HESI Comprehensive NCLEX-RN Practice (Pediatrics)

question

Which interventions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) A.Provide a low-fiber diet. B.Administer mineral oil daily. C.Decrease the daily fluids. D.Eliminate dairy products. E.Initiate consistent toileting routine.
answer

B, D, E Rationale: Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet, not option A, and increased daily fluids, not option C, are components of care for a child with encopresis.
question

The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child’s crying during the recovery period? A.Tear formation increases salivation. B. This behavior increases respirations. C. Excessive hysteria can lead to vomiting. D. Crying stresses the suture line.
answer

D Rationale: Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes options A, B, and C, these conditions do not create a problem for the child with a cleft lip repair
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A 6-month-old male infant is admitted to the post-anesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. Which nursing intervention should be included in this child’s plan of care? A. Keep restraints on at all times to prevent unplanned extubation. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities. D. Document the reason for application of the restraints every 72 hours.
answer

B Rationale: Removing restraints one at a time is safer than option C. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously. Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in the medical record.
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In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses
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D Rationale: Diminished femoral pulses could indicate coarctation of the aorta. In the normal transition period, options A and B occur during the 4 to 6 hours after birth (second period of reactivity). Option C is a normal finding in the newborn.
question

The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about the prevention of accidental poisonings. It is most important for the nurse to include which instruction? A. Tell children that they should not taste anything but food. B. Store all toxic agents and medicines in locked cabinets. C. Provide special play areas in the house and restrict play in other areas. D. Punish children if they open cabinets that contain household chemicals.
answer

B Rationale: The only reliable way to prevent poisonings in young children is to make the items inaccessible. Teaching children not to taste anything but food is important but ineffective for young children. Options C and D will not control a child’s curiosity.
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The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this child to exhibit? A. Throws a temper tantrum when told he must share the toys. B. Plays by himself for most of the day. C. Boasts aggressively when telling a story. D. Cries and is fearful when separated from his parents.
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C Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales. Options A and D are typical toddler behaviors. A preschooler’s play is usually cooperative, so playing alone is not typical.
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A nurse is preparing to end the shift and receives a laboratory report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take? A. Communicate the result to the oncoming nurse and document. B. Tell the oncoming nurse that the level is dangerously high. C. Ask the laboratory to redo the test because the result is faulty. D. Hold the next dose of theophylline based on this finding.
answer

A Rationale: The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child’s level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse’s report. Based on the laboratory finding, options B, C, and D are not indicated.
question

The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider? A. Sits or squats frequently when playing outdoors B. Exhibits a sudden and unexplained weight gain C. Is not completely toilet-trained and has some accidents D. Demonstrates irritation and fatigue 1 hour before bedtime
answer

B Rationale: Sudden and unexplained weight gain can indicate fluid retention and is a sign of congestive heart failure. Option A is used by the child to reduce chronic hypoxia, especially during exercise. Option C is common; 2-year-olds are not expected to be toilet-trained. Option D is normal.
question

The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP? A. Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care. D. Report any pain that the child experiences.
answer

A Rationale: All these are important measures to review with the UAP, but the most important is option A. Improper use of isolation precautions can place other staff and clients at risk for infection. Options B, C, and D promote client comfort and reduce anxiety but are of a lower priority than option A.
question

Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains 250 mg/5 mL. How many milliliters should the nurse administer in one dose? A. 10 B. 15 C. 20 D. 25
answer

B Rationale: Version: 1 Convert lbs to kg: 22lb ÷ 2.2kg = 10kg Multiply dose needed by weight: 75mg x 10kg =750mg Divide calculated dose needed by med on hand: 750mg ÷ 250mg = 3 Multiply mg needed by mL available: 3 x 5mL = 15mL Version 2: Rationale: 2.2 lb/1 kg = 22 lb/x kg x = 10 kg 1 kg/75 mg = 10 kg/x mg x = 750 mg 250 mg/5 mL = 750 mg/x mL x = 15 mL
question

A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which intervention should the nurse implement first? A. Place a mask on the child before transporting the child outside the room. B. Immunize exposed family members with the varicella vaccine. C. Place the child in strict isolation to prevent an outbreak on the unit. D. Determine which staff have had varicella before making assignments.
answer

Rationale: The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only personnel assigned to care for this client. Option A is not sufficient to prevent exposure to others. Option B must be done prior to exposure.
question

A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the first time tomorrow. During the school day, which intervention should be implemented for this child? A. Cover the tracheostomy site with clothing so that other children will not notice. B. Apply suction for 30 seconds when inserting a catheter into the stoma. C. Discourage the child from coughing deeply to remove mucous secretions. D. Place suctioning supplies on the back of the wheelchair when transporting.
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D Rationale: Suctioning supplies should always be readily available for use with any client who has a tracheostomy. Options A, B, and C do not describe safe practices for this child with a tracheostomy.
question

When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement? A. Use a blanket as a mummy restraint. B. Monitor the infant’s heart rate. C. Lubricate the catheter with saline. D. Explain the procedure to the parents.
answer

B Rationale: All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant’s heart rate, which may decrease because of vagal nerve stimulation and can occur when the tube is inserted. Options A, C, and D are of lower priority than option B.
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The nurse is assessing a male adolescent client’s knowledge of contraception. The teen states, “I have all the info I need.” What is the best response by the nurse? A. “Tell me what you know about birth control.” B. “Do you know how to apply a condom?” C. “Teen pregnancy should not be taken lightly.” D. “You need to visit with your guidance counselor.”
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A Rationale: Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception. It would be best for the nurse to ask a more general question, such as option A. Option B is narrow in focus. Options C and D are blocks to any further communication.
question

Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A. Adjustment of orthodontic appliances or braces B. Loss of deciduous teeth (baby teeth) C. Urinary catheterization D. Insect bites
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C. Rationale: Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization is an invasive procedure. Options A, B, and D are not invasive and do not require administration of prophylactic antibiotics.
question

Which nursing diagnosis has the highest priority when planning care for an infant with eczema? A. High risk for altered parenting related to feelings of inadequacy B. Altered comfort (pruritus) related to vesicular skin eruptions C. Altered health maintenance related to knowledge deficit of treatment D. Risk for impaired skin integrity related to eczema
answer

B Rationale: Altered comfort (pruritus) has the highest priority because itching will cause the infant to scratch, creating complications such as scarring or infection. Options A, C, and D are all important nursing diagnoses and should be considered when developing the infant’s plan of care, but they do not have the priority of option B.
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A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit? A. Shortness of breath B. Joint pain C. Persistent cold D. Organomegaly
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C Rationale: Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection. Options A, B, and D are symptoms of AIDS complications that may occur later as the disease progresses.
question

Which nursing interventions are therapeutic when caring for a hospitalized toddler? (Select all that apply.) A. Require parents to leave the room when performing invasive procedures. B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures. D. Insert a urinary catheter if bed-wetting occurs during hospitalization. E. Do not allow any toys to be brought in from the child’s home.
answer

B, C Rationale: Giving the toddler a choice may increase autonomy in the hospitalized setting. Brief but simple explanations are beneficial with the toddler. Separation from the parent can cause emotional distress. Regression is expected, and bedwetting is not an indication for a urinary catheter. The nurse should encourage age-appropriate toys to be brought in from home.
question

A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse? A. “My son often chokes while I am feeding him.” B. “Is it normal for my child’s legs to cross each other?” C. “He gets stiff when I pull him up to a sitting position.” D. “My 4-year-old son is jealous of his little brother.”
answer

A Rationale: Airway obstruction is always a priority when caring for any client. Options B and C are characteristics of spastic cerebral palsy and may involve one or both sides. These children have difficulty with fine motor skills, and attempts at motion increase abnormal postures. Option D is an expected behavior and may need to be addressed, but it is not a priority over choking.
question

A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is the nurse addressing when teaching inhalation therapy? A. Autonomy B. Industry C. Trust D. Initiative
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D Rationale: Children 4 to 5 years of age are in the “Initiative vs. Guilt” stage of Erikson theory of psychosocial development. They enjoy being active and participating in role playing. “Autonomy vs. Shame and Doubt” occurs at 1 to 3 years of age. “Industry vs. Inferiority” occurs at 6 to 11 years; “Trust vs. Mistrust” occurs from birth to 1 year of age.
question

A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take? A.Send the child home with the parents to see the health care provider before returning to school. B. Send the child home with the parents and report this to the health department. C. Cover the lesion with a dry gauze dressing and send the child back to class. D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class.
answer

A Rationale: Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition. Option B is not necessary because this is not a public health hazard. Option C slows the healing process and can contribute to spread of the infection. The lesions should be washed with soap and water, topical ointment applied, and left open to the air to dry. This will occur at the child’s home.
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A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first? A. Obtain a scale to weigh the infant’s diapers. B. Instruct the mother to offer Pedialyte regularly. C. Insert an intravenous (IV) line and begin IV fluids. D. Obtain a stool specimen for analysis.
answer

C Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse’s priority is to initiate IV fluids to rehydrate the infant. Options A, B, and D can then be implemented as needed.
question

During routine screening at a school clinic, an otoscope examination of a child’s ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take? A. No action is required because this is an expected finding for a school-aged child. B. Ask if the child has had a cold, runny nose, or any ear pain lately. C. Send a note home advising parents to have the child evaluated by a health care provider. D. Call the parents and have them take the child home from school for the rest of the day.
answer

B Rationale: More information is needed to interpret these findings. The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Because these findings are not completely normal, further assessment of history and related signs and symptoms are needed to interpret the findings accurately. Based on the data obtained from the otoscope examination, options A, C, and D are not indicated.
question

The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs? A. Place the child’s head flat, with the knees on pillows above the level of the heart. B. Have the child lie on the right side, with the head elevated on one pillow. C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated. D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths.
answer

C Rationale: Assuming a knee-chest position with the head and chest slightly elevated will help restore hemodynamic equilibrium. Options A and B are incorrect positions and may hinder the child’s condition. Option D may cause chest pain or a vasovagal response, with resulting hypotension.
question

The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease? A. Turkey salad, milk, and oatmeal cookies B. Baked chicken, coleslaw, soda, and frozen fruit dessert C. Tuna salad sandwich on whole wheat bread, milk, and ice cream D. Turkey sandwich on rye bread, orange juice, and fresh fruit
answer

B Rationale: A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats, wheat, rye, or barley.
question

An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement? A. Teach the parents how to ambulate the child in the room safely. B. Show the parents how to hold the child with the extremity extended. C. Restrain the child’s lower extremities for a minimum of 4 hours. D. Place the child in a prone position to apply pressure to the site.
answer

B Rationale: The extremity should be extended to prevent trauma to the femoral catheterization site. Options A and D increase the risk for complications and are contraindicated. Option C is not necessary. Only the extremity that was catheterized requires immobilization.
question

The nurse expects a 2-year-old child to exhibit which behavior? A.Build a house with blocks. B. Ride a small tricycle 6 feet. C. Display possessiveness with toys. D. Look at a picture book for 15 minutes.
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C Rationale: Two-year-old children are egocentric and unable to share with other children. Options A, B, and D are behaviors of a preschooler.
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At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions? A. Inspiration B. Coughing C. Apneic episodes D. Expiration
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A Rationale: Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring. During apnea, the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent.
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When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority? A. Administering oxygen therapy continuously B. Restricting fluids as ordered C. Maintaining adequate hydration D. Maintaining digoxin (Lanoxin) levels
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D Rationale: The key word in this question is polycythemia. Hydration decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia. Options A and D are nursing interventions for the cardiac client but do not treat polycythemia. Fluid intake should be increased, not restricted.
question

The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client? A. Remove the brace 1 hour each day for bathing only. B. Remove the brace only for back range-of-motion exercises. C. Wear the brace against the bare skin to ensure a good fit. D. Wearing the brace will cure the spinal curvature.
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A Rationale: The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis.
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The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child? A. “Our first child was born with a cleft lip.” B. “We are very careful not to get sunburns in our family.” C. “My first child sometimes got a diaper rash.” D. “My husband and our daughter are both lactose-intolerant.”
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D Rationale: Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis because milk allergies can contribute to the child’s outbreaks. Option A is not a contributing factor. Option B is an environmental factor in other skin diseases but does not have a strong correlation with eczema in children. Option C is not unusual and occurs in the diaper area, whereas atopic dermatitis occurs most often on the face and extensor aspects of the arms and legs.
question

The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement? A. Assess the child’s mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child’s food likes and dislikes. D. Ask the parents about the child’s recent dietary intake.
answer

A Rationale: An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit and then implement options B, C, and D.
question

A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother? A. Watch the boy a few more days and see if the cough begins to produce sputum. B. The full 10-day course of antibiotics must be completed before effectiveness can be evaluated. C. Give the child plenty of fluids and an over-the-counter cough suppressant. D. Bring the child to the clinic today for an examination related to the cough.
answer

D Rationale: The child should be evaluated as soon as possible for pneumonia. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production. Option B delays evaluation too long. Although giving fluids is advisable, cough suppressants might mask symptoms of a serious condition.
question

The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is the most likely cause of the child’s impaired mobility? A. Pathologic fractures B. Poor alignment of joints C. Dyspnea on exertion D. Joint inflammation
answer

D Rationale: Joint inflammation and pain are the typical manifestations of an exacerbation of JRA. Options A, B, and C are not specifically related to JRA.
question

Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) A. Steatorrhea B. Obesity C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion
answer

A, C, D, E Rationale: Options A, C, D, and E are all common assessment findings in the client with cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis.
question

A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child’s right hip during a routine physical examination. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors commonly associated with DDH. Which response is accurate? A. Vertex delivery B. Male gender C. Breech presentation D. Second-born child
answer

C Rationale: Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech position, not the vertex (head-first) position. Twice as many females as males present in the breech position; thus, 80% of children with DDH are females, not males. Of breech presentations, 60% occur with first-born children, not subsequent siblings, possibly because of the unstretched uterus and compaction of the surrounding abdominal contents, which tend to increase compression on the uterus in the nulliparous woman.
question

An infant is receiving digoxin (Lanoxin) for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab (Digibind) stat.
answer

B Rationale: Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority. Option A is not indicated at this time. Option C provides helpful assessment data but does not address the cause of the problem and delays needed intervention. Option D is indicated for a serious, life-threatening overdose with digoxin.
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A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome? A.Presence of a systolic murmur B. New onset of patchy alopecia C. Complaints of long bone pain D. Recent projectile vomiting
answer

A Rationale: Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly. Options B, C, and D are not recognized as common complications of trisomy 21.
question

A burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. When calculating the percentage of burn, which parts of the child’s body are proportionally larger than an adult’s? A. Head and neck B. Arms and chest C. Legs and abdomen D. Back and abdomen
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A Rationale: The standard rule of nines is inaccurate for determining burned body surface areas with children because a child’s head and neck are proportionately larger than an adult’s. Specially designed charts are commonly used to measure the percentage of burn in children. Options B, C, and D are not proportionately different
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The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a surgical procedure. Which action should the nurse take first? A. Evacuate the bowel of impacted feces B. Administer magnesium sulfate C. Place the child on a clear liquid diet D. Assess the stool for white color
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C Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day; then magnesium sulfate is administered for bowel evacuation. A barium enema is likely to cause option A. After the enema, white stool may be seen as the body naturally removes any remaining barium.
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A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman? A.”You can prevent SIDS if your baby sleeps on the side or back. You will have to monitor the baby carefully.” B. “The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?” C. “An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind that you need.” D. “My neighbor’s baby died of SIDS last year, and she went to a SIDS support group. That really helped her.”
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B Rationale: The most effective way to provide emotional support is to acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions. Option A implies to the mother that she can prevent SIDS from occurring, which is an unrealistic expectation. Offering a personal opinion about what will help this client or about what has helped a neighbor is not as effective as helping the client discover what would be best for her.
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The nurse admits a child to the intensive care unit with a diagnosis of acquired aplastic anemia. What is the most common cause of this type of anemia? A. Bacterial infections B. A diet deficient in iron C. Heart-lung congenital defects D. Exposure to certain drugs
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D Rationale: Aplastic anemia often follows exposure to certain drugs such as chloramphenicol, sulfonamides, and phenylbutazone (Butazolidin), insecticides such as DDT, and chemicals, especially, benzene. Options A and C are not related to the development of anemia. Option B is related to iron deficiency anemia.
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Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed? A.”I will give her a baby aspirin every 4 hours as needed for fever.” B. “I will call the clinic if her cry becomes high-pitched or unusual.” C. “I know I can expect her to be irritable over the next 2 days.” D. “I will exercise her legs regularly to decrease the soreness.”
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A Rationale: Although fever may occur, non-aspirin-containing medications should be used because of the risk of Reye syndrome. Option B indicates a severe reaction, whereas option C is a common side effect. Option D decreases soreness in the thigh injection site.
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A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need? A. 400 calories/day B. 500 calories/day C. 600 calories/day D. 700 calories/day
answer

C Rationale: An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to 10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1° F temperature elevation. Ten percent of 540 (calories/day) is 54, and 540 + 54 = 594. This infant will require approximately 600 calories/day. Options A, B, and D are incorrect.
question

A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning. D. Apply water-soluble lubricant to the suture line.
answer

A Rationale: The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.
question

A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally. Which intervention has the highest priority? A. Determine if the child has any allergies to antibiotics. B. Instruct the parent to give the child tepid baths. C. Instruct the parent to increase the child’s fluid intake. D. Tell the parent to take the child to the emergency department.
answer

D Rationale: The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation. Options A, B, and C are all valuable interventions after the client is assessed and diagnosed.
question

Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery? A. Crying that is unrelieved by comforting measures B. Presence of an inguinal bulge after gentle palpation C. Refusal to take oral feedings D. Straining during defecation
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B Rationale: The parents should notify the health care provider if the hernia remains irreducible after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release. Options A and D may cause the hernia to protrude but do not necessitate notification of the health care provider. Option C may not be specific to the hernia.
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A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit? A. Bone pain, pallor B. Weakness, tremors C. Nystagmus, anorexia D. Fever, abdominal distention
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A Rationale: Option A lists the most common presenting symptoms of leukemia. Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor. Options B and C could be associated with central nervous system disorders. Option D commonly occurs in children but is not specific for leukemia.
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Which preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? A. Monitor for signs of metabolic acidosis. B. Estimate the quantity of diarrhea stools. C. Place in a supine position after feeding. D. Observe for projectile vomiting.
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D Rationale: Projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic alkalosis. Metabolic acidosis is the opposite imbalance from alkalosis and is not an expected finding. An antidiarrheal agent is not indicated. Option C is dangerous because of the potential for aspiration with frequent vomiting.
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The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further assessment reveals that he is concerned about his edematous facial features. Based on these assessment findings, the nurse should plan interventions related to which nursing diagnosis? A. Social isolation B. Altered health maintenance C. Knowledge deficit D. Ineffective coping
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A Rationale: Peer acceptance and body image are significant issues in the growth and development of adolescents. Option A addresses the problem of a lack of contact with peers stemming from his desire to protect his ego. Options B, C, and D are not supported by the assessment finding.

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