PrepU - Pediatrics

A nurse is assessing a severely depressed adolescent. Which finding indicates the highest risk of suicide? -altered speech -a preoccupation with death -refusal to interact with others -excessive sleepiness

a preoccupation with death An adolescent who demonstrates a preoccupation with death (such as by talking frequently about death) should be considered at high risk for suicide. Although excessive sleepiness, altered speech, and voluntary seclusion may occur in suicidal adolescents, they also occur in adolescents who aren't suicidal. Verbal and emotional withdrawal and slowed speech are signs of possible depression; however, a focus on death is most concerning.

Which meal would be most appropriate for an adolescent with glomerulonephritis with severe hypertension? -baked ham, baked potato, pear, canned carrots, milk -egg noodles, hamburger, canned peas, milk -hot dog on a bun, corn chips, pickle, cookie, milk -baked chicken, rice, beans, orange juice

baked chicken, rice, beans, orange juice The best selection of food would include no added salt or salty food. Because sodium cannot be excreted due to the oliguria and to avoid increasing the hypertension, a low-salt diet is recommended. Most canned foods have sodium added as a preservative. Ham, hot dogs, canned peas, canned carrots, corn chips, pickles, and milk are high in sodium.

How should a nurse prepare a suspension before administration? -by diluting it with normal saline solution -by shaking it so that all the drug particles are dispersed uniformly -by crushing remaining particles with a mortar and pestle -by diluting it with 5% dextrose solution

by shaking it so that all the drug particles are dispersed uniformly The nurse should shake a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't recommended for this drug form.

When teaching a group of parents about the potential for febrile seizures in children, which information should the nurse include? -The exact cause is known. -Children older than age 3 years are most at risk. -These seizures commonly occur after immunization administration. -The seizures occur as the fever rises.

The seizures occur as the fever rises. Febrile seizures commonly occur as the fever rises. The exact cause of febrile convulsions is not known. Infants and young toddlers are the age-groups primarily affected. Febrile seizures typically do not follow immunization administration.

The health care provider (HCP) prescribes an intravenous infusion of 5% dextrose in 0.45 normal saline to be infused at 2 mL/kg per hour in an infant who weighs 9 lb (4.1 kg). How many milliliters per hour of the solution should the nurse infuse? Round to one decimal place.

8.2 4.1 kg × 2 mL/kg = 8.2 mL/hour

A nurse discussing injury prevention with a group of workers at a daycare center is focusing on toddlers. When discussing this age-group, the nurse should stress that: -toddlers can distinguish right from wrong. -toddlers will always chase a ball that rolls into the street. -accidents are the leading cause of death among toddlers. -the risk for homicide is highest among toddlers.

accidents are the leading cause of death among toddlers. The leading cause of death in toddlers is accidents, so it's important for parents, family members, and childcare providers to understand the importance of accident prevention. Toddlers don't have the highest risk for homicide. Toddlers are just beginning to understand right from wrong, but don't understand the consequences of their actions. Although many children will chase balls or toys into the street, not all children will do so.

Which topic would be most important to include when teaching the parents how to promote overall toddler development? -Discipline is critical to appropriate development. -Language is the most important achievement. -Eating habits that follow into adulthood begin now. -Safety is a priority concern for this age group.

Safety is a priority concern for this age group. Because of toddlers' high energy and poor impulse control, safety is a priority concern for this age group. Language is important in toddler development, but not the most important at this time. While parents should set clear guidelines for behavior, the priority for toddlers is ensuring safety. Diet habits should be developed at this time, but the most important subject to teach parents of toddlers is safety.

While assessing a child experiencing respiratory distress, the nurse notes subcostal retractions. Which graphic highlights the area where subcostal retractions are seen? (Picture question)

Subcostal retractions are retractions seen below the lower costal margin of the rib cage. Option B highlights the area where subcostal retractions are seen. Option A shows the areas where intercostal retractions would be seen. Option C shows the area for suprasternal retraction. Option D shows the areas for clavicular retractions.

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated? -airborne precautions -standard precautions -droplet precautions -contact precautions

droplet precautions Meningococcal infections are spread through close mucous membrane or respiratory contact with large respiratory droplets. Meningococcal infections are not spread by small airborne organisms or contact with a person's skin or contaminated items. Standard precautions, used when touching body fluids, are not sufficient to prevent the spread of meningitis.

A child underwent a tonsillectomy 4 hours ago. Which assessment finding should make the nurse suspect postoperative hemorrhage? -vomiting of dark brown emesis -frequent swallowing -refusal to drink clear fluids -decreased heart rate

frequent swallowing Frequent swallowing — an attempt to clear the throat of trickling blood — suggests postoperative hemorrhage. Emesis may be brown or blood-tinged after a tonsillectomy; only bright red emesis signals hemorrhage. The child may refuse fluids because of painful swallowing, not bleeding. Hemorrhage is associated with an increased, not decreased, heart rate.

An adolescent tells the nurse that the area below his knee has been hurting for several weeks. The nurse should obtain history information about participation in which sport? -swimming -soccer -golf -diving

soccer The adolescent's problem should alert the nurse to the possibility of Osgood-Schlatter disease. This disease, found primarily in boys 10 to 15 years of age and in girls 8 to 13 years of age, occurs when the infrapatellar ligament of the quadriceps muscle is not well anchored to the tibial tubercle. Excessive activity of the quadriceps muscle results in microtrauma, which causes swelling and pain. Track, soccer, and football commonly produce this condition. Osgood-Schlatter disease is self-limited and usually responds to rest and application of ice.

The nurse is caring for a 7-year-old client being admitted after experiencing two seizures within a 24-hour period. Client has no history of head trauma and has not experienced seizures in the past. Complete the following sentence(s) by choosing from the lists of options. After admission, the child begins to experience another seizure. The nurse should first address the client's __(1)__ while at the same time __(2)__. 1. -administering medication -airway -lab results -neurological status -vital signs 2. -educating the guardians -protecting from injury -preparing for surgery -promoting the child's self-esteem -documenting the episode

1. airway 2. protecting from injury The nurse will need to prioritize interventions to safely care for the client experiencing a seizure. It is critical that the airway be maintained and supplemental oxygen administered if the client changes color. The nurse must protect the client from injury during the seizure. This would include protecting the head by cradling and not restraining limbs. If client is on the floor, ensure they are far enough away from the wall or objects to minimize risk of injury. Pad rails should be padded, and bed in low position. Vital signs, lab results, administering medication, and assessing the neurological status are all appropriate nursing interventions, however, they are not the priority interventions. Educating guardians, documenting the seizure episode, and promoting the child's self-esteem are all appropriate nursing interventions, however, they are not the priority interventions. Preparing for surgery is not an appropriate nursing intervention. The client, after all other treatments have proven unsuccessful, may be considered for surgery. In this case, the client has no history of seizure except in the last 24 hours.

A child who had a cast applied to his arm earlier this morning tells the nurse that his fingers are numb. What should the nurse do next? -Assess the circulation to the fingers. -Notify the health care provider (HCP) who applied the cast. -Ensure that the arm is positioned correctly. -Cut the cast to loosen it.

Assess the circulation to the fingers. With a new problem of numbness in the fingers, the nurse needs to first assess the circulation to evaluate color, evidence of swelling, and presence of pulses to determine whether there is any circulatory compromise. Once the nurse has evaluated the child's circulatory status, the next action would be to verify the arm's position above the level of the heart. Notifying the HCP would not be done until the child's neurovascular status and position are checked. Cutting the cast would be done only with a HCP's prescription.

What advice should a nurse give to the caregivers of a 2-year-old client who frequently throws temper tantrums? -Allow the client more choices. -Ignore the behavior when it happens. -Give into the client's demands. -Move the client to a different setting.

Ignore the behavior when it happens. Ignoring tantrums is the best advice because paying attention to the undesirable behavior can reinforce it. Changing settings can actually increase the tantrum behavior. Allowing the client more choices may also increase tantrum behavior if the client is unable to follow through with choices. It's ill-advised to give into the client's demands because doing so only promotes tantrum behavior.

A 12-year-old child is scheduled for surgery to repair a fractured tibia. One hour prior to surgery, the nurse assesses that the child is febrile. What is the best action for the nurse to take? -Inform the surgeon. -Apply cool compresses. -Record the temperature. -Administer an antipyretic.

Inform the surgeon. The surgeon must be informed immediately so the decision can be made whether to proceed with the surgery. A child scheduled for surgery in 1 hour would be NPO, so oral antipyretics would not be an option. Although cool compresses might relieve some discomfort, the priority is to notify the physician.

The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant? -Your child will need oxygen at home. -Keep feedings small, but frequent. -It is dangerous to let your child cry. -There are no restrictions on play.

Keep feedings small, but frequent. Because children with heart defects fatigue so quickly, frequent small meals are suggested to ensure that the child receives adequate nutrition. Rough play would be considered too physically demanding on the child. Most children do not need oxygen at home.

A 12-year-old with asthma wants to exercise. Which activity should the nurse suggest to improve breathing? -soccer -track -swimming -gymnastics

swimming Swimming is appropriate for this child because it requires controlled breathing, assists in maintaining cardiac health, enhances skeletal muscle strength, and promotes ventilation and perfusion. Stop-and-start activities, such as soccer, track, and gymnastics, commonly trigger symptoms in asthmatic clients.

What toy should the nurse included as part of a recreational therapy plan of care for a 3-year-old child hospitalized with pneumonia and cystic fibrosis? -100-piece jigsaw puzzle -child's favorite doll -scissors, paper, and paste -fuzzy stuffed animal

child's favorite doll The child's favorite doll would be a good choice of toys. The doll provides support and is familiar to the child. Although a 3-year-old may enjoy puzzles, a 100-piece jigsaw puzzle is too complicated for an ill 3-year-old child. In view of the child's lung pathology, a fuzzy stuffed animal would not be advised because of its potential as a reservoir for dust and bacteria, possibly predisposing the child to additional respiratory problems. Scissors, paper, and paste are not appropriate for a 3-year-old unless the child is supervised closely.

A parent of a child with hemophilia states that she worries whenever the child has a bump or cut. The nurse should explain that after the area is cleansed, the wound should be treated by applying which measure? -gentle pressure -a tourniquet above the injured area -a wet-to-dry dressing -warm, moist compresses

gentle pressure In children with hemophilia (an inherited bleeding disorder), a bump or cut can cause serious bleeding. After the injured area is cleansed, gentle pressure should be applied to allow clot formation, which will help stop the bleeding. In addition, the area should be immobilized and elevated. Cold applications, instead of warm moist compresses, are commonly used to promote vasoconstriction and help control the bleeding. A tourniquet should not be used because of the high risk of tissue hypoxia and resulting necrosis. Wet-to-dry dressings should be avoided because they could be irritating to the area.

Which substance should the nurse include in the teaching plan for a teenager with acne who has requested information about cleansing the affected skin? -witch hazel -hydrogen peroxide -soap and water -baby lotion

soap and water Acne is a disorder of the pilosebaceous follicles (hair follicles and sebaceous gland complex). During adolescence, the secretions of the sebaceous glands increase, altering the follicular lining and causing occlusion of the ducts with accumulated sebum. Bacteria in the follicle then cause an infection. Frequent washing of affected areas with soap and water is recommended to act as a mild peeling agent and reduce secondary infection. Witch hazel is an astringent that can be used after thoroughly cleansing the skin. Hydrogen peroxide is a poor cleansing agent for skin with acne. Lotions and creams aggravate the condition by adding more oily substances to the already oily skin.

A physician orders an intravenous infusion of dextrose 5% in quarter-normal saline solution (D5.25 NSS) to be infused at 7 ml/kg/hour for a 10-month-old infant. The infant weighs 22 lb (10 kg). How many milliliters of the ordered solution would the nurse infuse each hour? Record your answer using a whole number.

70 To perform this dosage calculation, the nurse would first convert the infant's weight to kilograms if needed (in the United States):2.2 lb/kg = 22 lb/XX = 22/2.2 kgX = 10 kg. Next, the nurse would multiply the infant's weight by the ordered rate:10 kg x 7 ml/kg/hour = 70 ml/hour.

A nurse observes a family in the playroom. Which behavior would be considered to be an example of social affective play? -A 4-year-old child is listening to the mother's chest with a stethoscope. -An infant is making happy noises in response to her father speaking to her. -An 8-year-old child is taking turns playing a handheld video game with another child. -A 2-year-old child is sitting in her mother's lap hugging a teddy bear.

An infant is making happy noises in response to her father speaking to her. Social affective play occurs when infants take pleasure in relationships with people. The 8-year-old child is participating in interactive play. The 4-year-old child is participating in symbolic or pretend play. The 2-year-old child is exhibiting unoccupied behavior.

The nurse assesses the development of an 18-month-old. The nurse anticipates that the child will be able to do which skill? -Build a tower of four cubes. -Say three words. -Use a spoon with little spilling. -Throw a ball overhand.

Say three words. By age 18 months, 90% of children can say three words. Typically, a child 23 months of age can build a tower of four cubes. The ability to use a spoon or fork with little spilling is accomplished by the age of 20 months. Throwing a ball overhand typically is achieved by age 3.

An adolescent client is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do? -Restate the surgery risks to the parents. -Ask the parents if they have signed the operative permit. -Verify that the site, side, and level are marked. -Ask the teen to point to the surgery site.

Verify that the site, side, and level are marked. As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.

The nurse is providing nutrition counseling for an obese adolescent. What is the most effective way for the nurse to obtain a nutrition history from this client? -Ask her what she knows about good nutrition. -Telephone her mother and ask her what she ate yesterday. -Tell her to list what she plans to eat for the next 24 hours. -Ask her what she ate yesterday if it was a typical day.

Ask her what she ate yesterday if it was a typical day. A 24-hour recall history is the best method to obtain a dietary history from an adolescent. Open-ended questions tend not to provide sufficient details for a nutrition history. Asking what the client plans to eat in the future gives the client an opportunity to report the "right" answer. The nurse obtains the information directly from the client; asking the mother has the potential to undermine trust.

A community nurse is assessing a young child who has had a colostomy stoma for several years. The nurse notices that the stoma is dark pink and moist. What is the best response to the child's parents about the appearance of the stoma? -"The stoma looks healthy; continue your present care." -"The stoma is irritated; change the appliance more frequently." -"The stoma is too moist; we must try to prevent skin breakdown." -"The stoma looks infected; you need an antibiotic cream."

"The stoma looks healthy; continue your present care." A normal, healthy stoma should be dark pink and moist. This child's parents should continue the present care. There is no indication of infection or irritation. There is no data that support the stoma being "too moist" or that there is skin breakdown.

An infant's death is deemed due to sudden infant death syndrome (SIDS). The parents want to know the cause of SIDS and if they could have done something to prevent it. What explanation should the nurse provide these parents? -"SIDS occurs only in premature infants." -"SIDS occurs after an upper respiratory infections." -"SIDS occurs in babies who sleep on their abdomen." -"Unfortunately the cause of SIDS is unknown."

"Unfortunately the cause of SIDS is unknown." Unfortunately, while there are many theories as what causes SIDS, no one specific cause has been identified. SIDS is more frequent in male than female infants. Although cigarette smoke may have an association with SIDS, exposure to respiratory infection has not been proven to be correlated with an increased incidence of SIDS. Although SIDS is more common in preterm infants, it is often associated with multiple births, infants with low Apgar scores, and infants born to mothers who smoked during pregnancy. SIDS can also occur in babies who sleep face down on soft surfaces. That is why back sleeping is now recommended.

When developing the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery, which method is most appropriate? -Explain to the parents how the defect will be corrected. -Use an anatomically correct doll to show the child what will be "fixed." -Tell the child that his penis and scrotum will be "fixed." -Tell the child that he will not see any incisions after surgery.

Explain to the parents how the defect will be corrected. Preoperative teaching would be directed at the parents because the child is too young to understand the teaching. Telling the child that his penis and scrotum will be "fixed," telling the child he will not see incisions after surgery, and using a doll to illustrate the surgery are appropriate interventions for a preschool-age child.

A normal, healthy 2-month old infant is brought to the clinic for the first diphtheria, tetanus, and acellular pertussis (DTaP) immunization. Which route is appropriate to administer this vaccine? -IM -subcutaneous -oral -intradermal

IM DTaP vaccine is given intramuscularly and often in combination with other vaccines. The inactivated polio vaccine may be given in either the IM or subcutaneous route. The rotavirus vaccine is given orally. There are no approved intradermal vaccines for 2-month old infants.

A 10-year-old client has arrived to sleepover summer camp. The child's parent states that the client has just been diagnosed with insulin-dependent diabetes mellitus but does not perform self-injections. The child is nervous, cries, and jerks away when the nurse initially attempts to give insulin. Which is the best nursing action? -Ask the camp director to assist in administering the insulin injections. -Teach the child to self-administer the insulin injections. -Chart that the child refused the medication. -Call the parents and inform them that the insulin cannot be given.

Teach the child to self-administer the insulin injections. Teaching the child to administer the medication gives the child some control over the situation. Encourage the child and allow the child to show friends what the child can do. There is no need to call the parents, and the camp director has no knowledge of insulin injection. The child must have the insulin injection, so the medication cannot be charted as simply not done.

For a 3-year-old child with tracheobronchitis, the nurse formulates a nursing diagnosis of ineffective airway clearance related to stasis of secretions. After implementing interventions, what does the nurse indicate as the most desired outcome? -The child exhibits a respiratory rate of 36 breaths per minute. -The child exhibits clear breath sounds. -The child exhibits an arterial oxygen saturation of 92%. -The child exhibits decreased anxiety.

The child exhibits clear breath sounds. The nurse should expect clear breath sounds because this outcome indicates an improved respiratory status and airway clearance. A respiratory rate of 36 breaths per minute supports a nursing diagnosis of ineffective breathing pattern. An arterial oxygen saturation of 92% supports a nursing diagnosis of impaired gas exchange, and a decrease in anxiety supports the nursing diagnosis of anxiety.

The nurse is inserting a nasogastric tube in an infant to administer feedings. In the accompanying figure, indicate the location for the correct placement of the distal end of the tube.

The nasogastric tube should reside in the stomach. The site placement can be verified by inserting 3 to 5 mL of air in the tube and auscultating the infant's abdomen for the sound of air. The nurse should then aspirate the injected air and a small amount of stomach contents and then test the contents for acidity.

The nurse administers an intramuscular injection to an infant. Indicate the appropriate site for this injection.

The vastus lateralis in the thickest part of the anterolateral thigh is a safe injection site for infants. The needle should be inserted at a 90-degree angle to the long axis of the femur.

The nurse prepares a 3-year-old child to have blood specimens drawn for laboratory testing. What intervention should the nurse employ? -Provide verbal explanations about what will occur. -Explain why the blood needs to be drawn. -Explain the procedure in advance. -Use distraction techniques during the procedure.

Use distraction techniques during the procedure. A 3-year-old child responds best to distraction during a procedure because of the typical level of cognitive development of a 3-year-old and the fear of painful events. Preparation for the procedure should be done immediately beforehand, so that the child will not become too frightened. A 3-year-old is not concerned about the why of the procedure but about whether the procedure will hurt. This child is too young for verbal explanations alone because of the limited verbal abilities at this age and the fear of a painful event.

A toddler diagnosed with nephrotic syndrome has a fluid volume excess related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care? -Test urine specific gravity every shift. -Weigh the child before breakfast. -Limit visitors to 2 to 3 hours a day. -Maintain strict bed rest.

Weigh the child before breakfast. The best indicator of fluid balance is weight. Therefore, daily weight measurements help determine fluid losses and gains. Although limiting visitors to 2 to 3 hours per day or maintaining strict bed rest would help to ensure that the child gets adequate rest, this is unrelated to the child's fluid balance. In nephrotic syndrome, urine is tested for protein, not specific gravity.

A young child is returning to the pediatric unit after having surgery to form a colostomy. When assessing the stoma, the nurse becomes most concerned when what is observed? -slight bleeding of the stoma -stomal tissue that is moist -a dark maroon stoma -a stoma that is edematous

a dark maroon stoma Ischemia may occur within 24 hours of the ostomy surgery and result in a dark, necrotic stoma that appears maroon to black. Causes of stomal necrosis include constricting sutures, mesenteric tension, disproportionate clipping of the mesentery, emboli, pressure associated with barrier wafer constriction, and abdominal edema or distension. A healthy stoma is dark pink and moist. Following surgery, a stoma may be edematous, and there may be bleeding when the stoma is touched.

A parent brings in an 18-month-old to the clinic because the child "eats ashes, crayons, and paper." Which information about the toddler should the nurse assess first? -intake of a soft, low-roughage diet -amount of attention from the parent -any changes in the home environment -evidence of eruption of large teeth

any changes in the home environment A craving to eat nonfood substances is known as pica. Toddlers use oral gratification as a means to cope with anxiety. Therefore, the nurse should first assess whether the child is experiencing any change in the home environment that could cause anxiety. Teething or the eruption of large teeth and the amount of attention from the mother are unlikely causes of pica. Nutritional deficiencies, especially iron deficiency, were once thought to cause pica, but research has not substantiated this theory. A soft, low-roughage diet is an unlikely cause.

A nurse is preparing a health promotion program for teenagers focusing on lifestyle choices. Which of the following methods used by the nurse will best ensure the success of the program? -creating a safe environment for sharing information -validating the current lifestyle choices of the teenagers -disclosing and explaining personal lifestyle choices -reviewing data about common teenage lifestyle choices

creating a safe environment for sharing information Creating an environment where the teenagers feel safe to share their information leads to therapeutic communication that is client focused. This helps to establish trust, which facilitates a more successful program. The other options block the ability of the teenagers to share their thoughts and feelings openly.

A child is being seen in the emergency department for reports of severe sore throat, trouble swallowing, and fever. The child has swollen cervical lymph nodes and a fiery red pharynx on examination. Which assessment findings below should be reported immediately to the healthcare provider? -drooling and not swallowing -sudden onset of ear pain -loud snoring and noisy respirations -coughing and sneezing

drooling and not swallowing Drooling and refusal to open mouth indicate a potentially life-threatening situation as the child may be unable to swallow and have a severely narrowed throat. Coughing or sneezing does not indicate a priority problem. Noisy respirations could be indicative of a pending problem; however, the drooling is a higher priority. Sudden onset of ear pain is not as high a priority problem as the drooling and the inability to swallow.

A parent brings a preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment does the nurse anticipate? -I.V. infusion of normal saline solution -gastric lavage and administration of activated charcoal -insertion of a nasogastric tube and administration of an antacid -administration of a dose of ipecac syrup

gastric lavage and administration of activated charcoal The healthcare provider will probably order gastric lavage or activated charcoal administration. Ipecac syrup is no longer recommended, and an antacid is not an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting, but in itself is not effective in eliminating the poisonous substance.

A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone? -initiative -identity -autonomy -industry

identity According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. The hospitalized adolescent is separated from the peer group and the adolescent's body image may be altered. This alteration in body image may interfere with the ongoing development of the adolescent's identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

The nurse is caring for an adolescent who has been admitted several times with uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge. What should be the priority focus for the nurse when conducting discharge teaching? -coping with a chronic disease -relocating closer to the hospital -risk for injury and readmission -management of the therapeutic regimen

management of the therapeutic regimen The priority immediately after recovery is therapy management, including reviewing that the interruption of insulin administration may result in diabetic ketoacidosis. The multiple admissions suggest that the adolescent either does not understand the consequences of the disease or is making choices that are not consistent with the health teaching. This is an opportunity to review those choices.

A parent tells the nurse that their 6-year-old child has severe nosebleeds. To manage the nosebleed, the nurse should tell the parent to: -help the child assume a comfortable position with the head tilted backward. -place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum. -tilt the child's head backward and place firm pressure on the nose. -help the child lie on the stomach and collect the blood on a clean towel.

place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum. For the initial management of nosebleed, the client should sit up and lean forward with the head tipped downward. The soft tissues of the nose should be compressed against the septum with the fingers. The head-back position allows blood to flow down the throat, putting the client at risk for aspiration and allowing blood to enter the gastrointestinal tract, which can trigger vomiting.

A nurse is caring for an infant with dehydration and weight loss. The infant's parent states that the infant doesn't like to eat and the parent hates to make the infant eat. The nurse should: -contact the social worker on duty and give the social worker information about the situation. -contact the physician to have the child put in isolation. -request that a dietitian talk with the parent about infants and nutrition. -contact the local police department to report suspected child abuse.

request that a dietitian talk with the parent about infants and nutrition. The infant's parent needs assistance in maintaining the child's diet. Requesting that a dietitian speak with the parent about the child's diet is within the nurse's scope of practice. The nurse shouldn't call the local police or the social worker on duty because there is no evidence of child abuse or neglect. Many infants are picky eaters and choose not to eat or drink. The nurse doesn't need to call the physician to have the infant put in isolation. Isolation isn't indicated for dehydration.

A client with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? -strict hand washing -reverse isolation -respiratory isolation -standard precautions

respiratory isolation Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the client's room wears a mask. Reverse isolation is unnecessary because it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.

A pediatric nurse is caring for a child suspected of having been sexually abused. Which finding would best support the nurse's suspicions? -fear of parents -poor hygiene -poor eye contact -swelling of the genitals

swelling of the genitals The most likely finding for suspected sexual abuse would be difficulty walking or sitting; pain, swelling, or itching in the genitals; or bruises, bleeding, or lacerations of the genital area. Poor hygiene is a sign of physical neglect. Poor eye contact and fear of parents are common signs of physical, not sexual, abuse.

What is the primary reason that the nurse inserts an indwelling urinary catheter in a child with severe burns? -to assess urine specific gravity -to prevent urinary retention -to monitor for a urinary tract infection -to measure urine output accurately

to measure urine output accurately Accurate determination of urine output is a crucial factor in the care of a burn victim. Urinary tract infection is typically not a problem with a burn victim, though insertion of the catheter may predispose the child to a urinary tract infection. However, the benefits of using an indwelling catheter to measure urine output to the nearest milliliter outweigh the risk of infection and other problems associated with use. Unless the burns cover the perineal area and make urination painful, urinary retention is usually not a problem. Determining urine specific gravity can be done to assess hydration, but this is not the primary rationale for inserting an indwelling urinary catheter.

When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which possible source of infection? -a pet canary -unwashed fruit -undercooked eggs -nonrefrigerated custard

undercooked eggs Diarrhea related to Salmonella bacilli is commonly spread by raw or undercooked fowl and eggs, pet turtles, and kittens. Food poisoning caused by Staphylococcus species is commonly spread by inadequately cooked or refrigerated custards, cream fillings, or mayonnaise. Psittacosis, a respiratory illness, may be spread by canaries. Contaminated, unwashed fruit is associated with typhoid fever (caused by Salmonella typhi), a disorder rarely seen in the United States and Canada.

A 2-month-old infant is seen in the emergency department for symptoms of infection. The healthcare provider has prescribed an antibiotic via the IM route. In which location should the nurse administer the injection? -vastus lateralis -deltoid -dorsogluteal -ventrogluteal

vastus lateralis The recommended injection site for an infant is the vastus lateralis muscle. The maximum volume that can be injected in each site is 0.5ml. The deltoid or dorsogluteal muscles are not used in infants. The ventrogluteal site can be used only after 7 months of age.

A preschooler has vomiting, diarrhea, a potassium level of 3 mEq/L (3 mmol/L), and a sodium level of 137 mEq/L (137 mmol/L). Which prescribed treatment will the nurse implement first? -nasogastric tube to low intermittent suction -loperamide 15 ml by mouth -promethazine topical gel 12.5 mg -IV infusion of saline, dextrose, and potassium solution

IV infusion of saline, dextrose, and potassium solution A child with vomiting and diarrhea loses excessive fluids and electrolytes, putting them at risk for dehydration and cardiac arrhythmia. The first action by the nurse is to start the IV fluid and electrolyte replacement. The nurse would then administer the promethazine to reduce nausea and vomiting and then place the nasogastric tube to low intermittent suction. Loperamide is not recommended in children under age 6, so the nurse should seek clarification for this prescription.

A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should: -remove the weight from the left leg. -reposition the pulleys so the traction is looser. -assess the feet for signs of neurovascular impairment. -place a pillow under the child's buttocks to provide support.

assess the feet for signs of neurovascular impairment. The nurse should assess the client frequently for signs of neurovascular impairment of the feet, such as pallor, coldness, numbness, or tingling. Pillows are not placed under the buttocks because the pillows would alter the alignment of the traction. Weights provide traction and should not be removed. Pulleys help to maintain optimal alignment of the traction and therefore should be left alone.

Which toy should the nurse give to a toddler to use in the hospital playroom? -tricycle -truck with four wheels. -wheelbarrow -blocks

blocks As toddlers begin imaginative play, blocks are an excellent toy choice. Children can use blocks any way they desire, thus fostering imaginative play. A tricycle, wheelbarrow, or truck is an appropriate toy for a preschooler because it requires the use of specific motor skills developed during the preschool period. These motor skills are lacking in a toddler.

The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which action? -holding the infant prone while feeding -holding the infant in her lap to burp -burping the infant during and after the feeding -placing the infant prone after the feeding

burping the infant during and after the feeding Infants with colic should be burped frequently during and after the feeding. Much of the discomfort of colic appears to be associated with the presence of air in the stomach and the intestines. Frequent burping helps to relieve the air. Infants with colic should be held fairly upright while being fed, to help air rise. The preferred position for burping the infant with colic is to hold the infant at the mother's shoulder so that the infant's abdomen lies on the shoulder. This position causes more pressure to be exerted on the infant's abdomen, leading to a more forceful burp. The child should be placed in an infant seat after feedings.

A nurse observes two 2-year-old children playing. The nurse documents what form of play as normal for this age group? -riding tricycles near each other -playing a game of catch with a ball -digging side-by-side in a sandbox -pretending to "race" toy cars with each other

digging side-by-side in a sandbox Two-year-old children exhibit parallel play. They engage in similar activity, side by side. Two-year-old children have very short attention spans, so they change toys easily when playing. Taking turns in games does not occur until age 3 years, and playing catch is a "take turns" activity. Pretending to "race" toy cars is more suggestive of cooperative play, in which the children work together. Cooperative play is more typical of children 4 to 5 years of age. Riding tricycles near each other represents independent play. While the children are performing the same activity, they do not maintain the constant proximity ("side-by-side") exhibited in the parallel play that is common among 2-year-olds.

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding in the infant suggests that the parents require more teaching about administering the pancreatic enzymes? -fatty stools -bloody stools -liquid stools -normal stools

fatty stools Pancreatic enzymes normally aid in food digestion in the intestine. In a child with cystic fibrosis, however, these natural enzymes cannot reach the intestine because mucus blocks the pancreatic duct. Without these enzymes, undigested fats and proteins produce fatty stools. If the parents were administering the pancreatic enzymes correctly, the child would have stools of normal consistency. Noncompliance doesn't cause liquid or bloody stools.

A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff? -proper documentation of a verbal order from a physician -new education materials for the management of diabetes -policy changes in the administration of opioids -logging off a computer containing client information

logging off a computer containing client information All members of the healthcare team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use. Taking a verbal order, administering medications, and client education aren't within the scope of practice of the clerical support staff.

After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action? -removing the restraints while the infant is asleep -using the restraints until the infant recovers fully from anesthesia -keeping the restraints on both arms only while the child is awake -removing the restraints every 2 hours

removing the restraints every 2 hours Removing one elbow restraint at a time every 2 hours for about 5 minutes allows exercise of the arms and inspection for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.

A 4-year-old child is admitted to the hospital for surgery. The nurse applies interventions to address what major stressor for a child of this age? -separation from family -fear of pain -loss of control -fear of bodily injury

separation from family For infants through preschoolers, separation from the family is the major stressor posed by hospitalization. To minimize the effects of separation, the nurse may suggest that a family member stay with the child as much as possible. Reducing this stressor may help a young child withstand other possible stressors of hospitalization, such as fear of bodily injury, loss of control, and fear of pain.

To establish a good interview relationship with an adolescent, which strategy is most appropriate? -writing down everything the teen says -discussing the nurse's own thoughts and feelings about the situation -asking personal questions unrelated to the situation -asking open-ended questions

asking open-ended questions Open-ended questions allow the adolescent to share information and feelings. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel interrogated with unnecessary questions. Writing everything down during the interview can be a distraction and doesn't allow the nurse to observe how the adolescent behaves. Discussing the nurse's thoughts and feelings may bias the assessment and is inappropriate when interviewing any client.

An adolescent diagnosed with thalassemia major (Cooley's anemia) is at risk for which condition? -hypertrophy of the thymus -chronic hypoxia and iron overload -polycythemia vera and thrombosis -hypertrophy of the thyroid

chronic hypoxia and iron overload Thalassemia major increases destruction of red blood cells (RBCs), shortens the life span of RBCs, and causes anemia. The body responds by increasing RBC production, but it can't produce adequate numbers of mature cells. This process results in chronic hypoxia. In addition, children with thalassemia major require multiple transfusions of packed RBCs. The combination of excessive RBC destruction and multiple transfusions deposits excess iron that damages organs and tissues. Thalassemia major doesn't place the adolescent at risk for hypertrophy of the thymus or thyroid or polycythemia vera, which involves excessive RBC production that can lead to thrombosis.

A 5-month-old infant is brought to the clinic by his parents because he "cries too much" and "vomits a lot." The infant's birth weight was 6 lb, 10 oz (3,000 g), and his current weight is 7 lb, 4 oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which data should the nurse identify as the priority? -frequency of regular checkups -feeding pattern -family dynamics -pattern of weight gain

feeding pattern Because the infant falls below the 5th percentile on a standard growth chart, the nurse should consider failure to thrive, a term applied to an infant who is not growing at an acceptable rate. Information about feeding patterns, including types and amounts of food, is needed to determine the cause of failure to thrive. If a child does not receive sufficient calories, growth slows. Whether or not the infant has received regular checkups is important but not the priority because that information alone does not provide evidence or substantiation about the infant's growth patterns. The infant's pattern of weight gain is important but not the priority. Rather, the infant's pattern of weight gain provides valuable and useful information over a period of time. Information about family dynamics is important to provide data about family stresses that may affect or help explain the infant's failure to thrive. However, it is not the priority. This information needs to be viewed in conjunction with the infant's feeding patterns to gain a complete picture.

The nurse is caring for an 8-year-old girl with frequent urinary tract infections who is withdrawn and quiet. The nurse learns the child is left with a male caregiver while the mother is at work. The child states, "It hurts down there." What is the best response to the child? -"Are there other times you have hurt down there?" -"Is the babysitter touching you down there?" -"The medications will help your hurt soon." -"The hurt is from the urinary tract infection."

"Are there other times you have hurt down there?" The nurse needs to collect more data in any suspicious situation, so asking more about the "hurt" is most appropriate. It's acceptable to explain the infection and the medications, but these aren't the primary issues at the time. The nurse needs to be professional and not directly accuse the babysitter of touching the child.

The parent of an adolescent girl with Down syndrome tells the nurse that her daughter recently stated that she has a boyfriend. The parent is concerned that her daughter might become pregnant. Which is the most appropriate suggestion made by the nurse? -"I understand your concern; you may want to enroll your daughter in an abstinence program." -"This may be difficult, but you may want to suggest that your daughter break off the relationship." -"Women with Down syndrome are infertile, so you do not need to worry about her getting pregnant." -"I understand your concern; you may want to start your daughter on long-acting contraception."

"I understand your concern; you may want to start your daughter on long-acting contraception." Children with Down syndrome range from having severe intellectual disability to having low average intelligence, Thus the adolescent's ability to make informed choices regarding sexual activity is limited. Long-acting contraception, such as an intrauterine device or a progestin implant, greatly reduces the risk of unwanted pregnancy. Most women with Down syndrome are fertile; however, children born to women with Down syndrome often have congenital defects. An abstinence program may not be effective due to the intellectual level of children with Down syndrome. Suggesting that the adolescent break off the relationship does not ensure that she will.

The parents of a toddler do not want their child to have a varicella immunization, stating, "My child will have better immunity if he or she gets the disease now." Which is the nurse's best response? -"If the child contracts the disease, it could be very serious, even life threatening." -"You are correct and chicken pox is not fatal." -"The antibodies in the vaccine are good for other communicable diseases as well." -"Chicken pox is not very contagious, so it is unlikely your child will contract it naturally."

"If the child contracts the disease, it could be very serious, even life threatening." The varicella vaccine protects the child from chicken pox. Although most cases of chicken pox are not life threatening, children can die from the disease. It is highly contagious, and other children, or immunocompromised adult and children, may be exposed to the unvaccinated child. The vaccine is specific for chicken pox disease.

A nurse is caring for a 9-year-old child who is scheduled for surgery. The parents ask the nurse not to tell the child about the surgery until leaving for the operating room. What response best demonstrates the nurse's role in supporting the child's rights? -"Your child must be made aware of the impending surgery in order to obtain informed consent." -"I am legally obligated to inform your child of the surgery in advance of the procedure." -"It's important to tell your child about the surgery to allow time for any questions to be answered." -"I will not tell your child about the surgery until it's absolutely necessary."

"It's important to tell your child about the surgery to allow time for any questions to be answered." Advance awareness of the surgery and its significance offers a school-age child time to develop coping strategies and formulate questions. Failure to inform the child about the surgery ahead of time may result in fear or mistrust of healthcare workers or the healthcare system. Children are not able to sign consent. The legal obligation of informing the child of surgery is not seen as the best action to support the child's rights.

The school nurse is discussing healthy eating strategies with a group of 8-year-old students. One student repeatedly makes comments of a sexual nature. The student seems to be preoccupied with sexual comments and is knowledgeable regarding a variety of sexual activities. Which of the following is the most crucial intervention for the nurse to take to manage the student's behavior? -Talk with the student's parents about age-appropriate behavior. -Investigate the possibility that the student may have been sexually abused. -Ask the student about viewing sexually explicit content in a movie or on TV. -Discuss sibling behavior with the student to determine if mimicking is the cause.

Investigate the possibility that the student may have been sexually abused. When a child appears to be preoccupied with sexual comments and is knowledgeable regarding sexual activities, the nurse should suspect that the child may have been sexually abused and should explore the situation. The other options are possible, but the extent of this behavior is neither "typical," nor does it reflect one instance of viewing mature video content. The nurse should pursue and ensure the child's safety and investigate further.

A 9-year-old child with Guillain-Barré syndrome requires mechanical ventilation. Which action should the nurse take? -Maintain the child in a supine position to prevent unnecessary nerve stimulation. -Turn the child slowly and gently from side to side to prevent respiratory complications. -Engage the child in vigorous passive range-of-motion exercises to prevent loss of muscle function. -Transfer the child to a bedside chair three times a day to prevent postural hypotension.

Turn the child slowly and gently from side to side to prevent respiratory complications. Even in the absence of respiratory problems or distress, the child must be turned frequently to help prevent the cardiopulmonary complications associated with immobility, such as atelectasis and pneumonia. Maintaining the child in a supine position is unnecessary. Doing so does not prevent unnecessary nerve stimulation. In addition, maintaining a supine position may lead to stasis of secretions, placing the child at risk for pneumonia. Transferring the child to a chair will not prevent postural hypotension. However, doing so will increase vascular tone and help prevent respiratory and skin complications. During the acute disease phase, vigorous physiotherapy is contraindicated because the child may experience muscle pain and be hypersensitive to touch. Careful and gentle handling is essential.

(Picture Question) Laboratory Results Test: Urinalysis Date: 07/16/15 Time collected: 0700 Parameter / Results Color / Pale yellow Turbidity / Clear pH / 7.8 Specific gravity / 1.015 Protein / Negative Glucose / Positive Ketones / Positive Red blood cells / <1 per high-power field White blood cells / 20 per high-power field Casts / None An 11-year-old girl comes into the healthcare provider's office stating dysuria. The nurse suspects a urinary tract infection. Which findings on the laboratory report is consistent with a urinary tract infection? -Ketones: positive -WBCs: 20 per high-power field -Glucose: positive -pH 7.8

WBCs: 20 per high-power field Urinary tract infections are more common in school-aged girls than in school-aged boys. A normal urinalysis would show less than 5 WBCs per high-power field. An elevated WBC count of 20 is an indication of bacteria and urinary tract infection. The normal range of urinary pH is 4.6 to 8.0. The presence of glucose or ketones in the urine does not indicate a urinary tract infection, but may indicate diabetes mellitus.

Parents bring a child to the clinic who has not been eating or drinking well for the last few days. What action should the nurse take first to assess the child's overall hydration status? -Weigh the child. -Monitor the vital signs. -Obtain a urine specimen. -Draw blood for electrolyte levels.

Weigh the child. When implementing nursing care, the nurse should complete any noninvasive procedures before invasive ones. Therefore, the first step the nurse should take is to weigh the child. A decrease in body weight gives the most accurate information about the infant's hydration status. Monitoring vital signs would be the next step in the assessment process. The blood pressure reading would yield information about hypotension. A urinalysis would provide information about urine osmolality and specific gravity of the urine, which indicates dehydration. Obtaining electrolytes would provide information about electrolyte disturbances, not strictly about hydration.

The nurse is assessing a 4-month-old client. For what finding will the nurse take immediate action? -respiratory rate between 30 and 35 breaths/minute -abdominal wall rising with inspiration -intercostal retractions on inspiration -tympanic temperature is 99.4 °F (37.4 °C)

intercostal retractions on inspiration The presence of intercostal retractions is a sign of respiratory distress from an obstruction or a disease such as pneumonia, which causes the infant to have to work to breathe. Infants and children up to age 7 are abdominal breathers. After that age, they change to an adult pattern of breathing, which uses the diaphragmatic and thoracic muscles. A normal respiratory rate for an infant up to age 1 is 20 to 40 breaths/minute. A fever for an infant and child is defined as 100.4 °F (38 °C) or above.

While examining a 2-year-old client, the nurse sees that the anterior fontanel is open. The nurse should: -notify the physician. -look for other signs of abuse. -ask about a family history of Tay-Sachs disease. -recognize this as a normal finding.

notify the physician. Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the physician promptly of this abnormal finding. An open fontanel doesn't indicate abuse and isn't associated with Tay-Sachs disease.

While interviewing a preschool-age girl who has been sexually abused about the event, which approach would be most effective? -Draw a picture and explain what it means. -Name the perpetrator. -Describe what happened during the abusive act. -"Play out" the event using anatomically correct dolls.

"Play out" the event using anatomically correct dolls. A 3-year-old child has limited verbal skills and should not be asked to describe an event, explain a picture, or respond verbally or nonverbally to questions. More appropriately, the child can act out an event using dolls. The child is likely to be too fearful to name the perpetrator or will not be able to do so.

An adolescent client is sent to the school clinic with dizziness and nausea. While assessing the girl, who denies any health problems, the nurse smells alcohol on her breath. Which response by the nurse is most appropriate? -"What is the real reason that you are feeling sick this morning?" -"I know that high school is stressful, but drinking alcohol is not the best way to handle it." -"Don't tell me that you have been drinking alcohol before you came to school this morning!" -"Tell me everything that you have had to eat and drink yesterday and today."

"Tell me everything that you have had to eat and drink yesterday and today." Asking the client to report everything that she has had to eat and drink yesterday and today is the least judgmental approach and also provides helpful information. Confronting the client about drinking alcohol or asking her to admit the real reason for feeling sick can put the client on the defensive and block further communication. The nurse should avoid putting the client on the defensive to facilitate communication that may eventually enable the nurse to get the truth and identify interventions.

The nurse is assessing a child with a head injury following a motor vehicle accident. Which assessment leads the nurse to suspect extensive damage to the upper brain stem? -hyperextension of the arms and hyperflexion of the legs -hyperextension of both arms and legs -hyperflexion of both arms and legs -hyperflexion of the arms and hyperextension of the legs

hyperextension of both arms and legs Decerebrate posturing is seen in individuals with extensive upper brain stem damage. The client displays with hyperextension of both arms and legs and often an arched body. Simultaneous hyperflexion of the arms and hyperextension of the legs are exhibited in decorticate posture.

A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care? -checking every urine specimen for protein and specific gravity -ensuring that the child has accurate intake and output and eats a high-protein diet -obtaining a blood sample for electrolyte analysis every morning -taking vital signs every 4 hours and obtaining daily weight

taking vital signs every 4 hours and obtaining daily weight Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation — can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. These actions are less important nursing measures in this situation.

A school-age child reveals to the nurse that a parent has been abusive. What constitutes a breach of the child's right to confidentiality? -informing the child's attending physician about the conversation -telling the child you're required by law to report the abuse -telling the child in the next room, who also suffered abuse, so the two children can talk to each other -informing local authorities and reporting the case

telling the child in the next room, who also suffered abuse, so the two children can talk to each other Children have a right to privacy and confidentiality when it comes to their medical condition, treatment plans, and even the fact that they are hospitalized. Therefore, telling another child about the abuse (even if they have that in common) is a breach of confidentiality. A nurse is required by law to report suspected child abuse to the proper local authorities. The attending physician is part of the healthcare team and needs to be informed about the suspected abuse. These actions don't breach the child's right to confidentiality.

An infant who weighs 7.5 kg is to receive ampicillin 25 mg/kg intravenously every 6 hours. How many milligrams would the nurse administer per dose? Record your answer using one decimal place.

187.5 The nurse would calculate the correct dose using the following equation:25 mg/kg × 7.5 kg = 187.5 mg

A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate? -making the child feel ashamed for not cooperating -explaining the medication's effects in detail to ensure cooperation -showing trust in the child's ability to cooperate even with an unpleasant procedure -mixing the medication in milk so the child isn't aware that it's there

showing trust in the child's ability to cooperate even with an unpleasant procedure To gain a preschooler's cooperation, the most appropriate strategy is for the nurse to show trust and express faith in the child's ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.

An adolescent male with cystic fibrosis tells the nurse he wants to marry and raise a large family. How should the nurse respond? -"You need to consider what will happen to your wife when you die young." -"You may need to consult genetic and reproductive experts." -"You should consider adoption to avoid transmitting the disorder." -"Your goal is reasonable once you go three years without disease symptoms."

"You may need to consult genetic and reproductive experts." The nursing response to this client should use therapeutic communication skills, and provide accurate information. Cystic fibrosis can delay growth and the onset of puberty. Nearly all men with cystic fibrosis have infertility due to lack of a vas deferens and would need assistance from a fertility specialist to perform procedures such as in vitro fertilization to aid reproduction. Because cystic fibrosis is an autosomal recessive disorder, the client should have genetic counseling with his spouse about their risks for passing the condition to their children. The life expectancy of clients with cystic fibrosis in North America is between 40 and 50 years.

The nurse leading a group session for parents of children diagnosed with oppositional defiant disorder. The nurse should give which recommendation for discipline? -Use time-out as the primary means of punishment for the child regardless of what the child has done. -Avoid limiting the child's use of the television and computer for punishment. -Use primarily positive reinforcement for good behavior while ignoring any demonstrated bad behavior. -Be consistent with discipline while assisting with ways for the child to more positively express anger and frustration.

Be consistent with discipline while assisting with ways for the child to more positively express anger and frustration. Consistent discipline and alternative methods of anger management are two important tools for parents who have a child with oppositional defiant disorder. Consistent discipline sets limits for the child. Helping the child learn more appropriate ways to manage anger assists the child in living within societal expectations. Avoiding restriction of television and computer time for punishment or using time-out as the primary means of punishment has not been suggested as an appropriate management method. Typically, using many strategies is more effective. Ignoring bad behavior could be dangerous and does not reinforce to the child that limits on behavior exist in society.

An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect the client's rights during the physical examination? -Keep the client's friends (who are waiting in the lounge area) informed of her medical condition. -Keep the suspected attacker away from the examination room. -Leave the door open. -Have a female health care worker present.

Have a female health care worker present. A female health care provider should be present to observe an examination performed by a male health care provider. Leaving the door open and informing the client's friends about her condition violates her right to privacy and confidentiality. Although the suspected attacker should be kept away from the examination room, having a female health care worker present during the examination best protects the girl's rights.

A critically ill 4-year-old child is in the pediatric intensive care unit. Telemetry monitoring reveals junctional tachycardia. Identify where this arrhythmia originates. (Picture question)

In junctional tachycardia, the atrioventricular node fires rapidly. The atria are depolarized by retrograde conduction; however, conduction through the ventricles remains normal.

An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or reading books. What is the best action by the nurse? -Inform the teacher that the child has strabismus. -Request that the child be screened for myopia. -Try to determine the cause of the child's photophobia. -Call the parents to discuss therapy for hyperopia.

Request that the child be screened for myopia. Myopia is nearsightedness. The light rays focus at a point in front of the retina, and the client is able to see clearly objects directly in front but is unable to see at a distance.

When preparing to deliver back slaps to an infant who is choking on a foreign body, the nurse should place the infant in which position? -head up and raised above the trunk -head down and lower than the trunk -head to one side and even with the trunk lower than the head -head parallel to the nurse and supported at the buttocks

head down and lower than the trunk To deliver back slaps, the nurse should place the infant face down, straddled over the nurse's arm, with the head lower than the trunk and the head supported. This position, together with the back slaps, facilitates dislodgment and removal of a foreign object and minimizes aspiration if vomiting occurs. Placing the infant with the head up and raised above the trunk would not aid in dislodging and removing the foreign object. In addition, this position places the infant at risk for aspiration should vomiting occur. Placing the head to one side may minimize the risk of aspiration. However, it would not help with removal of an object that is dislodged by the back slaps. Placing the infant with the head parallel to the nurse and supported at the buttocks is more appropriate for burping the infant.

The nurse is caring for a young child who has been admitted to the hospital with pertussis. To prevent the spread of the infection, which of the following is the most important action of the nurse? -place the child in a negative pressure room -provide masks for everyone entering the room -wear gloves when providing care for the child -use eye protection for direct contact with the child

provide masks for everyone entering the room Pertussis is spread via droplet transmission, so droplet precautions are necessary for the first 5 days after the child has begun medical treatment. This requires that everyone entering the room wears a mask. When administering direct care, eye protection can be worn to prevent coughing of droplets into the eyes. The child does not need a negative pressure room, because the disease is not spread via aerosoled droplets. These types of droplets can travel for long distances. Diseases needing this type of isolation are tuberculosis, measles, and varicella. The droplets of pertussis are larger and travel only 3 feet. Gloves should always be worn as part of standard precautions when providing client care.

Which statement made by the parent of a school-age child who has had a craniotomy for a brain tumor would warrant further exploration by the nurse? -"I hope that she'll be able to go back to school soon." -"I wonder how long it will be before she can ride her bike." -"After this, I will never let her out of my sight again." -"Her best friend is eager to see her; I hope she won't be upset."

"After this, I will never let her out of my sight again." Parents of a child who has undergone neurosurgery can easily become overprotective. Yet, the parents must foster independence in the convalescing child. It is important for the child to resume age-appropriate activities, and parents play an important role in encouraging this. Statements about going back to school would be expected. Parents want the child to return to normal activities after a serious illness or injury as a sign that the child is doing well.

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? -"It's important to confirm a family history of seizures to determine the cause." -"The child will need to have blood drawn to determine the cause of the seizure." -"We will prepare your child to have spinal fluid withdrawn and analyzed." -"An important initial test is a computed tomography (CT) scan."

"An important initial test is a computed tomography (CT) scan." CT scans provide the most benefit of the list provided in determining if there are structural abnormalities, such as tumors or bleeding, that could explain the seizures. The lumbar puncture would be useful to determine infections. However, since it is invasive, the CT is done first unless the child presents with findings that suggest a central nervous system infection. Electrolyte blood levels can indicate imbalances that could be causing seizures, but it is rarely diagnostic. None of these exams will conclusively diagnose a seizure disorder. Other exams, like EEG, would be necessary. Family history will be collected but is not as important as CT in identifying the cause.

After being hospitalized for status asthmaticus, a child is discharged with prednisone and other oral medications. Two weeks later, when the child comes to the clinic for a checkup, the nurse instructs the parent to gradually decrease the dosage of prednisone, which will be discontinued. The parent asks why prednisone must be discontinued. How should the nurse respond? -"The child may develop a hypersensitivity to steroids with continued use." -"Long-term steroid therapy may interfere with a child's growth." -"Steroids increase the appetite, leading to obesity with prolonged use." -"Prolonged steroid use may cause depression."

"Long-term steroid therapy may interfere with a child's growth." Steroids suppress release of adrenocorticotropic hormone from the pituitary gland, stopping production of endogenous hormones by the adrenal cortex. Because prolonged adrenal suppression may cause growth restriction in a child, the duration and dosage of steroid therapy must be kept to a minimum. Steroids also may cause central nervous system effects, such as euphoria, insomnia, and mood swings. Although steroids increase the appetite, this effect isn't the reason for limiting their use in children. Steroids are present in the body, so hypersensitivity isn't a problem, and they're likely to cause euphoria, not depression.

(Picture question) Nurses Progress Notes 11/12/06 0300 Tylenol with Codein given PO. FACES pain scale changed from 5 to 2 within 15 minutes. 11/12/07 0600 Tylenol with Codeine given PO. FACES pain scale changed from 5 to 2 11/12/07 0930 Tylenol with Codeine given PO. FACES pain scale changed from 5 to 2 11/13/07 0100 Tylenol with Codeine given PO. FACES pain scale changed from 4 to 1 11/13/07 0700 Client rates pain on FACES pain scale as 4 A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next? -Administer the acetaminophen with codeine. -Distract the child by giving him breakfast. -Assess the child again in 1 hour. -Instruct the child to take deep breaths and blow his pain away.

Administer the acetaminophen with codeine. The nurse should administer the acetaminophen with codeine because the client indicates he is having pain. Although the child reports less severe pain, he is still experiencing pain. The nurse will also want the child to have less pain because he will need to be more active during the day. Assessing the child later will likely cause the pain to have increased and be more difficult to manage. While distraction is appropriate for short-term pain, such as from a needlestick or pain that the child might be able to manage himself, postoperative pain should be relieved with medication.

A nurse teaches an adolescent client with asthma to independently administer breathing treatments. Which principle should the nurse keep in mind when planning the teaching session? -The client will need supervision for the first self-administrations. -The client will learn better using a recorded video tutorial. -Adolescents tend to be uncooperative with instructions from adults. -Adolescents are worried about appearing different from their peers.

Adolescents are worried about appearing different from their peers. Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this information will help the nurse construct an effective teaching plan. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives to establish a sense of identity. There is no reason to think the adolescent will be uncooperative. Many people find video tutorials useful, but a return demonstration is the best way to ensure the client understands and is able to follow the instructions. The nurse can assess the client's abilities without the client requiring supervision at home.

A nurse is caring for an adolescent who is in the hospital for a long-term illness. Which of the following interventions would promote the development of the hospitalized adolescent? -Provide the teen structure in daily activities -Arrange for a tutor to cover missed schoolwork -Encourage the family to have fun game night activities once a week -Connect the teen to their peer group as much as possible

Connect the teen to their peer group as much as possible Peer visitation gives the adolescent an opportunity to continue along the path toward independence and identity. Structured daily activities would benefit the younger child, not the teenager's development. Tutoring may help maintain a positive self-image relative to schoolwork but does not have an impact on adolescent development.

A young child with sickle cell anemia prefers a side-lying position with the knees sharply flexed. The nurse should assess further for: -nausea. -abdominal pain. -backache. -emotional regression.

abdominal pain. The child's self-positioning on the side with the knees sharply flexed strongly suggests the possibility of abdominal pain. The child assumes this position to decrease the discomfort. Thus, the nurse should assess for further evidence of abdominal pain. Nausea usually causes a young child to refuse nourishment. A backache would most probably cause the young child to lie supine to relieve discomfort. Regression is common in acutely ill hospitalized children, but insufficient data are given to confirm regression.

The nurse is teaching the parent of a preschool-age child with celiac disease about a gluten-free diet. The nurse determines that teaching has been successful when the parent tells the nurse she will prepare which breakfast for the child? -oatmeal and skim milk -eggs and orange juice -wheat toast and grape jelly -rye toast and peanut butter

eggs and orange juice Children with celiac disease cannot digest the protein in common grains such as wheat, rye, and oats. Eggs and orange juice would be appropriate foods.

The nurse is educating parents of a child diagnosed with seasonal allergies. The nurse discusses therapeutic management of the child's allergies and works with the parents to set goals that best support a quality childhood experience. Which of the following goals is most important for the nurse to set with the parents? -identifying ways to reduce the child's exposure to the allergens -teaching the child how to manage the allergy symptoms -developing childhood interests that involve only indoor activities -controlling allergy symptoms with over-the-counter (OTC) medications

identifying ways to reduce the child's exposure to the allergens The primary goal of therapeutic management for the parents of a child diagnosed with allergies includes reducing the child's exposure to the allergens. This intervention will inevitably reduce the presenting clinical manifestations and corresponding discomfort.

After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which symptom? -coolness and dampness of the cast after 5 hours -vomiting after the cast is applied -inability to extend the fingers on the right hand -fussiness and reports that the cast is heavy

inability to extend the fingers on the right hand Inability to extend the fingers of the involved arm may indicate neurologic impairment caused by pressure on soft tissue. It is not unusual for a child to vomit after experiencing a traumatic injury. It may take up to 72 hours for a plaster cast to dry. Until the cast dries, the dampness causes the sensation of coolness. The cast will seem heavy until the child adjusts to the extra weight. The child may exhibit fussiness (such as whining, crying, or clinging) as a result of numerous causes, such as placement of the cast, the hospital experience, or pain. These reactions are normal and do not warrant medical advice.

An infant admitted to the hospital with an acute rotavirus infection is having frequent diarrheal stools. On assessment, the nurse notes 40 to 60 bowel sounds per minute. The child has poor skin turgor and dry mucous membranes. The nurse determines the infant's dehydration is related to which factor? -inability to metabolize nutrients -insufficient antidiuretic hormone -decreased gastric emptying -increased GI motility

increased GI motility Rotavirus is a type of viral infection that affects the GI tract. It causes diarrhea, which results in fluid loss. This type of infection can be very serious in infants who, because of their immature kidneys, cannot adjust to fluid loss as readily as adults. Acute diarrheal infection results in increased gastric emptying. Insufficient production of antidiuretic hormone is not a consequence of acute diarrheal infection. Acute diarrheal infection results in malabsorption, not an inability to metabolize nutrients that are absorbed.

The nurse assists with conscious sedation of a school-age client undergoing a bone marrow biopsy. What is the nurse's most important responsibility during the procedure? -keeping the parents informed -monitoring the patient -recording the procedure -administering the topical anesthetic

monitoring the patient During conscious sedation the client may lose protective reflexes and adequate respiratory and cardiac function may be impaired. At every procedure there must be one health care professional whose sole responsibility is to monitor the client. Topical agents must be given in advance of the procedure to be effective. During the procedure, the nurse would not leave the child to speak with the parents. While the procedure would be documented according to the facility's protocols, proper monitoring of the client is the intervention most associated with reducing risks.

A child with tetralogy of Fallot and a history of severe hypoxic episodes is to be admitted to the pediatric unit. What would be most important for the nurse to have at the bedside? -suction tubing and equipment -blood pressure cuff and stethoscope -morphine sulfate in a syringe ready to administer -oxygen tubing and flow meter plugged in

oxygen tubing and flow meter plugged in Because the child has a history of severe hypoxic episodes, having oxygen readily available at the bedside is most important. Should the child experience another hypoxic episode, oxygen could be administered easily and quickly. Although morphine causes peripheral dilation, which causes the blood to remain in the periphery, decreasing system volume and oxygen administration is the priority. Also morphine is a controlled substance and must be stored securely at all times. Typically, a child with tetralogy of Fallot with episodes of hypoxia does not require suctioning.

A 10-month-old looks for objects that have been removed from his view. How does the nurse explain the finding to the parents? -The child is showing typical neuromuscular development. -The child is now able to transfer objects from hand to hand. -The child understands objects are there even though the child cannot see them. -The child's curiosity has increased.

The child understands objects are there even though the child cannot see them. Understanding object permanence means that the child is aware of the existence of objects that are covered or displaced. Neuromuscular development, curiosity, and the ability to transfer objects are not associated with the principle of object permanence. Although, at 10 months, neuromuscular development is sufficient to grasp objects and a child's curiosity has increased, neither are related to the thought process involved in object permanence.

A school-age child with leukemia will be taking vincristine. The nurse should encourage the child to eat what kind of diet? -high-residue -low-fat -high-calorie -low-residue

high-residue Vincristine may cause constipation, so the client should be encouraged to eat a high-residue (fiber) diet. The other diets do not help with constipation that can occur while receiving vincristine.

When assessing a 2-year-old child at the clinic for a routine checkup, which skill should the nurse expect the child to be able to perform? -kicking a ball forward -riding a tricycle -using blunt scissors -tying shoelaces

kicking a ball forward A 2-year-old child usually can kick a ball forward. Riding a tricycle is characteristic of a 3-year-old child. Tying shoelaces is a behavior to be expected of a 5-year-old child. Using blunt scissors is characteristic of a 3-year-old child.

A preschool-age child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which comment by the nurse would be most appropriate? -"You were very good not to cry with the needle." -"That really didn't hurt, did it?" -"We are mean to hurt you that way." -"It's okay to cry when something hurts."

"It's okay to cry when something hurts." It is not normal for a preschooler to be totally passive during a painful procedure. Typically, a preschooler reacts to a painful procedure by crying or pulling away because of the fear of pain. However, an abused child may become "immune" to pain and may find that crying can bring on more pain. The child needs to learn that appropriate emotional expression is acceptable. Telling the child that it really did not hurt is inappropriate because it is untrue. Telling the child that nurses are mean does not build a trusting relationship. Praising the child will reinforce the child's response not to cry, even though it is acceptable to do so.

A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Record your answer as a whole number.

250 2,000 mL/8 hours = 250 mL/hour

A nurse is caring for a preschooler who sustained deep partial-thickness burns on the hands as a result of touching a hot pot on the stove. What is most important for the nurse to consider in discharge teaching? -Provide teaching to the parents in the treatment room. -Include the child in the teaching process. -Ask the child to verbalize why the accident occurred. -Delay the teaching until both parents are present.

Include the child in the teaching process. The nurse should include the preschooler in any discharge teaching performed. Preschoolers have developed reasoning skills and are beginning to understand the concepts of right and wrong and cause and effect, but verbalizing the reason for the accident is not the most important focus. It isn't necessary for both parents to be present during teaching, although it is desirable.

After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of parental role conflict related to child's hospitalization. Which defining characteristic suggests this diagnosis? -Parents make negative statements about health care provider. -The parents are expressing desire for more information. -Parents express feelings of inadequacy in caring for child. -The parents are questioning the nursing plan of care.

Parents express feelings of inadequacy in caring for child. Expression of feelings of inadequacy in providing for their child's needs is a defining characteristic of parental role conflict related to the child's hospitalization. Parents seeking more information or questioning the plan of care would support a diagnosis of readiness for enhanced parenting. Expressing negative feelings toward the health care provider would support a diagnosis of impaired coping.

A 2-year-old child is prescribed cyclosporine. The parent says the child doesn't like taking the liquid medication. Which statement by the nurse is most appropriate? -"Offer the medication diluted with chocolate milk or orange juice to make it more palatable." -"We can inquire about inserting a nasogastric (NG) tube to administer the medication." -"Give your child some control over what time the medication is taken during the day." -"Give the ordered dose in small amounts over 2 hours to make it less unpleasant."

"Offer the medication diluted with chocolate milk or orange juice to make it more palatable." Because liquid cyclosporine has a very unpleasant taste, diluting it with chocolate milk or orange juice will lessen the strong taste and help the child take the medication as ordered. It is not acceptable to miss a dose, because the drug's effectiveness is based on therapeutic blood levels, and skipping a dose could lower the level. It is also very important that the dosage be given at the same time every day. If it is given in the morning, it should always be given in the morning. Unfortunately, the child does not get to pick and choose when they will take the medication. Cyclosporine should not be given by NG tube, because it adheres to the plastic tube and, thus, some of the drug may not be administered. Taking the medication over a period of time could negatively affect the blood level. Cyclosporine comes in pill form, but a 2 year old is generally too young to swallow pills.

The parent asks the nurse about a 9-year-old child's apparent need for between-meal snacks, especially after school. What information should the nurse include in the teaching plan? -The child should eat the snacks the mother thinks are appropriate. -The child will instinctively select nutritional snacks. -The child should help with preparing the snacks. -The child does not need to eat between-meal snacks.

The child should help with preparing the snacks. Snacks are necessary for school-age children because of their high energy level. School-age children are in a stage of cognitive development in which they can learn to categorize or classify and can also learn cause and effect. By preparing their own snacks, children can learn the basics of nutrition (such as what carbohydrates are and what happens when they are eaten). The mother and child should make the decision about appropriate foods together. School-age children learn to make decisions based on information, not instinct. Some knowledge of nutrition is needed to make appropriate choices.

The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship? -the mother's fear that the staff do not respect her -communication barriers between the mother and staff -the mother's feelings of loss of control over her child -lack of knowledge about the child's illness and treatment

communication barriers between the mother and staff The communication barrier is the most significant and would require immediate attention. Strategies need to be implemented that include taking the time to share information via the written word with all new members of the healthcare team and the mother. Fear, loss of control, and lack of knowledge about the illness of the child may contribute to the overall stress of the situation.

The nurse should refer the parents of an 8-month-old child to a health care provider (HCP) if the child is unable to demonstrate which gross motor ability? -stand alone well for long periods of time -stand momentarily without holding onto furniture -stoop to recover an object on the ground -sit without support for long periods of time

sit without support for long periods of time According to the Denver Developmental Screening Examination, a child of 8 months should sit without support for long periods of time. An 8-month-old child does not have the ability to stand without hanging onto a stationary object for support. His muscles are not developed enough to support all his weight without assistance. His balance has not developed to the point that he can stand and stoop over to reach an object.

An adolescent who is immobilized in a cast to stabilize a recent fractured femur suddenly develops chest pain, dyspnea, diaphoresis, and tachycardia. The nurse should further assess the client for what condition? -atelectasis -pulmonary emboli -pulmonary edema -pneumonia

pulmonary emboli Chest pain and dyspnea in an immobilized adolescent with a large bone fracture suggest a fat embolus. With this condition, fat droplets, rather than a thrombus, are transferred from the marrow into the general blood stream by the venous-arterial route, possibly reaching the lung or brain. Atelectasis may develop; however, the onset of signs and symptoms is usually more gradual and subtler. Pneumonia can occur; however, the signs and symptoms usually do not develop suddenly. Pulmonary edema should not be a problem in a healthy adolescent who has sustained a fracture.

A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother? -"Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter." -"Mother, do you think your daughter is sexually active?" -"The two of you seem like you share everything. I'm going to ask questions about sexual history now." -"What do you think about having your mother leave the room now?"

"Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter." Confidentiality and privacy are critical developmental needs for the adolescent. These needs are important to enable the nurse to establish a relationship of trust with the adolescent. A sexual history should be conducted with a teen without parents. Therefore, the nurse should not ask the mother to provide information or put the daughter in a position of having to make a decision about her mother remaining in the room. Inform the adolescent that this information is confidential and will not be shared with the parent. Inform the adolescent that issues of abuse or life-threatening issues are required by law to be disclosed to the authorities, and all other information is private.

A nurse is caring for an adolescent after surgery. Which post-operative teaching statement is best to use for the adolescent? -"The instructions that I give you will help you get back to your regular activities quickly." -"It is important that you follow these instructions to prevent future complications." -"Do everything just as instructed to avoid problems with your parents." -"Just believe me that you need to do each thing exactly as I instruct you."

"The instructions that I give you will help you get back to your regular activities quickly." Postoperative teaching must be age specific and developmentally appropriate. The adolescent client needs instructions that are immediately relevant to his or her daily activities to understand the importance of instructions given. Having the client avoid problems with parents addresses the need of an adolescent to reach a sense of independence and identity. During this time, conflicts are heightened, not resolved. Adolescents rarely finalize plans for the future; this normally happens later in adulthood. Therefore, telling the client the teaching will avoid future complications does not mean as much and reduces the chances of compliance.

A nurse is providing health teaching to a group of adolescent females. The focus is on urinary tract infections. One of the adolescents tells the nurse that she wants to know what cystitis is. Which statement by the nurse is the most appropriate response? -"This condition happens frequently in young women and is not harmful." -"This condition can result from irritation and inflammation from sexual activity." -"This is a minor bacterial infection of the bladder that can occur at any time." -"This is a serious condition that occurs after intercourse or vaginal cleanses."

"This condition can result from irritation and inflammation from sexual activity." Cystitis is a lower urinary tract infection. It is sometimes seen among young adolescent females after the first sexual intercourse experience. The urinary tract infections occur because of inflammation and local irritation caused by sexual activity. Bladder infections can lead to complications, so they are not minor or harmless. A bladder or urethral infection is not the result of vaginal cleanses such as douches.

A premature infant has been placed on a home apnea monitor. The nurse is giving discharge instructions to the parents. The nurse begins teaching by stating: -"You can only give your baby sponge baths until monitoring is discontinued because it's dangerous to take the monitor off at any time." -"Remove the monitor at least 3 hours per day to allow the baby a rest period." -"Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required." -"Your baby will probably need to be monitored until at least age 1."

"Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required." Home apnea monitoring helps the physician determine the frequency of apneic events and how long monitoring is required. Use of home monitoring has been helpful in improving neonatal survival. The average length of monitoring is 6 weeks; only occasionally is it required beyond 1 year. The monitor can be removed for bathing and during times when parent or caregiver is physically present and actively engaged with the care of the infant.

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time? -maintaining fluid and electrolyte balance -evaluating vital signs frequently -managing the child's pain -preventing wound infections

maintaining fluid and electrolyte balance Although monitoring vital signs frequently is important, for the first few days the primary concern in burn care is fluid and electrolyte balance, with the goal being to replace fluid and electrolytes lost. With burns, fluid and electrolytes move from the interstitial spaces to the burn injury and are lost. These must be replaced. Once the child's fluid and electrolyte status has been addressed and fluid resuscitation has begun, preventing wound infection is a priority and efforts to control the child's pain can be initiated.

A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which treatment? -transferring the child to pediatric intensive care. -starting oxygen. -prescribing a chest CT scan. -providing sedation.

starting oxygen. The infant is experiencing signs and symptoms of respiratory distress indicating the need for oxygen therapy. Sedation will not improve the infant's respiratory distress and would likely cause further respiratory depression. If the infant's respiratory status continues to decline, she may need to be transferred to the pediatric intensive care. Oxygen should be the priority as it may improve the infant's respiratory status. A chest CT is not indicated. However, a CXR would be another appropriate recommendation for this infant.

An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which action should the school nurse do first? -Take the adolescent's temperature. -Move the adolescent to a cool environment. -Have the adolescent go to the swimming pool. -Administer cold water with ice cubes.

Move the adolescent to a cool environment. The adolescent is most likely experiencing heat exhaustion or heat collapse, which are common after vigorous exercise in a hot environment. Symptoms result from loss of fluids and include nausea, vomiting, dizziness, headache, and thirst. Treatment consists of moving the adolescent to a cool environment and giving cool liquids. Cool liquids are easier to drink than cold liquids. Taking the adolescent's temperature would be appropriate once these actions have been completed. However, the adolescent's temperature is likely to be normal or only mildly elevated.. Lying in the supine position increases the risk for aspiration if vomiting occurs in a patient with nausea.

A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: -"Does your child have any hearing problems?" -"Does anyone in your family have hearing problems?" -"Does your child tug at either ear?" -"Does your child's ear hurt?"

"Does your child tug at either ear?" Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful because a young child usually can't describe symptoms accurately.

The nurse reviews the plan of care for the child with leukemia who is at risk for bleeding. Which intervention would the nurse question? -IM injections -visits with friends and siblings -use of stool softeners -frequent position changes in bed

IM injections For a child with leukemia who is at risk for bleeding, all treatments should be performed gently. However, all injections should be limited or avoided as much as possible to reduce the risk of tissue injury and subsequent bleeding and bruising. Stool softeners are used to facilitate bowel elimination by preventing the passage of hard stool that may damage the rectal mucosa and subsequently lead to bleeding. Frequent position changes in bed help maintain skin integrity and minimize the risk of trauma to the skin, thereby reducing the possibility of bleeding and bruising secondary to this trauma. Visits with friends and siblings are important for adequate growth and development of the child. Visitation would be curtailed if the child were at risk for possible infection secondary to a decreased neutrophil count.

The school nurse is counseling a female client who is concerned about an incident that occurred at a school dance. The young client describes becoming drowsy and disoriented after drinking punch and waking up hours later in the back of a stranger's car. What is the most appropriate advice for the nurse to give the adolescent? -"You need to tell your friends to take you home if you become disoriented." -"Be careful not to exhaust yourself when you go to dances in the future." -"The punch may have contained alcohol, which you should be aware of next time." -"It's possible that you were raped and will need information on pregnancy testing."

"It's possible that you were raped and will need information on pregnancy testing." It is highly likely that the punch contained flunitrazepam, a date rape drug. It is colorless, odorless, and tasteless. The effects are drowsiness, impaired motor skills, and amnesia, making the victim an easy target for rape.

The nurse is caring for a 5-year-old child with a congenital heart defect. The nurse is reviewing with the parents the actions that would be necessary if the child experiences cardiopulmonary arrest and needs resuscitation. Which of the following statements by the parents indicate to the nurse that the teaching has been understood? Select all that apply. -"I will call 911 before I start resuscitation efforts." -"I will give two breaths for every 30 compressions." -"I have to use compressions to circulate the blood." -"I will check for responsiveness before starting CPR." -"The chance of my child arresting is unlikely."

-"I have to use compressions to circulate the blood." -"I will give two breaths for every 30 compressions." -"I will check for responsiveness before starting CPR." The correct options indicate that the parents understand the procedure for performing CPR. For children CPR is initiated before calling 911. Children with any kind of heart disease are at high risk for cardiopulmonary arrest.

A preschool child immobilized in a hip spica cast has trouble breathing after meals. Which action would be best? -Encourage the child to drink more between meals. -Offer the child small feedings several times a day. -Teach the child pursed-lip breathing. -Give the child a laxative after meals.

Offer the child small feedings several times a day. A hip spica cast extends up over the abdomen. Because the abdomen is in a fixed space, abdominal distention secondary to eating pushes the abdominal contents against the diaphragm, resulting in decreased chest expansion and subsequent possible respiratory distress. The child's problems are associated with meals, so offering small, frequent meals provides nutritional support while minimizing distention. Encouraging increased drinking would increase abdominal distention, thus increasing the child's respiratory distress. Pursed-lip breathing would prevent air trapping, not decreased chest expansion. Administering a laxative with meals would not relieve the decreased chest expansion.

The nurse is providing an education program to a group of adolescents on the importance of testicular self-examinations. One of the participants asks the nurse, "when is the best time to do the examination?" What is the best response by the nurse? -when you are in the shower or immediately after -in the evening prior to going to bed -prior to urinating in the morning -when you first arise in the morning

when you are in the shower or immediately after Testicular cancer occurs most frequently between the ages of 15 and 34; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures. The nurse should inform the group that the best time to perform a testicular self-examination is in the shower or immediately afterward because the scrotum is relaxed. When the male first rises in the morning, in the evening, or prior to urinating, the scrotum is not in the optimal condition for the examination.

Which statements would indicate that the parents of a child being treated with antibiotics for an ear infection understand the reason for a follow-up visit after the child completes the course of therapy? -"The health care provider wants to make certain she has taken all the antibiotics." -"Her hearing needs to be checked to see if the infection has done any damage." -"She needs to get another prescription for second course of antibiotics." -"We need to make sure that her ear infection has completely cleared."

"We need to make sure that her ear infection has completely cleared." Because ear infections are sometimes difficult to treat, determining if the antibiotic has resolved the infection is essential. If the child is not rechecked, it will be difficult to determine if another infection is a continuation of a previous infection or a separate, new infection. Although studies may be done to determine if an infection has impaired the child's hearing, they are not done routinely after each course of antibiotic therapy. A visit to the primary care provider's office cannot validate that all the medication was taken. A follow-up visit helps to determine if the infection has completely cleared. If the infection is resolved with one course of antibiotics, another course would not be prescribed.

A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child? -giving the child's drawings to the abuser -role-playing -reporting the abuse to a prosecutor -engaging in play therapy

engaging in play therapy The dolls and toys in a play therapy room are useful props to help the child remember situations and reexperience the feelings, acting out the experience with the toys rather than putting the feelings into words. Role-playing without props commonly is more difficult for a child. Although drawing itself can be therapeutic, having the abuser see the pictures is usually threatening for the child. Reporting abuse to authorities is mandatory, but does not help the child express feelings.

An infant undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively? -impaired tissue perfusion -imbalanced nutrition: less than body requirements -ineffective airway clearance -risk for aspiration

ineffective airway clearance Ineffective airway clearance has the highest priority in the immediate postoperative period. The infant's airway must be carefully assessed, and frequent suctioning may be necessary to remove mucus while taking care not to pass the catheter as far as the suture line. The nurse should assess breath sounds, respiratory rate, skin color, and ease of breathing. Because of the risk of edema and airway obstruction, keep a laryngoscope and endotracheal intubation equipment readily available. There could be impaired tissue perfusion from the edema, but keeping the airway patent is the priority. The risk for aspiration is present, but a risk does not take priority over an actual nursing problem. Imbalanced nutrition can occur because the infant is unable to ingest any food—nutrients must be provided via enteral or parenteral nutrition—but this diagnosis does not have priority over the airway.

An adolescent presents with a large round ring with a swollen border on the left arm. The adolescent often plays ball games in a field behind the school. What condition does the nurse suspect? -Lyme disease -impetigo -actinic keratosis -cellulitis

Lyme disease Lyme disease, which results from a tick bite, is characterized by a large round ring with a raised swollen border at the site of the bite. Treatment at this stage can prevent systemic involvement that could lead to cardiac, neurologic, and musculoskeletal symptoms. Impetigo is a clustering of vesicles that ooze and form a crust on the skin. Cellulitis is caused by a microorganism entering through broken skin, resulting in red, painful, swollen skin that is hot and tender. Actinic keratosis appears on sun-exposed surfaces like the arms and neck and causes thick, scaly, and discolored skin that is sometimes red or pink.

An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifies which complication that can result of using the same site? -development of resistance to insulin and need for increased amounts -destruction of the fat tissue and poor absorption -damage to nerves and painful neuritis -thickening of the subcutis and too-rapid insulin uptake

destruction of the fat tissue and poor absorption Repeated use of the same injection site can result in atrophy of the fat in the subcutaneous tissue and lead to poor insulin absorption. The neuritis that develops from diabetes is related to microvascular changes that occur. Subcutaneous tissue may thicken and harden, but this leads to decreased, not rapid, insulin absorption. Resistance to insulin is caused by an immune response to the insulin protein.

The nurse lifted up a neonate from the bassinet. The neonate became startled, extended the arms with hands open and started crying. What intervention would be most appropriate for the nurse? -Give the neonate a pacifier. -Document the finding as a normal response. -Contact the health care provider. -Do a complete neurological examination.

Document the finding as a normal response. The Moro or startle reflex is present in all neonates up until 3 to 4 months of age. It has three components: spreading out the arms (abduction), pulling the arms in (adduction), and crying. With the arms outstretched, the palms of the hands are up and open with the thumbs being flexed. This reflex occurs as a response to a sudden loss of support. It is a normal response, so the nurse would document as such. There is no need to notify the health care provider or do a neurological exam. A pacifier will not prevent the Moro reflex but it may help soothe the neonate after being startled. Even though it is a caring intervention it is not the most important. The most important is to know if the reflex is present or absent.

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well. The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess? -Number of hours infant has slept in the last 24 hours -Skin color and cap refill -Number of wet diapers the in the last 24 hours -Number of feeds in the last 24 hours

Number of wet diapers the in the last 24 hours A sunken fontanel indicates dehydration. The nurse should assess the number of wet diapers the infant has had in the past 24 hours. This helps to determine the severity of the dehydration. Knowing the amount of fluid intake for 24 hours also helps assess the severity of the dehydration. If the baby is bottle fed the mother could give a specific amount. If breast fed the nurse would want to know how many times fed and for how long each time. Just knowing the number of feeds in 24 hours will not give accurate information to determine dehydration status. The number of normal hours slept at this age is variable and could be misleading without normal context for this infant. As well, lethargy with a sunken fontanel is related to dehydration as opposed to a neurological issue. Skin color and capillary refill assessment could indicate a perfusion problem.

A school health nurse is teaching a group of 7-year-old girls about preventing urinary tract infections. What is the most appropriate education for the nurse to include in the teaching? -Tell the girls to avoid bubble baths and other perfumed bath additives. -Encourage the girls to drink cranberry juice throughout the day. -Recommend that the girls wear lightweight nylon undergarments. -Teach the girls to wipe from back to front after going to the bathroom.

Tell the girls to avoid bubble baths and other perfumed bath additives. Avoiding bath additives that can irritate the urethra is recommended to avoid urinary tract infections in girls. Though there is some evidence cranberry juice can reduce bladder infections, it is not advised that children consume sugar-containing beverages throughout the day. Children should also drink water, not just juice. Young girls should be encouraged to wear cotton undergarments because they are breathable. Young girls need to wipe front to back to take germs away from the opening that leads to the urinary system and decrease the risk of developing urinary tract infections.

Before surgery, a neonate is to receive an IM injection of an antibiotic. Which gauge and size of needle should the nurse select? -19G, 1 1/2" (3.8 cm) needle -23G, 2" (5 cm) needle -20G, 1" (2.5 cm) needle -25G, 5/8" (1.6 cm) needle

25G, 5/8" (1.6 cm) needle When administering an IM injection to most term neonates, a 25G to 27G, 5/8? (1.6 cm) long needle is appropriate. A 19G, 1 1/2? (3.8 cm) needle is too large for an infant. A 20G 1? (2.5 cm) needle is too large for an infant. A 23G, 2? (5 cm) needle is too large for an infant.

A school-age client with rheumatic fever is on long-term aspirin therapy. Which client statement most indicates that the client is experiencing a serious adverse reaction to aspirin? -"I put lotion on my itchy skin." -"I hear ringing in my ears." -"My stomach hurts after I take that medicine." -"These pills make me cough."

"I hear ringing in my ears." Tinnitus is an adverse effect of prolonged aspirin therapy, and the child should be examined by a health care provider (HCP) for hearing loss. Itchy skin commonly accompanies the rash associated with rheumatic fever and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fluid intake during administration.

The public health nurse is teaching the parents of a 5-year-old client diagnosed with sickle cell disease. What education will the nurse include? Select all that apply. -Monitor for abnormal skin color. -Avoid giving the client pain medication. -Keep the client's immunizations up to date. -Schedule regular appointments with a hematologist. -Wait 24 hours to call the healthcare provider if the client has a fever.

-Keep the client's immunizations up to date. -Schedule regular appointments with a hematologist. -Monitor for abnormal skin color. Sickle cell disease occurs when red blood cells (RBCs) morph into sickle cell shape and plug up the blood vessels causing extreme pain. To prevent sickle crisis, the client should have scheduled immunizations, regular appointments with a hematologist, and be monitored for abnormal skin color. The client will have pain due to the sickling of the cells and will need pain medication as needed. When a fever presents, the parents should call the healthcare provider immediately to prevent a sickle cell crisis.

When interacting with the mother of a child who has Duchenne muscular dystrophy, the nurse observes behavior indicating that the mother may feel guilty about her child's condition. The nurse interprets this behavior as guilt stemming from which factor? -the genetic mode of transmission -the terminal nature of the disease -the dependent behavior of the child -the sudden onset of the disease

the genetic mode of transmission The guilt that mothers of children with muscular dystrophy commonly experience usually results from the fact that the disease is genetic and the mother transmitted the defective gene. Although many children die from the disease, the disease is considered chronic and progressive. As the disease progresses, the child becomes more dependent. However, guilt typically stems from the knowledge that the mother transmitted the disease to her son rather than the dependency of the child. The disease onset is usually gradual, not sudden.

A toddler has been admitted to the pediatric unit with pneumonia. While assessing a toddler the nurse finds bruise marks consistent with a belt buckle on the buttocks. The nurse suspects the toddler is being abused. What action should the nurse take? -Confront the caregiver with the nurse's suspicions. -Talk with the toddler about what the nurse suspects. -Report the case to local authorities. -Place the toddler in a monitored room

Report the case to local authorities. By law, the nurse is obligated to report injuries to a child to local authorities. The nurse should notify the health care provider of the suspicion. The toddler will be assessed and the injuries will be documented. The social worker would also be notified of the suspicion. The health care provider or social worker would refer the case to local agencies, such as Child Protective Services (Canadian Centre for Child Protection) for investigation. Social workers should be consulted before approaching a toddler and discussing child abuse. Confronting the caregiver could increase the risk of harm to the toddler and to the nurse. Placing the toddler in a monitored room would only be required if it is according to hospital policy.

Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused? -talking easily with the nurse -clinging to the parent during the examination -playing with toys on the examination room floor -absence of crying during the examination

absence of crying during the examination Children who are being abused may demonstrate behaviors such as withdrawal, apparent fear of parents, and lack of an appropriate reaction, such as crying and attempting to get away when faced with a frightening event (an examination or procedure).

A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. His urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the health care provider? -respiratory rate of 28 breaths/minute -pulse rate of 85 bpm -blood pressure of 80/45 mm Hg -body temperature of 102.8° F (39.3° C)

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 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 parent is planning to enroll a 9-month-old infant in a day-care facility. The parent asks a nurse what to look for as indicators that the facility is adhering to good infection control measures. The nurse identifies which as an indication of meeting proper infection control standards? Select all that apply. -Soiled clothing and cloth diapers are sent home in labeled paper bags. -Soiled diapers are discarded in covered receptacles. -Toys are kept on the floor for the children to share. -Disposable papers are used on the diaper-changing surfaces. -Facilities for hand hygiene are located in every classroom. -The facility keeps boxes of gloves in the director's office.

-Soiled diapers are discarded in covered receptacles. -Disposable papers are used on the diaper-changing surfaces. -Facilities for hand hygiene are located in every classroom. A parent can assess infection control practices by appraising steps taken by the facility to prevent the spread of disease. Placing soiled diapers in covered receptacles, covering the diaper-changing surfaces with disposable papers, and ensuring that hand sanitizers and sinks are available for personnel to wash their hands after activities are all indicators that infection control measures are being followed. Gloves would be readily available to personnel and, therefore, would be kept in every room—not in an office. Toys typically are shared by numerous children; however, this contributes to the spread of germs and infections. All soiled clothing and cloth diapers would be placed in a sealed plastic bag before being sent home.

A 16-year-old client is admitted to the emergency department following an accident. The client sustained a head injury, is unconscious, and has compound fractures of the right tibia and fibula. No family members accompanied the client and none can be reached by phone. The surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent? -Take the client to the operating room for surgery without informed consent. -Keep the client in the emergency department until the family is contacted. -Call the nursing supervisor and ask that the hospital lawyer be contacted. -Contact the hospital chaplain to sign the consent on the client's behalf.

Take the client to the operating room for surgery without informed consent. The surgeon can take responsibility for consent in this situation because the condition is life (and limb) threatening and delaying the surgical treatment would have a negative impact on the client. The other options would delay the life-saving surgery and would result in negative outcomes for the client. The hospital chaplain has no authority to sign a consent form on behalf of the client.

When the nurse is assessing an infant with suspected inguinal hernia, which finding would be most concerning? -The infant's diaper is wet with urine, and the abdomen is nontender. -The inguinal swelling can be reduced, and the infant has a stool in the diaper. -The infant is irritable, and a thickened spermatic cord is palpable. -The inguinal swelling is reddened, and the abdomen is distended.

The inguinal swelling is reddened, and the abdomen is distended. Abdominal distention and a redness of the inguinal swelling are significant findings. Their presence in conjunction with area tenderness and inability to reduce the hernia indicate an incarcerated hernia. An incarcerated hernia can lead to strangulation, necrosis, and gangrene of the bowel. Other findings associated with strangulation include irritability, anorexia, and difficulty in defecation. A strangulated hernia necessitates immediate surgical intervention. The ability to reduce the hernia and normal stooling do not indicate it is incarcerated. Irritability is nonspecific and could be caused by various factors. A palpable, thickened spermatic cord on the affected side is diagnostic of inguinal hernia and would be an expected finding. A wet diaper indicates that urine is being excreted, a finding unrelated to inguinal hernia.

Parents of a 4-year-old child with acute leukemia ask a nurse to explain the concept of complementary therapy. The nurse should tell the parents that: -the health care provider should talk with them about it. -complementary therapy wouldn't help their child. -there's no research that indicates that complementary therapies are effective. -complementary therapy can be used along with conventional medical therapies.

complementary therapy can be used along with conventional medical therapies. The nurse should tell the parents that complementary therapy is a form of alternative medicine that can be used in conjunction with conventional medicine. This type of therapy can include diet, exercise, herbal remedies, and prayer. Answering the parents' questions builds rapport and trust. The nurse shouldn't dismiss the parents' idea by telling them complementary therapy wouldn't help their child. The nurse doesn't need to direct the parents to the health care provider. The nurse can provide the basic information and let the parents determine if they would like to seek further assistance. Studies indicate that complementary therapies are beneficial to the child and the parents.