.

A nurse is providing teaching to the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the teaching? A. "Donepezil might slow the progression of the disorder." B. "My child will prefer group therapy with other children." C. "We can help our child by structuring our daily routine." D. "Our child probably has this condition as a result of prematurity

Correct Answer: C. "We can help our child by structuring our daily routine." Children who have autism spectrum disorder benefit from a structured routine. This environment can minimize the anxiety the child might have with sudden schedule changes and socialization requirements and satisfy a preference for ritualistic behavior.

A nurse is caring for a 4-month-old child who is hospitalized. Which of the following toys should the nurse provide for the child? A. A board book with large pictures B. A toy with movable parts C. A plastic mirror D. Push-pull toy

Correct Answer: C. A plastic mirror A 4-month-old infant can recognize herself and will also attempt to play with "the baby in the mirror." A mirror is a bright object that provides appropriate visual stimulation for this age group. For the infant's safety, however, the mirror must be unbreakable.

A nurse is providing anticipatory guidance about the accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk. B. Go to an emergency department. C. Call the poison control center. D. Induce vomiting.

Correct Answer: C. Call the poison control center. According to evidence-based practice, the nurse should instruct the parents to call the poison control center, which will then identify what further actions the parents should take.

A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? A. Preschoolers have the highest rates of maltreatment. B. In single-parent families, the parent's non-biological partner is typically the abuser of the child. C. Children who were born prematurely are more likely to be maltreated. D. Child maltreatment occurs equally across all socioeconomic groups.

Correct Answer: C. Children who were born prematurely are more likely to be maltreated. Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often have increased care needs, which increases the risk of caregiver fatigue and can lead to an increased potential for maltreatment.

A nurse is assessing the vital signs of a 1-month-old infant. Which of the following actions should the nurse perform? A. Use a cuff to auscultate blood pressure B. Determine heart rate by taking the radial pulse C. Count respirations before taking other vital signs D. Measure temperature by placing the thermometer in the infant's ear

Correct Answer: C. Count respirations before taking other vital signs It is best to count the infant's respirations while the infant is calm and before being disturbed. The pulse should be taken next, followed by the temperature, which is the most disruptive assessment to an infant.

A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? A. Pull the infant's pinna up and back when examining the ears B. Palpate and count the infant's radial pulse for 15 seconds C. Examine the infant's throat at the end of the examination D. Check the infant's blood pressure in both arms

Correct Answer: C. Examine the infant's throat at the end of the examination The nurse should perform noninvasive assessments first to avoid causing the infant to cry, which can make the remainder of the examination difficult.

A nurse is assessing a 24-month-old toddler who has a new diagnosis of autism spectrum disorder (ASD). Which of the following findings should the nurse expect? A. Wanting to be held frequently B. Ability to build a tower of 10 cubes C. Impaired language skills D. Ability to stand on 1 foot

Correct Answer: C. Impaired language skills The nurse should expect a 24-month-old toddler who has ASD to exhibit impaired language skills (e.g. failing to respond to his or her name, pointing to objects instead of speaking).

nurse in an emergency department is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report as an indication of impending airway obstruction? A. Bradycardia B. Respiratory depression C. Nasal flaring D. Barking cough

Correct Answer: C. Nasal flaring Acute laryngotracheobronchitis (croup) causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increasing restlessness, flaring nares, and intercostal retractions.

A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria

Correct Answer: C. Tachypnea An infant who has moderate dehydration will have slight tachypnea.

A nurse is assessing a 3-year-old child during a well-child examination. Which of the following findings should the nurse report to the provider? A. The child wets the bed when sleeping B. The child cannot catch a ball C. The child cannot walk on tiptoe D. The child builds a tower of 10 cubes

Correct Answer: C. The child cannot walk on tiptoe The nurse should identify that a child should be able to take a few steps on tiptoe by 30 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A. Bruising of the right elbow B. Dislocated left shoulder revealed by X-ray C. Thin, frail extremities D. Abrasions on both wrists

Correct Answer: C. Thin, frail extremities The nurse should identify that thin, frail extremities are related to malnourishment and can indicate child maltreatment. The nurse should investigate this finding further and report the results to the provider.

A nurse in the emergency department is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as an indication of digoxin toxicity? A. Irritability B. Diaphoresis C. Vomiting D. Tachycardia

Correct Answer: C. Vomiting The nurse should identify that vomiting, especially when unrelated to feedings, is a manifestation of digoxin toxicity. The nurse should report this finding to the provider immediately.

A nurse is reviewing the laboratory reports of a child with acute nephrotic syndrome who has been receiving prednisone by mouth for the past week. Which of the following findings should the nurse report to the provider? A. Serum sodium 142 mEq/L B. Serum potassium 4 mEq/L C. WBC count 3,000/mm^3 D. Platelet count 298,000/mm^3

Correct Answer: C. WBC count 3,000/mm^3 The nurse should understand that the use of corticosteroids suppresses the child's immune system and increases the risk of infection. The nurse should identify that a WBC count of 3,000/mm^3 is below the expected reference range for a child and should report this finding to the provider.

A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? A. Monitor the child's blood pressure twice per 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

Correct Answer: C. Weigh the child once each day The nurse should weigh the child at the same time each day to monitor fluid balance.

A nurse is providing teaching about home care to the guardian of a school-aged child who has seizures. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will call an ambulance if my child's seizure lasts more than 10 minutes." B. "I will offer my child clear liquids immediately following a seizure." C. "I will tightly hold my child to restrain her during a seizure." D. "I will turn my child onto her side when a seizure begins."

Correct Answer: D. "I will turn my child onto her side when a seizure begins." To reduce the risk of aspiration and to improve oxygenation, the guardian should place the child in a side-lying position.

A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include? A. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." B. "A toddler first shows interest in looking at pictures at 20 months of age." C. "A toddler should have daytime control of his bowel and bladder by 24 months of age." D. "Your child should be able to scribble spontaneously using a crayon at 15 months of age."

Correct Answer: D. "Your child should be able to scribble spontaneously using a crayon at 15 months of age." At the age of 15 months, the toddler should be able to scribble spontaneously. At the age of 18 months, the toddler should be able to make strokes imitatively.

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A. Small plastic doll with clothes and accessories B. Alphabet flash cards C. Handheld video game D. 10-piece wooden puzzle

Correct Answer: D. 10-piece wooden puzzle Age-appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow manipulation and exploration and meet the child's developmental and diversional activity needs.

A nurse in the emergency department is assessing a preschooler for indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Frequent urinary tract infections D. Bruises at various stages of healing

Correct Answer: D. Bruises at various stages of healing The nurse should recognize that bruises at various stages of healing are a manifestation of physical abuse.

A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. Give the child a kaleidoscope and ask the child to find different designs B. Encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. Encourage the child to focus on a recent pleasurable experience

Correct Answer: D. Encourage the child to focus on a recent pleasurable experience The nurse should encourage the child to focus on a recent pleasurable experience such as a trip to the zoo, when using the nonpharmacological technique of guided imagery. This technique encourages the child to focus on the pleasurable experience rather than the sensation of pain. The technique can also be combined with relaxation and breathing techniques.

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

Correct Answer: D. Hematuria Hematuria can be detected visually in clients who have acute post-streptococcal glomerulonephritis.

A nurse is caring for a child with cystic fibrosis who has a pulmonary infection. Which of the following findings is the nurse's priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions

Correct Answer: D. Inability to clear secretions The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the inability to clear secretions is the priority-finding because the child has a compromised airway; the nurse must act in a manner that ensures transportation of oxygen to the body's cells.

​A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take? A. Administer 81 mg of aspirin to the toddler B. Give the toddler a cold bath C. Place the toddler in a supine position D. Pad the rails of the toddler's bed

Correct Answer: D. Pad the rails of the toddler's bed When caring for a toddler who has manifestations of bacterial meningitis, the nurse should implement seizure precautions, which includes padding the side rails of the bed.

A nurse is creating a plan of care for a preschooler who was admitted for the treatment of measles. Which of the following activities should the nurse include in the client's care plan? A. Constructing a model airplane B. Playing a video game in the playroom C. Pulling a wagon with toys in the hallway D. Putting together a puzzle with large pieces

Correct Answer: D. Putting together a puzzle with large pieces The nurse should recommend putting together a puzzle with large pieces for a hospitalized preschooler. Other recommended activities for preschoolers on airborne precautions include playing pretend and dress up, painting, and looking at illustrated books.

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelets 120,000/mm^3 B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL

Correct Answer: D. Serum cholesterol 700 mg/dL A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids.

A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A. Excessively prolonged expiration B. Increased diaphoresis C. Increased production of frothy sputum D. Sudden decrease in wheezing

Correct Answer: D. Sudden decrease in wheezing When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose a larger risk to the client. A sudden decrease in wheezing can indicate that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilatory failure and imminent respiratory arrest.

A nurse is admitting an adolescent who is suspected of having pertussis. Which of the following findings should the nurse expect? Koplik spots on buccal mucosa Maculopapular rash on neck Cough with a whooping sound Enlarged tonsils with exudate

Cough with a whooping sound The nurse should recognize that a cough with a whooping sound is a manifestation of pertussis. This communicable disease usually presents itself as an upper respiratory tract infection that lasts for 1 to 2 weeks. The dry, hacking cough then becomes more severe and has a whooping sound. Some adolescents can have this cough for up to 10 weeks.

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? Identifies right from left hand Uses a utensil to spread butter Cuts an outlined shape using scissors Draws a stick figure with seven body parts

Cuts an outlined shape using scissors The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape.

A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? Decreased edema Increased abdominal girth Decreased appetite Increased protein in the urine

Decreased edema A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema.

A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? Deep respirations of 32/min Shallow respirations of 10/min Paradoxic respirations of 26/min Periods of apnea lasting for 20 seconds

Deep respirations of 32/min The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis.

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? Expresses a reluctance to leave home Provides a detailed description of how the burns occurred Denies discomfort during assessment of injuries Describes strong relationships with peers

Denies discomfort during assessment of injuries The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.

A nurse is providing preoperative teaching to an adolescent who is scheduled for an open appendectomy. Which of the following interventions should the nurse take? Select nonthreatening words such as "special opening" instead of "incision." Limit teaching session to 10 min. Delay postoperative teaching until after the procedure. Discuss the effect the surgical scar will have on the client's self-perception.

Discuss the effect the surgical scar will have on the client's self-perception. Adolescents tend to have an increased consciousness of personal appearance. The nurse should encourage the client to discuss feelings regarding the presence of a scar and discuss methods to minimize its appearance if it is concerning to the client.

A nurse is teaching home care to the parent of a school-age child who has cystic fibrosis. Which of the following information should the nurse include in the teaching? Encourage participation in sports activities. Decrease daily fat intake to less than 30% of calories. Measure the child's growth once every 6 months. Administer 1 mg of loperamide twice per day.

Encourage participation in sports activities. The nurse should instruct the parent to encourage the child to participate in physical activities, such as sports, to increase lung capacity, promote the excretion of mucus, support muscle development, and enhance cardiovascular health.

A nurse is planning care for a newly admitted school-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? Ensure that a padded tongue blade is at the child's bedside. Allow the child to play video games on a tablet computer. Allow the child to take a tub bath independently. Ensure the oxygen source is functioning in the child's room.

Ensure the oxygen source is functioning in the child's room. The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure.

A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? Controls impulsive feelings Understands right from wrong Easily separates from parents for long periods of time Expresses likes and dislikes

Expresses likes and dislikes The nurse should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions.

A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use? FACES Numeric CRIES Visual analog

FACES The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management.

A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following behaviors should the nurse expect the infant to display? Fascinated with own image in mirror Opens doors and drawers to locate objects Refers to self by name Participates in parallel play

Fascinated with own image in mirror The nurse should expect a 9-month-old infant in the sensorimotor phase of cognitive development to be fascinated with their own image in a mirror.

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? Provide small, frequent meals for the child. Schedule time in the play room for the child. Weigh the child weekly. Maintain the child in a supine position.

Provide small, frequent meals for the child. The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.

A nurse is creating a plan of care for a newly-admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? Until the adolescent is afebrile For 7 days following admission to the facility Until the adolescent has a negative blood culture For 24 hr following initiation of antimicrobial therapy

For 24 hr following initiation of antimicrobial therapy The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent

A nurse is preparing a toddler for an intravenous catheter insertion. Which of the following actions should the nurse include in the plan of care? Show the toddler the intravenous catheters 30 min before the procedure. Use the toddler's favorite doll to demonstrate the procedure. Explain the procedure to the toddler using the correct medical terminology. Give the toddler one direction at a time during the procedure.

Give the toddler one direction at a time during the procedure. The nurse should give one direction at a time and use simple terms and phrases during the procedure to gain cooperation from the toddler.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control? Have a designated stethoscope in the infant's room. Place the infant in a room equipped with negative airflow. Administer palivizumab as prescribed for the infant. Remove gloves after leaving the infant's room.

Have a designated stethoscope in the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? Hematocrit 28% Hemoglobin 13.5 g/dL WBC count 8,000/mm3 Platelets 250,000/mm3

Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity.

A nurse is assessing an infant who has aortic stenosis. Which of the following manifestations should the nurse expect? Bradycardia Headache Hypotension Epistaxis

Hypotension The nurse should expect an infant who has aortic stenosis to have decreased blood pressure. This manifestation is due to decreased cardiac output.

A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? Position the infant side-lying with their head at a 0° to 5° angle. Perform a neurological assessment every 4 hr. Suction the infant's nares to remove secretions. Implement seizure precautions for the infant.

Implement seizure precautions for the infant. An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child.

A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? Administer pancreatic enzymes 2 hr after meals. Discontinue the use of pancreatic enzymes if steatorrhea develops. Limit fluid intake to 750 mL per day. Increase fat content in the child's diet to 40% of total calories.

Increase fat content in the child's diet to 40% of total calories. A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.

A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? Decreased cerebrospinal fluid pressure Decreased WBC count Increased protein concentration Increased glucose level

Increased protein concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.

A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? Place the child in a room with positive-pressure airflow. Place the child in a room with negative-pressure airflow. Initiate contact precautions for the child. Initiate droplet precautions for the child.

Initiate droplet precautions for the child. The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.

A nurse in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? Obtain a throat culture from the child. Monitor the child's oxygen saturation. Put a warm mist humidifier in the child's room. Place the child in the supine position.

Monitor the child's oxygen saturation. The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment.

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.) Negative Babinski reflex Ankle clonus Exaggerated stretch reflexes Uncontrollable movements of the face Contractures

Negative Babinski reflex is incorrect. The nurse should expect a child who has spastic cerebral palsy to exhibit a positive Babinski reflex. Ankle clonus is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed. Exaggerated stretch reflexes is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes. Uncontrollable movements of the face is incorrect. The nurse should expect a child who has nonspastic (dyskinetic) cerebral palsy, rather than spastic (pyramidal) cerebral palsy to exhibit uncontrollable movements of the face and extremities. Contractures is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles.

A nurse is assessing a 1-month-old infant at a well-child visit. Which of the following findings should the nurse report to the provider? Visible pulsations on the anterior fontanel Exhibits a positive doll's eye reflex Obligatory nose breathing Nonremovable white patches on the tongue

Nonremovable white patches on the tongue Nonremovable white patches on the infant's tongue should be reported to the provider because they can be an indication of oral candidiasis. Oral candidiasis can be painful and inhibit the infant's desire to eat or suck, causing weight loss. Candidiasis is treated with oral antifungal medications.

A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? Apple juice Peanut butter Chicken broth Oral rehydration solution

Oral rehydration solution A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.

A nurse is planning care for a 1-year-old toddler who has cerebral palsy and a gastrostomy tube for supplemental feedings. Which of the following interventions should the nurse include in the plan? Decrease the toddler's daily fiber intake. Dissolve crushed pills in the formula and administer during feeding. Place the toddler in contact isolation. Organize care to provide frequent rest periods.

Organize care to provide frequent rest periods. Children who have cerebral palsy use a lot of energy in accomplishing activities of daily living. Therefore, the nurse should provide frequent rest periods to avoid fatigue.

A nurse is caring for a child who has increased intracranial pressure and is unconscious. Which of the following prescriptions should the nurse clarify with the provider? Insert an indwelling urinary catheter. Provide oral care twice daily. Perform nasopharyngeal suctioning every 2 hr. Elevate and maintain the head of the bed at a 15 to 30° angle.

Perform nasopharyngeal suctioning every 2 hr. Nasopharyngeal suctioning is contraindicated in children who have increased intracranial pressure due to the risk of hypoxia which can further increase intracranial pressure. The nurse should contact the provider for clarification of this prescription.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? Reports a headache as 6 on a 0 to 10 pain scale Petechiae on the lower extremities Nuchal rigidity Positive Kernig's sign

Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? Place the child in a side-lying position. Delay documentation until the child is fully alert. Give the child a high-carbohydrate snack. Administer an oral sedative to the child.

Place the child in a side-lying position. The nurse should place the child in a side-lying position to prevent aspiration.

A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? Playing pat-a-cake Using a push-pull toy Creating a scrapbook Playing dress-up

Playing dress-up The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child.

A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect? Resists having an axillary temperature taken Exhibits withdrawal behaviors when their parent leaves Has multiple bruises on their knees Poor personal hygiene

Poor personal hygiene A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision.

A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? Furosemide Captopril Regular insulin Potassium chloride

Potassium chloride The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia.

A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take? Provide the child with a book about adventure. Arrange frequent visits from family members and peers. Give the child a large-piece puzzle. Use puppets to entertain the child.

Provide the child with a book about adventure. The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read.

A nurse is assessing a preschooler who is taking digoxin and furosemide for the treatment of heart failure. The nurse should identify that which of the following findings indicates the treatment is effective? Heart rate 140/min Potassium 3.1 mEq/L Sodium 130 mEq/L Respiratory rate 25/min

Respiratory rate 25/min A respiratory rate of 25/min is within the expected reference range of 20 to 25/min for a preschooler. A preschooler who has heart failure with decreased cardiac output is expected to have tachypnea and hypoxemia. Therefore, a respiratory rate within the expected reference range is an indication of effective treatment.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? Blood pressure 90/50 mm Hg Respiratory rate 45/min Weight 14.5 kg (32 lb) Heart rate 110/min

Respiratory rate 45/min The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse identify as a manifestation of severe dehydration? Weight loss of 5% Mild irritability Capillary refill of 3 seconds Skin cool to the touch

Skin cool to the touch The nurse should identify that if the infant's skin is cool to the touch, acrocyanotic, or mottled, it is an indication of severe dehydration. The infant might also display a very delayed capillary refill of greater than 4 seconds.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment? Potassium 2.9 mEq/L Sodium 140 mEq/L Urine specific gravity 1.035 BUN 25 mg/dL

Sodium 140 mEq/L The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective.

A nurse in an emergency department is assessing a 2-week-old newborn. Which of the following findings is the priority for the nurse to report to the provider? White patches on the tongue and palate Substernal retractions Yellow sclera Asymmetric Moro reflex

Substernal retractions When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This indicates the newborn is experiencing difficulty breathing, which could progress to respiratory failure.

A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? Heart rate 124/min Increased tear production Sunken anterior fontanel Capillary refill 2 seconds

Sunken anterior fontanel The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid.

A nurse is caring for a child who has diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia? Sweating Fruity breath odor Increased urination Ketonuria

Sweating The nurse should identify diaphoresis, or sweating, as a manifestation of hypoglycemia. Other manifestations include hunger, tremors, headache, and dizziness.

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? Recurrent urinary tract infections Symmetric burns of the lower extremities Failure to thrive Lack of subcutaneous fat

Symmetric burns of the lower extremities The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurse's priority? Skin breakdown Hypotension Hyperpyrexia Tachypnea

Tachypnea When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.

A nurse is caring for a preschooler who has a new diagnosis of epilepsy and begins to have a tonic-clonic seizure. Which of the following actions should the nurse take? Place the child in a prone position. Administer phenytoin oral solution. Tuck the child's arms and legs tightly in a bedsheet. Time the length of the seizure activity.

Time the length of the seizure activity. The nurse should note and document the type and length of the seizure activity, as well as any alteration in the level of consciousness, any changes in behavior prior to the onset of the seizure, and the child's state during the postictal period. This allows the provider to properly manage the seizure based on the documentation of seizure activity.

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? Zinc oxide Antibiotic ointment Talcum powder Antiseptic solution

Zinc oxide Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.

A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved? A. Sitting alone B. Attempting to stack objects C. Picking up small objects with a crude pincer grasp D. Turning from back to stomach

Correct Answer: D. Turning from back to stomach A 6-month-old infant should be able to turn over completely, sit momentarily without support, and reach to be picked up

A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment

Correct Answers: A. Enlarged heart B. Enuresis C. Leg ulcers E. Retinal detachment Chronic vaso-occlusive phenomena result from the obstruction of organs by red blood cells, leading to stasis and enlargement of the organs, infarction due to ischemia, and scarring. An enlarged heart, enuresis, leg ulcers, and retinal detachment are manifestations of chronic vaso-occlusive phenomena.

A nurse is providing teaching to the parents of a school-aged child who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following responses by a parent indicates an understanding of the teaching? A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." B. "I will give my child 2 units of regular insulin." C. "I will insist that my child lie down to rest for 30 min." D. "I will check my child's urine for glucose twice daily."

Correct Answer: A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." Giving the child 10 to 15 g of simple carbohydrates such as 240 mL (8 oz) of milk will elevate the blood glucose level and alleviate hypoglycemia.

A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints D. Withhold live virus immunizations

Correct Answer: A. Administer ibuprofen The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic.

A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the client's bathroom to strain the client's urine D. Administer folic acid with meals

Correct Answer: A. Attach a latex allergy alert identification band Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk of latex allergy; therefore, the nurse should avoid the use of common medical products containing latex such as latex gloves for this client.

A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A. Measure the client's weight daily B. Check for tears C. Palpate the fontanel D. Assess skin turgor

Correct Answer: A. Measure the client's weight daily When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weight.

A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? A. Monitor the child's oxygen saturation level B. Administer prescribed antibiotics to the child C. Increase the child's fluid intake D. Apply warm compresses to the child's affected joints

Correct Answer: A. Monitor the child's oxygen saturation level When using the airway, breathing, and circulation (ABC) approach to client care, the priority intervention is to monitor the child's oxygen saturation level. Promoting oxygen utilization prevents further sickling of the child's red blood cells and allows adequate oxygenation of the surrounding tissue.

A nurse is caring for a 2-day-old infant who has myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference B. Position the infant supine C. Place the infant under a radiant warmer D. Tape a piece of plastic over the protruding membranes

Correct Answer: A. Monitor the infant's head circumference Infants with myelomeningocele have an increased risk of hydrocephalus. Measuring the infant's head circumference helps determine any increase of fluid.

A nurse is caring for an infant who has tetralogy of Fallot and is experiencing a hypercyanotic episode. Which of the following actions should the nurse take? A. Place the infant in a knee-chest position B. Initiate a fluid restriction C. Provide oxygen by nasal cannula D. Administer acetaminophen

Correct Answer: A. Place the infant in a knee-chest position The nurse should place the infant in a knee-chest position during a hypercyanotic episode. This position reduces the return of desaturated blood from the legs through the venous system and promotes the diversion of blood into the pulmonary artery.

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 vital signs C. Loosen any restrictive clothing D. Check the child for head injuries

Correct Answer: A. Position the child on his side Using evidence-based practice, the nurse should first position the child on his side. Salivation increases and the swallowing reflex is lost during a tonic-clonic seizure, placing the child at risk for aspiration. It is essential to maintain the airway during a seizure.

A nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately? A. Slurred speech B. Hemoglobin level of 9 g/dL C. Hematuria D. Pain level of 7 on FACES scale

Correct Answer: A. Slurred speech The nurse should identify that slurred speech in a child who has sickle cell anemia is an indication of a stroke. The nurse should report this finding to the provider immediately.

A nurse is assessing a 3-year-old preschooler. Which of the following developmental milestones should the nurse expect the preschooler to demonstrate? A. Stacking 10 blocks B. Printing 1 letter C. Tying shoelaces D. Using 7-word sentences

Correct Answer: A. Stacking 10 blocks The nurse should expect a 3-year-old preschooler to have the fine motor ability to stack 10 blocks.

A nurse is teaching an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching? A. "You should drink 8 oz of a regular soft drink if you experience hypoglycemia." B. "You should drink 4 oz of orange juice if you experience hypoglycemia." C. "You should take 2 glucose tablets if you experience hypoglycemia." D. "You should take 3 tsp of sugar if you experience hypoglycemia."

Correct Answer: B. "You should drink 4 oz of orange juice if you experience hypoglycemia." The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs.

A nurse is caring for a child who received penicillin IM 15 minutes ago. The child is now irritable and restless. Which of the following actions should the nurse take first? A. Administer diphenhydramine B. Assess for laryngeal edema C. Initiate hourly urine output monitoring D. Give epinephrine IV push

Correct Answer: B. Assess for laryngeal edema The greatest risk to this child is bronchoconstriction due to an anaphylactic reaction to penicillin. Therefore, the first action the nurse should take is to assess the child for laryngeal edema and implement interventions to maintain a patent airway.

A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing B. Check the child's respiratory status C. Administer an antidote to the child D. Establish IV access for the child

Correct Answer: B. Check the child's respiratory status The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. This child's lips are edematous and inflamed, and he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway.

A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure

Correct Answer: B. Murmur at the left sternal border A ventricular septal defect (a hole in the septal wall between the ventricles) is an acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal border. The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area.

A nurse is discussing play activities with a group of parents of toddlers. Which of the following activities should the nurse recommend for this age group? A. Jumping rope B. Pushing a toy lawn mower C. Sorting colored marbles D. Playing a board game

Correct Answer: B. Pushing a toy lawn mower The nurse should recommend pushing a toy lawn mower as a play activity for a toddler. Toddlers are developmentally ready for push-pull toys, and they enjoy play activities that allow imitation of adults.

A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A. "Children commonly begin having imaginary friends when they reach school age." B. "Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." D. "Set limits by not allowing your child to have the imaginary friend present during family meals."

Correct Answer: C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions.

A nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take? A. Offer the infant water before feedings B. Discontinue amoxicillin C. Administer an antifungal medication after feedings D. Give the infant formula instead of breast milk

Correct Answer: C. Administer an antifungal medication after feedings The nurse should administer an antifungal medication to the infant after feedings to ensure adequate contact time with the oral mucosa and tongue to enhance treatment of the oral candidiasis.

A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale B. Color tool C. FACES pain rating scale D. Numeric scale

Correct Answer: C. FACES pain rating scale The FACES scale includes various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels.

A nurse is planning care for a preschooler who is scheduled for a surgical procedure. The nurse should identify that the preschooler is in which of the following of Erikson's psychosocial stages of development? A. Industry vs. inferiority B. Trust vs. mistrust C. Initiative vs. guilt D. Identity vs. role confusion

Correct Answer: C. Initiative vs. guilt A preschooler is in the developmental stage of initiative versus guilt. Preschoolers initiate play activities and experience a feeling of guilt if their efforts at independence receive a negative reaction from caregivers.

A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

Correct Answer: C. Palpate the abdomen for bladder distension A neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess for bladder distension due to the possibility of incomplete emptying of the bladder.

A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? A. Side-lying B. Supine C. Prone D. Semi-Fowler's

Correct Answer: C. Prone When providing preoperative care for an infant who has a myelomeningocele, the nurse should maintain the infant in a prone position. This position reduces pressure and the risk of trauma to the sac.

A nurse is assessing a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggests a possible delay in development? A. Inability to tie shoes B. Adding 3 parts to a stick figure C. Speaking using 2- or 3-word sentences D. Inability to walk backward

Correct Answer: C. Speaking using 2- or 3-word sentences A 4-year-old child should be speaking in 4- to 5-word sentences. Speaking in 2- to 3-word sentences is typical of a 2-year-old child.

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 infection."

Correct Answer: D. "The test shows us if your child had a recent strep infection." An ASO titer indicates the child had a recent strep infection. When determining a definitive diagnosis for acute glomerulonephritis, this must be documented because the condition is usually the result of this type of infection.

A nurse on a pediatric unit has just received reports for 4 newly admitted clients. For which of the following children should the nurse plan to initiate droplet precautions? A. A child who has Rocky Mountain spotted fever B. A child who has roseola C. A child who has Molluscum contagiosum D. A child who has pertussis

Correct Answer: D. A child who has pertussis The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to others on the unit. Pertussis, or whooping cough, is a bacterial infection that is transmitted via exposure or direct contact with the respiratory secretions from an infected person. Manifestations of pertussis include a fever, sneezing, and a severe productive cough that generally becomes worse before getting better.

A nurse in the emergency department is caring for a child who accidentally ingested an overdose of acetaminophen. Which of the following medications should the nurse expect to administer? A. Naloxone B. ​Diphenhydramine C. Glucagon D. Acetylcysteine

Correct Answer: D. Acetylcysteine The nurse should expect to administer acetylcysteine to the child because it is an antidote to acetaminophen

A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer to the child? A. Zafirlukast B. Budesonide C. Montelukast D. Albuterol

Correct Answer: D. Albuterol The nurse should plan to administer albuterol to a child who is experiencing an acute exacerbation of asthma. This is considered a rescue medication due to its rapid onset of action. Albuterol is a beta-adrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs.

A nurse is providing teaching to the guardians of a 4-month-old infant on how to play with the infant. Which of the following play activities should the nurse suggest for this infant? A. Show the infant a board book with large pictures B. Imitate the sounds of different farm animals for the infant C. Give the infant a large push-pull toy D. Allow the infant to splash in the bathtub

Correct Answer: D. Allow the infant to splash in the bathtub The nurse should suggest allowing this 4-month-old infant to splash in the bathtub as a play activity. Splashing is appropriate for the developmental age of the infant and provides tactile stimulation. However, the nurse should emphasize and teach bath safety to prevent injury

A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers with blocks

Correct Answer: D. Building towers with blocks Building towers with blocks is an appropriate activity for a 2-year-old child. and promotes fine-motor development. Also, knocking blocks down provides a means of dealing with the stress of hospitalization.

A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss >10% C. Lethargy D. Dry mucous membranes

Correct Answer: D. Dry mucous membranes Dry mucous membranes are an expected finding of moderate dehydration.

A nurse is providing teaching about home care to the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? A. Dry the affected area with a hair dryer on the low setting twice per day B. Use cloth diapers washed in a low-residue detergent C. Wash the genital area vigorously with each diaper change D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes

Correct Answer: D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes Zinc oxide can be applied as a barrier ointment to areas that are reddened or open and moist. While removing the waste material, zinc oxide should be left in place as much as possible during a diaper change. More ointment can be applied as needed. The ointment can be removed, if necessary, by applying mineral oil to the area and gently wiping.

A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL

Correct Answer: D. RBC 6.8 million/uL A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.

A nurse is assessing the fine motor skills of a 3-year-old preschooler. Which of the following findings should the nurse expect? A. The preschooler can draw a stick figure that has 7 parts B. The preschooler can print her first name C. The preschooler can cut out a picture using scissors D. The preschooler builds a tower of 9 cubes

Correct Answer: D. The preschooler builds a tower of 9 cubes The nurse should expect a 3-year-old preschooler to have the fine motors skills needed to build a tower of 9 to 10 blocks.

A nurse is planning preoperative teaching for a preschooler who is scheduled for a tonsillectomy. Which of the following interventions should the nurse plan to include? A. Encourage the preschooler to bring a favorite toy to the hospital B. Spend 30 minutes teaching the preschooler about what to expect C. Schedule the teaching session for the morning of the preschooler's procedure D. Reassure the preschooler that medicine will prevent pain after the procedure

Correct Answer: A. Encourage the preschooler to bring a favorite toy to the hospital The nurse should encourage the preschooler to bring a favorite toy or blanket to the hospital on the day of the procedure. A familiar object provides comfort and relieves fear.

A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse plan to take to help decrease the risk of a vaso-occlusive crisis? A. Provide adequate fluid intake throughout the day B. Provide oxygen at 2 L/min via nasal cannula C. Administer a blood transfusion D. Give ibuprofen to manage pain

Correct Answer: A. Provide adequate fluid intake throughout the day Adequate hydration is an effective strategy to help prevent sickle cell crises. Maintaining adequate hydration can reduce the risk of sickle cell formation.

A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age

Correct Answer: A. The child prefers to sit on the parent's lap during the examination Toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the examination.

A nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. Which of the following interventions should the nurse include? A. Use a mobile walker for the toddler B. Discourage activities involving repetitive joint movement C. Use manual jaw control when feeding the toddler D. Discourage the use of wrist splints

Correct Answer: C. Use manual jaw control when feeding the toddler The nurse should encourage the parent to include the use of manual jaw control during feedings. Children diagnosed with cerebral palsy can lose jaw control, and more effective control can be achieved by providing stability to the jaws during feeding.

A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to the body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.

Correct Answers: A. The child views death as similar to sleep. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. Preschool-age children may think of death like sleep. Preschool-age children also believe that their thoughts and wishes can make things happen since they are egocentric. This is part of why the death of a family member can be difficult for a child at this age. Finally, preschool-age children sometimes believe that death is the result of guilt or a punishment for something they did, said, or thought.

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 and suction tubing B. Ease the child to the floor in Sims' position C. Time the length of the seizure D. Notify the child's parents

Correct Answer: B. Ease the child to the floor in Sims' position The greatest risk to the child is an injury resulting from a fall; therefore, the nurse should first gently ease the child to the floor to decrease the chance of injury and turn the child on the left side to prevent aspiration.

A 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

Correct Answer: D. Keep the child away from people who have an infection Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections.

A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? A. Assess for edema of the extremities B. Apply warm compresses to the neck area C. Initiate airborne precautions D. Maintain a cardiorespiratory monitor

Correct Answer: D. Maintain a cardiorespiratory monitor Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidified oxygen and suction equipment should be used as needed.

A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DTaP) B. Pneumococcal (PCV) C. Haemophilus influenzae type B (Hib) D. Hepatitis B (Hep B)

Correct Answer: A. Diphtheria, tetanus, and pertussis (DTaP) Children should receive booster doses of the DTaP immunization between the ages of 4 and 6. Around this age, blood titers drop due to decreasing antibodies.

A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot

Correct Answer: D. Standing on 1 foot The nurse should expect a 3-year-old child to have the gross motor ability to stand on 1 foot for a few seconds.

A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child? A. Jump rope B. Coloring book and crayons C. Checkers game D. Jack-in-the-box

Correct Answer: B. Coloring book and crayons Preschoolers have increasing fine motor control and imagination. They enjoy toys that allow creativity and self-expression.

A nurse is providing education for a group of parents about toddler language development during a well-child visit. Which of the following findings should the parent expect in an 18-month-old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Following simple directional commands D. Naming a single color

Correct Answer: B. Vocabulary of 10 or more words At 18 months, children typically have a vocabulary of 10 or more words.

A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first? A. Tell the guardian that a repeat dose of medication should not be given B. Verify the prescribed medication regimen C. Determine if the infant has been exposed to others who are ill D. Ask the guardian about the infant's urinary output

Correct Answer: A. Tell the guardian that a repeat dose of medication should not be given The greatest risk to this infant is an injury from digoxin toxicity. Therefore, the priority action for the nurse to take is to instruct the guardian not to administer another dose of medication. The nurse should follow-up with the guardian frequently to determine if the child has further episodes of vomiting. If so, the nurse should notify the provider immediately because vomiting is a possible indication of digoxin toxicity.

A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will use my peak flow meter whenever I feel short of breath." B. "I will continue to take my medication when my peak flow rate is in the green zone." C. "I need to use the average of 3 readings when I measure my flow rate." D. "My asthma is being controlled if my flow rate is in the yellow zone."

Correct Answer: B. "I will continue to take my medication when my peak flow rate is in the green zone." This statement by the adolescent indicates an understanding of the teaching. A peak flow rate in the green zone indicates the current treatment has been effective; therefore, the adolescent should continue with their current medication regimen.

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 blood pressure every 4 hr C. Administer albumin to the child every 8 hr D. Provide the child with a low-carbohydrate diet

Correct Answer: B. Check the child's blood pressure every 4 hr The nurse should check the child's blood pressure every 4 to 6 hours to monitor for hypertension.

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

Correct Answer: B. Explain the sounds the child is hearing The noises in a facility can be frightening to a child who is experiencing a sensory loss. Explaining these noises can allay the child's fears.

A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. Dullness with chest percussion B. Heart rate 118/min C. Conjunctival discharge D. Respiratory rate 28/min

Correct Answer: B. Heart rate 118/min The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia.

A nurse is planning to teach a 9-year-old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-age children are attempting to master which of the following developmental tasks? A. Initiative vs. guilt B. Industry vs. inferiority C. Trust vs. mistrust D. Identity vs. role confusion

Correct Answer: B. Industry vs. inferiority When planning to teach, the nurse should identify that school-age children are attempting to master the developmental task of industry vs. inferiority. During this stage, children enjoy learning new skills and experiencing the sense of accomplishment that comes with mastery of the skill.

A nurse is assessing the dynamics of a family in which child maltreatment is suspected. Which of the following findings should the nurse report to the provider? A. The parents provide emotional support to the child during the assessment process. B. The child has several unexplained scars and bruises. C. The child cries and appears afraid of the health care provider. D. The parents offer consistent, detailed stories about the child's injuries.

Correct Answer: B. The child has several unexplained scars and bruises. The nurse should suspect child maltreatment when the child has multiple unexplained scars and bruises. The nurse should report this finding to the provider.

A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop-side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons." D. "I should ensure the crib slats are no more than 3 inches apart."

Correct Answer: C. "I should make sure my baby's clothing does not have buttons." The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration.

A nurse is providing education to the parent of a toddler who is about to receive an MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should not play with other children for 2 days." B. "I will need to return in 2 weeks for my child to receive the varicella immunization." C. "I will help my child to blow bubbles during the injection." D. "My child may have some drainage from the injection site."

Correct Answer: C. "I will help my child to blow bubbles during the injection." Providing distraction, such as helping or allowing a child to blow bubbles while receiving an injection, is a technique that can minimize pain and discomfort for the child.

A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." B. "Your child will be unable to participate in recreational activities." C. "Your child will need a botulinum toxin A injection to reduce muscle spasticity." D. "Your child will need throw rugs placed over non-carpeted areas."

Correct Answer: C. "Your child will need a botulinum toxin A injection to reduce muscle spasticity." Children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which reduce spasticity.

A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. Human papillomavirus (HPV) and hepatitis A B. Measles, mumps, and rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAIV)

Correct Answer: C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) The recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization series consists of 3 to 4 doses, depending on the immunization used. At minimum, it is administered at 2 months, 4 months, and 12 to 15 months of age. The IPV immunization series consists of 4 doses and is administered at 2 months, 4 months, 6 to 18 months, and 4 to 6 years of age.

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities B. Administer meperidine every 4 hr until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for 8 hr

Correct Answer: C. Maintain the child on bed rest The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs.

A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should reply that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism

Correct Answer: C. Object permanence Object permanence refers to the cognitive skill of knowing an object still exists even when out of sight. By discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.

A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.

Correct Answer: C. The child complains daily about going to school. Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children at this stage want to learn and master new concepts. If the child complains daily about going to school, further evaluation is warranted.

A nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing. Which of the following findings is the priority for the nurse to report to the provider? A. The child's temperature is 39°C (102°F) B. The child's skin is sallow C. The child is drooling D. The child's voice is hoarse

Correct Answer: C. The child is drooling When using the urgent versus nonurgent approach to client care, the nurse should determine that the presence of drooling is the priority finding because it can indicate the child might have developed epiglottitis, a medical emergency. Left untreated, the child can develop a complete respiratory obstruction.

A nurse is planning preoperative teaching for a school-age child who is scheduled for cardiac surgery. Which of the following actions should the nurse plan to take when teaching the child? A. Limit teaching sessions to 10 min B. Use simple, concrete terms when giving explanations C. Use photographs to help explain the procedure D. Conduct the teaching session 2 days before the procedure

Correct Answer: C. Use photographs to help explain the procedure The nurse should recognize the school-age child's increased language ability and desire for knowledge. The nurse should use photographs and simple diagrams to explain the procedure in an interesting and concrete way that the child can understand.

A nurse is caring for a 7-year-old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books

Correct Answer: D. Chapter books The nurse should offer chapter books as an appropriate diversional activity for a school-age child who has limited movement due to skeletal traction

A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hr B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the skin before attaching the sensor D. Cover the oximetry sensor with clothing

Correct Answer: D. Cover the oximetry sensor with clothing The nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading.

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. Contact precautions C. Protective environment D. Droplet precautions

Correct Answer: D. Droplet precautions The nurse should maintain droplet precautions for a client who has meningococcal meningitis for 24 to 72 hours after the initiation of antibiotic therapy. Disease transmission can occur through large-droplet particles when the client is talking. There is no drainage of infected body fluids with meningitis, so contact precautions are not necessary.

A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short

Correct Answer: D. Ensure that staff visits with the child are kept short Children who have autism spectrum disorders have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible.

A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level? A. Word-Graphic Rating Scale B. Color Tool C. Poker Chip Tool D. FACES Rating Scale

Correct Answer: D. FACES Rating Scale The nurse should use the FACES rating scale to assess this child's pain level. This scale is appropriate for a 3-year-old and provides a series of facial expressions representing amounts of pain.

A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake C. Follow the child's cues to time food and fluids D. Sit beside the child's high chair for feedings E. Play music videos during scheduled meal times

Correct Answers: A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. A nutritional goal for this child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake.

A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching? A. Toddlers will react to the parents' anxiety and sadness. B. Toddlers view death as punishment for bad behavior. C. Toddlers view death as permanent and irreversible. D. Toddlers have a realistic concept of death.

Correct Answer: A. Toddlers will react to the parents' anxiety and sadness. The nurse should identify that toddlers have little understanding of death. Their reaction is related to changes in routine and the parents' emotions.

A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head-to-toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical terminology D. Stop the assessment if the child becomes uncooperative

Correct Answer: B. Minimize physical contact with the child initially The nurse should initially minimize physical contact with the toddler and progress from the least traumatic to the most traumatic procedures.

A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella vaccine at 6 months of age." B. "Your baby can start the pneumococcal vaccine now." C. "Your baby should receive the flu vaccine before 6 months of age." D. "You baby can start the measles, mumps, and rubella vaccine now."

Correct Answer: B. "Your baby can start the pneumococcal vaccine now." The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age.

A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take? A. Measure the infant's intake and output B. Measure the infant's head circumference C. Check the infant's lower-extremity function D. Monitor the infant's blood pressure

Correct Answer: B. Measure the infant's head circumference Increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements.

A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy? A. Insert the catheter to 2 cm (0.79 in) beyond the end of the tracheostomy tube B. Remove the catheter while applying intermittent suction C. Instill 0.9% sodium chloride irrigation to loosen secretions while suctioning D. Continue suctioning until the secretions are removed

Correct Answer: B. Remove the catheter while applying intermittent suction The nurse should insert the catheter without suction and then withdraw the catheter while applying intermittent suction.

A nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse. Which of the following actions should the nurse take? A. Ask the child if his parents are responsible for the abuse B. Notify the facility's risk manager C. Interview the child with his parents present D. Report the suspected abuse to local authorities

Correct Answer: D. Report the suspected abuse to local authorities The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement.

A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room? A. Pulse oximeter B. Oxygen therapy C. Bag valve mask D. Suction equipment

Correct Answer: D. Suction equipment When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority item to have in the child's room is suction equipment. If the child experiences a tonic-clonic seizure, the child is at risk for aspiration and airway occlusion due to secretions, food, or fluids. The nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bag valve mask if needed.

A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child's parent about the illness? (Select all that apply.) A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water C. Administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area

Correct Answers: A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water E. Wash hands before and after contact with the affected area Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on teaching the child's parents about topical application of an antibacterial ointment. The parents should wash their hands before and after contact with the affected area and wash the child's bed linens daily in hot water to decrease the risk of reinfection or transmission.

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

Correct Answer: B. Test the nasal secretions for glucose The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are a leakage of cerebrospinal fluid (CSF). The leakage of CSF is positive for glucose and occurs if the child has a skull fracture.

A nurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? A. Withhold the medication if the infant's heart rate is less than 110/min B. Mix the medication in 120 mL (4 oz) of infant formula C. Expect the infant to vomit frequently while taking this medication D. Double the dose if the infant has increased edema

Correct Answer: A. Withhold the medication if the infant's heart rate is less than 110/min The parent should withhold the medication and notify the provider if the infant's heart rate is less than 110/min.

A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should recommend which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster

Correct Answer: B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis (which affects the brain) and meningococcemia (which affects the blood). Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention issued a recommendation that all incoming college students receive the meningococcal immunization.

A nurse is taking the history of and performing a physical on a school-age child who has attention deficit hyperactivity disorder (ADHD). Which of the following findings in the child's medical record should the nurse identify as a risk factor for ADHD? A. The child's family has a middle-class socioeconomic background. B. The child had prenatal exposure to alcohol on a regular basis. C. Both siblings of the child show moderate activity levels in school and play activities. D. The child's mother currently has diabetes mellitus.

Correct Answer: B. The child had prenatal exposure to alcohol on a regular basis. Prenatal exposure to alcohol on a regular basis is a contributing factor to ADHD, along with prenatal nicotine exposure and exposure to lead or mercury.

A nurse is providing teaching about disease-management strategies to a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? A. "Thorough and effective pulmonary clearance can help prevent the need for a lung transplant when you get older." B. "You should eat these kinds of foods because they will help you grow big and strong." C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." D. "Your medication follows a certain schedule to help you sleep better."

Correct Answer: C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." A 9-year-old child should understand that the production of thick mucus is a part of the disease process.

A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL

Correct Answer: C. A child who has sickle cell anemia and a urine specific gravity of 1.030 The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A child who has sickle cell anemia must maintain adequate hydration because dehydration could cause sickle cell crisis that can occlude the child's circulation.

A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL. C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32%

Correct Answer: C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL The initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report this result so that the provider can adjust the client's insulin dosage.

A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider immediately? A. A school-age child with a urine specific gravity of 1.035 B. A toddler with a BUN of 25 mg/dL and a creatinine of 0.5 mg/dL C. An infant with a WBC count of 24,000/mm3 D. An adolescent with a positive beta human chorionic gonadotropin test

Correct Answer: C. An infant with a WBC count of 24,000/mm3 The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. This WBC count is high and indicates infection and possibly sepsis, which poses the greatest risk. The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy.

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

Correct Answer: C. Deep, rapid respirations This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia.

A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? A. Lethargy B. Spontaneous coughing C. Drooling D. Hoarseness

Correct Answer: C. Drooling Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is an expected finding due to the toddler's inability to swallow saliva.

A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP

Correct Answer: C. FLACC The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age.

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area B. Initiate contact isolation precautions C. Give the child flavored popsicles D. Administer phytonadione

Correct Answer: C. Give the child flavored popsicles Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children often accept flavored popsicles as a source of fluid.

A nurse is planning preoperative teaching for a 5-year-old child. Which of the following interventions should the nurse include? A. Explain the long-term benefits of the procedure. B. Provide diagrams and pictures while explaining the procedure. C. Use correct medical terminology during the teaching session. D. Explain the procedure in terms of what the child will feel, see, hear, and taste.

Correct Answer: D. Explain the procedure in terms of what the child will feel, see, hear, and taste. Teaching for a preschooler should focus on the child's sensory experience. The teaching can also include what the child can do during the procedure.

A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (Select all that apply.) A. "I should eat extra food on busy days when I am more active." B. "I should wait for 2 hr after eating before going swimming with my friends." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." E. "I should have a 16 oz sports drink if I start feeling weak or shaky."

Correct Answers: A. "I should eat extra food on busy days when I am more active." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." The nurse should instruct the adolescent to increase the intake of allowable foods when the level of activity is increased. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. Additionally, the nurse should instruct the adolescent to increase the intake of sugar-free fluids when sick because fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids such as water, broth, and tea. The adolescent should continue with the usual intake at mealtimes and follow the recommended meal plan as much as possible. Finally, the nurse should instruct the adolescent to eat a recommended snack 30 minutes prior to a planned activity such as playing in a baseball game. If the game is prolonged, a snack should be consumed every 45 minutes to 1 hour. If, for some reason, the extra food cannot be tolerated, the next intervention is to decrease the adolescent's insulin dose before baseball games.

A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (Select all that apply.) A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min

Correct Answers: B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea. The nurse should plan to hold the infant in a semi-upright position during feedings to promote maximum chest expansion and decrease the risk of respiratory distress. The nurse should plan to withhold oral feedings and provide gavage feedings if the infant shows indications of stress or fatigue. An infant who has a respiratory rate of 80/min to 100/min has tachypnea, which is an indicator of infant stress.