Peds Saunders Questions
The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse should monitor for which sign of a serious complication associated with this type of traction? Lack of appetite Elevated temperature Increase in the blood pressure Decrease in the urinary output
Elevated temperature
A 4-year-old child with acute glomerulonephritis is admitted to the hospital. The nurse identifies which client problem in the plan of care as the priority? Infection related to hypertension Injury related to loss of blood in urine Excessive fluid volume related to decreased plasma filtration Retarded growth and development related to a chronic disease
Excessive fluid volume related to decreased plasma filtration Rationale: Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. The child with acute glomerulonephritis will have an excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume would be a focus for this disease process. No risk for infection is associated with this disease; it is a postinfectious process, usually from a pneumococcal, streptococcal, or viral infection. Hematuria is present, but the loss of blood is not enough to constitute a risk for injury. The disease is acute as opposed to chronic, and almost all children recover completely.
The primary health care provider prescribes patching for a child with strabismus of the right eye, and the nurse instructs the mother regarding this procedure. What should the nurse include in the instructions? Place the patch on both eyes. Place the patch on the left eye. Place the patch on the right eye. Alternate the patch from the right to the left eye hourly.
Place the patch on the left eye. Rationale: Patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the better-functioning eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years.
The mother of a child who has undergone a myringotomy, with insertion of tympanoplasty tubes, telephones and tells the nurse that the tubes have fallen out. Which is the appropriate response to the mother? "Bring the child to the nearest emergency department." "Replace the tubes immediately so that the opening does not close." "Place the tubes in hydrogen peroxide for 1 hour before replacing them in the child's ears." "This is not an emergency. I will speak to the primary health care provider and call you right back."
"This is not an emergency. I will speak to the primary health care provider and call you right back."
A child with developmental dysplasia of the hip is placed in a Pavlik harness. The nurse should demonstrate to the parents how to place the child in this harness by placing the child's legs in which position? Prone Abduction Extension Adduction
Abduction
The nurse is performing an assessment on a child with a head injury. The nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. What should the nurse document that the child is experiencing? Decorticate posturing Decerebrate posturing Flexion of the arms and legs Normal expected positioning after head injury
Decorticate posturing
A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? Eat twice the amount normally eaten at lunchtime. Take half the amount of prescribed insulin on practice days. Take the prescribed insulin at noontime rather than in the morning. Eat a small box of raisins or drink a cup of orange juice before soccer practice.
Eat a small box of raisins or drink a cup of orange juice before soccer practice.
The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? Stress Trauma Infection Fluid overload
Fluid overload
The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? Hypertension Generalized edema Increased urinary output Frank, bright red blood in the urine
Generalized edema
The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. Administer regular insulin. Encourage the child to ambulate. Give the child a teaspoon of honey. Provide electrolyte replacement therapy intravenously. Wait 30 minutes and confirm the blood glucose reading. Prepare to administer glucagon subcutaneously if unconsciousness occurs.
Give the child a teaspoon of honey. Prepare to administer glucagon subcutaneously if unconsciousness occurs.
The nurse is caring for a child who sustained a head injury after falling from a tree. On assessment of the child, the nurse notes the presence of a watery discharge from the child's nose. The nurse should immediately test the discharge for the presence of which substance? Protein Glucose Neutrophils White blood cells
Glucose
The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. Time the seizure. Restrain the child. Stay with the child. Place the child in a prone position. Move furniture away from the child. Insert a padded tongue blade in the child's mouth.
Time the seizure. Stay with the child. Move furniture away from the child.
The nurse enters a child's room and discovers that the child is having a seizure. Which actions should the nurse take? Select all that apply. Call a code. Run to get the crash cart. Turn the child on her side. Loosen any restrictive clothing. Check the child's respiratory status. Place an airway into the child's mouth.
Turn the child on her side. Loosen any restrictive clothing. Check the child's respiratory status.
An adolescent is examined in the hospital emergency department after taking an overdose of acetylsalicylic acid. The adolescent has rapid breathing, nausea and vomiting, and lethargy. The primary health care provider prescribes arterial blood specimens for blood gas analysis to be drawn. Aspirin toxicity is suspected when the blood gas results are reported as which value? pH 7.50, Pco2 60 mm Hg, HCO3 30 mEq/L (30 mmol/L) pH 7.44, Pco2 30 mm Hg, HCO3 21 mEq/L (21 mmol/L) pH 7.29, Pco2 29 mm Hg, HCO3 19 mEq/L (19 mmol/L) pH 7.33, Pco2 52 mm Hg, HCO3 28 mEq/L (28 mmol/L)
pH 7.29, Pco2 29 mm Hg, HCO3 19 mEq/L (19 mmol/L) metabolic acidosis
Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided? "Administer the antibiotics until they are gone." "Administer the antibiotics if the child has a fever." "Administer the antibiotics until the child feels better." "Begin to taper the antibiotics after 3 days of a full course."
"Administer the antibiotics until they are gone."
A child sustains a fall at home and is brought to the hospital emergency department by the child's mother. After a radiographic examination, the child is determined to have a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding neurocirculatory assessment and function. Which statement by the mother indicates a need for further instruction? "I'll need to check her skin twice a day at the cast edges." "If her hand gets real cool and pale, I can apply the heating pad to it." "For the first couple of days, I should try to keep her hand higher than her heart most of the time using pillows." "If she seems way too fussy and her arm is painful even after I've given her the pain medication, it might be a problem, and I should call you for help to decide on what is happening."
"If her hand gets real cool and pale, I can apply the heating pad to it."
The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than how many cells/mm3? 200,000 mm3 (200 × 109/L) 180,000 mm3 (180 × 109/L) 160,000 mm3 (160× 109/L) 150,000 mm3 (150 × 109/L)
150,000 mm3 (150 × 109/L)
The nurse caring for an infant with a diagnosis of hydrocephalus should monitor the infant for which sign of increased intracranial pressure? Proteinuria Bradycardia A drop in blood pressure A bulging anterior fontanel
A bulging anterior fontanel
The nurse is assisting a primary health care provider (PHCP) during the examination of an infant with developmental hip dysplasia. The PHCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted? A shrill cry from the infant Asymmetry of the affected hip Reduced range of motion in the right and left hip A palpable click during abduction of the affected hip
A palpable click during abduction of the affected hip
The nurse is providing care to a child admitted for acute otitis media. What is the nurse's priority concern for this child? Acute pain Problems with skin integrity Risk for interrupted breathing patterns Mucous membrane dryness and cracking
Acute pain Rationale: In acute otitis media, symptoms and signs such as acute ear pain, fever, and a bulging yellow or red tympanic membrane usually are present. Nursing interventions focus on relieving pain. Analgesic medications such as acetaminophen or ibuprofen are used to treat mild pain. The priority concern for this condition would be acute pain.
The nursing student is writing a plan of care for a child who presents with an acute head injury. The nursing instructor reviews the plan of care and praises the student for identifying which assessment as a priority? Inspecting the scalp Pupillary assessment Airway and breathing Palpating the child's head
Airway and breathing
A child arrives at the emergency department with a nosebleed. On assessment, the nurse is told by the mother that the nosebleed began suddenly and for no apparent reason. What is the initial nursing action? Insert nasal packing. Prepare a nasal balloon for insertion. Place the child in a semi-Fowler's position, and apply ice packs to the nose. Ask the child to sit down and lean forward, and apply pressure to the nose.
Ask the child to sit down and lean forward, and apply pressure to the nose.
A child has just returned from surgery and has a hip spica cast. What is the nurse's priority action for this client? Elevate the head of the bed. Assess the circulatory status. Abduct the hips using pillows. Turn the child onto the right side.
Assess the circulatory status.
An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take their child home? Leave the diapers off to allow the site to heal. Avoid tub baths until the stent has been removed. Encourage toilet training to ensure that flow of urine is normal. Restrict fluid intake to reduce urinary output for the first few days.
Avoid tub baths until the stent has been removed.
An adolescent with diabetes receives 30 units of Humulin N insulin at 7:00 a.m. The nurse would monitor for a hypoglycemic episode at what time? At bedtime Before supper At midmorning After breakfast
Before supper Rationale: Humulin N insulin is an intermediate-acting insulin that peaks in approximately 6 to 12 hours. It would peak before supper if given at 7:00 a.m. Short-acting insulin would peak after breakfast or midmorning. Long-acting insulins would peak at bedtime.
A child is seen in the health care clinic for complaints of fever. On data collection, the nurse notes that the child is pale, tachycardic, and has petechiae. Aplastic anemia is suspected. The nurse should prepare the child to obtain which specimen that will confirm the diagnosis? Platelet count Granulocyte count Red blood cell count Bone marrow biopsy
Bone marrow biopsy
A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? Nausea Irritability Headache Bradycardia
Bradycardia
The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. Easy bruising occurs. Gum bleeding occurs. It is a hereditary bleeding disorder. Treatment and care are similar to that for hemophilia. It is characterized by extremely high creatinine levels. The disorder causes platelets to adhere to damaged endothelium.
Easy bruising occurs. Gum bleeding occurs. It is a hereditary bleeding disorder. Treatment and care are similar to that for hemophilia. The disorder causes platelets to adhere to damaged endothelium.
An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? Sweating and tremors Hunger and hypertension Cold, clammy skin and irritability Fruity breath odor and decreasing level of consciousness
Fruity breath odor and decreasing level of consciousness
After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant? Urinary incontinence Impaired tissue integrity Inability to suck and swallow Lack of knowledge about the disease (parents)
Impaired tissue integrity
A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? Limited range of motion in the affected hip An apparent lengthened femur on the affected side Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table
Limited range of motion in the affected hip
The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? Maintain enteric precautions. Maintain neutropenic precautions. No precautions are required as long as antibiotics have been started. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.
Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.
The nurse recognizes that clinical manifestations of nephrotic syndrome include which findings? Hematuria, bacteriuria, weight gain Gross hematuria, albuminuria, fever Hypertension, weight loss, proteinuria Massive proteinuria, hypoalbuminemia, edema
Massive proteinuria, hypoalbuminemia, edema
A 2-year-old boy with a diagnosis of hemophilia is admitted to the hospital with bleeding into the joint of the right knee. Which intervention should the nurse plan to implement with this child? Measure the injured knee joint every shift. Take the temperature by rectal method only. Administer acetylsalicylic acid for pain control. Immobilize the joint and apply moist heat to the joint.
Measure the injured knee joint every shift.
An alert child who is crying loudly is brought to the hospital emergency department for a simple fracture to the lower right arm that occurred after a fall off a bicycle. What is the nurse's priority assessment? Mobility Skin integrity Neurovascular Level of consciousness
Neurovascular
The clinic nurse is assessing a child for dehydration. The nurse determines that the child is moderately dehydrated if which finding is noted on assessment? Oliguria Flat fontanels Pale skin color Moist mucous membranes
Oliguria Rationale: In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be dry, and the skin color would be dusky. Also, oliguria would be present.
Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. Which beverage is the best option to recommend with iron administration? Milk Water Apple juice Orange juice
Orange juice Vitamin C increases the absoprtion of iron.
The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? Platelet count Hematocrit level Hemoglobin level Partial thromboplastin time
Partial thromboplastin time Rationale: Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia.
A child is brought to the emergency department after being accidentally struck in the lower back region with a baseball bat. When gathering assessment data, the nurse discovers that the child has hemophilia. The nurse should immediately assess for which data? Slurred speech Presence of hematuria Complaints of headache Change in respiratory rate
Presence of hematuria Rationale: Because the kidneys are located in the flank region of the body, trauma to the back area can cause hematuria, particularly in a child with hemophilia. The nurse would be most concerned about the child's airway and respiratory rate if the child had sustained an injury to the neck region. Slurred speech and headache are associated with head trauma.
Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? Elevated hemoglobin level Decreased reticulocyte count Elevated red blood cell count Red blood cells that are microcytic and hypochromic
Red blood cells that are microcytic and hypochromic
Russell's traction is prescribed for a child with a lower leg fracture. The mother of the child asks the nurse about the purpose of the traction. The nurse explains to the mother that which is the primary action of this type of traction? Relieves the child's pain Reduces or realigns a fracture site Provides a form of restraint for the child Keeps the child from moving around in bed
Reduces or realigns a fracture site
The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? Restrict fluids as prescribed. Care for the arteriovenous fistula. Encourage foods high in potassium. Administer analgesics as prescribed.
Restrict fluids as prescribed. Rationale: Hemolytic-uremic syndrome is thought to be associated with bacterial toxins, chemicals, and viruses that result in acute kidney injury in children. Clinical manifestations of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria would be on fluid restriction.
Which is a priority problem for a child with severe edema caused from nephrotic syndrome? Risk for constipation Risk for skin breakdown Inability to regulate body temperature Consumption of more calories or nutrients than the body requires
Risk for skin breakdown
On assessment during a well-baby visit, the nurse notes that a 6-month-old infant has crossed eyes. Which interpretation would the nurse make based on this finding? The condition will resolve without treatment. The condition is normal up to the age of 2 years. Surgical intervention may be necessary to realign weak eye muscles. Once the child begins to read, eye muscles strengthen and the condition will resolve.
Surgical intervention may be necessary to realign weak eye muscles.
The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child? Soccer Basketball Swimming Field hockey
Swimming
The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding should the nurse expect to note in this child? Cyanosis Bronze skin Tachycardia Hyperactivity
Tachycardia
The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition? The child has difficulty hearing. The child consistently tilts the head to see. The child does not respond when spoken to. The child consistently turns the head to hear.
The child consistently tilts the head to see.
The nurse is caring for a 2-year-old child with an ear infection who requires the administration of antibiotic eardrops. The nurse observes the mother administering the eardrops to the child. Which observation by the nurse indicates that the mother is performing the procedure correctly? The mother pulls the earlobe up and back. The mother pulls the earlobe down and back. The mother holds the child in a sitting position. The mother must wear gloves to administer the medication.
The mother pulls the earlobe down and back.
The nurse has a prescription to give eardrops to a 5-year-old child. Which position should the nurse use to pull the pinna of the ear? Upward and outward Upward and backward Downward and outward Downward and backward
Upward and backward
The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care? Wound care Pain control measures Measurement of intake Cold and heat applications
Wound care Rationale: The most common complications associated with orchiopexy are bleeding and infection. Discharge instruction should include demonstrating wound cleansing and dressing and teaching parents to identify signs of infection, such as redness, warmth, swelling, or discharge. Testicles will be held in a position to prevent movement, and great care should be taken to prevent contamination of the suture line.
Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? "Treatment needs to be started as soon as possible." "I realize my infant will require follow-up care until fully grown." "I need to bring my infant back to the clinic in 1 month for a new cast." "I need to come to the clinic every week with my infant for the casting."
"I need to bring my infant back to the clinic in 1 month for a new cast."
The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? "I will encourage my child to perform prescribed exercises." "I will have my child wear soft fabric clothing under the brace." "I should apply lotion under the brace to prevent skin breakdown." "I should avoid the use of powder because it will cake under the brace."
"I should apply lotion under the brace to prevent skin breakdown."
The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip. The child will be placed in the Pavlik harness. Which statement by the family indicates that they understand the care of their child while placed in the Pavlik harness? "I know that the harness must be worn continuously." "I will bring my child back to the orthopedic office in a month or two so the straps can be checked." "I realize that I will also need to put two diapers on my child so that the harness will stay dry and does not get soiled." "I will watch for any redness or skin irritation where the straps are applied and call the primary health care provider for red areas."
"I will watch for any redness or skin irritation where the straps are applied and call the primary health care provider for red areas."
An 11-year-old child is admitted to the hospital in vaso-occlusive sickle cell crisis. The nurse plans for which priority treatments in the care of the child? Splenectomy, correction of acidosis Adequate hydration, pain management Frequent ambulation, oxygen administration Passive range-of-motion exercises, adequate hydration
Adequate hydration, pain management
An adolescent is seen in the emergency department for a suspected sprain of the ankle. X-rays have been obtained, and a fracture has been ruled out. Which instruction should the nurse provide to the adolescent regarding home care for treatment of the sprain? Elevate the extremity, and maintain strict bed rest for a period of 7 days. Immobilize the extremity, and maintain the extremity in a dependent position. Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.
Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.
The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding should the nurse expect to note documented in the infant's record regarding this condition? Full range of motion in the affected hip An apparent short femur on the unaffected side Asymmetrical adduction of the affected hip when placed supine, with the knees and hips flexed Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? Hematuria Proteinuria Bacteriuria Glucosuria
Bacteriuria This anatomical characteristic facilitates entry of bacteria into the urine.
The pediatric nursing instructor asks a nursing student to prioritize care for a child diagnosed with sickle cell disease. Which student response correctly identifies the priority of care? Fatigue Hypoxia Delayed growth Avascular necrosis
Hypoxia
A neighborhood nurse is attending a soccer game at a local middle school. One of the students falls off the bleachers and sustains an injury to the left arm. The nurse quickly attends to the child and suspects that the child's arm may be broken. Which nursing action would be the priority before transferring the child to the hospital emergency department? Immobilize the arm. Ask for the name of the child's pediatrician or family primary health care provider so that he or she can be contacted. Have someone call the radiology department of the local hospital to let staff know that the child will be arriving. Tell the child that the arm probably is fractured but not to worry because permanent damage to the arm will not occur.
Immobilize the arm.
The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. Use the fingertips to lift the cast while it is drying. Keep small toys and sharp objects away from the cast. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity.
Keep small toys and sharp objects away from the cast Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity. Rationale: While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the PHCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the PHCP should be notified.
The nurse is assisting a primary health care provider (PHCP) examine a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PHCP to assess? Babinski's sign The Moro reflex Ortolani's maneuver The palmar-plantar grasp
Ortolani's maneuver
The nurse is caring for an infant with gastroenteritis who is being treated for dehydration. The nurse reviews the health record and notes that the primary health care provider has documented that the infant is mildly dehydrated. Which assessment finding should the nurse expect to note in mild dehydration? Anuria Pale skin color Sunken fontanels Dry mucous membranes
Pale skin color Rationale: In mild dehydration, the skin color is pale. Anuria and sunken fontanels are assessment characteristics of severe dehydration. Dry mucous membranes are an assessment characteristic of moderate dehydration.
The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply. Pallor Edema Anorexia Proteinuria Weight loss Decreased serum lipids
Pallor Edema Anorexia Proteinuria
The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? Emergency cart Tracheotomy set Padded tongue blade Suctioning equipment and oxygen
Suctioning equipment and oxygen
The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? "Caution should be used when straddling my infant on a hip." "Vital signs should be taken daily to check for bladder infection." "Catheterization will be necessary when my infant does not void." "Circumcision has been delayed to save tissue for surgical repair."
"Circumcision has been delayed to save tissue for surgical repair." Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised, because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 1, 2, and 3 are unrelated to this disorder.
The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? Hold the next dose of insulin. Come to the clinic immediately. Encourage the child to drink liquids. Administer an additional dose of regular insulin.
Encourage the child to drink liquids. Rationale: When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.
A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? Injection of factor X Intravenous infusion of iron Intravenous infusion of factor VIII Intramuscular injection of iron using the Z-track method
Intravenous infusion of factor VIII Rationale: Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed depending on the source of bleeding from the disorder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Factor X and iron are not used to treat children with hemophilia A
The nurse is assessing for Kernig's sign in a child with a suspected diagnosis of meningitis. Which action should the nurse perform for this test? Tap the child's facial nerve and assess for spasm. Compress the child's upper arm and assess for tetany. Bend the child's head toward the knees and hips and assess for pain. Raise the child's leg with the knee flexed and then extend the leg at the knee and assess for pain
Raise the child's leg with the knee flexed and then extend the leg at the knee and assess for pain
A child with sickle cell anemia who is in vaso-occlusive crisis is admitted to the hospital. Which primary health care provider prescription would assist in reversing the vaso-occlusive crisis? Monitor pulse oximetry. Begin intravenous fluids. Administer oxygen by face mask. Monitor vital signs and respiratory status.
Begin intravenous fluids.
The nurse is performing an assessment of a 7-year-old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure? "Does twitching occur in the face and neck?" "Does the muscle twitching occur on one side of the body?" "Does the muscle twitching occur on both sides of the body?" "Does the child have a blank expression during these episodes?"
"Does the child have a blank expression during these episodes?"
The nurse provides discharge instructions to the mother of a child following a myringotomy with insertion of tympanoplasty tubes. Which statement by the mother indicates the need for further teaching? "My child should not swim or dive in deep water." "I need to prevent my child from blowing the nose." "My child can swim in the lake or pool as long as the water is not too deep." "I will put Vaseline on cotton balls and place them in my child's ears before a bath."
"My child can swim in the lake or pool as long as the water is not too deep." Rationale: Bath water and lake water are potential sources of bacterial contamination. Diving and swimming deeply under water are prohibited. Parents need to be instructed that the child should not blow the nose for 7 to 10 days. The child's ears need to be kept dry, and Vaseline on cotton balls or earplugs can be placed in the ears during a bath or shower.
The mother arrives at a well-baby clinic with her 1-month-old infant. She expresses concern because one of the infant's eyes appears to be crossed. What is the nurse's best response? "The infant will probably need surgery." "This condition is probably permanent." "It requires monitoring because the other eye may do the same thing." "This is normal in the young infant but should not be present after the age of about 4 months."
"This is normal in the young infant but should not be present after the age of about 4 months." Rationale: Strabismus, also called lazy eye, is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. It is normal in the young infant but should not be present after the age of about 4 months.
The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse should include which instruction? Expect an increased urine output from the shunt. Notify the primary health care provider if the infant is fussy. Call the primary health care provider if the infant has a high-pitched cry. Position the infant on the side of the shunt when the infant is put to bed.
Call the primary health care provider if the infant has a high-pitched cry.
A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? Ensure that all ropes are outside the pulleys. Ensure that the weights are resting lightly on the floor. Restrict diversional and play activities until the child is out of traction. Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied.
Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied.
A pediatrician prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? Obtains a weight Takes the temperature Takes the blood pressure Checks the amount of urine output
Checks the amount of urine output Rationale: In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hr, potassium chloride should not be administered.
The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which action to maintain the infant's safety? Covering the back dressing with a binder Placing the infant in a head-down position Strapping the infant in a baby seat sitting up Elevating the head with the infant in the prone position
Elevating the head with the infant in the prone position Rationale: Elevating the head will decrease the chance that cerebrospinal fluid will accumulate in the cranial cavity. The infant needs to be prone or side-lying to decrease the pressure on the surgical site on the back. Binders and a baby seat should not be used because of the pressure they would exert on the surgical site.
A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply. Provide a soft diet. Position the child on the left side. Administer an antihistamine twice daily. Irrigate the right ear with normal saline every 8 hours. Administer ibuprofen for fever every 4 hours as prescribed and as needed. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.
Provide a soft diet. Administer ibuprofen for fever every 4 hours as prescribed and as needed. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy. Rationale: The child's fever should be treated with ibuprofen. The child is positioned on her or his affected side to facilitate drainage. A soft diet is recommended during the acute stage to avoid pain that can occur with chewing. Antibiotics are prescribed to treat the bacterial infection and should be administered for the full prescribed course. The ear should not be irrigated with normal saline because it can exacerbate the inflammation further. Antihistamines are not usually recommended as a part of therapy.
The nurse is reviewing a primary health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. Restrict fluid intake. Position for comfort. Avoid strain on painful joints. Apply nasal oxygen at 2 L/minute. Provide a high-calorie, high-protein diet. Give meperidine, 25 mg intravenously, every 4 hours for pain.
Restrict fluid intake. Give meperidine, 25 mg intravenously, every 4 hours for pain. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.
The community health nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs/symptoms of meningitis include which findings? Nausea, delirium, and fever Severe headache and back pain Photophobia, fever, and confusion Severe headache, fever, and a change in the level of consciousness
Severe headache, fever, and a change in the level of consciousness
The nurse in the health care clinic receives a telephone call from the mother of a child who reports that an insect has somehow flown into the child's ear. The mother reports that the child is complaining of a buzzing sound in the ear. Which priority instruction should the nurse provide to the mother? Report to the clinic immediately. Irrigate the ear with diluted alcohol. Use tweezers to try to remove the insect. Use a flashlight to coax the insect out of the ear.
Use a flashlight to coax the insect out of the ear. Rationale: Insects that make their way into an ear often can be coaxed out using a flashlight or a humming noise. If this is unsuccessful, then the insect must be killed before removal. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by means of an ear forceps. The mother should be instructed not to irrigate the ear or attempt to remove the insect by using tweezers because this could damage the ear. If the mother is unsuccessful in coaxing the insect out of the ear, she should be instructed to report to the clinic or the hospital emergency department.
The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? Increased systolic blood pressure Abnormal posturing of extremities Significant widening pulse pressure Changes in level of consciousness
Changes in level of consciousness
A home care nurse is teaching an adolescent with type 1 diabetes mellitus about insulin administration and rotation sites. Which statement, if made by the adolescent, would indicate effective teaching? "I should use only my stomach and my thighs for injections." "I need to use a different major site for each insulin injection." "I should use the same major site for 1 month before rotating to another site." "I need to give 4 to 6 injections in 1 area, about an inch apart, and then move to another area."
"I need to give 4 to 6 injections in 1 area, about an inch apart, and then move to another area."
The nurse is assisting in providing an educational session to new mothers regarding the methods that will decrease the risk of recurrent otitis media in infants. Which statement by a mother in the group indicates a need for further teaching? "I need to feed my infant in an upright position." "I need to stop breast-feeding as soon as possible." "Bottle-feeding should be stopped as soon as possible." "I should not provide my infant with a bottle during naptime."
"I need to stop breast-feeding as soon as possible."
The nurse is talking to the parents of a child newly diagnosed with diabetes mellitus. Which statement by the parents indicates an understanding of preventing and managing hyperglycemia? "I will give 8 oz of diet cola at the first sign of weakness." "I will administer glucagon immediately if shakiness is felt." "I will check for ketones when my child is suffering from an illness." "I will report to the emergency department if the blood glucose level is over 150 mg/dL (8.6 mmol/L)."
"I will check for ketones when my child is suffering from an illness."
The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? "I need to wash my hands frequently." "I need to clean the eye as prescribed." "It is okay to share towels and washcloths." "I need to give the eye drops as prescribed."
"It is okay to share towels and washcloths."
An ambulatory care nurse makes a follow-up telephone call to the mother of a child who underwent a myringotomy with insertion of tympanoplasty tubes on the previous day. The mother of the child tells the nurse that the child is complaining of discomfort. What should the nurse instruct the mother to do? Administer acetaminophen. Give one children's aspirin with water. Call the pharmacist for a stronger analgesic. Call the primary health care provider immediately
Administer acetaminophen. Rationale: Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. It is not necessary to notify the primary health care provider (PHCP), and additionally, this response to the mother may alarm her. Aspirin should not be given to the child. Acetaminophen can be given to relieve the discomfort. Calling the pharmacist is inappropriate.
The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents? Administer the iron at mealtimes. Administer the iron through a straw. Mix the iron with cereal to administer. Add the iron to formula for easy administration.
Administer the iron through a straw. Rationale: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The parents should be instructed to brush or wipe the child's teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items.
The home care nurse is visiting a child newly diagnosed with diabetes mellitus. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse should tell the child to take which action? Administer glucagon immediately if shakiness is felt. Drink 8 ounces of diet cola at the first sign of weakness. Report to a hospital emergency department if the blood glucose is 60 mg/dL (3.4 mmol/L). Carry hard candies whenever leaving home in case a hypoglycemic reaction occurs.
Carry hard candies whenever leaving home in case a hypoglycemic reaction occurs.
The nurse is creating a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique should be performed that will best detect the presence of an increase in intracranial pressure? Check urine for specific gravity. Monitor for signs of dehydration. Assess anterior fontanel for bulging. Assess blood pressure for signs of hypotension.
Assess anterior fontanel for bulging.
A 4-year-old child is diagnosed with otitis media. The mother asks the nurse about the causes of this illness. Which risk factors should the nurse include in response to this mother? Select all that apply. Bottle-feeding Household smoking A history of urinary tract infections Exposure to illness in other children Congenital conditions such as cleft palate
Bottle-feeding Household smoking Bottle-feeding Household smoking Rationale: Factors that increase the risk of otitis media include bottle-feeding, household smoking, exposure to illness from other children in day care centers, and congenital conditions such as Down's syndrome and cleft palate. The use of a pacifier beyond age 6 months has been identified as another risk factor. Allergies are also thought to precipitate otitis media.
A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? Clear CSF, decreased pressure, and elevated protein level Clear CSF, elevated protein, and decreased glucose levels Cloudy CSF, elevated protein, and decreased glucose levels Cloudy CSF, decreased protein, and decreased glucose levels
Cloudy CSF, elevated protein, and decreased glucose levels
The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? Cover the bladder with petroleum jelly gauze. Cover the bladder with a nonadhering plastic wrap. Apply sterile distilled water dressings over the bladder mucosa. Keep the bladder tissue dry by covering it with dry sterile gauze.
Cover the bladder with a nonadhering plastic wrap.
The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? Enteric Contact Droplet Neutropenic
Droplet
The nurse is caring for a 7-year-old child with glomerulonephritis and is preparing to discuss the plan of care with the parents. In anticipating this encounter, the nurse recognizes that which is a common reaction of parents to the diagnosis of glomerulonephritis? Fear of the complicated treatment regimen Anger at the child for requiring hospitalization Guilt that they did not seek treatment more quickly Depression that the child may not be able to play sports
Guilt that they did not seek treatment more quickly
The nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, which is the priority problem? Choking Infection Inability to tolerate stimulation Delayed growth and development
Infection
The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? Meningitis Spinal cord injury Intracranial bleeding Decreased cerebral blood flow
Meningitis
A nurse is caring for an infant with a respiratory infection and is monitoring the infant for signs of dehydration. What is the nurse's best action to determine fluid loss in the infant? Monitor body weight. Obtain a temperature. Monitor intake and output. Assess the mucous membranes.
Monitor body weight. Rationale: Body weight is the most reliable method of measuring body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. The remaining options are also appropriate measures to assess for dehydration, but the most reliable method is to monitor body weight.
The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for which early sign of increased ICP? Nausea Papilledema Decerebrate posturing Alterations in pupil size
Nausea
A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? Potassium infusion NPH insulin infusion 5% dextrose infusion Normal saline infusion
Normal saline infusion
An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? Test the urine for protein. Reposition the infant frequently. Provide a stimulating environment. Assess blood pressure every 15 minutes.
Reposition the infant frequently. In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown
A child in whom sickle cell anemia is suspected is seen in a clinic, and laboratory studies are performed. The nurse checks the laboratory results, knowing that which value would be increased in this disease? Platelet count Hematocrit level Hemoglobin level Reticulocyte count
Reticulocyte count Reticulocyte counts are increased in children with sickle cell disease because the life span of their sickled red blood cells is shortened.
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? Flaccid paralysis of all extremities Adduction of the arms at the shoulders Rigid extension and pronation of the arms and legs Abnormal flexion of the upper extremities and extension and adduction of the lower extremities
Rigid extension and pronation of the arms and legs
The nurse is caring for an infant with cryptorchidism. The nurse anticipates that the most likely diagnostic study to be prescribed would be the one that assesses which item? Babinski reflex DNA synthesis Urinary function Chromosomal analysis
Urinary function Rationale: Cryptorchidism (undescended testes) may occur as a result of hormone deficiency, intrinsic abnormality of a testis, or a structural problem. Diagnostic tests for this disorder are performed to assess urinary and kidney function because the kidneys and testes arise from the same germ tissue.
The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record? Polyuria Weight gain Hypotension Grossly bloody urine
Weight gain
Which question should the nurse ask the parents of a child suspected of having glomerulonephritis? "Did your child fall off a bike onto the handlebars?" "Has the child had persistent nausea and vomiting?" "Has the child been itching or had a rash anytime in the last week?" "Has the child had a sore throat or a throat infection in the last few weeks?"
"Has the child had a sore throat or a throat infection in the last few weeks?"
An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information? "I should obtain new contact lenses." "I should not wear my contact lenses." "My old contact lenses should be discarded." "My contact lenses can be worn if they are cleaned as directed."
"My contact lenses can be worn if they are cleaned as directed." Rationale: If the adolescent wears contact lenses, the adolescent should be instructed to discontinue wearing them until the infection has cleared completely. Obtaining new contact lenses would eliminate the chance of reinfection from contaminated contact lenses and would lessen the risk of a corneal ulceration.
The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis? Hypotension Brown-colored urine Low urinary specific gravity Low blood urea nitrogen level
Brown-colored urine Gross hematuria resulting in dark, smoky, cola-colored, or brown-colored urine is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.
The nurse is monitoring an infant for signs of increased intracranial pressure. On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? Increase oral fluids. Document the finding. Notify the primary health care provider. Place the infant supine in a side-lying position.
Notify the primary health care provider.
A 10-year-old child complains of ear pain that is aggravated by palpation of the auricle. A foul-smelling, tenacious yellow discharge is noted in the ear canal, and the child is diagnosed with acute otitis externa. In providing information to the child and parent, the nurse emphasizes which information? Dizziness is common with this disorder. Cotton-tipped applicators should be used to clean the ears. Nothing smaller than the child's elbow should be placed in the ear. Biannual ear testing must be done by a special primary health care provider.
Nothing smaller than the child's elbow should be placed in the ear. Rationale: The nurse should provide information about ear care to children because it is not uncommon for them to put sharp or small objects, such as cotton swabs, into their ears, and these behaviors can cause injury. A facecloth on a fingertip is safe to use for ear cleaning. Acute otitis externa may cause a low-pitched tinnitus but usually does not cause dizziness unless the condition has progressed to an otitis media
The nurse is caring for a child with a diagnosis of hemophilia, and hemarthrosis is suspected because the child is complaining of pain in the joints. Which measure should the nurse expect to be prescribed for the child? Range-of-motion exercises to the affected joint Application of a heating pad to the affected joint Nonsteroidal anti-inflammatory drugs for the pain Application of a bivalved cast for joint immobilization
Application of a bivalved cast for joint immobilization Rationale: In an acute period, immobilization of the joint would be prescribed. Range-of-motion exercise during the acute period can increase the bleeding and would be avoided at this time. Heat will increase blood flow to the area, so it would promote increased bleeding to the area. Nonsteroidal anti-inflammatory drugs (NSAIDs) can prolong bleeding time and would not be prescribed for the child.
The nurse is teaching the parent of a preschool child how to administer the child's insulin injection. The child will be receiving 2 units of Humulin R insulin and 12 units of Humulin N insulin every morning. How should the nurse instruct the parents to prepare the insulin? Draw the insulin into separate syringes. Draw the Humulin R insulin first and then the Humulin N insulin into the same syringe. Draw the Humulin N insulin first and then the Humulin R insulin into the same syringe. Check blood glucose first, and if the result is between 70 and 99 mg/dL (3.9 and 5.5 mmol/L), withhold the insulin injection.
Draw the Humulin R insulin first and then the Humulin N insulin into the same syringe Rationale: When mixing types of insulin, always withdraw the clear, rapid-acting insulin into the syringe first and then the long-acting insulin. This procedure avoids contaminating the short-acting insulin with the longer-acting insulin. Therefore, the Humulin R insulin would be drawn into the syringe first, followed by the Humulin N insulin. When a child's insulin dosage requires the injection of both short- and intermediate-acting insulin at the same time, it is preferable to mix the two and use a single injection. Blood glucose results between 70 and 99 mg/dL (3.9 and 5.5 mmol/L) are considered to be euglycemic (normal), and the prescribed dose would be administered to maintain euglycemia.
A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply. Remain calm. Time the seizure. Ease the child to the floor. Loosen restrictive clothing. Keep the child on her back.
Remain calm. Time the seizure. Ease the child to the floor. Loosen restrictive clothing.
A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? "The cast may feel warm as the cast dries." "I can use lotion or powder around the cast edges to relieve itching." "A small amount of white shoe polish can touch up a soiled white cast." "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."
"I can use lotion or powder around the cast edges to relieve itching." The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation.
The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates the need for further instruction? "I'll check his temperature." "I'll give him medication so he'll be comfortable." "I'll check his voiding to be sure there's no problem." "I'll let him decide when to return to his play activities."
"I'll let him decide when to return to his play activities." Rationale: Cryptorchidism is a condition in which 1 or both testes fail to descend through the inguinal canal into the scrotal sac. Surgical correction may be necessary. All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This prevents dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output.
The nurse is providing home care instructions to the mother of a 9-year-old child diagnosed with bacterial conjunctivitis. Topical antimicrobial therapy is prescribed for the child. Which statement by the mother indicates the teaching has been effective? "My child cannot return to school until seen by the pediatrician in 1 month." "My child can return to school immediately because my child is not contagious." "My child needs to stay at home from school for at least 3 weeks to complete the entire prescription of eyedrops." "My child will need to stay home from school until my child has received the eye medication for at least 24 to 48 hours."
"My child will need to stay home from school until my child has received the eye medication for at least 24 to 48 hours."
The nurse notes that an infant with the diagnosis of hydrocephalus has a head that is heavier than that of the average infant. The nurse should determine that special safety precautions are needed when moving the infant with hydrocephalus. Which statement should the nurse plan to include in the discharge teaching with the parents to reflect this safety need? "Feed your infant in a side-lying position." "Place a helmet on your infant when in bed." "Hyperextend your infant's head with a rolled blanket under the neck area." "When picking up your infant, support the infant's neck and head with the open palm of your hand."
"When picking up your infant, support the infant's neck and head with the open palm of your hand."
