Peds NCLEX Questions
A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new enters the room, says a few words, and is asking for "mama" and "dada". The nurse should make which of the following assessments for this child? A. 6 months B. 12 months C. 18 months D. 24 months
12 months Rationale: The nurse should know that his infant must be less than 18 months old because her anterior fontanel is still open. The infant is approximately 12 months due to the presence of teeth 6 teeth. Her skills-sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say 2 words (12 months)-should also help the nurse estimate the infant's age as 12 months.
A nurse is preparing to administer acetaminophen 240mg PO daily to a child who has a temperature of 38.9C (102F). The amount available is acetaminophen oral solution 160mg/5ml. How many ml should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)
7.5
A nurse is teaching the parent of a school-age child who has celiac disease. Which of the following foods selected by the parent indicated and understanding of the teaching? A. Corn tortilla with black beans. B. Pizza C. Canned soup D. Hot dogs
A. Corn tortilla with black beans. Rationale: Children who have celiac disease are placed on a gluten-free diet. Gluten is found in wheat, rye, and barley. Selecting products made from corn indicates an understanding of the teaching, as corn and beans are gluten-free foods.
A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should teach the family to expect the preschooler to have which of the following concepts of death? A. People can come back to life after they die. B. Death eventually occurs for all people. C. Death is a scary monster that causes people to die. D. People are unable to be anything but alive.
A. People can come back to life after they die. Rationale: A preschooler typically views death as temporary and interchangeable with life.
A nurse is planning care fo 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.
A. Encourage the parents to bring the child's stuffed animal Rationale: Encouraging parents to bring in a child's favorite stuffed animal may lessen the disruptiveness of hospitalization.
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.
A. Encourage the preschooler to bring a favorite toy to the hospital. Rationale: The nurse should encourage the preschooler to bring a favorite toy or blanket to the hospital the day of the procedure. A familiar object provides comfort and relieves fear.
A nurse teaching the parent of a 3-year-old toddler about promoting sleeping. Which of the following pieces of information should the nurse include? A. Follow a nightly routine and established bedtime. B. Encourage active play prior to bedtime. C. Let the child remain awake until tired enough to go to sleep. D. Reward the child with a food treat just before sleep if the child goes to bed on time.
A. Follow a nightly routine and established bedtime. Rationale: Preschool-age children test limits. A consistent approach to bedtime is important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night.
A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile for height which of the following findings should the nurse report to the provider? A. Heart rate 175/min B. Respiratory rate 26/min C. Blood pressure 88/40mmHg D. Temperature 37.6C (99.7F)
A. Heart rate 175/min Rationale: A heart rate of 175/min is above the expected reference range for a 12-month-old infant; therefore, the nurse should report this finding to the provider.
A nurse is providing teaching about immunization schedules to the parent of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A. Initial vaccines should be administered between birth and 2 weeks of age. B. Your child will need to begin the vaccination series over again if subsequent doses in the series are missed. C. An allergic reaction to a vaccine is due to the active ingredient in the vaccine" D. A vaccination should be postponed if your child has a rectal temperature of 99.5F and head congestion.
A. Initial vaccines should be administered between birth and 2 weeks of age. Rationale: The first dose of hepatitis B vaccine should be administered within the first 2 weeks after birth. The doses should be given before discharge from the hospital if the mother is hepatitis B surface antigen (HBsAg) negative.
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
A. Measure the client's weight daily Rationale: 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 teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. My child may take aspirin for his joint pain. B. My child will need a blood transfusion prior to discharge. C. I will need to wear a gown when I'm in my child's room. D. I will apply lotion to my child's peeling hands.
A. My child may take aspirin for his joint pain. Rationale: Children who have rheumatic fever may take salicylates (aspirin) to control inflammatory process that occurs in the joints.
A school nurse is assessing an adolescent who returned to school following a case of mononucleosis. This child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma. B. Deficient dietary intake C. Exposing peers to the illness D. Straining sore joints.
A. Potential for sustaining abdominal trauma. Rationale: An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avid activities that might result in trauma to the enlarged spleen.
A nurse is assessing a 6-year-old client at a well-child visit. Which of the following findings requires further assessment by the nurse? A. Presence of sparse, fine pubic hair B. Decreased head circumference compared to full height C. Increased leg length in relation to height D. Presence of a loose central incisor.
A. Presence of sparse, fine pubic hair Rationale: The development of sexual characteristics prior to the age of 9 years in boys and 8 years in girls is an indication of precocious puberty and requires further evaluation.
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? A. The PICC line will last for several weeks with proper care. B. The public health nurse will rotate the insertion site every 3 days. C. You will need to ensure the arm board is in place at all times. D. Your child will go to the operating room to have the line placed.
A. The PICC line will last for several weeks with proper care. Rationale: A PICC line is the preferred venous access device for short- to moderate-term IV therapy. It can remain in place for long periods with proper care.
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 parent's anxiety and sadness. B. Toddlers view death as a punishment for bad behavior. C. Toddlers view death as permanent and irreversible. D. Toddlers have a realistic concept of death.
A. Toddlers will react to the parent's anxiety and sadness. Rationale: The nurse should identify that toddlers have little understanding of death. Their reaction is related to changes in routine and the parent's emotions.
A nurse is talking with a parent of a preschooler. The parent reports that she struggles to get her child to go to bed at a consistent time. She explains that the child gets out of bed, enters her parents' room, and cries when they tell him to stay in his own bed. Which of the following instructions should the nurse give to the parent? A. Use a stable, relaxing routine like a bath and story time before bed. B. Make sure the room is completely dark when placing your child in bed C. Let your child go to sleep in your lap and then put him in his bed. D. Respond consistently if your child cries for you after putting him to bed.
A. Use a stable, relaxing routine like a bath and story time before bed. Rationale: Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime and allow parental-child interaction prior to bed.
A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse provide to foster a rapport and encourage conversation? A. " Do you like school?" B. " Tell me about your favorite video game." C. " We have another child your age on the unit." D. " Would you like your friends to visit you?"
B. " Tell me about your favorite video game." Rationale: The nurse should use therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters a rapport and encourages communication.
A nurse is caring for a 10 year old child who should reduce his fat intake. Which of the following menu choices should the nurse suggest? A. A hotdog on a whole-wheat bun. B. 3 oz backed chicken on a whole-wheat roll. C. 1/2 cup of diced potatoes with scrambled eggs. D. Medium blueberry muffin.
B. 3 oz backed chicken on a whole-wheat roll. Rationale: A baked chicken sandwich on a whole wheat bun has the lowest fat content at 6.2 g
A nurse is caring for a child who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medications should the nurse plan to administer? A. Digoxin immune fab B. Acetylcyteine C. Naloxone D. Vitamin K
B. Acetylcyteine Rationale: Acetylcysteine is the antidote for acetaminophen overdose or poisoning.
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find? A. Stepping B. Babinski C. Extrusion D. Moro
B. Babinski Rationale: The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits.
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
B. Check the child's respiratory status. Rationale: Apply ABC priority-setting framework. The 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 caring for a 3-year-old 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
B. Coloring book and crayons Rationale: Preschoolers have increasing fine motor control and imagination. They enjoy toys that allow creativity and self-expression.
A nurse in a provider's office is assessing a client. The nurse determines the client's body mass index is 21.2. The finding is classified as which of the following? A. Underweight B. Healthy weight C. Overweight D. Obese
B. Healthy Weight Rationale: BMI is a measure of an individual's weight relative to height. A BMI from 18.5 to 24.9 is the healthy range. Therefore, this client's wight is considered healthy.
A nurse is providing teaching to a 13-year-old client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of diabetes mellitus management? A. I will need to avoid snacks between meals B. I should check my blood glucose level more often when I am sick. C. I will need to limit my exercise to 1 hour per day. D. I should consume 30g of simple carbohydrates if I feel shaky.
B. I should check my blood glucose level more often when I am sick. Rationale: Blood glucose levels should be checked every 3 hours during illness for a client who has type 1 diabetes mellitus, even if the client consumes fewer calories than usual. Hyperglycemia often occurs with an infection, requiring additional doses of insulin.
A nurse is caring for a 4-year-old who has pneumonia. The child's mother left 2 hours ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb sucking C. Showing interest in nearby toys D. Attempting to escape and find the parent.
B. Inactivity and thumb sucking Rationale: A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair.
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
B. Minimize physical contact with the child initially Rationale: The nurse should initially minimize physical contact with the toddler and progress from the least traumatic to most traumatic procedures.
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
B. Murmur at the left sternal border. Rationale: 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 hear in this area.
A nurse is caring for an infant who as a tracheoesophageal fistula. Which of the following actions should the nurse take? A. Place the infant in a lateral position. B. Perform oropharyngeal suctioning C. Administer ranitidine orally D. Thickening the infant's formula
B. Perform oropharyngeal suctioning Rationale: When caring for an infant who has a tracheoesophageal fistula, the nurse should perform frequent oropharyngeal suctioning to decrease the infant's risk of aspiration.
A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take? A. Initiate NPO statues for the adolescent. B. Place the adolescent in a supine position. C. Place a moist, warm pack on the adolescent's lower back. D. Apply a eutectic mixture of local anesthetic (EMLA) to the adolescents puncture site.
B. Place the adolescent in a supine position. Rationale: The nurse should place the adolescent in a supine position for 30 minutes to 1 hour following a lumbar puncture to decrease the risk of a post-dural puncture headache.
A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hr. B. Position the child on a cooling blanket and cover her with .a sheet. C. Place the child in a tub filled with water cooled to 26.7 to 29.4C (80 to 85 degrees F) D. Assess the child's temperature every 2 hr during the cooling process.
B. Position the child on a cooling blanket and cover her with .a sheet. Rationale: A cooling blanket will lower the temperature of the blood circulating at the skin's surface. This cooler blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated and dispense to the cooler outside surface.
A nurse is assessing a child who is postoperative. Which of the following findings should the nurse identify as an indication that naloxone should be administered? A. Crackles in the lung bases B. Respiratory depression C. Nausea and vomiting D. Tachycardia
B. Respiratory depression Rationale: The nurse should monitor the child's respiratory status postoperatively and plan to administer naloxone if respiratory depression is present. Naloxone is an opioid antagonist used to reverse the effects of opioids administered perioperatively.
A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure. A. Bottle formula with added protein. B. Small, frequent bottle feedings of electrolyte solution. C. Continuous nasoduodenal tube feedings. D. Bolus feedings via gastrostomy tube.
B. Small, frequent bottle feedings of electrolyte solution. Rationale: Feedings begin 4 to 6 hours after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water.
A nurse in an acute pediatric unit is caring for a 2-year-old who has separation anxiety when her parents leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. The child tried to bite the nurse. B. The child is withdrawn and refuses to talk. C. The child attempts to run away to find her parents. D. The child screams and cries loudly.
B. The child is withdrawn and refuses to talk. Rationale: Separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stay of despair.
A nurse is evaluating the outcome of surgery for an infant who had a bile duct obstruction. Which of the following findings should indicate to the nurse that the surgery was successful? A. The infant's stool becomes fatty B. The color of the infants stool is yellowish-brown. C. The infant's direct bilirubin level has increased. D. A palpable mass is noted in the infant's right upper quadrant.
B. The color of the infants stool is yellowish-brown. Rationale: An infant who has a biliary obstruction will have clay colored stools because the flow of bilirubin into the intestinal tract is blocked. If the surgery is successful the infant's stools will change to yellow and then brown in color.
A nurse in a provider's office enters an examination room to assess an 8-month-old infant for the first time. Which of the following reactions by the infant should the nurse expect? A. The infant gives the nurse a social smile. B. The infant turns away when the nurse approaches. C. The infant reaches out to the nurse to be held. D. The infant is responsive and alert as the nurse comes closer.
B. The infant turns away when the nurse approaches. Rationale: The nurse should expect an 8-month-old infant to have a heightened fear of strangers. The infant is expected to cling to her parent and turn away when approached by a stranger.
A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches. B. An area of deep blue pigmentation over the buttocks. C. A blue coloring of the sclera. D. A patchy red rash with a raised centers.
C. A blue coloring of the sclera. Rationale: This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding.
A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who has tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortion C. Barking cough D. Projectile vomiting
C. Barking cough Rationale: Infants who have tracheomalacia have a weakened trachea, which can lead to a collapse. Clinical manifestations of tracheomalacia include a barking cough, stridor, wheezing cyanosis, and apnea.
A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse identify as a manifestation of this complication? A. Slow heart rate B. Protruding eyeballs C. Deep, rapid respirations D. Decreased urinary output
C. Deep, rapid respirations Rationale: Deep and rapid respirations are known as Kussmaul respirations, which is a manifestation of DKA. This respiratory pattern in caused by the body's attempt to rid itself of the excess carbon dioxide that results from the presence of ketones. The child's breath can be sweet smelling due to the body's attempt to eliminate ketones through the respiratory system.
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 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.
C. Examine the infant's throat at the end of the examination Rationale: 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 providing teaching for a parent about pinworm testing. At which of the following times should the nurse advise the parent to perform the tape test? A. Immediately after the child has a bowel movement. B. After being on a clear liquid diet for 24 hours. C. Immediately after the child wake up in the morning. D. After soaking for 20 minutes in a warm bath.
C. Immediately after the child wake up in the morning. Rationale: The nurse should instruct the parent to perform the tape test as soon as the child wakes up in the morning and before the child bathes or uses the restroom. The test should be repeated for 3 mornings in a row.
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
C. Impaired language skills Rationale: 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).
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusion 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.
C. Maintain the child on bedrest. Rationale: The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize the energy expenditure and avoid additional oxygen needs.
A nurse in an emergency department is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report and an indication of impending airway obstruction? A. Bradycardia B. Respiratory depression C. Nasal flaring D. Barking cough
C. Nasal flaring Rationale: Acute laryngotracheobronchitis (croup) causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increased restlessness, flaring nares, and intercostal retractions.
A nurse is caring for a 6-month-old infant who has intussusception. Which of the following action should the nurse take? A. Prepare to administer high-dose steroids. B. Give the child magnesium hydroxide PO. C. Prepare the child for a barium enema D. Inform the parents that the child will need a colostomy.
C. Prepare the child for a barium enema Rationale: The pressure created by a barium enema might force the bowel to resume a normal configuration. Some children with intussusception are treated with the barium enema and do not require surgical intervention.
A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicated the infant has moderate dehydration? A. Bulging anterior fontanel. B. Bradycardia C. Tachypnea D. Polyuria
C. Tachypnea Rationale: An infant who has moderate dehydration will have slight tachypnea
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.
C. The child complains daily about going to school. Rationale: Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychological 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 HIV. Which of the following manifestations should the nurse expect? A. Generalized petechiae B. Jaundice C. Obesity D. Chronic diarrhea
D. Chronic diarrhea Rationale: Chronic diarrhea is an expected finding for a preschooler who has HIV.
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
D. Acetylcysteine Rationale: Acetylcysteine 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
D. Albuterol Rationale: The nurse should plan to administer albuterol to a children 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 caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0-10. Which of the following actions should the nurse take? A. Administer an NSAID B. Perform passive ROM exercise on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint.
D. Apply an ice pack to the joint. Rationale: Immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint.
A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiber glass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen B. Elevate the adolescent's leg on pillows C. Place an ice pack on the cast D. Assess for manifestations of circulatory impairment.
D. Assess for manifestations of circulatory impairment. Apply ABC priority setting framework to ensure there is no vascular compromise.
A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before the child can have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months for surgery to prevent which of the following outcomes? A. Repeated ear infections B. Nutritional deficits C. Immune system deficits D. Difficulty with language acquisitions.
D. Difficulty with language acquisitions. Rationale: Clients who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. Because of the cleft in the palate, these infants could develop poor speech habits.
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 children'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.
D. Ensure that staff visits with the child are kept short. Rationale: Children who have autism spectrum disorder have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible.
A nurse is teaching parents of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. I can give my baby 4oz of juice to drink each day. B. I will offer my baby dry cereal and chilled banana slices as snacks. C. I am introducing my baby to the same foods the family eats. D. My infant drinks at least 2 qt of skim milk each day.
D. My infant drinks at least 2 qt of skim milk each day. Rationale: As the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz per day. Too much milk can affect the child's intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids, which are needed for growth and development.
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 81mg 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.
D. Pad the rails of the toddler's bed. Rationale: When caring for a toddler who has manifestations of bacterial meningitis, the nurse should implement seizure precautions, which include padding the side rails of the bed.
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
D. Periorbital edema Rationale: Periorbital edema is an expected finding in a child who has glomerulonephritis
A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? A. Dilated pupils B. Tremors C. Yawning D. Pruritus
D. Pruritus Rationale: Pruritus is an adverse effect of opioids. Constipation respiratory depression, nausea, vomiting, agitation, orthostatic hypotension, and hallucinations are also adverse effects of opioids.
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
D. RBC 6.8 million/uL Rationale: A child who has tetralogy of Fallot experiences cyanosis; therefore the body responds buy increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? A. Ask the child to hold a breath and blow it out slowly. B. Ask the child to describe a pleasurable event. C. Bounce the child gently while holding him upright. D. Rock the child using long, rhythmic movements.
D. Rock the child using long, rhythmic movements Rationale: The nurse can implement relaxation strategies by sitting with the child in a well supported position such as against the chest and rocking or swaying back and forth in long, wide movements.
A nurse is assessing a 10-month-old infant at a well-infant checkup. Which of the following assessment findings should the nurse report to the provider? A. The infant is unable to walk independently B. The infant's Moro reflex is absent C. The infant's anterior fontanel is open D. The infant needs assistance to sit up
D. The infant needs assistance to sit up Rationale: An infant is expected to have the ability to sit up unsupported around 8 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following directions should the nurse provide? A. Your child will need to take estrogen daily when she reaches puberty. B. Your child will need monthly coagulation studies. C. Your child will need surgery to remove the diseased thyroid. D. Your child will need to take thyroid hormone replacement for her entire life.
D. Your child will need to take thyroid hormone replacement for her entire life. Rationale: In congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require lifelong thyroid hormone replacement to support normal growth and development.
A nurse is caring for a female adolescent who is being treated for frequent urinary tract infections (UTIs). Which of the following statements by the adolescent indicates a possible cause of the UTIs? A. I have bowel movements every 4 to 5 days. B. My mom taught me to wipe from front to back after going to the bathroom. C. I urinate every 2 to 3 hr during the day. D. I don't wear nylon underwear.
The nurse should identify that this frequency of UTIs indicated the adolescent is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection.