RN Nursing Care of Children 2016 B
A nurse is preparing to administer a hep B vaccine to a 1-month-old. The nurse should plan to inject the medication at which location?
Thigh
A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss The toddler has a vocabulary of 25 words. The toddler developed a mild rash following a recent varicella vaccine. The toddler's Moro reflex is absent. The toddler received tobramycin during a hospitalization 2 weeks ago
The toddler received tobramycin during a hospitalization 2 weeks ago: The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment. At the age of 18 months the toddler should have a vocabulary of at least 10 words; therefore, a vocabulary of 25 words does not indicate a need to assess the toddler for hearing loss.
A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data Episodes of vomiting Formula consumption Weight Temperature
Episodes of vomit: When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention; therefore, this is the priority finding. A weight of 5.9 kg (13 lb) is an expected finding for a 4-month-old infant who weighed 3.2 kg (7 lb) at birth; therefore, there is another finding that is the nurse's priority. The infant should gain 680 g (1.5 lb) per month until the age of 5 months, and double his birth weight at the age of 6 months.
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero
1
A nurse is caring for a 2-week-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain Instruct the mother not to breastfeed for 1 hr after the procedure. Undress the infant and place him under a radiant warmer prior to the procedure. Administer sucrose to the infant prior to the procedure. Recommend the mother avoid placing the infant in the kangaroo hold after the procedure.
Administer sucrose to the infant prior to the procedure
A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make "I think it is important that you provide emotional support for your family at this time." "I agree that you have to do what you feel is best for yourself during this stressful time." "You can't mean that; I'm sure you want to be there for your family." "Let's talk about some of the ways you have handled previous stressors in your life."
"Let's talk about some of the ways you have handled previous stressors in your life
A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent should the nurse identify as understanding the teaching "Mononucleosis is caused by an infection with the Epstein-Barr virus." "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." "A Monospot is a throat culture used to diagnosis mononucleosis." "Children who get mononucleosis will need to refrain from sports for 6 months."
"Mononucleosis is caused by an infection with the Epstein-Barr virus Mononucleosis is a mildly contagious illness that occurs sporadically or in groups and is primarily caused by the Epstein-Barr (Franken stein = tired and look like a monster) virus. A Monospot is a blood test that uses a special piece of paper to assist in diagnosing mononucleosis,
A nurse is teaching a school-age child and his parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include Stay home from school for 1 week following the procedure." "Follow a diet that is low in fiber for 1 week." "Wait 3 days before taking a tub bath." "Apply a pressure dressing to the site for 3 days."
"Wait 3 days before taking a tub bath: The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. He should not take a tub bath for 3 days to avoid immersion of the incision in water. The child can resume his regular diet after the procedure.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan Administer ibuprofen to the child for a temperature greater than 38º C (101º F). Assess the child's blood pressure every 8 hr. Weigh the child weekly at various times of the day. Initiate seizure precautions for the child.
Initiate seizure precautions for the child: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions in order to maintain the child's safety.
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect Loud, harsh murmur Dysrhythmias Weak femoral pulses High blood pressure
Loud, harsh murmur Weak femoral pulses are a manifestation of coarctation of the aorta.
A nurse is caring for a school-age child who has acute rheumatic fever. Which of the following actions should the nurse take Limit the child's sodium intake. Place a "no visitors" sign on the child's door. Maintain the child on bed rest. Avoid administering salicylates to the child.
Maintain the child on bed rest Rheumatic fever is an inflammatory disease resulting from an immune response that involves the heart, joints, skin, and central nervous system The nurse should maintain the child on bed rest as well as limit the child's activity during the acute phase of rheumatic fever to assist with the prevention of cardiac damage.
A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect Resists having an axillary temperature taken exhibits withdrawal behaviors when her parent leaves Has multiple bruises on her knees Poor personal hygiene
Poor personal hygiene Poor personal hygiene in a toddler is a potential indication of physical neglect. Because toddlers are still dependent on their parents for help with hygiene needs, poor personal hygiene indicates a lack of supervision. The 18-month-old toddler has accomplished the gross motor skills of standing and walking and has begun to try to run but falls easily and can have bruises on her knees. Therefore, this finding is not an indication of physical neglect.
A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take Use surgical asepsis when providing routine care for the child. Administer the measles, mumps, rubella (MMR) vaccine to the child. Screen the child's visitors for indications of infection. Infuse packed RBCs.
Screen the child's visitors for indications of infection packed RBC is not solution to chemo patients. Its WBC not RBC
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first Skin breakdown Hypotension Hyperpyrexia Tachypnea
tachypnea: When using the airway, breathing, circulation approach to client care, the first finding the nurse should address is the toddler's tachypnea, which results when the kidneys are unable to excrete hydrogen ions and produce bicarbonate leading to metabolic acidosis.
A nurse is assessing a toddler who has leukemia and is receiving his first round of chemotherapy. Which of the following findings is the priority for the nurse to report to the provide Urticaria Fatigue Vomiting Anorexia
urticaria The greatest risk to a toddler who is receiving his first round of chemotherapy is an anaphylactic reaction; therefore, urticaria is the priority finding for the nurse to report to the provider. The nurse should monitor the child for anaphylaxis during and up to 1 hr after the infusion is complete, and immediately report associated findings, such as urticaria, rash, angioedema, and wheezing to the provider.
A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip
wheezes Rhonchi are low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed.
A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? Hypotension Hyperactivity Decreased attention span Tachycardia
Decreased attention span The nurse should recognize decreased attention span, inability to follow commands, and difficulty in school are manifestations of increased intracranial pressure because of the decreased blood flow within the brain. ITS THE OPPOSITE OF DEHYDRATION SYMPTOMS
A nurse is caring for a toddler who has acute otitis media and a temperature of 40º C (104º F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? Apply a cooling blanket to the toddler. Dress the toddler in minimal clothing. Give the toddler a tepid bath. Administer diphenhydramine to the toddler.
Dress the toddler in minimal clothing The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature.
A nurse is reviewing laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following values should the nurse identify as an indication of a potential complication Erythrocyte sedimentation rate 18 mm/hr WBC 6,200/mm3 C-reactive protein 1.4 mg/L RBC 4.7 106/µL
Erythrocyte sedimentation rate 18 mm/hr: An erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range and is an indication of osteomyelitis.
A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycling accident. Which of the following actions should the nurse take first
Explore the parents' feelings and wishes regarding organ donation
A nurse is planning care for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan Administer pancreatic enzymes 2 hr after meals. Decrease pancreatic enzymes if steatorrhea develops. Limit fluid intake to 750 mL per day. Increase fat content in the child's diet to 40% of total calories.
Increase fat content in the child's diet to 40% of total calories :A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to equal 40% of total caloric intake. The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks
A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. The nurse should identify which of the following statements by the child as understanding the teaching "I will puncture the pad of my finger when I am testing my blood glucose." "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." "I will decrease the amount of fluids I drink when I am sick."
"I will give myself a shot of regular insulin 30 minutes before I eat breakfast The child should administer regular insulin 30 min before meals so that the onset coincides with food intake. The child should avoid puncturing the pads of the fingers because they have fewer blood vessels and more nerve fibers. Instead, the child should puncture the skin to either side of the finger pad to promote blood flow and decrease pain.
A nurse is teaching the mother of a 6-month-old infant about teething. Which of the following statements should the nurse make "Your baby may pull at her ears when she is teething." "Rub your baby's gums with an aspirin to decrease her discomfort." "Place a beaded teething necklace around your baby's neck." "Your baby's upper middle teeth will erupt first."
"Your baby may pull at her ears when she is teething The nurse should inform the mother that teething can result in discomfort for the infant. Therefore, the mother should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness. The parent should avoid using aspirin or teething powders due to the risk of aspiration, infection, or irritation of the gum tissues. The nurse should recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort.
A nurse is providing anticipatory guidance to the parents of an 8-month-old infant during a well-child visit. Which of the following statements should the nurse make Your baby should be able to stand while holding on to furniture." "Your baby should be able to say one to two words." "Your baby should be able to sit unsupported." "Your baby should be able roll a ball to you."
"Your baby should be able to sit unsupported The nurse should recognize that an infant should sit unsupported at the age of 8 months. The infant should roll a ball to another person at the age of 11 months. The infant should say one word at the age of 10 months. The infant should stand while holding on to furniture at the age of 10 months.
A nurse is assessing a school-age child who has appendicitis with possible perforation. The nurse should identify which of the following as a manifestation of peritonitis Hyperactive bowel sounds Abdominal distention Bradycardia Polyuria
abd distention The nurse should recognize that abdominal distention is a manifestation of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention.
A nurse is preparing to suction an infant who has a tracheostomy. Which of the following actions should the nurse take Routinely suction every 30 min. Instill 0.9% sodium chloride prior to suctioning. Limit suctioning pressure to 40 mm Hg. Suction for 5 seconds or less.
Suction for 5 seconds or less The nurse should suction an infant who has a tracheostomy for 5 seconds or less to prevent hypoxia. The nurse should ensure the vacuum pressure is set between 60 and 100 mm Hg for an infant. A pressure of 40 mm Hg could be insufficient to effectively clear the infant's airway. The practice of instilling normal saline before suctioning a child who has a tracheostomy is not supported by research and is not a recommended practice because it causes a decrease in oxygen saturation that can last up to 2 min following suctioning. The nurse should only suction an infant who has a tracheostomy as often as needed to prevent hypoxia and to maintain patency of the tube.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first Prednisone Epinephrine Diphenhydramine Albuterol
epinephrine: This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs. Even though histamines are not the major mediators of an anaphylactic reaction, administering an antihistamine such as diphenhydramine can help to decrease the allergic reaction. However, it is not the first medication the nurse should administer.
A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following findings should the nurse expect Koplik spots Hoarseness Facial rash Splenomegaly
Facial rash: Erythema on the face, predominantly on the child's cheeks, is a manifestation of erythema infectiosum (fifth disease). The erythema causes the child to have the appearance of a "slapped face." The rash lasts from 1 to 4 days. Splenomegaly is a manifestation of infectious mononucleosis.
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates his abdominal pain at 7 on a 0 to 10 scale. Which of the following actions should the nurse take Instill a 500 mL tap water enema. Give morphine 0.05mg/kg IV. Administer polyethylene glycol 1g/kg PO. Apply a heating pad to the child's abdomen.
Give morphine 0.05mg/kg IV Administering laxatives accelerates bowel motility and increases the risk for perforation of the appendix. Administering an enema accelerates bowel motility and increases the risk for perforation of the appendix.
A nurse is teaching the parent of an infant who has a Pavlik harness to treat developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching "I should remove the harness at night to allow my infant to stretch her legs." "I will need to adjust the straps on the harness once each week." "I will place my infant's diapers under the harness straps." I should apply baby powder to my infant's skin twice daily."
"I will place my infant's diapers under the harness straps The use of powders and lotions should be avoided during treatment with the Pavlik harness because these products in combination with the harness can cause skin irritation and breakdown. The Pavlik harness is designed to maintain the infant's hips in a position of flexion and abduction. The nurse should instruct the parents not to adjust the harness in any way to avoid complications.
A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe Identifies right from left hand Uses a utensil to spread butter Cuts a shape using scissors Draws a stick figure with seven body parts
Cuts a shape using scissor The nurse should recognize that an expected developmental milestone for a 4-year-old child is using scissors to cut out a shape. using a utensil to spread butter is an expected developmental milestone of a 6-year-old child. Identifying the right from left hand is an expected developmental milestone of a 6-year-old child. Drawing a stick figure with seven body parts is an expected developmental milestone of a 5-year-old child.
A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect Deep respirations of 32/min Shallow respirations of 10/min Paradoxic respirations of 26/min Periods of apnea lasting for 20 seconds
Deep respirations of 32/min: The nurse should expect deep and rapid respirations in a child who has diabetic ketoacidosis. This respiratory rhythm is the body's attempt to blow off excess carbon dioxide and achieve a state of homeostasis. The nurse should expect shallow respirations in a child who has respiratory depression related to opioid administration. However, shallow respirations are not an expected finding in a child who has ketoacidosis. The nurse should expect paradoxic respirations in a child who has flail chest. However, paradoxic respirations are not an expected finding in a child who has ketoacidosis. The nurse should expect periods of apnea in a child who has obstructive sleep apnea. However, periods of apnea are not an expected finding in a child who has ketoacidosis.
A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse's priority when making a room assignment Length of stay Treatment schedule Disease process Self-care ability
Disease proces
A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child's respiration, which of the following actions should the nurse take next Insert an indwelling urinary catheter. Measure weight and height. Initiate IV access . Maintain ECG monitoring.
Initiate IV access Since the child's airway is established and respirations are stabilized, the next action the nurse should take using the airway, breathing, circulation approach to client care is to establish IV access to maintain the child's circulatory volume.
A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take Place the child in a room with positive-pressure airflow. Place the child in a room with negative-pressure airflow. Initiate contact precautions for the child. Initiate droplet precautions for the child.
Initiate droplet precautions for the child The nurse should place a child who has undergone an allogeneic hematopoietic stem cell transplant in a room with positive-pressure airflow to reduce the risk of disease transmission to the child.
A nurse in an emergency department suspects that a toddler has epiglottitis. Which of the following actions should the nurse take Obtain a culture from the toddler's throat. Prepare the toddler for nasotracheal intubation. Visually inspect the epiglottis using a tongue depressor. Administer the Haemophilus influenzae type B conjugate vaccine.
Prepare the toddler for nasotracheal intubation: When epiglottitis is suspected the nurse should prepare for nasotracheal intubation or a tracheostomy, which might be required if the toddler begins to experience severe respiratory distress When epiglottitis is suspected the nurse should avoid any actions, such as direct visualization of the epiglottis with a tongue depressor, which can cause further inflammation, irritation, or obstruction of the airway..
A nurse is assessing a 6-month-old infant at a well-infant visit. Which of the following findings should the nurse report to the provider Presence of strabismus Presence of corneal light reflex Presence of open anterior fontanel Presence of cerumen
Presence of strabismus: Strabismus, or crossing of the eyes, disappears at 3 to 4 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan Use sterile scissors to remove the dressing from the site. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. Access the site using a noncoring angled needle. Use a semipermeable transparent dressing to cover the site.
Use a semipermeable transparent dressing to cover the site. The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. The nurse should use a noncoring angled or straight needle when accessing an implanted port. The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter.
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect Increase in anterior convexity of the lumbar spine Increased curvature of the thoracic spine Lateral flexion of the neck A unilateral rib hump
a unilateral rib hump: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature. Lateral flexion of the neck is an indication of torticollis as a result of contracture of the sternocleidomastoid muscle. Torticollis can be congenital, the result of intrauterine fetal posturing or abnormality of the cervical spine, or it can be acquired, due to such factors as a traumatic lesion to the sternocleidomastoid muscle.
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction Laryngeal edema Flank pain Distended neck veins Muscular weakness
flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. Distended neck veins are an indication of circulatory overload, which is a complication of a blood transfusion.
A nurse in the emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply
increased temperature is correct. Kawasaki disease is an acute illness associated with a fever lasting more than 4 days that is unresponsive to antipyretics or antibiotics. Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction. Cervical lymphadenopathy is correct. The child who has Kawasaki disease may develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period Place the child in a lateral position. Delay documentation until the child is fully alert. Give the child a high-carbohydrate snack. Administer an oral sedative to the child.
Place the child in a lateral position
A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take Place the infant in a knee chest position administer a dose of meperidine iv discontinue administartion of iv fluids apply oxygen at 2L/mn via nasal cannula
Place the infant in a knee-chest position: The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance. The nurse should apply oxygen at 100% via face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brain.
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan Provide small, frequent meals to the child. Schedule time in the play room for the child. Weigh the child weekly. Maintain the child in a supine position.
Provide small, frequent meals to the child The metabolic rate for a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals to the child because it helps to conserve energy. The nurse should weigh the child daily
A nurse is caring for a newly-admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to recommend to the parents for treating the child's condition desmopressin luteinizing hormone-releasing hormone recombinant growth hormone levothyroxine
Recombinant growth hormone: Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to recommend this treatment to the child's parents. The nurse's role is to provide emotional support for the parents as they make a decision about the treatment they feel is best for their child. Levothyroxine is used to treat various hypothyroid conditions.
A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include The child should be able to stand on the balls of her feet when sitting on the bike. The child should ride her bike 2 feet to the side of other bike riders. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. The child should ride the bike facing traffic when it is necessary to ride in the street.
The child should be able to stand on the balls of her feet when sitting on the bike
A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis Decreased cerebrospinal fluid pressure Decreased WBC count Increased protein concentration Increased glucose level
increased protein concentration: The nurse should recognize that an increased protein concentration in the spinal fluid is a finding associated with bacterial meningitis. High protein contents of the CSF have infectious causes such as bacterial, cryptococcal, or tuberculous meningitis, as well as non-infectious causes, such as subarachnoid hemorrhage, central nervous system (CNS) vasculitis, CNS neoplasm, and autoimmune disease A decreased glucose level in the spinal fluid is a finding associated with bacterial meningitis.
A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply steatorrhea vomiting lethargy constipation weight gain
vomiting, lethargy: Steatorrhea is incorrect. The nurse should expect the infant with intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis. Vomiting is correct. The nurse should expect the infant with intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. Lethargy is correct. The nurse should expect the infant with intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably leading to exhaustion and decreased nutritional intake. Constipation is incorrect. The nurse should expect the infant with intussusception to have mucus-filled and currant jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen. Weight gain is incorrect. The nurse should expect the infant with intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.
A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching "You may bathe your infant in an infant bathtub when you go home." "Apply hydrocortisone cream to your infant's penis daily." "You should clamp your infant's stent twice daily." "Allow the stent to drain directly into your infant's diaper."
"Allow the stent to drain directly into your infant's diaper: The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow Hypospadias repair is surgery to correct a defect in the opening of the penis that is present at birth.
A nurse is providing teaching to the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent should the nurse identify as understanding the teaching "I will use a humidifier in my child's room at night." "I will give my child a cough suppressant every six hours if he has a cough." "I should avoid using a wet mop on my floors when I am cleaning." "I should keep my child indoors when I mow the yard."
"I should keep my child indoors when I mow the yard Dehumidifiers or air conditioners are recommended to control the room temperature because heat and humidification can cause an asthma exacerbation. The parent should wet mop bare floors weekly because sweeping floors can trigger an asthma attack due to the inhalation of the dust that becomes airborne during sweeping.
A nurse is providing discharge teaching to the parent of a school-age child who has undergone a tonsillectomy. Which of the following statements by the parent should the nurse identify as understanding the teaching "My child may resume usual activities since this was just an outpatient surgery." "My child will be able to drink the chocolate milkshake I promised to get for her tonight." "I will notify the doctor if I notice that my child is swallowing frequently." "I will have my child gargle with warm salt water to relieve her sore throat."
"I will notify the doctor if I notice that my child is swallowing frequently: The nurse should instruct the parent that frequent swallowing is a sign of bleeding and, if it is observed, to notify the primary care provider immediately.
A nurse is providing anticipatory guidance to the parents of a 2-week-old infant about risk factors for sudden infant death syndrome (SIDS). Which of the following risk factors should the nurse include in the teaching Covering the sleeping infant with a blanket Supine sleeping Maternal history of milk allergy Pacifier use during sleep
Covering the sleeping infant with a blanket The use of quilts or blankets to cover the sleeping infant increases the risk of SIDS due to the potential for suffocation. The nurse should recommend the parents dress the infant warmly and increase the temperature in the home. Evidence-based practice indicates that pacifier use is a protective factor against SIDS. Infants should use a pacifier at naptime and bedtime. Parents whose infants are breastfeeding should wait to have the infant use a pacifier until she is breastfeeding successfully.
A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant Wrist Great toe Index finger Heel
Great toe: he nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for pulses, temperature, and color. It is important for the sensor to be positioned in the correct area in order to obtain an accurate reading. The nurse should avoid placing the sensor on the heel of the infant's foot because this placement will result in an inaccurate reading.
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler Apple juice Peanut butter Chicken broth Oral rehydration solution
Oral rehydration solution A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water and promote recovery from dehydration. A toddler who has acute diarrhea should not drink apple juice because it is high in carbohydrates and osmolarity and low in electrolytes.
A nurse is providing discharge teaching to the parents of a Caucasian toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the parents to report which of the following findings to the provider Capillary refill time less than 2 seconds Restricted ability to move the toes Swelling of the casted foot when the leg is dependent Toes that are deep pink in color
Restricted ability to move the toe The nurse should inform the parents that a restricted ability of the toddler to move his toes is a sign of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage may occur in just a few hours. Swelling of the casted foot when the leg is dependent is an expected finding. The nurse should instruct the parents that frequent rest is needed for the next several days, and that the casted foot should not be in a dependent position for more than 30 min. When the toddler is resting, the casted extremity should be elevated on a pillow at chest level to minimize swelling.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney Negative leukocyte esterase Serum creatinine 3.0 mg/dl Negative urine protein Urine output 40 ml/hr
Serum creatinine 3.0 mg/dt: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the normal reference range and may indicate rejection of the kidney. Negative leukocyte esterase level is an expected finding and indicates that the adolescent does not have a urinary tract infection. Leukocyte esterase does not provide information about rejection of the kidney.
A nurse is teaching a school-age child who has a severe allergy to bee venom and his parent about epinephrine. Which of the following instructions should the nurse include in the teaching Use a second dose if the first dose of epinephrine does not completely reverse the symptoms. Store unused epinephrine syringes in the refrigerator. Shake the epinephrine syringe prior to use to dissolve the precipitate. Administer the medication subcutaneously in the back of the arm.
Use a second dose if the first dose of epinephrine does not completely reverse the symptom: A biphasic response, in which the child will appear to recover and then experience a recurrence of symptoms, is possible with some allergic reactions. The nurse should instruct the parent and child to use a second dose if the first dose does not resolve all the symptoms. The nurse should instruct the child and his parent that the formation of precipitate or a brown coloration to the solution is an indication that the medication should be replaced and not used.
A nurse in an emergency department is caring for a school-age child who has sustained a superficial minor burn from fireworks on his forearm. Which of the following actions should the nurse take Administer a tetanus toxoid if more than 1 year since prior dose. Use an antimicrobial ointment on the affected area Leave the burn area open to air. Place an ice pack on the affected area.
Use an antimicrobial ointment on the affected area. The nurse should apply an antimicrobial ointment to the burned area to prevent infection. Applying ice to the affected area may impair circulation to the area and increase tissue damage.
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should teach the parent to apply which of the following to the affected area Antibiotic ointment zinc oxide Talcum powder Antiseptic solution
Zinc oxide: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal. Diaper dermatitis can be the result of an overgrowth of yeast, such as Candida albicans, on the skin. Treatment for yeast-related dermatitis includes a topical antifungal medication; however, antibiotic ointment is not recommended for the treatment of diaper dermatitis.
A nurse is reviewing the laboratory report of a 6-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider Hgb 8.5 g/dL WBC 9,500/mm3 Prealbumin18 mg/dL Platelets 300,000/mm3
hgb: The child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range for a 6-year-old child and should be reported to the provider.
