question

3. A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.)

answer

A. Monitor the the infant's weight and number of wet diapers per day. - child should at least have 6 wet diapers per day. B. Increase the infant's intake per feeding by 1 to 2 ounces per week.- child is always fatigue, need to increase to 30 oz a day D. Allow the infant to rest and re-feed on demand or every 2 hours.- child is always fatigue, this will ensure adequate feeding. E. Use a softer nipple or increase the size of the nipple opening.- this will save energy

question

33. A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide?

answer

Explain that menarche varies and occurs between the ages of 12 and 18 years.

question

81. Which finding in a 19-year-old female client should trigger further assessment by the nurse?

answer

Menstruation has not occurred- menarche usually occur between the ages of 12 and 18 years old

question

34. At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first?

answer

Administer PRN prescription of nifedipine (Procardia) sublingually. -CA channel blocker -always assess physiological needs

question

56. A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis?

answer

Sequestration.- pooling of blood causes and pain and anemia d/t blockage of blood in the spleen 1. Aplastic anemia- anemia d/t drugs 2. Hyperhemolytic anemia- anemia d/t the breakdown of RBC 3.Vaso-occlusive anemia- sickle cells are clogging up small capillaries- and pain but not enlarged spleen and liver

question

49. A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?

answer

pre school age children are conceded about lost of body mutilation or body integrity. nurse should explain- they did not cause the illness, procedure is not punishment, restoring body image with a band-aid.

question

26. The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first?

answer

Start an IV infusion of normal saline- patient is experiencing fluid vole deficit

question

40. A 6-month-old boy and his mother are at the healthcare provider's office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today?

answer

6 month shots: DTAP; HEP -B (1st dose: birth, 2nd dose: 1-2 months, 3rd dose 6-9 months); PCV; IPV; INFLUENZA~ adminster at a different site

question

38. A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first?

answer

Determine the child's pulse and respiration~ always ABC assess: respiratory, cardiac, and neuro

question

27. The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain?

answer

Description of vomiting episodes in past 24 hours.- assessment of what cause vomiting episodes leaning towards treatment

question

4. The nurse is planning care for school-aged children at a community care center. Which activity is best for the children?

answer

Playing follow-the-leader. Erikson: industry vs inferiority achieve independence and productivity

question

60. The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother?

answer

Walk away from him and ignore the behavior -temper tantrums are normal, just ignore the behavior.

question

25. A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan?

answer

Consistently follow a set mealtime routine - always follow a consistent home schedule

question

18. As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider?

answer

A 6-month-old with failure to thrive that has a closed anterior fontanel.

question

5. Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate?

answer

A trial of human chorionic gonadotrophic hormone Frequent stimulation of the cremasteric reflex~ causes the testes to ascend, not descend.

question

70. When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement?

answer

Record weight daily = nutrition for infants

question

63. The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview?

answer

Are you experiencing any type of nervousness? - physiological answers: nervousness, apprehension, palpitations, hyper excitability *hyperthrydoism will have exopthalamus, not double vision

question

2. Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations?

answer

Oven-baked potato chips and cola avoid: oats, wheat, rye and barley; intolerance to protein gluten

question

37. Which action by the nurse is most helpful in communicating with a preschool-aged child?

answer

Use a doll to play and communicate. Correct

question

74. To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?

answer

Use a happy-face/sad-face pain scale. -faces pain scale minimm of age 3 years old

question

nonverbal signs of pain vital signs of pain pain rating scale (PRS) when to use cries when to use verbal report when to use numeric pain scale

answer

-grimacing -irritability -restlessness -difficulty in sleeping or feeding -increased HR -increased RR -diaphoresis -decreased 0xygen saturation levels 14-36 months of age 36-60 weeks 3 year old can point out location and degree of pain minimum of 9 years old

question

29. A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization?

answer

Explain hospital schedules to the child, such as mealtimes. -always keep a consistent schedule, if possible try to copy home schedule. This will help to decrease separation anxiety

question

23. The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question?

answer

Do not give if the child has chickenpox, the flu, or any other viral illness. -pepto bismol: contains aspirin, aspirin + any viral, flu or infection = reyes syndrome -->reyes syndrome (encephalophy + hepatic dysfunction)

question

1. A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?

answer

Serum BUN and creatinine levels. adding potassium = need adequate renal function + urine output

question

54. The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit?

answer

Clubbed fingers r/t hypoxia -tachycardia not bradycardia

question

84. An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?

answer

Prevent the return of oxygenated blood to the lungs

question

51. The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?

answer

Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.

question

83. When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?

answer

Cessation of growth in a child that had been normal. hypothyrodism-->d/t metabolism--> decrease metabolism--> cessation of the growth

question

17. The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family?

answer

Polyuria and polydipsia growth hormone causes increase in blood sugar *monitor for diabetes

question

30. The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication?

answer

Changes in level of consciousness. fluid retention + DILUTED s/s hyponatremia

question

11. A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information?

answer

Children need to retain a sense of initiative without impinging on the rights and privileges of others. -Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others

question

36. A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?

answer

Wash the hair and skin frequently with soap and hot water. teenage growth hormones causes increase in sebaceous glands and increased glandular secretions which predispose the teenager to acne.

question

79. During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?

answer

EYE EXAM JRA= EYE EXAM

question

12. The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits?

answer

Half of child's speech is understandable (15-24 months) by 18 months is capable of making a three word sentence. 3-5 years old is able to name four colors & count five blocks

question

15. A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?

answer

Nystatin (Mycostatin).

question

31. Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?

answer

Tetracyclines causes destruction of enamel and tooth discoloration able to give: aminoglycodides, penicillins, Quinolones.

question

68. A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan?

answer

Use sunscreen when lying by the pool. also avoid taking with milk because it interferes with absoprtion

question

16. A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit?

answer

Choking, coughing, and cyanosis.

question

53. The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?

answer

12 to 15 months. second dose: 4- 6 years old

question

32. Preoperative nursing care for a child with Wilms' tumor should include which intervention?

answer

Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." *prevents rupture of the encapsulated tumor and spreading to other organs

question

10. An 18-month-old is admitted to the hospital with possible Hirschsprung's disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?

answer

Ribbon-like and brown. Hirschsprung's is a mechanical obstruction in part of the intestines resulting in inadequate motility. Bile-colored and watery = gastroenteritis Foul-smelling and fatty = cystic fibrosis Semi-solid and yellow= normal in breast fed neonates

question

66. The nurse is planning the care of a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis?

answer

Place elbow restraints on the child's arms elbow restraints prevent arm flexion and scratching of involved areas, but do not inhibit use of the hands for play activities

question

42. The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift?

answer

Tympanic and oral temperatures are equally accurate. hypothalamus and eardrum are perfused by the same circulation & causes the same core temp by ear and oral

question

59. A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention?

answer

Apical heart rate of 60. normal HR 80-150bpm

question

61. In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first?

answer

5 year old = process of glucose testing (think of it as playing a game) 9 year old = can self administer the medication with proper demonstration

question

6. The nurse observes a 4-year-old boy in a daycare setting. Which behavior would the nurse consider normal for this child?

answer

Demonstrates aggressiveness by boasting when telling a story.

question

57. A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is calculated as a larger percentage of total body surface than an adult's?

answer

child= head + neck adult= chest + arms

question

21. The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take?

answer

Pass the information on in the report theophylline: 10-20 mcg/dl (normal range)

question

28. A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?

answer

Have a bulb syringe readily available to remove secretions. a patent airway is highest priority and humidification will liquefy the nasal secretions

question

65. All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old child?

answer

Assessing fontanels. by 20 months, the fontanels are suppose to be closed already.

question

43. The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that

answer

A tympanic measurement of temperature will provide the most accurate reading.

question

55. A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The nurse determines the daily caloric need for this child is approximately

answer

600 calories per day. 10.9 divide by 2.2 = 5kg x 108 kg/cal/day = x 5 = 540. since there is a 10% increase, 54 +540= 594, 600 calories per day.

question

24. The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?

answer

Store all toxic agents and medicines in locked cabinets.

question

14. The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?

answer

I understand that I will be in a body cast and I will show you how you taught me to turn

question

71. To take the vital signs of a 4-month-old child, which order provides the most accurate results?

answer

Respiratory rate, heart rate, then rectal temperature.

question

82. 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. What action should the nurse take next?

answer

Ask the child if he/she has had a cold, runny nose, or any ear pain lately.

question

50. What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?

answer

Observe for projectile vomiting leads to metabolic alkalosis

question

41. A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child?

answer

Remove restraints one at a time and provide range of motion exercises. *needs to have movement and passive ROM exercises.

question

13. A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?

answer

Congenital heart disease is the most common defect found in those with DS

question

80. When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it

answer

stresses the suture line *need to maintain the skin integrity

question

58. Which behavior would the nurse expect a 2-year-old child to exhibit?

answer

Display possessiveness of toys. *egocentric thinking

question

46. When assessing a child with asthma, the nurse should expect intercostal retractions during

answer

inspiration! inspiraiton causes show the presence of intercostal retractions

question

22. A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client's social interaction, what intervention is best for the nurse to initiate?

answer

Arrange for an Internet connection in the client's room for email communication. adolescent: body image and peer acceptance are the main concerns; email communication will still allow peer communication and acceptance while preserving his body image

question

62. A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?

answer

Tell the student to proceed directly to his regularly scheduled class. -he just came from football practice, which increases his muscle activity. 100.4 is a regular temp.

question

77. A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?

answer

Wash the wound gently with mild soap and water. -hydrogen peroxide +povidone-iodine = will irritate the wound. clean the wound first to prevent infection then put ice

question

44. A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take?

answer

Administer tetanus toxoid booster. Detanus is part of DTAP vaccine. -first dose: 6 months -booster shoot: adolescent or adults -booster shot: traumatic injury-->contaminated with by dirt, feces, soil or saliva puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite

question

78. During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?

answer

Stop the infusion immediately and notify the healthcare provider. -adjust IV fluids -TPN- cannot d/c or increase fluids--> hypoglycemia -blood transfusion--> can d/c it -->anaphylic reaction

question

72. The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider?

answer

Pale bluish coloration of the toes. -skin traction: force is applied to the skin -skeletal traction: pin or wire applies pull directly to the distal bone fragment

question

69. A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?

answer

The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her. -room air is 21%, since the oxygen hood is at 35% the baby needs the oxygen hood. offer an alternative like stroke the infant and offer reassurance

question

9. The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand?

answer

aersol therapy then postural drainage before meals or 1 hour after aerosl therapy loosens up the secretions, then posutral drainage moves it up

question

52. The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain?

answer

Type of reaction to loud noises. ototoxicity can cause tinnitus and vertigo in children if the mother uses aspirin during pregnancy; aspirin side effect of tinnitus only occurs during utero. -NO RISK FOR BLEEDING FOR THE INFANT, ONLY THE MOTHER

question

64. The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's repeated hospitalizations. Which is the best response that the nurse should offer?

answer

Encourage the mother to have the children visit the hospitalized sibling. *incorporate a home environment, prevent separation anxiety (toddler or pre schooler's greatest threat/fear) and allow sibling visitors to decrease stress and anxiety

question

7. A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?

answer

Call the healthcare provider immediately if the nail beds appear blue

question

48. The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?

answer

Engage the child through drawing pictures. -since babies are egocentric, they do things on their own and draw. this will allow the nurse to assess the picture

question

67. The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching?

answer

Using a teaspoon will help me measure this correctly.

question

35. Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.)

answer

A. child height + weight C. body surface area of the child F. nomogram determined mathematical consent

question

45. Which restraint should be used for a toddler after a cleft palate repair?

answer

Elbow restraints post op during procedure--use mummy restraint

question

20. When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline?

answer

Parental control should be consistent. consistent parenting will prevent misbehavior of children; consistent parents will prevent misinterpretation of rules.

question

73. A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?

answer

Steatorrhea is foul smelling stools and float because of excess fat/grease on the feces

question

76. The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child's cooperation?

answer

Use a colorful straw iron causes staining of the teeth

question

8. Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant?

answer

A thin stratum corneum that increases topical absorption. infants have a thin skin called the stratum corneum, this will aid increased topical absorption

question

75. A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?

answer

RICE = REST ICE COMPRESSION ELEVATE

question

19. A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child's care?

answer

Plenty of fluids should be consumed daily hydration #1 priority to prevent viscosity of blood; since the sickle cell can impact the spleen, liver, kidney, bones and CNS this can increase the risk for infection w/ decreased or no function of the spleen a routine immunization schedule is needed

question

47. The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?

answer

low neutrophil count = risk for infection because body is no longer fighting the infection high neutrophil count= an infection and body is fighting it off

question

39. A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?

answer

any burn patient: always remember ABC!

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