Peds practice A w/rationales

a nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. which should be included?

"Award your child with a sticker when they sit on the potty chair." A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair.

A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?

"I should keep my child indoors when I mow the yard." answer: The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks. "I will use a humidifier in my child's room at night."The nurse should instruct the parent that dehumidifiers or air conditioners are recommended to control the room temperature because heat and humidification can cause an asthma exacerbation. "I will give my child a cough suppressant every 6 hours if he has a cough."The nurse should instruct the parent that cough suppressants are contraindicated for children who have asthma because they need to be able to cough up mucus to keep their airway open. "I should avoid using a wet mop on my floors when I am cleaning."The nurse should instruct the parent to wet mop bare floors weekly because sweeping floors can trigger an asthma attack due to the inhalation of the dust that becomes airborne during sweeping.

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.)

-Ankle clonus-Exaggerated stretch reflexes-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.

The nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect?

Abdominal distention answer: The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness. Hyperactive bowel soundsHypoactive bowel sounds are a manifestation of peritonitis. The peritoneal inflammation caused by the feces and bacteria released from the perforated appendix results in the development of an ileus and a decrease in bowel motility. BradycardiaTachycardia is a manifestation of peritonitis, resulting from infection and fluid shifts within the abdomen, which causes hypovolemia. Bloody stoolBloody stool is a manifestation of Meckel diverticulum, not peritonitis. Diarrhea or constipation can be manifestations of appendicitis.

a nurse is caring for a child who has tetralogy of fallot. which of the following labs should the nurse expect to find?

RBC 6.8 million

a nurse is caring for a 12 month old infant following the surgical repair of a cleft palate. the nurse should plan to feed the infant using which instrument?

a cup

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?

coloring book and crayons

a nurse is admitting a 4-month old infant who has heart failure. which of the following findings is the nurse's priority?

episodes of vomiting When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. not weight because: The infant should gain 680 g (1.5 lb) per month until the age of 5 months.

school age children are attempting to master which of the following?

industry vs. inferiority

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?

maintain the child on bed rest

A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?

"I should secure the car seat using lower anchors and tethers instead of the seat belt." answer: Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used. "I should position the car seat harness 1 inch above my baby's shoulders."The car seat harness in rear-facing car seats should be positioned at or just below the infant's shoulders. I will make sure that the car seat is placed at a 90-degree angle."The car seat should be positioned at a 45° angle to prevent slumping and injury to the infant. "I will pad my baby's car seat with a blanket for traveling long distances."Padding placed underneath the infant or anywhere in the car seat can compress and/or create space between the infant and the harness. This can increase the risk for injury to the infant and should be avoided.

A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make?

"Let's talk about some of the ways you have handled previous stressors in your life." ANSWERThis statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation. "It is important that you provide emotional support for your family at this time."This statement tells the parent how to behave, which can make them feel as if they must behave as the nurse does and can lead to dependence. "You have to do what you feel is best. Everything will turn out fine."This statement offers false reassurance to the parent, which can invalidate the parent's feelings and cause the parent to become defensive. "I know how you feel. This is an extremely stressful time for your family."This statement is making artificial consolation. These types of statements do not encourage the parent to express their thoughts, concerns, and fears.

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." answer: The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension. "Provide the medication through a straw."The nurse should instruct the parent to put the medication directly in the child's mouth and make sure the child swishes it around before swallowing. "Rinse the child's mouth with water immediately after giving the medication."The nurse should instruct the parent to have the child keep the medication in their mouth for as long as possible before swallowing it. Rinsing the mouth can wash some of the medication away and decrease its effectiveness. "Mix the medication with applesauce if the child dislikes the taste."The parent should not mix the medication with food because this will interfere with the absorption.

A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" Which of the following responses should the nurse make?

"You can sign the consent form because you are married." answer: The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age. "Your spouse should sign the consent form for you."The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of their spouse. "Your parent should sign the consent form for you."The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of a parent. "You can appoint a legal guardian to sign the consent form."The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of a legal guardian.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?

A unilateral rib hump answer: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature. Increase in anterior convexity of the lumbar spineAn increased anterior convexity of the lumbar spine is a manifestation of lordosis, an expected finding in toddlers. Lordosis can indicate a complication of a disease process, such as flexion contractures, congenital dislocation of the hip, or obesity, when seen in older children. Increased curvature of the thoracic spineAn increased curvature of the thoracic spine is a manifestation of kyphosis. Kyphosis can be a manifestation of a congenital condition or disease process such as rickets, or it can be posture-related. In posture-related kyphosis, the adolescent presents with rounded shoulders and a slouching posture. Lateral flexion of the neckLateral flexion of the neck is an indication of torticollis as a result of contracture of the sternocleidomastoid muscle. Torticollis can be congenital, the result of intrauterine fetal posturing or abnormality of the cervical spine, or it can be acquired, due to factors such as a traumatic lesion to the sternocleidomastoid muscle.

A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?

Administer an analgesic to the child.Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder. Apply topical antimicrobial ointment to the child's wound. A nurse should apply topical antimicrobial ointment to the child's wound following hydrotherapy to prevent infection. Place a mesh gauze dressing over the child's wound. A nurse should apply mesh gauze to the child's wound following hydrotherapy to prevent infection.

A nurse is caring for a school-age child who in in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take?

Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling. The nurse should maintain the child in a supine position while in Buck's traction. Elevating the head of bed should be implemented for a child who is in cervical traction. Ensure that the head of the bed is elevated to a 90° angle.

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 MY ANSWER 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 providing teaching to the family of a school age child who has juvenile idiopathic arthritis. which should be included?

Encourage the child to perform independent self-care." MY ANSWER The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem.

The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take?

First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?

Flank pain answer: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. Laryngeal edemaLaryngeal edema is an indication of an allergic reaction to the blood transfusion. Distended neck veinsDistended neck veins are an indication of circulatory overload, which is a complication of a blood transfusion. Muscular weaknessMuscle weakness is an indication of an electrolyte disturbance, which is a complication of a blood transfusion.

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. answer; 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. Place the infant in a room equipped with negative airflow.The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. A room equipped with negative airflow is not necessary and is only initiated for infants who need airborne precautions. Administer palivizumab as prescribed for the infant.Palivizumab is used for prophylaxis in at-risk infants and is not used in the treatment of RSV. Remove gloves after leaving 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. To reduce the risk of transmission, all health care personnel should remove their gloves prior to leaving the infant's room.

a nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. which should the nurse do?

Have the adolescent sign a consent form for treatment. MY ANSWER The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent.

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% answer: 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. Hemoglobin 13.5 g/dLThis hemoglobin level is within the expected reference range of 9.5 to 14 g/dL for a school-age child. WBC count 8,000/mm3This WBC count is within the expected reference range of 5,000 to 10,000/mm3 for a school-age child. Platelets 250,000/mm3This platelet count is within with expected reference range of 150,000 to 400,000/mm3 for a school-age child.

A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy. Which of the following lab values should the nurse report to the provider?

Hgb 8.5 g/dL answer: A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider. WBC count 9,500/mm3A child receiving chemotherapy is at risk for infection due to the myelosuppressing effects of the medication used to treat the cancer. The presence of infection can be evaluated through body temperature, redness, edema, warmth, or drainage of wound or IV sites, as well as through measurements of WBC and absolute neutrophil counts. A WBC count of 9,500/mm3 is within the expected reference range of 5,000 to 10,000/mm3 for a 7-year-old child. Prealbumin 18 mg/dLA child receiving chemotherapy is at risk for malnutrition as a result of nausea and vomiting, stomatitis, and pain. Nutritional status can be evaluated through prealbumin, albumin, and transferrin levels. A prealbumin level of 18 mg/dL is within the expected reference range of 15 to 33 mg/dL for a 7-year-old child. Platelets 300,000/mm3A child receiving chemotherapy is at risk for hemorrhage due to the thrombocytopenic effects of the medications used to treat cancer. The development of thrombocytopenia is diagnosed through laboratory testing of platelet levels. A platelet count of 300,000/mm3 is within the expected reference range of 150,000 to 400,000/mm3 for a 7-year-old child.

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?

Implement seizure precautions for the infant. answer: An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child. Position the infant side-lying with their head at a 0° to 5° angle.The nurse should position the infant with their head slightly elevated in a midline position to reduce the risk of increased intracranial pressure. Perform a neurological assessment every 4 hr.The nurse should perform a neurological assessment as frequently as every 15 min to detect changes in the child's condition and monitor for intracranial pressure. Suction the infant's nares to remove secretions.The nurse should avoid suctioning the infant's nares due to the risk of exposure of the suction catheter to the brain through the fracture; however, oral suctioning can be performed.

a nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. which of the following should be included?

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. The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis, NOT 2 hours.

a nurse in an ED is assessing a toddler who has kawasaki disease. which of the following should the nurse expect?

Increased temperature is correct. Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics.Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia.Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia.Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction.Cervical lymphadenopathy is correct. A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?

Initiate seizure precautions for the child. answer: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety. Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F).A child who has AKI can develop a fever due to an infection. Because AKI is a contraindication for receiving medications that are nephrotoxic, such as NSAIDs, the nurse should use compensatory measures, such as turning on a fan in the room. Assess the child's blood pressure every 8 hr.A child who has AKI is often hypertensive due to fluid volume excess and the activation of the renin-angiotensin system. To prevent complications, such as hypertensive encephalopathy, the nurse should assess the child's blood pressure every 4 to 6 hr. Weigh the child weekly at various times of the day.In the oliguric phase of AKI, the child will have decreased urine output and fluid retention. This can result in water intoxication, which predisposes the child to neurologic alterations such as seizures. To ensure accurate evaluation of fluid balance, the nurse should plan to weigh the child daily, at the same time, in the same clothing, and using the same scale.

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?

Loud, harsh murmur answer: The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle. DysrhythmiasVentricular septal defect does not affect the electrical conduction of the heart. Therefore, the nurse should not expect to hear dysrhythmias when assessing this infant. Weak femoral pulsesThe nurse should expect weak femoral pulses when assessing an infant who has coarctation of the aorta. High blood pressureThe nurse should expect an elevated blood pressure when assessing an infant who has coarctation of the aorta.

a nurse is admitting an infant who has intussuscpetion. which of the following findings should the nurse expect?

MY ANSWER Steatorrhea is incorrect. The nurse should expect an infant who has intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis.Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel.Lethargy is correct. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake.Constipation is incorrect. The nurse should expect an infant who has intussusception to have mucus-filled and red jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen.Weight gain is incorrect. The nurse should expect an infant who has intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?

Perform a finger stick. answer: The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease. Obtain a sputum specimen.Sputum specimens are collected to identify the infectious organism in a child who has an acute respiratory tract infection. Therefore, this is not a component of the sickle-turbidity test. Perform an Allen test.An Allen test determines adequate circulation by observing capillary refill before an arterial puncture. Therefore, this is not a component of the sickle-turbidity test. Obtain a stool specimen.Stool specimens are collected to identify organisms or parasites that cause diarrhea or to check for the presence of occult blood. Therefore, this is not a component of the sickle-turbidity test.

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?

Petechiae on the lower extremities answer: 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. Reports a headache as 6 on a 0 to 10 pain scaleHeadache is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report. Nuchal rigidityNuchal rigidity is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report. Positive Kernig's signPositive Kernig's sign is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report.

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. ANSWER The nurse should place the child in a side-lying position to prevent aspiration. Delay documentation until the child is fully alert.To ensure accurate description of the event, the nurse should document the treatment of the seizure and the postictal period as early as possible. Give the child a high-carbohydrate snack.The child should not be given any foods or liquids until protective reflexes have returned to prevent aspiration. Administer an oral sedative to the child.The child should not be given anything by mouth until protective reflexes have returned to prevent aspiration.

A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?

Playing dress-up answer: 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. Playing pat-a-cakePlaying pat-a-cake is a recommended play activity for an infant. Using a push-pull toyUsing a push-pull toy is a recommended play activity for a toddler. Creating a scrapbookCreating a scrapbook is a recommended play activity for a school-age child.

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. answer: 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. Schedule time in the play room for the child.The nurse should restrict play activities to the child's bed to minimize energy expenditure. Weigh the child weekly.The nurse should weigh the child daily. Maintain the child in a supine position.To provide for maximum chest expansion, the nurse should maintain the child's bed in a semi-Fowler's position.

a nurse is planning developmental activities for a newly admitted 10 y/o child with neutropenia. which of the following actions should the nurse take?

Provide the child with a book about adventure. MY ANSWER 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 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

Respiratory rate 45/min answer: 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. Blood pressure 90/50 mm HgThe nurse should identify that a blood pressure of 90/50 mm Hg is within the expected reference range of 86 to 118 mm Hg systolic and 44 to 74 mm Hg diastolic for a 3-year-old toddler. Weight 14.5 kg (32 lb)The nurse should identify that a weight of 14.5 kg (32 lb) is the average weight for a 3-year-old toddler. Heart rate 110/minThe nurse should identify that a heart rate of 110/min is within the expected reference range of 80 to 120/min for a 3-year-old toddler.

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?

Schedule the toddler for a yearly rescreening.The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure. The nurse should instruct the toddler's parents to provide a diet rich in calcium because calcium, vitamin C, and iron decrease lead absorption. Chelation therapy is required for a lead level of 45 mcg/dL or greater and, depending on the situation, can be initiated for lead levels over 10 mcg/dL.

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?

Screen the child's visitors for indications of infection. ANSWER A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection. Use surgical asepsis when providing routine care for the child.It is not necessary for the nurse to use surgical asepsis when providing direct care. Strict hand hygiene and medical asepsis are recommended to prevent the spread of infection. Administer the measles, mumps, and rubella (MMR) vaccine to the child.The MMR vaccine is contraindicated for a child who is severely immunocompromised because it is a live virus vaccine and the child might not be able to build adequate antibodies to prevent infection with the organism. Infuse packed RBCs.A child who is immunocompromised as a result of chemotherapy will have a decreased neutrophil count. The nurse should plan to infuse packed RBCs for the child who is anemic. However, packed RBCs will not increase the child's neutrophil count.

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?

Serum creatinine 3.0 mg/dL answer: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney. Negative leukocyte esteraseThe nurse should identify that a negative leukocyte esterase level is an expected finding and indicates that the adolescent does not have a urinary tract infection. A negative leukocyte esterase does not indicate rejection of the kidney. Negative urine proteinThe nurse should identify that a negative urine protein is an expected finding and does not indicate rejection of the kidney. Urine output 40 mL/hrThe nurse should identify that a urine output of 40 mL/hr is within the average hourly urine output of 33 to 62.5 mL/hr for an adolescent and does not indicate rejection of the kidney.

A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings in an indication of early septic shock?

Temperature 39.1° C (102.4° F) answer: The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills. Blood pressure 130/90 mm HgA blood pressure of 130/90 mm Hg is above the expected reference range of 97 to 128 mm Hg systolic and 58 to 88 mm Hg diastolic for a 10-year-old child. The nurse should expect a child who has early septic shock to have a blood pressure within the expected reference range. Heart rate 60/minA heart rate of 60/min is within the expected reference range of 60 to 100/min when awake and 50 to 90/min when sleeping for a 10-year-old child. The nurse should expect a child who has early septic shock to have a heart rate above the expected reference range. Urinary output 100 mL/hrUrinary output of 100 mL/hr is above the expected reference range of 33 to 58 mL/hr for a 10-year-old child. The nurse should expect a child who has early septic shock to have urinary output within the expected reference range.

a nurse is planning an educational program for school-age child and their parents about bicycle safety. which should be included?

The child should be able to stand on the balls of their feet when sitting on the bike. To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar.

A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point?

The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness.

The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?

The toddler received tobramycin during a hospitalization 2 weeks ago. answer: The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment. The toddler has a vocabulary of 25 words.At the age of 18 months, the toddler should have a vocabulary of at least 10 words. Therefore, a vocabulary of 25 words does not indicate a need to assess the toddler for hearing loss. The toddler developed a mild rash following a recent varicella immunization.Approximately one in 25 people develop a mild rash following administration of the varicella vaccine. This reaction does not indicate a need to assess the toddler for hearing loss. The toddler's Moro reflex is absent.Primitive reflexes, such as Moro, rooting, and tonic neck, disappear by 5 months of age. Therefore, an absent Moro reflex does not indicate a need to assess the toddler for hearing loss.

a nurse is planning care for a school-age child who has a tunneled central venous access device. which of the following interventions should be planned?

Use a semipermeable transparent dressing to cover the site. The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.

A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

White rice answer: The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease. Wheat crackersWheat crackers contain gluten and should be avoided by children who have celiac disease. Rye breadRye bread contains gluten and should be avoided by children who have celiac disease. Barley soupBarley soup contains gluten and should be avoided by children who have celiac disease.

A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

Withhold the measles, mumps, and rubella (MMR) vaccine. answer: The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine.It is safe to administer the DTaP vaccine at the same time as the MMR vaccine and tuberculin skin test (TST). DTaP vaccines are not contraindicated for children who have mild acute illness or asthma. Withhold the influenza vaccine.A child who has asthma can receive the inactivated influenza vaccine. Withhold the tuberculin skin test (TST).It is safe to perform a TST at the same time as administering MMR and varicella vaccines. A TST is not contraindicated for children who have mild acute illness or asthma.

a nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. which should the nurse state?

You should offer your child high-protein meals and snacks throughout the day." MY ANSWER 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 charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. which of the following statements should the nurse include

a 6 year old should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands

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 plastic mirror

A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?

absence of peristalsis answer: The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning. Purulent nasogastric drainagePurulent drainage is not an expected finding following a perforated appendix repair. The nurse should expect brown to green-tinged drainage from the NG tube. Passage of dark red stool with mucusPassage of dark red stool with mucus is not an expected finding immediately following a perforated appendix repair. The nurse should identify this finding as a manifestation of Meckel diverticulum. WBC count 6,000/mm3The nurse should expect a WBC count greater than 20,000/mm3 in a client who has had a ruptured appendix.

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

administer epinephrine IM to the child ANSWERWhen using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart. Elevate the head of the child's bed.Elevating the head of the child's bed is important to facilitate breathing and circulation. However, it is not the priority action the nurse should take. Insert a large bore IV catheter for the child.Inserting a large bore IV catheter is important to facilitate administration of IV fluids and medications. However, it is not the priority action the nurse should take. Determine the allergen that caused the child's reaction.Determining the allergen that caused the child's reaction is important to prevent any additional episodes of anaphylaxis. However, it is not the priority action the nurse should take.

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

administer ibuprofen

a nurse is caring for a child who has paralytic poliomyelitis. which of the following actions should the nurse take?

administer oral analgesics prior to exercises

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?

administer the immunization using a 24 gauge needle answer: The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences. Place the child in a prone position for the immunization.The nurse should place the child in an upright sitting position for the immunization because this decreases the child's fear and anxiety. Request that the child's caregiver leave the room during the immunization.The nurse should allow the caregiver to stay near the child during the immunization to provide a sense of security and reduce the child's anxiety level. Inject the immunization slowly after aspirating for 3 seconds.The nurse should inject the immunization rapidly and avoid aspiration. These actions decrease the risk of needle displacement and lower the child's fear and anxiety level by decreasing the amount of time it takes to administer the immunization.

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?

alcohol consumption

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?

answer: "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. "I will puncture the pad of my finger when I am testing my blood glucose."The child should avoid puncturing the pads of the fingers because they have fewer blood vessels and more nerve fibers. Instead, the child should puncture the skin on either side of the finger pad to promote blood flow and decrease pain. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low."The child should eat a snack of 10 to 15 g of carbohydrates, such as 120 mL (4 oz) of fruit juice or 66 g (1/2 cup) of ice cream, to rapidly increase the blood glucose level during a mild hypoglycemic reaction. "I will decrease the amount of fluids I drink when I am sick."During acute illness, the child is prone to hyperglycemia and ketonuria and is at risk for dehydration. Therefore, the child's fluid intake should be increased, rather than decreased.

A nurse is receiving change-of-shift report on four children. Which of the following children should the nurse see first?

answer: 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 school-age child who has cystic fibrosis and a frequent nonproductive coughA frequent nonproductive cough is an expected and nonurgent finding for a child who has cystic fibrosis. Therefore, the nurse should see another child first. A preschooler who has asthma and a peak flow meter reading in the green zoneA peak flow meter reading in the green zone is an expected and nonurgent finding for a child who has asthma. Therefore, the nurse should see another child first. An adolescent who has meningitis and reports a sensitivity to lights and noiseA sensitivity to light and noise is an expected and nonurgent finding for a child who has meningitis. Therefore, the nurse should see another child first.

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?

answer: Sodium 140 mEq/LThe 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. Potassium 2.9 mEq/L A potassium level of 2.9 mEq/L is below the expected reference range of 4.1 to 5.3 mEq/L and indicates hypokalemia. Urine specific gravity 1.035 A urine specific gravity of 1.035 is above the expected reference range of 1.005 to 1.030 and indicates concentrated urine. BUN 25 mg/dL A BUN level of 25 mg/dL is above the expected reference range of 5 to 18 mg/dL and indicates the kidneys are not excreting BUN as they should be.

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as suggestive of potential physical abuse?

answer: symmetric burns of the lower extremities Recurrent urinary tract infections Recurrent urinary tract infections are a clinical manifestation that can indicate sexual abuse. 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. Failure to thrive Failure to thrive can be an indication of physical neglect due to malnutrition. Lack of subcutaneous fatLack of subcutaneous fat can be an indication of physical neglect. This manifestation can be a result of poor health care, infections that were untreated, and/or a lack of or delayed childhood immunizations.

A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?

apply a topical analgesic cream to the site 1 hr prior to procedure ANSWERThe nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted. Place a cardiac monitor on the adolescent prior to the procedure.Cardiac monitoring is not necessary during a lumbar puncture. Keep the adolescent in a semi-Fowler's position for 4 hr following the procedure.The nurse should place the adolescent in the prone position or flat in bed for up to 12 hr following the procedure to prevent postprocedural spinal headache. Restrict fluids for 2 hr following the procedure.The nurse should encourage the adolescent to drink extra fluids following the procedure to replace the cerebrospinal fluid removed during the procedure.

a nurse is providing discharge teaching to the guardian of an infant who has a tracheostomy. which should the nurse ID as an item that should be in the infant's home prior to discharge

bag-valve mask The nurse should teach the guardian that the infant's home should contain the equipment necessary to care for and maintain oxygenation, such as a bag-valve mask. The nurse should instruct the infant's guardian to notify the utility company, as well as local emergency medical services, of the infant's condition prior to discharge.

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'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 in the emergency department is caring for a toddler who has a partial thickness burns on their right arm. Which of the following actions should the nurse take?

cleanse with mild soap and water answer: The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection. Insert a nasogastric tube.The nurse should be aware that inserting a nasogastric tube to empty the contents of the stomach and maintain decompression is an intervention for major burn management. Initiate prophylactic antibiotic therapy.The nurse should be aware that antibiotics are not routinely administered for the prevention of infection at the burn site because the decreased circulation in the burned area decreases the distribution of the medication to the deeper tissues. Apply a topical corticosteroid to the affected area.The nurse should apply an antimicrobial ointment to the affected area to prevent infection.

a nurse is caring for a toddler. which of the following labs would the nurse report to the provider?

creatinine 0.9

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?

cuts an outlined shape using scissors ANSWERThe nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape. Identifies right from left handIdentifying the right from left hand is an expected developmental milestone of a 6-year-old child. Uses a utensil to spread butterUsing a utensil to spread butter is an expected developmental milestone of a 6-year-old child. Draws a stick figure with seven body partsDrawing a stick figure with seven body parts is an expected developmental milestone of a 5-year-old child.

a nurse is preparing to administer ondansetron to a school-age child who is receiving chemotherapy to treat cancer. which of the following assessment findings should the nurse id as an indication that the ondansetron has been effective

decreased nausea Chemotherapy can cause nausea and vomiting. Administration of ondansetron 30 min before chemotherapy can minimize nausea and vomiting. Scheduled administration of ondansetron should continue for at least 24 hr following chemotherapy.

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?

denies discomfort during assessment of injuries following are ASLO signs: The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury. The nurse should suspect child maltreatment in the form of physical abuse if the adolescent expresses a reluctance to return home or demonstrates a fear of parents. The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has withdrawn behavior and poor relationships with peers. The nurse should suspect child maltreatment in the form of physical abuse if the adolescent's description of the injury is vague and inconsistent with the actual wounds.

a nurse is admitting a preschooler who is suspected to have pharyngeal diphtheria. what transmission-based precautions should the nurse initiate

droplet

A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?

dry, hacking cough answer: The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night Inflamed throat with exudateThe nurse should identify that an inflamed throat with exudate is a manifestation of acute streptococcal pharyngitis. Purulent eye drainageThe nurse should identify that purulent eye drainage is a manifestation of bacterial conjunctivitis. Koplik spots on buccal mucosaThe nurse should identify that Koplik spots on buccal mucosa are a manifestation of rubeola, or measles.

A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?

epinephrine answer: This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs. PrednisonePrednisone is an anti-inflammatory agent that can treat severe inflammation. Although it will benefit a child who is having an anaphylactic reaction, it is not the first medication the nurse should administer. DiphenhydramineEven though histamines are not the major mediators of an anaphylactic reaction, administering an antihistamine such as diphenhydramine can help to decrease the allergic reaction. However, it is not the first medication the nurse should administer. AlbuterolAlbuterol is a beta adrenergic agonist that can treat acute bronchospasms. Although albuterol will improve the child's breathing, it is not the first medication the nurse should administer.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take?

give morphine ANSWERA pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief. Instill a 500 mL tap water enema.Administering an enema accelerates bowel motility and increases the risk for perforation of the appendix. Administer polyethylene glycol 1g/kg PO.Administering laxatives accelerates bowel motility and increases the risk for perforation of the appendix. Apply a heating pad to the child's abdomen.Applying heat to the child's abdomen increases the risk for perforation of the appendix.

A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?

give the infant a pacifier answer The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping. "Place the infant in a prone position to sleep."The nurse should instruct the parent to place the infant in a supine position to sleep. Prone and side-lying positions are risk factors for SIDS. "Allow the infant to sleep on a large pillow."Placing the infant on a large pillow to sleep can increase the risk of suffocation, asphyxiation, and SIDS. "Use a soft mattress in the infant's crib."The nurse should instruct the parent to use a firm mattress and avoid the use of waterbeds, beanbags, or soft mattresses when placing the infant in bed. The use of a soft mattress in the infant's crib is a risk factor for SIDS and can lead to asphyxiation.

a nurse is providing teaching about car seat safety with the guardian of an 18 month old toddler who weighs 9.1 kg. which of the following responses by the guardian indicates an understanding of the teaching

i will place the car seat rear-facing in the back seat of my car

A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis?

increased protein concentration ANSWERThe nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis. Decreased cerebrospinal fluid pressureIncreased cerebrospinal fluid pressure is a finding associated with bacterial meningitis. Decreased WBC countAn increased WBC count in the spinal fluid is a finding associated with bacterial meningitis. Increased glucose levelA decreased glucose level in the spinal fluid is a finding associated with bacterial meningitis.

A nurse is admitting a school-age child who has Pertussis. Which of the following actions should the nurse take?

initiate droplet precautions answer: 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. Place the child in a room with positive-pressure airflow.The nurse should place a child who has undergone an allogeneic hematopoietic stem cell transplant in a room with positive-pressure airflow to reduce the risk of disease transmission to the child. Place the child in a room with negative-pressure airflow.The nurse should place a child who has an airborne infection, such as measles or varicella, into a room with negative-pressure airflow. Initiate contact precautions for the child.The nurse should initiate contact precautions for a child who has an illness that can be transmitted by direct contact or contact with the child's items, such as hepatitis A and rotavirus.

a nurse is reviewing the lab results of a 6 month old infant who has GER and is receiving treatment with lansoprazole. which of the following should indicate that the lansoprazole should be withheld and the provider should be notified?

magnesium 1.1 mEq/L A magnesium level of 1.1 mEq/L is below the expected reference range of 1.4 to 1.7 mEq/L for a 6-month-old infant. Decreased magnesium levels, which can be seen with lansoprazole therapy, can cause cardiac dysrhythmias, respiratory depression, and diminished deep tendon reflexes. Therefore, the nurse should withhold the lansoprazole and notify the provider immediately.

a nurse is providing teaching to the guardians of a school-age child who has partial seizures and a new prescription for gabapentin. which of the following info should the nurse included in the teaching

monitor the child for new or worsening depression Gabapentin can cause neuropsychiatric adverse effects, such as new or worsening depression, suicidal thoughts, confusion, and dizziness. The nurse should instruct the guardians to monitor the child closely for behavior changes that could indicate depression or suicidal thoughts

A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?

my child will receive antibiotics for several weeks answer: The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful. "My child will have a cast until healing is complete."Bearing weight must be avoided with osteomyelitis. Therefore, the child should be placed in a comfortable position with the limb supported. There is no indication for a cast. "My child can return to playing sports once they have been discharged."Bearing weight should be avoided to prevent complications and minimize pain. Therefore, it will be several weeks to months before the child can play contact sports. "My child needs to be in contact isolation."Contact isolation is not necessary because osteomyelitis is not a communicable illness.

a nurse is assessing a school-aged child who has acute glomerulonephritis. which of the following manifestations should the nurse expect

periorbital edema

A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?

place diapers under the harness straps answer: To prevent soiling of the harness, the parent should apply the infant's diaper under the straps. "I should remove the harness at night to allow my infant to stretch her legs."The harness is to be worn continuously until the hip is stable, which usually occurs within 6 to 12 weeks. Removing the harness frequently or for long periods of time will reduce the effectiveness of the treatment. "I will need to adjust the straps on the harness once each week."The Pavlik harness is designed to maintain the infant's hips in a position of flexion and abduction. The nurse should instruct the parent not to adjust the harness in any way to avoid complications. "I should apply baby powder to my infant's skin twice daily."The use of powders and lotions should be avoided during treatment with a Pavlik harness because these products, in combination with the harness, can cause skin irritation and breakdown.

a nurse is planning care for a preschooler who is immediately postoperative following the replacement of a ventriculoperitoneal shunt. which of the following interventions should the nurse include in the plan?

position the child NOT on the shunt side post-op to avoid pressure on the site

a nurse is teaching the parent of a 13-month-old toddler about home safety precautions. which of the following statements should the nurse make?

provide your child's milk and juice in a cup instead of a bottle The nurse should instruct the parent to wean the toddler from a bottle by 14 months of age. Drinking milk or juice from a bottle, especially at bedtime, coats the teeth in sugar and increases the risk for tooth decay.

a nurse is caring for a 10 y/o child following a head injury. which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus

sodium 155 A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L.

The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the inter professional team should the nurse initiate a referral?

speech therapist ANSWERThe nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation Occupational therapistThe nurse should initiate a referral for an occupational therapist for a child who has physical disabilities and requires assistance with ADLs. Respiratory therapistThe nurse should initiate a referral for a respiratory therapist for a child who requires airway support. Physical therapistThe nurse should initiate a referral for a physical therapist for a child who requires assistance with mobility and increasing physical strength.

A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?

substernal retractions answer: 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 finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure. Excoriated scrotal areaThe nurse should report an excoriated scrotal area to the provider. However, there is another finding that is the nurse's priority to report. Multiple capillary hemangiomasThe nurse should report the presence of multiple capillary hemangiomas to the provider. However, there is another finding that is the nurse's priority to report. Depressed posterior fontanelThe nurse should report a depressed posterior fontanel to the provider. However, there is another finding that is the nurse's priority to report.

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?

tachypnea ANSWER 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. Skin breakdownToddlers who have gastroenteritis and are dehydrated are at increased risk for skin breakdown because of changes in circulation and loss of skin elasticity. However, there is another finding that is the nurse's priority. HypotensionToddlers who have gastroenteritis and are dehydrated can exhibit hypotension because of reduced blood volume. However, there is another finding that is the nurse's priority. HyperpyrexiaToddlers who have gastroenteritis and are dehydrated can exhibit hyperpyrexia, or fever, which is caused by the effect of fluid volume depletion on the hypothalamus. However, there is another finding that is the nurse's priority.

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following?

tachypnea ANSWERThe nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia. Biot respirationThe nurse should identify Biot respirations as periods of apnea alternating with breaths of increased but consistent depth. Cheyne-Stokes respirationThe nurse should identify Cheyne-Stokes respirations as periods of apnea alternating with periods of hyperventilation. BradypneaThe nurse should identify bradypnea as a slow, regular breathing pattern.

a nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has HIV. which of the following should the nurse include in the teaching?

the pneumococcal and influenza vaccines are recommended for your 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?

the test shows us if your child had a recent strep infection.

a nurse is caring for a school-age child who has varicella. the parent asks the nurse when their child will no longer be contagious. which is correct?

when your child's lesions are crusted, usually about 6 days after they appear The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.

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 after you eat ANSWERPreschoolers 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. "Your daddy will be back at 7 p.m."A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words. "Your daddy will be back after he takes care of your brother."A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words. Also, this response by the nurse does not relate to the child directly. "Your daddy will be back in the morning."A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words.

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 Zinc oxideMY ANSWERDiaper 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. Antibiotic ointmentDiaper dermatitis can be the result of an overgrowth of yeast, such as Candida albicans, on the skin. Treatment for yeast-related dermatitis includes a topical antifungal medication. However, antibiotic ointment is not recommended for the treatment of diaper dermatitis. Talcum powderDiaper dermatitis can be treated with several different products at the same time, including a protective ointment and a protective powder, such as a powder made with karaya or cornstarch. However, talcum powder is not recommended for the treatment of diaper dermatitis because it has been linked to respiratory disorders in infants. Antiseptic solutionInfants who have diaper dermatitis should have the affected areas gently washed with water and a mild soap. Antiseptic solution is not recommended because this can cause burning and pain to the infant.

A nurse is caring for a 15 year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Mental confusion answer: A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur. Sodium 148 mEq/LA sodium level of 148 mEq/L is above the expected reference range of 136 to 145 mEq/L. SIADH is caused by the secretion of excess antidiuretic hormone, which results in a decreased serum sodium level due to increased circulation of free water. Urine specific gravity 1.020A urine specific gravity of 1.020 is within the expected reference range of 1.005 to 1.030. A child who has SIADH is more likely to have concentrated urine and urine specific gravity above the expected reference range. Weak peripheral pulsesA child who has SIADH is more likely to have fluid overload, full, bounding pulses, increased blood pressure, and tachycardia.

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?

Oral rehydration solution answer: 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. Apple juiceA toddler who has acute diarrhea should not drink apple juice because it is high in carbohydrates and osmolarity and low in electrolytes. Peanut butterA toddler who has acute diarrhea should not eat peanut butter because it is high in carbohydrates and fiber. The high sugar content can result in prolonging the diarrhea and worsening of the dehydration, because water is pulled into the bowel lumen in response to the increased osmolality caused by the sugar. The fiber content further stimulates the bowel, worsening the diarrhea. Chicken brothA toddler who has acute diarrhea should not consume chicken broth because it is high in sodium and is not nutrient-dense.