Peds Nurs350
A nurse enters the room of a 6-year-old child admitted for neurological observation and observes that the child is slightly disoriented to surroundings and appears to be vague in response to questioning by the nurse. What priority action should the nurse take?
Document Glasgow Coma Scale
A nurse is caring for a child who has intracranial pressure (ICP) monitoring. The nurse assesses the child and notes that the ICP is 9 mm Hg. Which action by the nurse is most appropriate?
Document the finding in the chart.
The pediatric nurse is examining a newborn infant and notes a turning in of the foot and turning out of the toes when the sole of the foot is stroked. Which action by the nurse is most appropriate?
Document the findings in the patients chart.
A child is being released from the hospital after surgical correction of an atrioventricular canal defect (AVC). What referral by the nurse is most appropriate?
Down's syndrome support group
A couple who recently married and want to have children ask the nurse what the chances are that their children will inherit thalassemia from them, as they both are carriers. What information from the nurse is most accurate?
Each child has a 25% chance of inheriting it.
A pediatric nurse examines a 7-year-old at a well-child visit. Based on developmental milestones, what observation should the nurse anticipate should be present?
Eager to participate in the conversation.
A child hospitalized with heart failure has extremely high blood pressure. Which medication does the nurse prepare to administer?
Enalapril (Vasotec)
The pediatric nurse is discharging a child diagnosed with cytomegalovirus infection (CMV). Which teaching is most appropriate for this child?
Ensure adequate rest.
The pediatric clinic nurse assesses a young patient who has been diagnosed with cat scratch disease. Which treatment options should the nurse anticipate the physician to order? Select all that apply.
Erythromycin.
The nurse is admitting an adolescent with known myasthenia gravis to the intensive care unit with respiratory failure. Which questions would be most important for the nurse to ask to the family to attempt to find the cause of the problem? Select all that apply.
Has your child been sick or overly fatigued recently?" "Could your child have skipped medication doses?"
A nurse is assessing a school-age child admitted with a new heart murmur, arthritis-type symptoms, erythema marginatum, and fever. When taking the child's history, which question is most likely to provide important information?
Has your child had a sore throat in the last 2 to 3 weeks?
A student nurse on the pediatric floor finds a patient in pain and gives the child some toys to play with. The registered nurse asks why the student did not medicate the child. The student states that because the child was easily distracted, it did not appear that the child needed pain medication. What action by the registered nurse is most appropriate?
Have the student reassess the child's pain.
A nurse is caring for an HIV-positive child diagnosed with Pneumocystis jiroveci pneumonia who is receiving trimethoprim-sulfamethoxazole. Which finding indicates a possible complication of using this drug?
Hemorrhagic blisters
A nurse is assessing a school-age child who complain of stomach aches after eating. Which question is appropriate for the "D" component of the OLD CAT mnemonic?
How long does the pain last after you eat?
The clinic nurse is reviewing laboratory results for an adolescent that reveals atypical lymphocytes with an increase in monocytes. What clinical diagnosis should the nurse suspect?
Mononucleosis
A child has a closure device inserted in interventional radiology for an atrial septal defect (ASD). Two hours later, the child is pale, tachycardic, and hypotensive. Which action by the nurse takes priority?
Prepare the child to return to interventional radiology.
An HIV-positive child has low titers after a measles vaccination. She has now been exposed to the disease. Which action by the nurse is most appropriate?
Prepare to administer immunoglobulin.
The nurse reads in the child's chart that the Hirschberg test demonstrated displacement of light reflection in one eye. What does this indicate to the nurse?
Presence of strabismus
A group of student nurses are reviewing common causes of iron-deficiency anemia (IDA). Which findings support a clinical diagnosis of IDA? Select all that apply.
Preterm birth at 32 weeks." "High cereal content in diet." "History of menorrhagia."
A nurse is teaching the parents of a 10-year-old child diagnosed with cystic fibrosis. Which instruction by the nurse is most appropriate?
Preventing respiratory infections is crucial for quality of life."
A nurse is assessing an 18-month-old child at the clinic for a well-child visit. Which findings indicate normal growth and development outcomes for this age range? Select all that apply.
"Able to walk forwards and backwards" "Observed playing in the waiting room alongside other children"
A teenager has been diagnosed with an anxiety disorder. Which medications should the nurse anticipate that the health-care provider will order? Select all that apply.
"Alpha blocker." "Beta blocker."
A child has been hospitalized with rubeola. Which actions by the nursing staff are most important? Select all that apply.
"Assess the child for Koplik's sports." "Report the disease to health authorities."
A teenage girl is diagnosed with systemic lupus erythematosus (SLE). Which health promotion guidance is important for the nurse to provide?
"Consider adding vitamin D to your daily routine."
A nurse is providing education to the parents of a newborn who has been diagnosed with Fetal Alcohol Spectrum Disorder. Which findings correlate with this clinical diagnosis? Select all that apply.
"Difficulty feeding." "Groove noted in upper lip." "Low birth weight."
The mother of a toddler reports to the nurse that the child becomes cyanotic when he cries. Which question by the nurse is most important to ask the mother?
"Does he squat while he cries?"
A teenager has been diagnosed with bipolar disorder and is having manic symptoms. What is the best nursing response? Select all that apply.
"Have you been taking your medication as prescribed?" "When was the last time you saw your therapist?" "What types of problems are you experiencing?"
An infant is discharged after open heart surgery. The infant is going home on oxygen and with multiple medications. Which instruction by the nurse is the priority?
"If your baby is irritable, check oxygen saturation."
The nurse is preparing discharge teaching for the parents of a 7-year-old boy with hydrocephalus and a ventriculoperitoneal shunt. Which information does the nurse include in the discharge teaching? Select all that apply
"Monitoring for shunt infection is always a priority action" "Report any nausea, vomiting, or change in behavior"
The nurse is preparing to provide information to the parents of a 14-year-old who is within normal limits for growth and development. What information is appropriate for the nurse to include? Select all that apply.
"Peer group influence is often stronger than family influence" "Growth, although slowed, can still be significant" "Children of this age can anticipate long-term consequences of choices" "The child of this age may be able to give informed consent in some situations"
A parent is concerned about giving vaccines to her young child. What is the best nursing response to the parent's stated concern?
"There are different types of vaccines that have less risk to children that may be of benefit."
A nurse is providing anticipatory guidance to the parents of a 5-month-old baby. Which nursing statements are most appropriate by the nurse to these parents? Select all that apply.
"peek -a-boo is a appropriate game for this age" "Do not leave the child alone on the changing table"
A patient is experiencing an anaphylactic reaction. Which IV solution does the nurse anticipate will be ordered for this patient?
0.9% normal saline
A child who weighs 35 lb. needs chloral hydrate (Aquachloral) for sedation prior to a medical procedure. What dose should this child receive?
1,000 mg
Prioritize the following steps for the administration of pain medication to a preschool-aged child postappendectomy. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1.Administer within 30 minutes of scheduled time 2. Confirm rights of medication administration 3. Assess for drug allergies 4. Verify using two unique identifiers *** answer is: 4321
A nurse is assessing patients for the presence of patent ductus arteriosus (PDA). which patient should the nurse assess first
4-year-old, blood pressure of 102/36 mm Hg.
A nurse is assessing several children during a shift at the well-child clinic. Which child demonstrates the most successful resolution of the Erikson stage of autonomy versus shame and doubt?
A 24-month-old being allowed to independently dress himself
Using the preceding pain scale, which patient should the nurse select to assess for pain? (FACE SCALE)
A 5-year-old who has a stomachache
A nurse is caring for a child who has a chest tube. After ambulating and returning the child to bed, the nurse notes that the child has dyspnea and decreasing oxygen saturation readings. Which nursing action is the priority?
Assess the tubing for kinks.
An adolescent patient is taking combination retroviral therapy for HIV infection. He is not responding as expected. Which action by the nurse is most appropriate?
Assessing the patient for noncompliance
A 66-lb. Child complains of mild pain after a procedure. What action by the nurse is best?
Administer 300 mg of acetaminophen (tylenol)orally and provide a movie to watch.
A child has significant polycythemia. When consulting with the health-care provider, which intervention does the nurse inquire about?
Administering anticoagulants
A nurse is assessing children for reactive attachment disorder (RAD). Which child would the nurse identify as being at highest risk for this disorder?
Adopted from a foreign orphanage
A nurse is caring for an infant diagnosed with esophageal atresia (EA) and a tracheoesophageal fistula (TEF) prior to surgical correction. Which assessment finding indicates that a priority goal is being met?
Airway patent with frequent suction
A nurse needs to administer medication to a toddler. What action by the nurse is most likely to gain cooperation from the child?
Allow the parent to give the medication
A child will be hospitalized in the following week. To decrease the child's and parents' stress related to the hospitalization, which action by the clinic nurse would be most helpful?
Arrange for the family to visit the hospital and have a tour
The pediatric nurse is assessing a child who complains of a stomachache. This is the child's fourth visit to the clinic for the same problem, and there has not been a diagnosis yet. What action by the nurse is best?
Ask about the child's functioning and development.
A pregnant woman has been taking care of her child who has rubella who is now recovering. Which information would be most important for the nurse to obtain?
Ask how far along the mother is in her pregnancy."
A child is being treated for a thrush infection. Which observation of a nurse performing medication administration would warrant additional training?
Asking the child to spit out the solution once 30 seconds has completed
A mother brings her child to the well-child clinic. She is distraught because the child tested well below normal on a school-administered intelligence (IQ) test. Which action by the nurse is the most appropriate?
Assess cultural background and economic status.
A nurse is caring for an HIV-positive school-age child who is moderately malnourished. Which interventions are appropriate to include in this child's plan of care. Select all that apply.
Assess the oral cavity once per shift Encourage adequate fluid intake Provide oral hygiene after each meal Determine the child's food preferences
A new nurse in the emergency department is examining a 4-year-old child who is sitting upright, is drooling, and is restless. Which action by the new nurse causes an experienced nurse to intervene?
Attempts to assess throat with a tongue blade
A nursing instructor is evaluating a nursing student on the placement of a nasogastric tube on a pediatric patient. Which findings indicate correct procedure? Select all that apply.
Auscultate stomach following insertion of air Use dominant hand to insert Gloves are applied following hand hygiene
A nurse has assessed a 14-year-old hospitalized patient over several days and notes that the child has difficulty with abstract concepts and is unable to appreciate diverse points of view. According to Piaget, how would the nurse categorize this child's development?
Behind development
A nurse is caring for four patients in the pediatric intensive care unit with head injuries or brain infections. Which child should the nurse see first?
Blood pressure change from 110/58 to 134/40 mm Hg in a child with brain injury
A student asks the faculty why a premature infant with patent ductus arteriosus (PDA) is being given indomethacin (Indocin). Which response by the faculty is the most appropriate?
Closes the PDA
A student nurse is preparing to give a 48.5-lb. (22-kg) child IV mannitol (Osmitrol). What action by the student causes the nursing instructor to intervene?
Confirms the dose of 66 g in a 20% solution
A father is at the bedside of his hospitalized disabled child. He begins crying, saying he has lost his job and no longer has insurance, so he is unsure of how to pay for the child's medical bills. What action by then nurse would be most helpful?
Consult with a social worker who can discuss state and federal insurance programs
A child with attention deficit-hyperactivity disorder (ADHD) is in the clinic with parents who complain that even though they are following the treatment plan, the child is not improving. What action can the nurse suggest to improve the effectiveness of the plan?
Consult with the school nurse to follow through with behavior logs.
A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?
Do not let this prescription run out.
A child is hospitalized with heart failure has manifestations related to increased preload. Which drug does the nurse prepare to administer?
Furosemide (Lasix)
A child with severe pertussis has been prescribed erythromycin (Erythrocin) and prednisone (Deltasone). Four days later, the parent informs the clinic nurse the child is sleeping more than usual and is not eating well. Which response by the nurse is the most appropriate?
Go to the emergency department for an infection work-up."
A 10-month-old-child is in the pediatric clinic for his eighth ear infection. Which assessment is most important for the nurse to perform on this child?
Graph height and weight on the growth chart.
A child has been admitted with bacterial meningitis. Which action by the nurse takes priority?
Facilitating blood cultures and lumbar puncture
An infant is being discharged from the hospital after treatment for respiratory syncytial virus (RSV). The infant still has some mild respiratory distress at times. Which discharge instruction is the priority for this infant?
Feed baby small amounts while they are sitting up.
A nurse is reviewing the clinical symptoms of pertussis in the catarrhal stage. Which findings would the nurse anticipate being present? Select all that apply
Fever 100 F Generalized aches and body pains
A child has been seen in the clinic and diagnosed with bronchitis. The next day, the mother calls the clinic to ask about using cough medicine to decrease the child's cough. Which response by the nurse is the most appropriate?
If she cant' sleep due to a cough, a dose would be okay at night.
A nurse is interviewing a mother of two children, ages 5 and 14. They were in a hotel fire a year ago in which their father was killed. The mother is concerned because the younger child has nightmares. The older child does not seem to have any problems. What action by the nurse is the most appropriate?
Inquire if the older child avoids hotels, even on television.
A 4-year-old girl is brought to the emergency department. She has a "frog-like" croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. Which nursing action is the priority for this patient?
Maintain the airway
A patient is experiencing an anaphylactic reaction. Which action by the nurse takes priority?
Maintain the patient's airway.
A parent of a child suspected of having systemic lupus erythematosus (SLE) asks why so many blood tests are being done. Which response by the nurse is the most appropriate?
Many of these blood tests look for possible organ damage from SLE."
A nurse is auscultating a pediatric patient's heart and determines there is a heart murmur present between the left atrium and the left ventricle. What cardiac pathology should the nurse suspect? Select all that apply
Mitral valve prolapse Aortic stenosis Tetralogy of fallot
A child is taking desmopressin acetate (DDAVP) for von Willebrand's disease. What teaching about this medication does the nurse provide?
Monitor your child's weight and report a gain.
Parents of a school-age child are asking the nurse about methods to help with improving the sleeping pattern of their child. What information should the nurse include in the teaching plan? Select all that apply.
No playing of video games at least 30 minutes prior to sleeping." "Refrain from giving snacks prior to bedtime." "Apply consistency of a sleep routine each night."
A father calls the pediatric clinic to report that his child was diagnosed with influenza at an urgent care facility yesterday and was prescribed oseltamivir (tamiflu). The father worries that the dose of 75 mg twice a day is too high. He reports that his child weighs 90 lb. which repose by the nurse is best?
No, that is an appropriate dose for your child.
A group of nurses are reviewing congenital cardiac conditions. Which findings would be associated with cyanotic heart disease? Select all that apply.
Not corrected with supplemental oxygen Clinical signs appear early following birth
A mother bring her severely disabled child to the pediatric clinic with complaints that the child has his fourth upper respiratory infection in 3 months. The mother appears disheveled and fatigued. What action by the nurse is best?
Offer the mother information on local respite care options.
Parents are concerned about their 4-year-old child due to frequent allergic rhinitis episodes. Which factors would the nurse identify as being most important when making a home visit? Select all that apply.
Parents vap rather than smoke cigarettes Rugs throughout the home There are curtains in the bedroom
A nurse is working with a student on the pediatric unit caring for patients in contact isolation for infectious diarrhea. Which action by the student warrants intervention by the nurse?
Performs hand hygiene with alcohol-based rubs after caring for patients
An immunocompromised child has been admitted to the hospital with Fifth's disease. Which action by the nurse is most appropriate?
Place the child in droplet precautions.
Parents of a 2-year-old child are having difficulty with establishing a bedtime routine for sleep. Which observation if noted by the nurse would warrant intervention?
Placing toys and stuffed animals on the bed.
A nurse is caring for a 5-year-old child diagnosed with Wiskott-Aldrich syndrome. When reviewing today's laboratory results, which finding does the nurse correlate with this condition?
Platelet count: 6,000
A child had a tonsillectomy this morning. What action by the nurse is most important for the child's safety?
Position the child on their side.
A nurse is assisting the physician during a lumbar puncture for a pediatric patient what priority actions should be included in the plan of care? Select all that apply
Positioning of the patient is based on developmental age Vital signs taken post procedure Patient should remain flat for at least 1 hour
During assessment of a 6-year-old child with meningitis, the nurse places the child supine and attempts to put the child's chin on their chest. The child cries out in pain and flexes their knees. How does the nurse document this assessment finding in the medical record?
Positive Brudzinski sign
A nurse is teaching a class to new mothers who are also high school students. What action by the nurse is the most appropriate to decrease the risk of child maltreatment?
Provide education on normal childhood development.
A nurse is working with a family whose child has bipolar disorder. Which item is the most appropriate for the nurse to including in the teaching session for this child and family?
Provide routine and structure and appropriate freedom.
An advanced practice nurse is working with a child diagnosed with oppositional defiant disorder. What action by the nurse is most appropriate?
Screen the child for other psychosocial problems.
A nurse is assessing a 10-month-old baby's anterior fontanel and finds it slightly depressed; the fontanel measures 2 inches (5.08 cm). What conclusion and action are most appropriate?
Sign of dehydration; assess fluid status.
A nurse is caring for a child who only awaken to painful stimuli and produces no verbal responses. Which term is the most appropriate when documenting this child's status?
Stupor.
A nurse observes several preschool-aged children during play and overhears one of them say, "my mommy wont let me do that". What conclusion is the most appropriate by the nurse regarding this child's development?
The child has developed a superego according to Freud.
A nurse notes that when an infant is startled, she looks at her mother. What conclusion can the nurse make about this infant's development?
The infant can develop other relationships because he is secure.
A father is frustrated that his child frequently disobeys well-established rules and then attempts to excuse the action by stating "well I just thought...." The father asks for guidance with discipline. What information is most appropriate for the nurse to provide?
This is a normal developmental stage.
A mother brings her 1-year-old child to the pediatric clinic and appears frustrated and stressed. During the assessment, the mother states she tries to give her child exposure to new situations and people several times a week, but the outings always end with the child screaming and crying. Which response by the nurse is the most appropriate?
Use an established routine and add new experiences slowly"
The pediatric nurse performs a pain assessment on a 5-year-old girl who is admitted to the hospital for fractures following an accident. Depending on the assessment, the nurse could implement which of the following interventions? Select all that apply
Use distraction plus regularly timed analgesic administration for moderate pain relief Manage mild pain with a combination of mild analgesics such as NSAIDs and distraction Manage severe pain with strong analgesics
A preschool-age child is going ot have a potentially painful procedure. What action by the nurse is best to prepare the child for this event?
Use play to demonstrate the procedure to the child
A preschool-age child is going to have a potentially painful procedure. What action by the nurse is best to prepare the child for this event?
Use play to demonstrate the procedure to the child.
The nurse is caring for a 15-year-old suspected of having HIV infection. Which laboratory tests does the nurse anticipate will be ordered for this patient? Select all that apply.
Western blot test ELISA antibody test
Four children are in the pediatric clinic waiting to be seen. Which patient should the nurse see first?
Wheezing, retracting, no wet diapers today
A nurse is caring for a 5-year-old who broke his arm and is complaining of pain. What statement by the nurse to the child would be most helpful?
You didn't do anything wrong that caused the hurt."
