PP Pediatrics (Transitions)
A nurse is obtaining the history of a child, age 4. Which question best evaluates the child's developmental status?
"Can you ride a tricycle?"
An school-age client is brought to the health clinic for a routine checkup. To assess the client's vision, what question should the nurse ask?
"How are you doing in school?"
The nurse is caring for an infant diagnosed with thrush. Which instruction would the nurse give to a client's mother who will be administering nystatin oral solution?
Administer the drug right after meals by dabbing the solution to the sites.
The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse should include which information points in the teaching plan?
Formula can be changed to whole milk when the infant is 12 months old.
The nurse is caring for a child with an acute exacerbation of asthma. Oral methylprednisolone has been ordered. Which of the following actions is most important for the nurse to take when administering this medication?
Give the medication with food.
The nurse observes as a child with Duchenne muscular dystrophy attempts to rise from a sitting position on the floor. After attaining a kneeling position, the child "walks" their hands up to their legs to stand. The nurse documents this as which sign?
Gower sign With the Gower sign, the child walks the hands up the legs in an attempt to stand, a common approach used by children with Duchenne muscular dystrophy when rising from a sitting to a standing position. Galeazzi sign refers to the shortening of the affected limb in congenital hip dislocation. Goodell sign refers to the softening of the cervix, considered a sign of probable pregnancy. Goodenough sign refers to a test of mental age.
Which nursing intervention would be most effective in helping a 2-year-old child stay quiet after a bronchoscopy?
Have the parents stay at the bedside.
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the internet." What should the nurse do?
Help the client find information on the internet.
A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48 breaths/min, a heart rate of 120 bpm, and a temperature of 100.8°F (38.2°C) rectally. The nurse is having difficulty calming the child. What should the nurse do next?
Notify the health care provider (HCP) immediately. The nurse may be having difficulty calming the child because the child is experiencing increasing respiratory distress. The normal respiratory rate for a 21-month-old is 25 to 30 breaths/min. The child's respiratory rate is 48 breaths/min. Therefore, the HCP needs to be notified immediately. Typically, acetaminophen is not given to a child unless the temperature is 101°F (38.6°C) or higher. Letting the toddler cry is inappropriate with croup because crying increases respiratory distress. Offering fluids every few minutes to a toddler experiencing increasing respiratory distress would do little, if anything, to calm the child. Also, the child would have difficulty coordinating breathing and swallowing, possibly increasing the risk for aspiration.
A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse's best response to this situation?
Notify the local Child Protective Services.
The nurse cares for a child receiving a blood transfusion. The child becomes flushed and is wheezing. What should the nurse do first?
Switch the transfusion to normal saline solution.
On a crisis shelter hotline, the nurse talks to two 11-year-old children who think a friend abuses inhalants. They say their friend's breath sometimes smells like glue and they act drunk. They say they are afraid to tell their parents about the friend. When the nurse is formulating a reply, what is the most important factor for the nurse to consider?
The callers probably fear punishment.
A nurse realizes she is 1 hour and 30 minutes late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next?
The nurse should follow facility procedures for reporting an error.
The charge nurse on the adolescent unit must decide which nurse should admit a new client. Based on the present client care assignments, who is the best candidate to admit the client?
a nurse who was reassigned from another ward at the beginning of the shift
A nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent?
fear related to altered body image
Which finding is expected when the nurse is assessing a child who has sustained full-thickness burns?
minimal pain
A school nurse is called to assess a 12-year-old child with type 1 diabetes mellitus who is experiencing lightheadedness, tachycardia, and pallor during physical education class. What is the priority action by the nurse?
Give the child some fruit juice to drink. Increased exercise has likely caused a drop in serum glucose levels, producing symptoms of hypoglycemia. The first action is to give the child a source of fast-acting carbohydrate (approximately15 grams) such as juice or candy. Cheese and crackers can be given once the acute symptoms of hypoglycemia have resolved to provide a longer-lasting source of complex carbohydrate and protein. Ideally the nurse would use blood glucose monitoring to direct this treatment. The nurse should not give insulin even if it is due now, because of the child's symptoms. The parents need to be notified of the child's symptoms, but the priority action is to care for the client.
The nurse provides postoperative care to a child after insertion of a ventriculoperitoneal shunt. Which action is most indicated?
Monitor for increased temperature
The nurse reviews the medical record of an adolescent with a history of losing weight and fatigue who has been admitted to the hospital with a diagnosis of stage I chronic renal failure (see exhibit). Based on these findings, what action should the nurse take?
Notify the health care provider (HCP). The nurse would expect a person with a normal glomerular filtration rate (GFR) to have approximately equal inputs and outputs. Chronic renal failure has five stages. In stage I, the GFR is approximately greater than or equal to 90 mL/min/1.73 m2. In stage II, the GFR decreases to approximately 60 to 89 mL/min/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client's intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fluids.
The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which findings should the nurse anticipate?
Ortolani's sign Assessment in a child with a congenital hip dislocation typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.
An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The parent reports that the infant has become mobile even while wearing the splint. What should the nurse advise the parent to do?
Remove any unsafe items from the area in which the infant is mobile.
An adolescent client scheduled for an emergency appendectomy is to be transferred directly from the emergency department to the operating room. Which statement by the client should the nurse interpret as most significant?
"All of a sudden, it does not hurt at all."
An infant is brought to the clinic with a possible diagnosis of Wilms' tumor. When obtaining the health history, which question should the nurse consider a priority to ask the parent?
"Did the healthcare provider find a mass in the abdominal area?" The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Projectile vomiting after a feeding is found with pyloric stenosis. A reddish, jelly-like bowel movement referred to as "currant jelly" is seen in intussusception. A pulsating anterior fontanel is a normal finding.
An adolescent client is seeking care in a primary care clinic and asks the nurse about sexually transmitted infection screening. The nurse asks the client some questions and determines that the client is engaging in high-risk sexual behavior. What statement would indicate to the nurse that the client is in the contemplation phase of behavior change?
"I know I should use condoms, and I will think about it."
A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the parent indicates the need for further teaching?
"Immunizations will have to be delayed until the casts come off."
Two toddlers are arguing over a toy in the playroom. What should the nurse should say to the children?
"Let me see if I can get both of you a similar toy."
A toddler is admitted to the emergency department with a suspected seizure disorder. When informing the parents about necessary diagnostic procedures, which statement is most appropriate for the nurse?
"The best way to diagnose seizures is through a computed tomography (CT) scan."
The nurse admits an 8-year-old child who is unconscious secondary to ketoacidosis. During the admission history, which parental statement is most consistent with the diagnosis of insulin-dependent diabetes?
"They started to wet the bed at night for the first time in 3 years."
What would be the nurse's best response to the parents of a child being discharged from the day surgery center after insertion of tympanostomy tubes when they ask, "What will happen to the tubes in my child's ears?"
"They typically fall out in about 6 months."
During a well-baby visit, a 2-month-old infant receives a diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. How does the nurse respond?
"This vaccine protects against serious bacterial infections, such as meningitis."
An athletic teenager who is diagnosed with infectious mononucleosis is told to avoid contact sports for 3 to 4 weeks. The teenager protests to the nurse and demands to know why sports must be avoided for so long. What is the best response by the nurse?
"Your spleen is enlarged from your illness and could easily rupture with an injury." In a client with infectious mononucleosis, the spleen enlarges, and the individual is at risk for a spontaneous rupture with any trauma to the area. The client is placed on bed rest during the acute phase of illness, which usually lasts about 7 to 10 days, and should avoid contact sports for 3 to 4 weeks to prevent this complication.
A 3-year-old client is admitted to the pediatric unit with pneumonia. The child has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the child has not been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should the nurse include in the care plan? Select all that apply.
- Perform chest physiotherapy as ordered -encourage coughing & deep breathing -perform postural drainage -maintain humidification with a cool mist humidifier
When talking with 10-year-old children about death, the nurse should incorporate which guidelines? Select all that apply.
- The children will be curious about the physical aspects of death. -The children will know that death is inevitable and irreversible. -Attitudes of the adults in their lives will influence the children.
An adolescent child is admitted to the nursing unit after an attempted suicide. The nurse is discussing the attempted suicide with the parents. Which of the following statements by the parents indicate to the nurse that the parents need more teaching? Select all that apply.
-"Our child is just trying to get attention." -"Our child would not do this again." -"Our child will be fine in a couple of days."
A 17-year-old client confides in the school nurse an interest in understanding safe sex practices. In instructing the client on how to correctly use a condom, which information would be stressed? Select all that apply.
-Condoms should be stored in a cool, dry place to prevent damage. -Leave a 1/2-inch space at the tip of the condom. -Never reuse a condom. -The condom should be applied on an erect penis.
The nurse draws a venipuncture for a laboratory specimen. Place the steps in the order that the nurse should perform them. All options must be used.
-Perform hand hygiene and gather the supplies. -Select puncture site and place in dependent position. -Don gloves and ask the client to make a fist. -Apply tourniquet, cleanse the skin, and puncture the site. -Remove tourniquet and apply dry gauze . -Withdraw needle and apply pressure.
An adolescent is being seen in the clinic for abdominal pain with a fever. In what order should the nurse assess the abdomen? All options must be used.
-inspect -auscultate -percuss -palpate
The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply.
-potatoes -apples -corn Celiac disease is an intolerance to the gluten factor of protein found in grains. Specific grains to be removed from the diet include wheat, rye, oats, and barley. Clients with a diagnosis of celiac disease can tolerate corn, fruits, and vegetables.
A student with type 1 diabetes tells the nurse they are feeling light-headed. The student's blood sugar is 60 mg/dL (3.3 mmol/L). Using the 15-15 rule, the nurse should perform which action to treat the blood glucose?
15 g of carbohydrate, and retest the blood sugar in 15 minutes. The 15-15 rule is a general guideline for treating hypoglycemia where the client consumes 15 g of carbohydrate and repeats testing the blood sugar in 15 minutes. Fifteen grams of carbohydrate equals 60 calories and is roughly equal to ½ cup (120 mL) of juice or soda, six to eight Life Savers, or a tablespoon of honey or sugar. The general recommendation is if the blood sugar is still low, the client may repeat the sequence. Fifteen milliliters of juice would only provide 8 calories. This would not be sufficient carbohydrates to treat the hypoglycemia. Protein does not treat insulin-related hypoglycemia; however, a protein-starch snack may be offered after the blood glucose improves. Fifteen ounces of juice would be approximately 440 mL—almost four times the recommended 4 oz (120 mL) of juice.
The parent says that the infant's health care provider recommends certain foods, but the 7-month-old infant refuses to eat them after breastfeeding. How should the nurse suggest that the parent alter the feeding plan?
Allow the infant to nurse for a few minutes and then offering solid foods.
The nurse caring for a 7-year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. What should the nurse do first?
Apply pressure just above the catheter insertion site. Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the HCP. The dressing can be reinforced after the bleeding has been contained.
A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which information would the nurse expect to include in the client's teaching plan?
As ovulation approaches, cervical mucus becomes clear and stretchy. As ovulation approaches, cervical mucus is abundant, clear, and stretchy, resembling raw egg white. Ovulation generally occurs 14 days (± 2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone. Cervical mucus is always present.
The nurse must administer a unit of packed red blood cells to a 4-year-old child. The child's blood type is Type B Rh factor positive. When the unit of blood arrives, it is labeled as Type O Rh factor negative. What is the appropriate action for the nurse to take?
Begin the administration of the blood as ordered. Type O Rh negative blood is the universal donor and can be administered to a child who is Type B. As long as the crossmatch report confirms "OK to transfuse," there would be no need to return this unit to the blood bank. This should not be considered an error and would not be documented as such. There is no indication for retesting the child's blood type.
A nurse discovers a 5-year-old child who is unresponsive, apneic, and pulseless. In what order should the nurse provide aid?
Call for help, deliver 30 chest compressions at a rate of 100 per minute, open the airway, and provide two rescue breaths. After calling for help, the nurse should deliver 30 chest compressions at a rate of 100-120 per minute, then open the airway and give two breaths. The nurse should then reassess for a pulse. If the child remains pulseless, the nurse should repeat the compressions, breaths, and assessment until relieved by an emergency response team or until another rescuer arrives with a defibrillator. Resuscitation efforts should be initiated as soon as pulselessness is established; continuing attempts to rouse the child delays critical treatment.
Which action should the nurse take in the immediate period following the application of a plaster cast to correct a child's congenital clubfoot?
Change the child's position at least every 2 hours. Complete drying of a plaster cast takes several hours. Thus, turning the child with a newly applied cast at least every 2 hours helps the cast to dry uniformly. The cast must not be coated with any substance that would inhibit moisture evaporation from the plaster. Dryers are not used to dry the cast because they dry the cast on the surface but not underneath. Furthermore, heat may be conducted to the tissues through the wet cast, causing burns. The drying cast must be handled with the palms only to prevent finger indentations that could cause pressure areas.
Which method is reliable for identifying a preschooler before administering a medication?
Check the hospital identification bracelet.
A parent brings their 2-year-old child to the clinic because of their concerns about the child's nutritional status. For the last week, the child has refused to eat anything except animal crackers and peanut butter and jelly sandwiches. Which measure would be most appropriate for the nurse to suggest?
Do not worry about this behavior because food fads usually last only a short time.
The nurse assesses the results of gentamicin through blood level for an adolescent with cystic fibrosis who has been treated with gentamicin several times over the last year. The drug level is high. What is the nurse's primary concern?
The child may experience hearing loss. When given for an extended period of time, aminoglycoside antibiotics can cause permanent hearing loss. The high trough level may indicate that the child has decreased kidney function and is not clearing the drug out of their system efficiently. Although hepatotoxicity has been shown in isolated reports, changes in liver function resolve rapidly once gentamicin is stopped. Errors in medication administration can cause abnormal lab test results, but the child's clinical history and frequency of gentamicin use support an elevated blood level. The lab result indicates that the dose of gentamicin may need to be decreased.
A child with cystic fibrosis does not like taking a pancreatic enzyme supplement with meals and snacks. The parent does not like to force the child to take the supplement. What is the most important reason for the child to take the pancreatic enzyme supplement with meals and snacks?
The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins.
A child who was hospitalized for sickle cell crisis is being discharged. Which parent outcome demonstrates effective teaching regarding prevention of future crises?
The parent verbalizes the need to stay away from persons with known infections.
Which step should a nurse take first when administering a liquid medication to an infant?
Verify the physician order The nurse should first verify the physician's order. Next, the nurse should verify the drug, dose, route, and time. The nurse should then verify the client by checking the infant's armband. After these steps, the nurse should hold the infant securely in the crook of the arm and raise the infant's head to about a 45-degree angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing this keeps the infant from spitting out the drug and reduces the risk of aspiration.
The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which problem in the future?
a speech defect
Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which problem?
abnormally high salt loss through perspiration One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Extra salt is almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual. In a child with cystic fibrosis, the functioning of the sweat glands is the problem, causing abnormal amounts of salt to be lost with perspiration. The ability to concentrate urine is not the problem. Little skin pigment is not a condition associated with cystic fibrosis. A poorly functioning temperature control center is not a condition related to cystic fibrosis.
The nurse assesses a preschooler with gastroenteritis. Which finding would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration?
absence of tear formation
What is Wilm's tumor?
also known as a nephroblastoma, is a tumor located on the kidney. The most common intra-abdominal tumor in children, Wilms' tumor usually affects children ages 6 months to 4 years and favors the left kidney.
When assessing a toddler's growth and development, the nurse understands that a child in this age group displays behavior that fosters which developmental task?
autonomy
A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child?
being an infant
A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. The child's urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the health care provider?
body temperature of 102.8° F (39.3° C) Temperature of 102.8°F (39.3°C) is elevated, suggesting an infection. The nurse should notify the health care provider. The child is displaying signs and symptoms of nephrotic syndrome. With this disorder, blood pressure is characteristically normal or slightly low. The other vital signs are likely to be normal unless edema causes respiratory distress and respirations increase and become labored. The blood pressure reading, heart rate, and respiratory rate here are within the normal range for a toddler. A pulse rate of 85 bpm is normal for a toddler. In nephrotic syndrome, the pulse rate would be normal unless other problems arise. A respiratory rate of 28 breaths/min is normal for a toddler. In nephrotic syndrome, the respiratory rate would be normal unless edema causes respiratory distress and the respirations increase and become labored.
A nurse is preparing immunizations for a child being treated for leukemia. Which immunization will the nurse hold at this time?
chickenpox A child being treated for leukemia is at risk for having a weakened immune system and should not receive attenuated (weakened) live virus vaccines such as chickenpox, rotavirus, influenza nasal mist, or measles, mumps, and rubella. Administering these vaccines in a person with a weakened immune system may result in illness. Tetanus vaccine is a detoxified toxoid and cannot cause disease. Hepatitis A vaccine is an inactivated (killed) virus and cannot cause disease. Haemophilus influenzae B is a conjugate vaccine consisting of proteins, not virus, and cannot cause disease.
A client is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the client has
coarctation of the aorta. The nurse should suspect coarctation of the aorta because it causes signs of peripheral hypoperfusion, such as a weak femoral pulse and a bounding radial pulse. These signs are rare in patent ductus arteriosus, ventricular septal defect, and truncus arteriosus.
The nurse implements a plan targeted at maintaining a positive self-concept in an adolescent with renal failure. Which behavior by the adolescent would indicate that the plan is working?
demonstration of a desire to do the dressing changes and take care of the medications
A 2-month-old infant has been diagnosed with pyloric stenosis. The infant will undergo a pyloromyotomy to remedy the condition. Prior to the surgery, which conditions represent the most danger to the infant?
electrolyte imbalance
An infant diagnosed with Hirschsprung disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?
encouraging them to ask questions
The nurse observes a parent of a child with cystic fibrosis performing chest percussion. The nurse determines that the skill is being done correctly when the parent uses which technique?
firmly but gently striking the chest wall to make a popping sound The parent should firmly yet gently strike the chest wall with the hand cupped to make a hollow popping sound. A slapping sound indicates that an incorrect technique is being used. The area over the rib cage is percussed to loosen mucus from the underlying lung passages. The child should wear a thin piece of clothing (T-shirt) over the chest area to protect the skin without diminishing the effect of the percussion.
A 5-year-old child is brought to the emergency department after being stung multiple times on the face by yellow jackets. Which symptom of anaphylaxis requires priority medical intervention?
heart rate less than 60 beats/minute Bradycardia, a slow but steady heartbeat at a rate less than 60 beats/minute, is an ominous sign in children. Older children experiencing anaphylaxis initially demonstrate tachycardia in response to hypoxemia. When tachycardia can no longer maintain tissue oxygenation, bradycardia follows. The development of bradycardia usually precedes cardiopulmonary arrest. The average systolic blood pressure of children ages 1 to 7 can be determined by this formula: age in years plus 90. Thus, an average blood pressure for a 5-year-old child is 95 mm Hg. Urticaria should be treated after airway control has been established. The normal respiratory rate for a 5-year-old is 20 to 25 breaths/minute.
A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can
hold and rock the child and give the child a security object. The toddler with Down syndrome may have difficulty coping with painful procedures and may regress during illness. Holding, rocking, and giving the child a security object is helpful because it may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; however, the success of these tactics depends on the child.
Which assessment finding is an early sign of heart failure in a client?
increased respiratory rate Increased respiratory and heart rates are the earliest signs of heart failure. Decreased urine output and increased weight are later signs.
A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The physician diagnoses type 1 diabetes and admits the child to the facility for insulin regulation. The physician orders an insulin regimen of insulin and isophane insulin administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act?
½ to 1 hour Regular insulin, a rapid-acting insulin, begins to act in ½ to 1 hour, reaches peak concentration levels in 2 to 10 hours, and has a duration of action of 5 to 15 hours.
After teaching the parents about the urethral catheter placed after surgical repair of their child's hypospadias, the nurse determines that the teaching was successful when the parent states that the catheter in their child's penis accomplishes which goal?
keeps the new urethra from closing The main purpose of the urethral catheter is to maintain the patency of the reconstructed urethra. The catheter prevents the new tissue inside the urethra from healing on itself. However, the urethral catheter can cause bladder spasms. Recently, stents have been used instead of catheters. The urethral catheter will have no effect on the child's pain level. In fact, because bladder spasms are associated with its use, the child's problems of pain may actually increase. Urine output can be measured through the suprapubic catheter because it provides an alternative route for urinary elimination, thus keeping the bladder empty and pressure free.
A 14-year-old brought to the emergency department with right lower quadrant pain is tentatively diagnosed with acute appendicitis. The nurse should further assess the client for which sign or symptom?
low-grade fever
A 4-month-old infant is diagnosed with congenital hypothyroidism and prescribed levothyroxine. When should the nurse teach the parents to administer the medication?
on an empty stomach
The nurse develops the family discharge teaching plan for a child with chronic renal failure. The nurse should emphasize restriction of which nutrient?
phosphorus With minimal or absent kidney function, the serum phosphate level rises, and the ionized calcium level falls in response. This causes increased secretion of parathyroid hormone, which releases calcium from the bones. Therefore, the intake of foods high in phosphorus is restricted. Because renal failure results in decreased erythropoietin production, an increase in ascorbic acid intake is needed. Because magnesium is minimally affected by renal failure, its intake need not be restricted.
A school-age client is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the client's risk of infection?
practicing thorough hand washing Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room.
A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating which stage of separation anxiety?
protest Young children have specific reactions to separation and hospitalization. In the protest stage, the toddler physically and verbally attacks anyone who attempts to provide care. Here, the child is fussing and crying and visibly pushes the nurse away. In the despair stage, the toddler becomes withdrawn and obviously depressed (e.g., not engaging in play activities and sleeping more than usual). Regression is a return to a developmentally earlier phase because of stress or crisis (e.g., a toddler who could feed themself before this event is not doing so now). Denial or detachment occurs if the toddler's stay in the hospital without the parent is prolonged because the toddler settles into hospital life and denies the parents' existence (e.g., not reacting when the parents come to visit).
The parents of a preschooler are refusing a blood transfusion to treat severe hypovolemia because they are Jehovah's Witnesses. The parents are aware of the potential consequences of refusing the treatment. The priority intervention for the nurse at this point is to:
pursue obtaining orders for alternative treatments to a blood transfusion.
The nurse conducts a developmental screening of a 15-month-old child with cerebral palsy. Which milestones would the nurse expect a typically developing toddler of this age to have achieved?
putting a block in the cup Delay in achieving developmental milestones is a characteristic of children with cerebral palsy. Ninety percent of typically developing 15-month-old children can put a block in a cup. Walking up steps typically is accomplished at 18 to 24 months. A child usually can use a spoon at 18 months. The ability to copy a circle is achieved at approximately 3 to 4 years of age.
A client with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?
respiratory isolation
A parent asks the nurse what types of activities the 3-year-old child should be able to do at this age. What is the nurse's best response?
ride a tricycle The nurse should expect the child to ride a tricycle because at age 3 gross motor development and refinement in eye-hand coordination enable a child to perform such an action. The fine motor skills required to lace shoelaces and the gross motor skills required for throwing a ball overhanded and jumping rope develop around age 4.
Upon the child's return from the postanesthesia recovery unit (PACU) after a tonsillectomy, the nurse should place the child in which position?
side lying Placing the child in a side-lying position facilitates drainage of secretions and helps prevent aspiration. The Trendelenburg position is contraindicated because it decreases effective lung volumes. The supine position is contraindicated because of the increased risk for aspiration. The lithotomy position is used for a pelvic examination.
A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is
skin traction applied to a lower extremity, with the extremity suspended above the bed.
When assessing a 13-year-old adolescent, what is an expected finding?
subjective judgments of right and wrong
The nurse is about to assess an infant's thyroid gland. In which position should the nurse place an infant to best examine the thyroid gland?
supine
A 12-year-old child with asthma wants to exercise. Which activity should the nurse suggest to improve breathing?
swimming
A 4-year-old child is admitted for cardiac catheterization. Which is most important to include as the nurse teaches this child about cardiac catheterization?
the child's parents The most important aspect of teaching a preschooler is to have the family members there for support. Preschoolers are able to understand information that is individualized to their level. Including a plastic model of the heart and a catheter as part of the preoperative preparation may be helpful. The other family members will understand the heart model and catheter better than the preschooler will.
An infant who has been in foster care since birth requires a blood transfusion. Who will the nurse approach to give written, informed consent for the procedure?
the foster mother
A school nurse interviews the parent of a middle school student who is exhibiting behavioral problems, including substance abuse, following a sibling's suicide. The parent says "I'm a single parent who has to work hard to support my family, and now I've lost one child and my other child is acting out and making me crazy! I just can't take all this stress!" Which concern regarding this family has top priority at this time?
the potential suicidal thoughts/plans of both family members
The nurse teaches the child with scoliosis being treated with a Boston brace about exercises. The nurse explains that the exercises are performed primarily for what reason?
to strengthen the back and abdominal muscles
A nurse is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should
use the heel of one hand for sternal compressions. The nurse should use the heel of one hand and compress one-third to one-half the depth of the chest. The nurse should use the heels of both hands clasped together and compress the sternum 1½″ to 2″ (at least 5 cm) for an adult. For a small child, two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of 12 breaths/minute.
The parent of a 9-month-old expresses concern that the baby "is developing slowly." The nurse is concerned about a developmental delay when finding the baby is unable to accomplish which skill?
vocalizing single syllables
The nurse is preparing a teaching plan for a 14-year-old child who is newly diagnosed with asthma. Which content should be taught first?
when to seek immediate medical attention
A parent brings their 18-month-old child to the clinic because the child eats ashes, crayons, and paper. Which information would be most important to obtain about this toddler?
whether the toddler is experiencing changes in the home environment
The nurse should advise the mother of a toddler suspected of having pinworms to do the cellophane tape test at which time?
while the child is asleep Pinworms come out of the rectum during the nighttime and early morning hours. Therefore, the best time to apply the tape to get results is while the child is asleep.
