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ATI PEDIATRICS PROCTORED 2021

Chapter 1: Family centered nursing care

1. Parenting styles

-Dictatorial or authoritarian:

-Parents try to control the child’s behaviors and attitudes through unquestioned

rules and expectations

-Ex: The child is never allowed to watch television on school nights

-Permissive:

-Parents exert little or no control over the child’s behaviors, and consult the child

when making decisions

-Ex: The child assists with deciding whether he will watch television

-Democratic or authoritative:

-Parents direct the child’s behavior by setting rules and explaining the reason for

each rule setting

-Ex: The child can watch television for 1 hr on school nights after

completing all of his homework and chores

-Parents negatively reinforce deviations form the rules

-Ex: The privilege is taken away but later reinstated based on new

guidelines

Chapter 2: Physical assessment findings

1. Vital signs

-Usually vital signs are all high except for BP

-Temperature:

-3 – 6 months 99.5

-1 year 99.9

-3 year 99.0

-5 years 98.6

-7 years 98.2

-9 – 11 years 98.1

-13 years 97.9

-Pulse: -Newborn 80 – 180/min

-1 weeks – 3 months 80 – 220/min

-3 months – 2 years 70 – 150/min

-2 – 10 years 60 – 110/min

-10 years and older 50 – 90/min

-Respirations:

-Newborn – 1year 30 – 35/min

-1 – 2 years 25 – 30/min

-2 – 6 years 21 – 25/min

-6 – 12 years 19 – 21/min

-12 years and older 16 – 19/min

-Blood pressure:

-Low as a baby but increases the older they get

-Infants:

-Systolic: 65-78

-Diastolic: 41-52

2. Head

-Fontanels should be flat

-Posterior fontanel:

-Closes by 6-8 weeks

-Anterior fontanel:

-Closes by 12-18 months

3. Teeth

-Infants should have 6-8 teeth by 1 year old

-Children and adolescents should have teeth that are white and smooth, and begin

replacing the 20 deciduous teeth with 32 permanent teeth

4. Infant Reflexes

Stepping Birth to 4 weeks

Palmar Grasp Birth to 3

months

Tonic Neck Reflex (Fencer Position) Birth to 3 – 4

months Sucking and Rooting Reflex Birth to 4 months

Moro Reflex (Fall backward) Birth to 4 months

Startle Reflex (Loud Noise) Birth to 4

months Plantar Reflex Birth to 8

months

Babinski Reflex Birth to 1 year

Chapter 3: Health promotion of infants (2 days to 1 year)

1. Physical Development

-Weight:

-Doubled by 5 months

-Tripled by 12 months

-Quartered by 30 months

-Height:

-2.5 cm (1 in) per month for the first 6 months

-Length:

-Increases by 50% by 12 months

-Dentition:

-First teeth erupt between 6-10 months

2. Motor skill development

▪1 Month

oHead lag

oStrong grasp reflex

▪2 Months

oLifts head when prone

oHolds hand in open position | Grasp reflex fades

▪3 Months

oRaises head and shoulders when prone | Slight head lag

oNo grasp reflex | Keeps hands loosely open

▪4 Months

oRolls from back to side

oGrasp objects with both hands

▪5 Months

oRolls from front to back

oPalmar grasp dominantly

▪6 Months

oRolls from back to front

oHolds bottle

▪7 Months

oBears full weight on feet | Sits, leaning forward on both hands

oMoves objects from hand to hand

▪8 Months

oSits unsupported

oPincer grasp

▪9 Months

oPulls to a standing position | Creeps on hands and knees instead of crawling

oCrude pincer grasp | Dominant hand is evident

▪10 Months

oProne to sitting position

oGrasps rattle by its handle

▪11 Months

oWalks while holding onto something | Walks with one hand held

oPlaces objects into a container | Neat pincer grasp

▪12 Months

oStands without support briefly | Sits from standing position without assistance

oTries to build a two-block tower w/o success | Can turn pages in a book

3. Cognitive development

-Piaget: sensorimotor (birth to 24 months)

-Object Permanence: objects still exists when it is out of view

-Occurs at 9-10 months

4. Language development

-3-5 words by the age of 1 year

5. Psychosocial development

-Erikson: Trust vs. Mistrust:

– Learn delayed gratification

-Trust is developed by meeting comfort, feeding, simulation, and caring needs

-Mistrust develops if needs are inadequately or inconsistently met or if needs are

continuously met before being vocalized by the infant

6. Social development

-Separation Anxiety: protest when separated from parents

-Begins around 4-8 months

-Stranger Fear: ability to discriminate between familiar and unfamiliar people

-Begins 6-8 months

7. Age appropriate activities

-Rattles

-Playing pat-a cake

-Brightly colored toys

-Playing with blocks

8. Nutrition

-Breastfeeding provides a complete diet for infants during the first 6 months

-Solids are introduced around 4-6 months

-Iron-fortified cereal is the first to be introduced

-New foods should be introduced one at a time, over a 5-7 day period to observe

for allergy reactions

-Juice and water usually not needed for 1st year

-Appropriate finger foods:

-Ripe bananas

-Toast strips

-Graham crackers

-Cheese cubes

-Noodles

-Firmly cooked vegetables

-Raw pieces of fruit (except grapes)

9. Injury prevention

-Avoid small objects (grapes, coins, and candy)

-Handles of pots and pans should be kept turned to the back of the stove

-Sunscreen should be used when infants are exposed to the sun

-Infants and toddlers remain in a rear-facing car seat until age 2

-Crib slats should be no farther apart than 6 months

-Pillows should be kept out of the crib

-Infants should be placed on their backs for sleep

Chapter 4: Health Promotion of Toddlers (1 to 3 years)

1. Physical development

-Weight:

-30 months: 4 times the birth weight

-Height:

-Toddlers grow 7.5 cm (3 in) per year

-Head circumference and chest circumference:

-Usually equal by 1 to 2 years of age

2. Cognitive development

-Piaget: sensorimotor stage transitions to preoperational stage 19 – 24 months

-Object Permanence: fully developed

3. Language development

-1 year: using one-word sentences

-2 years: 300 words, multiword sentences by combining 2-3 words

4. Psychosocial Development

-Autonomy vs. Shame and Doubt

-Independence is paramount for toddlers who are attempting to do everything for

themselves

-Use negativism or negative responses to express their independence

-Ritualism, or maintaining routines and reliability, provides a sense of comfort for

toddlers as they begin to explore the environment beyond those most familiar to them

5. Age appropriate activities

-Parallel play: Toddlers observe other children and then might engage in activities

nearby

-Appropriate activities:

-Playing with blocks

-Push-pull toys

-Large-piece puzzles

-Thick crayons

-Toilet training can begin when toddlers have the sensation of needing to urinate or

defecate

6. Motor skill development

▪15 Months

oWalks without help | Creeps up stairs

oUses a cup well | Builds 2 tower blocks

▪18 Months

oRuns clumsily | Throws overhand | Jumps in place w/ both feet |

Pulls/Pushes toys

oManages a spoon w/o rotation | Turns pages 2-3 pages /time | Builds 3-

4 blocks | Uses crayon to scribble spontaneously | Feeds self

▪24 Months (2 years)

oWalks backwards | Walks up/down stairs w/ 2 feet on each step

oBuilds 6-7 blocks | Turns pages 1 @ a time

▪30 Months (2.5 years)

oBalances on 1 leg | Jumps across floor / off chair w/ both feet | Walks tiptoe

oDraws circles | has good hand-finger coordination

7. Nutrition

-Whole milk at 1 year old

-Can start drinking low-fat milk after 2 years of age

-Juice consumption should be limited to 4-6 oz. per day

-Foods that are potential choking hazards:

-Nuts

-Grapes

-Hot dogs

-Peanut butter

-Raw carrots

-Tough meats

-Popcorn

Chapter 5: Health Promotion of Preschoolers (3-6 years)

1. Physical development

-Weight:

-Gain 2-3 kg (4.5-6.5 lb) per year

-Height:

-Should grow 6.9-9 cm per year

2. Fine and gross motor skills

▪3 Years

oToe and heel walks

oTricycle

oJumps off bottom step

oStands on one foot for a few seconds

▪4 Years

oHops on one foot | Skips

oThrows ball overhead

oCatches ball reliably

▪5 Years

oJumps rope

oWalks backward

oThrows and catches a ball

3. Cognitive development

-Piaget: preoperational stage

-Moves from totally egocentric thoughts to social awareness and the ability to

consider the viewpoint of others

-Magical thinking:

-Thoughts are all-powerful and can cause events to occur

-Animism:

-Ascribing life-like qualities to inanimate objects

4. Psychosocial development

-Erikson: Initiative vs. guilt:

-Preschoolers become energetic learners, despite not having all of the physical

abilities necessary to be successful at everything

-Guilt can occur when preschoolers believe they have misbehaved or when they are

unable to accomplish a task

-During stress, insecurity, or illness, preschoolers can regress to previous immature

behaviors or develop habits (nose picking, bed-wetting, thumb sucking)

5. Age appropriate activities

-Preschooler’s transition to associative play

-Play is not highly organized, but cooperation does exist between children

-Appropriate activities:Document continues below

Discover more from:

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-Playing ball

-Putting puzzles together

-Riding tricycles

-Playing pretend dress up activities

-Role-playing

6. Sleep and rest

-On average, preschoolers need about 12 hours of sleep

-Keep a consistent bedtime routine

-Avoid allowing preschoolers to sleep with their parents

Chapter 6: Health promotion of School-Age children (6-12 years)

1. Physical development

-Weight:

-Gain 2-3 kg (4.4-6.6 lb.) per year

-Height:

-Grows 5 cm (2 in.) per year

2. Cognitive development

-Piaget: Concrete operations

-Able to see the perspective of others

3. Psychosocial development

-Erikson: Industry vs. Inferiority

-A sense of industry is achieved through the development of skills andknowledge that

allows the child to provide meaningful contributions to society

-A sense of accomplishment is gained through the ability to cooperate and

compete with others

-Peer groups play an important part in social development

4. Age appropriate activities

-Competitive and cooperative play is predominant

-Play simple board and number games

-Play hopscotch

-Jump rope

-Ride bicycles

-Join organized sports (for skill building)

5. Sleep and rest

-Need 9 hrs of sleep at age 11

6. Dental health

-The first permanent teeth erupt around 6 years of age

Chapter 7: Health promotion of Adolescents (12 to 20 years)

1. Physical development

-Girls stop growing at about 2-2.5 years after the onset of menarche

-In girls, sexual maturation occurs in the following order:

-Breast development

-Pubic hair growth

-Axillary hair growth

-Menstruation

-In boys, sexual maturation occurs in the following order:

-Testicular enlargement

-Pubic hair growth

-Penile enlargement

-Growth of axillary hair

-Facial hair growth

-Vocal changes

2. Cognitive development

-Piaget: Formal operations

-Increasingly capable of using formal logic to make decisions

3. Psychosocial development

-Erikson: Identity vs. role confusion

-Adolescents develop a sense of personal identity and to come to view themselves

as unique individuals

4. Age-appropriate activities

-Nonviolent videogames

-Nonviolent music

-Sports

-Caring for a pet

-Reading

Chapter 8: Safe Medication Administration

1. Oral

-This route of medication administration is preferred for children

-Avoidmixingmedicationwithformulaor puttingit inabottleofformulabecause

the infant might not take the entire feeding, and the medication can alter the taste

of the formula

-Use the smallest measuring liquid medication for doses of liquid medication

-Avoid measuring liquid medication in a tsp. or tbsp.

-Administer the medication in the side of the mouth in small amounts

-Stroke the infant under the chin to promote swallowing while holding the cheeks

together

2. Otic

-Children younger than years:

-Pull the pinna downward and straight back

-Children older than 3 years:

-Pull the pinna upward and back

3. Intramuscular

-Use a 22-25 gauge, 1/2-1 inch needle

-Vastus lateralis is the recommended site in infants and small children

-Other sites:

-Ventrogluteal and deltoid

4. Intravenous

-Avoid terminology such as “bee sting” or “stick”

-Apply EMLA to the site for 60 minutes prior to attempt (helps numb)

-Keep equipment out of site until procedure begins

-Perform procedure in a treatment room (don’t do it in their room)

-Allow parents to stay if they prefer

-Swaddle infants

-Offer nutritive sucking to infants before, during, and after the procedure

Chapter 9: Pain management

1. Atraumatic measures

-Use play therapy to explain procedures, allowing the child to perform the procedure on

a doll or toy

2. Pharmacological measures

-Give medications routinely, vs. PRN, to manage pain that is expected to last for an

extended period of time

3. Pain assessment tool

-Flacc: 2 months- 7 years

-Faces: 3 years and older

-Oucher: 3-13 years

-Numeric scale: 5 years and older

Chapter 10: Hospitalization, illness, and play

1. Infant

-Experiences stranger anxiety between 6-18 months

-Displays physical behaviors as expressions of discomfort due to inability to verbalize

2. Toddler

-Limited ability to describe illness

-Limited ability to follow directions

-Experiences separation anxiety

-Can exhibit an intense reaction to any type of procedure

-Behavior can regress

3. Preschooler

-Fears related to magical thinking

-Can experience separation anxiety

-Might believe illness and hospitalization are a punishment

-Explain procedures using simple, clear language

-Avoid medical jargon

-Give choices when possible, such as, “Do you want your medicine in a cup or spoon?”

4. School-age child

-Ability to describe pain

-Increasing ability to understand cause and effect

-Provide factual information

-Encourage contact with peer group

5. Adolescent

-Perceptions of illness severity are based on the degree of body images

-Develops body image disturbance

-Experiences feelings of isolation from peers

-Provide factual information

-Encourage contact with peer group

Chapter 11: Death and Dying

1. Grief and mourning

-Anticipatory grief:

-When death is expected or a possible outcome

-Complicated grief:

-Extends for more than 1 year following the loss

2. Current stages of development

-Infants/toddlers (birth-3 years):

-Have little to no concept of death

-Mirror parental emotions

-Can regress to an earlier stage of behavior

-Preschool (3-6):

-Magical thinking allows for the belief that thoughts can cause an event such as death

resulting in feeling guilt and shame

-Interpret separation from parents as punishment for bad behavior

-View dying as temporary

-School-age (6-12):

-Begin to have adult concept of death

-Fear often displayed through uncooperative behavior

-Adolescent (12-20):

-Can have adult-like concept of death

-Can have difficulty accepting death

-Rely more on peers than the influence of parents

-Can become increasingly stressed by changes in physical appearance

3. Physical manifestations of death

-Sensation of heat when the body feels cool

-Decreased sensation and movement in lower extremities

-Swallowing difficulties

-Bradycardia/hypotension

-Cheyne-strokes respirations

4. After death

-Allow family to stay with the body as long as they desire

-Allow family to rock the infant/toddler

-Remove tubes and equipment

-Offer to allow family to assist with preparation of the body

Chapter 12: Acute Neurological disorders

1. Meningitis

-Viral (aseptic) Meningitis: supportive care for recovery

-Bacterial (septic) Meningitis: contagious infection

-Hib and PCV vaccines decrease the incidence

-Newborns:

-Poor Muscle Tone

-Weak Cry

-Poor Suck | Refuses Feedings

-Vomiting/Diarrhea

-Bulging Fontanels (late sign)

-3 Months – 2 Years:

-Seizures with a High-Pitched Cry

-Bulging Fontanels

-Poor Feedings | Vomiting

-Possible nuchal rigidity

-Brudzinki’s sign and Kernig’s sign not reliable for diagnosis

-2 Years – Adolescence:

-Seizures (often initial sign)

-Nuchal rigidity

-Fever/chills

-Headache/vomiting

-Irritability/restlessness that can progress to drowsiness/stupor

-Petechiae or purpuric type rash (with meningococcal infection)

-+ Brudzinski Sign: flexion of extremities with deliberate flexion of

the neck

-+ Kernig’s Sign: resistance to extension of the leg from a flexed

position

-Laboratory Tests

-Blood Cultures | CBC | CSF Analysis

-Viral CSF

-Clear Color | Slightly Elevated WBC & Protein | Normal Glucose | –

Gram

-Bacterial CSF

-Cloudy Color | Elevated WBC | Elevated Protein | Decreased Glucose |

+Gram

-Diagnostic Procedures

-Lumbar Puncture (Definitive Diagnostic Test)

-Empty Bladder

-EMLA Cream 45min – 1-hour prior

-Side-lying Position, Head Flexed, Knees Drawn up to Chest

-Remain in Flat Position to prevent Leakage and Spinal HA

-Nursing care:

-Droplet precautions

-Maintain NPO status if the client has decreased LOC

-Decrease environmental stimuli

-Medications:

-IV antibiotics for bacterial infections

-Complications:

-ICP:

-Newborns and Infants

-Bulging or Tense Fontanels

-Increased Head Circumference

-High-Pitched Cry | Irritability

-Distended Scalp Veins

-Bradycardia | Respiratory Changes

-Children

-Headache

-N/V

-Diplopia

-Seizures

-Bradycardia | Respiratory Changes

2. Reye Syndrome

-Affects the liver (liver dysfunction) and brain (cerebral edema)

-Follows a viral illness (Influenza | Gastroenteritis | Varicella)

-Giving Aspirin for treating fevers

-Laboratory tests:

-Elevated liver enzymes (ALT and AST)

-Elevated serum ammonia

-Diagnostic procedures:

-Liver biopsy/CSF analysis

Chapter 13: Seizures

1. Risk factors

-Febrile Episode

-Cerebral Edema

-Intracranial Infection / Hemorrhage

-Brain Tumors / Cyst

-Toxins or Drugs

-Lead Poisoning

-Hypoglycemia

-Electrolyte imbalances

2. Generalized seizures

-Tonic-clonic seizures: -Also known as Grand mal

-Tonic Phase (10-30 seconds)

-Loss of Consciousness | Loss of Swallowing Reflex | Apnea leading to

Cyanosis

-Tonic Contraction of entire body: arms and legs flexed, head and neck

extended

-Clonic Phase (30-50 seconds)

-Violent jerking movements of the body

-Postictal State (30 minutes)

-Remains semiconscious but arouses with difficulty and confused

-No recollection of the seizure

-Absence seizure: petit mal or lapses

-Onset between ages 5 – 8 years and ceases by the teenage years

-Loss of Consciousness lasting 5 – 10 seconds

-Minimal or no change in behavior

-Resembles daydreaming or Inattentiveness

-Can drop items being held, but the child seldom falls

-Lip Smacking | Twitching of Eyelids or Face | Slight Hand Movements

-Myoclonic seizure:

-Brief contraction of muscle or groups of muscle

-No postictal state

-Atonic or akinetic seizure:

-Muscle tone is lost for a few seconds

3. Diagnostic procedures

-EEG:

-Abstain from caffeine for several hours prior to the procedure

-Wash hair (no oils or sprays) before and after the procedure to remove

electrode gel

4. Nursing care

-Initiate Seizure Precautions:

-Pad side rails of Bed | Crib | Wheelchair

-Keep bed free of objects that could cause Injury

-Have Suction and Oxygen Equipment available

-During a Seizure:

-Protect from Injury (move furniture away, hold head in lap)

-Maintain a position to provide a patent airway

-Suction Oral Secretions

-Side-lying Position (decreases risk of aspiration)

-Loosen restrictive clothing

-Do NOT restrain the child

-Do NOT put anything in the child’s mouth

-Do NOT open the jaw or insert an airway during seizure

-This can damage teeth, lips, or tongue

-Remain with the child

-Note onset, time, and characteristics of seizure

-Allow seizure to end spontaneously

-Post-Seizure:

-Side-lying position to prevent aspiration and facilitate drainage of secretions

-Check for breathing, V/S and position of head

-NPO until swallowing reflex has returned

5. Medications

-Antiepileptic Drugs (AEDs):

-Diazepam (Valium) | Phenytoin | Carbamazepine | Valporic Acid |

6. Therapeutic procedures

-Focal Resection: of an area of the brain to remove epileptogenic zone

-Corpus Callostomy: separation of two hemispheres in the brain

-Vagal Nerve Stimulator

7. Complications

-Status Epilepticus:

-Prolonged Seizure Activity that Lasts >30 minutes or Continuous seizure

activity in which the client does not enter a Postictal Phase

-Maintain Airway, Administer oxygen, IV access

Chapter 14: Head injury

1. Physical assessment findings

-Minor injury:

-Vomiting

-Pallor

-Irritability

-Lethargy/drowsiness

-Severe injury: Increased ICP

-Infants:

-Bulging fontanel

-Irritability (usually 1st sign)

-High-pitched cry

-Poor feeding

-Children:

-Nausea/headache

-Forceful vomiting

-Blurred vision

-Seizures

-Late signs:

-Alterations in pupillary response

-Posturing (flexion and extension)

-Decreased motor response

-Decreased response to painful stimuli

-Cheyne-stokes respirations

-Seizures

-Flexion: severe dysfunction of the cerebral cortex

-Extension: Severe dysfunction at the level of the midbrain

2. Nursing care

-Ensure the spine is stabilized until a spinal cord injury is ruled out

-Implement actions to decrease ICP:

-Keep the head midline with the bed elevated 30 degrees, which will also

promote venous draining

-Avoid extreme flexion, extension, or rotation of the head and maintain in

midline neutral position

-Keep the client’s body in alignment, avoiding hip flexion/extension

-Minimize oral suctioning

-Nasal suctioning is contraindicated

-Instruct the client to avoid coughing and blowing the nose

-Insert and maintain indwelling catheter

-Administer stool softeners to avoid straining

3. Medications

-Mannitol:

-Osmotic diuretic used to treat cerebral edema

-Antiepileptic:

-Used to prevent or treat seizures

-Corticosteroid: dexamethasone

-To help decrease edema

4. Therapeutic procedures

-Craniotomy: to help relieve pressure

5. Complications

-Epidural hematoma:

-Bleeding between the dura and the skull

-Subdural hemorrhage:

-Bleeding between the dura and the arachnoid membrane

-Brain herniation:

-Downward shift of brain tissue

Chapter 15: Cognitive and sensory impairments

1. Visual impairments

-Myopia: Nearsightedness

-Sees close objects clearly, but not objects in the distance

-Hyperopia: Farsightedness

-Sees distant objects clearly, but not objects that re close

-Strabismus:

-Esotropia: inward deviation of the eye

-Exotropia: outward deviation of the eye

-Occlusion therapy:

-Patch stronger eye to make weaker eye stronger

2. Visual screening

-Snellen letter, tumbling E, or picture chart

-Place the client 10 feet from the chart with heels on the 10-foot mark

Chapter 16: Oxygen and Inhalation therapy

1. Metered-dose Inhaler

-Shake the inhaler 5-6 times

-Attach the spacer

-Helps facilitate proper inhalation

-Take a deep breath and then exhale

-Tilt the head back slightly, and press the inhaler

-While pressing the inhaler, begin a slow, deep breath that lasts for 3-5 seconds

-Hold the breath for 5-10 seconds

2. Dry powder inhaler

-DO NOT shake

3. Chest physiotherapy

-Is a set of techniques that includes manual or mechanical percussion, vibration, cough,

forceful expiration (or huffing), and breathing exercises

-Helps loosen respiratory secretions

-Schedule treatments before meals or at least 1 hr after meals and at bedtime

-Administer bronchodilator medication or nebulizer treatment prior 4

4. Hypoxemia

-Early signs:

-Tachypnea

-Tachycardia

-Restlessness

-Use of accessory muscles

-Nasal flaring

5. Oxygen toxicity

-Can result from high concentrations of oxygen, long duration of oxygen therapy, and

the child’s degree of lung disease

-Hypoventilation and increased PaCO2 levels allow for rapid progression into

unconscious state

Chapter 17: Acute and infectious respiratory illnesses

1. Tonsillitis

-Physical assessment findings:

-Report of sore throat with difficulty swallowing

-Mouth odor/mouth breathing

-Fever

-Tonsil inflammation with redness and edema

-Laboratory tests:

-Throat culture:

-For GABHS

-Medications:

-Antipyretics/analgesics: acetaminophen

-Antibiotics: for Tx of GABHS

-Tonsillectomy: for recurring tonsillitis

-Side-lying position after then elevate HOB when child is awake

-Assess for evidence of bleeding:

-Frequent swallowing/clearing the throat

-Avoid red-colored liquids, citrus juice, and milk-based foods

-Discourage coughing, throat clearing, and nose blowing in order to

protect the surgical site

-Avoid straws: can damage surgical site

-Alert parents that there can be clots or blood-tinged mucus in vomitus

-Limit activity to decrease the potential for bleeding

-Fully recovery usually occurs in 14 days

2. Croup syndromes

-Bacterial epiglottis (acute supraglottis):

-Expected findings:

-Drooling

-Dysphonia: thick, muffled voice and froglike croaking sound

-Dysphagia

-High fever

-Nursing care:

-Avoid throat culture/putting tongue blade in the mouth

-Prepare for intubation

-Administer ABX therapy starting with IV, then transition to oral to

complete a 10-day course

-Droplet isolation precautions for first 24 hr after IV ABX initiated

3. Influenza A and B

-Expected findings:

-Sudden onset of chills and fever

-Body aches

-Antivirals can be given but must be within 48 hrs of onset

-Amantadine, Zanamivir, Oseltamivir

Chapter 18: Asthma

1. Triggers to asthma

-Allergens

-Smoke

-Exercise

-Cold air or changes in the weather or temperature

2. Expected findings

-Dyspnea

-Cough

-Audible wheezing

-Use of accessory muscles

3. Medications

-Bronchodilators: albuterol

-SE: tremors/tachycardia

-Anticholinergics: atropine/ipratropium

-Dries you up

-Corticosteroids: prednisone

-Rinse mouth afterwards

4. How to use a peak flow meter

-Ensure the marker is zeroed

-Close lips tightly around the mouthpiece

-Blow out as hard and as quickly as possible

-Repeat 3 more times

-Record highest number

5. Complications

-Status asthmaticus:

-Airway obstruction that is often unresponsive to treatment

-Prepare for emergency intubation

Chapter 19: Cystic Fibrosis

1. Cystic fibrosis

-Both biological parents carry the recessive trait for CF

-Characterized by mucus glands that secrete an increase in the quantity of thick,

tenacious mucus, which leads to mechanical obstruction of organs

2. Expected findings

-Early manifestations:

-Wheezing, rhonchi

-Dry, nonproductive cough

-Increased involvement:

-Dyspnea

-Paroxysmal cough

-Obstructive emphysema and atelectasis on chest x-ray

-Advanced involvement:

-Cyanosis

-Barrel-shaped chest

-Clubbing of fingers and toes

-GI findings:

-Large, frothy, bulky, foul-smelling stools (steatorrhea)

-Failure to gain weight or weight loss

-Delayed growth patterns

-Distended abdomen

-Thin arms and legs

-Deficiency of fat-soluble vitamins (Vitamin A,D,E,K)

-Integumentary findings:

-Sweat, tears, and saliva having high content of sodium and chloride

3. Diagnostic procedures

-Sweat chloride test (most definitive)

4. Nursing care

-Chest physiotherapy

-High protein/calorie

-Give pancreatic enzymes within 30 min of eating a meal or snack

-Multivitamin A,D,E,and K

5. Medications

-Bronchodilators: albuterol

-Anticholinergics: ipratropium bromide

-Dornase alfa (pulmozyme): decreases viscosity of mucus and improves lung function

Chapter 20: Cardiovascular disorders

1. Defects that INCREASE pulmonary blood flow

-Ventricular septal defect (VSD):

-A hole in the septum between the right and left ventricle that results in

increased pulmonary blood flow (left-to-right shunt)

-Expected finding:

-Loud, harsh murmur at the left sternal border

-Atrial septal defect (ASD):

-A hole in the septum between the right and left atria that results in increased

pulmonary blood flow (left-to-right shunt)

-Expected findings:

-Loud, harsh murmur with a fixed split second heart sound

-Patent ductus arteriosus (PDA):

-Connection between pulmonary artery and aorta stays open after birth causing

mixing of blood

-Expected findings:

-Murmur (machine hum)

-Bounding pulses

2. Defects that DECREASE pulmonary blood flow

-Tricuspid atresia:

-A complete closure of the tricuspid valve that results in mixed blood flow

-Tetralogy of Fallot:

-Pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and

ventricular septal defect (PROV)

3. Obstructive defects

-Pulmonary stenosis:

-A narrowing of the pulmonary valve or pulmonary artery that results in

obstruction of blood flow from the ventricles

-Expected findings:

-Systolic ejection murmur

-Aortic stenosis:

-A narrowing of the aortic valve

-Coarctation of the aorta:

-A narrowing of the lumen of the aorta

-Expected findings: (BP/pulse elevated on top, but not on the bottom)

-Elevated blood pressure in the arms

-Bounding pulses in the upper extremities

-Decreased blood pressure in the lower extremities

-Cool skin of lower extremities

-Weak or absent femoral pulses

4. Mixed defects

-Transportation of the great arteries:

-A condition in which the aorta is connected to the right ventricle instead of the

left, and the pulmonary artery is connected to the left ventricle instead of the

right

-Expected findings:

-Severe to less cyanosis depending on the size of the associated defect

-Truncus arteriosus:

-Failure of septum formation, resulting in a single vessel that comes off of the

ventricles

-Hypoplastic left heart syndrome:

-Left side of the heart is underdeveloped

-Expected findings:

-Lethargy/cyanosis

5. Cardiac catherization

-Check for allergies to iodine or shellfish

-Provide for NPO status 4-6 hr prior

-Locate and mark the Dorsalis pedis and posterior tibial pulses on both extremities

-Prevent bleeding by maintaining the affected extremity in a straight position for 4-8 hr

6. Heart medications

-Digoxin: Improves myocardial contractility

-Infant: hold if pulse<90

-Children: hold if pulse <70

-Monitor for toxicity:

-Bradycardia

-Dysrhytmias

-Nausea/vomiting

-Anorexia

-Ace inhibitors: captopril

-Beta-blockers: metroprolol

-Potassium-wasting diuretics: furosemide

-Watch for hypokalemia (nausea/vomiting/dizziness)

-Foods high in potassium:

-Bran cereal, potatoes, tomatoes, dark green leafy veggies,

bananas, orange juice, oranges, and melons

7. Hypoxemia

-Immediately place the child in the knee-chest position, attempt to calm the child,

and call for help

8. Infective (bacterial) endocarditis

-Counsel the family of high-risk children about the need for prophylactic antibiotics

prior to dental and surgical procedures

9. Rheumatic fever

-Usually occurs within 2-6 weeks following an untreated or partially treated upper

respiratory infection (strep throat) with GABHS

-Laboratory tests:

-Throat culture for GABHS

-Serum antistreptolysin-O titer:

-Elevated or rising titer, most reliable diagnostic test

-Jones Criteria:

-The diagnosis of rheumatic fever is made on the basis of modified jones criteria

-The child should demonstrate the presence of 2 major criteria or thepresence of 1

major and 2 minor criterion following an acute infection with GABHS infection

-Major criteria:

-Carditis

-Subcutaneous nodules

-Polyarthritis

-Rash (erythema marginatum)

-Chorea: involuntary muscle movements

-Minor criteria:

-Fever

-Arthralgia

10. Kawasaki disease

-Acute systemic vasculitis (inflammation of the blood vessels in the body)

-Expected findings:

-Acute phase:

-Fever greater than 102 F lasting 5 days to 2 weeks and unresponsive to

antipyretics

-Irritability

-Red eyes without drainage

-Bright red, chapped lips

-Strawberry tongue with white coating or red bumps on the posterior

aspect

-Red oral mucous membranes with inflammation including the

pharynx

-Swelling of hand and feet with red palms and soles

-Sub acute phase:

-Peeling skin around the nails, on the palms/soles

-Medication:

-Gamma globulin: IVGG

-Aspirin

-Client education:

-Avoid live immunizations for 11 months

Chapter 21: Hematologic disorders

1. Epistaxis

-Have the child sit up with the head tilted slightly forward to prevent aspiration of blood

-Apply pressure to the lower nose with the thumb and forefinger for at least 10 min

-If needed, pack cotton or tissue into the side of the nose that is bleeding

-Apply ice across the bridge of the nose if bleeding continues

2. Iron deficiency anemia

-Adolescents are at risk due to poor diet, rapid growth, menses, strenuous activities, and

obesity

-Risk factors:

-Excessive intake of cow’s milk in toddlers

-Milk is not a good source of iron

-Milk takes the place of iron-rich solid foods

-Nursing care:

-Modify the infants diet to include high iron and vitamin C

-Iron supplements:

-Give 1 hr before or 2 hr after milk or antacid to prevent decreased absorption

-Give with Vitamin c to increase absorption

-Use a straw to prevent staining of the teeth

-Use a z-track method for injection

-Do not massage the injection site

-Tarry green stools are expected

-Instruct the child to brush teeth after oral dose to minimize or prevent staining

-Dietary sources of iron:

-Infants: Iron-fortified cereals and formula

-Older children: Dried beans, lentils, peanut butter, green leafy veggies, iron-

fortified breads and flour, and red meat

3. Sickle cell anemia

-SCD is an autosomal recessive genetic disorder

-Primarily affects African Americans

-Causes cell to be sickled shape causing increased blood viscosity, obstruction of

blood flow, and tissue hypoxia

-Expected findings:

-Reports of pain: due to tissue ischemia

-Shortness of breath/fatigue

-Pallor

-Jaundice

-Vaso-occlusive crisis (painful episode):

-Severe pain, usually in bones, joints, and abdomen

-Nursing care:

-Keep patient hydrated

-Schedule administration of analgesics to prevent pain

-Complications:

-CVA

4. Hemophilia

-Bleeding time is extended due to lack of a factor required for blood to clot

-Hemophilia A: deficient of factor VIII

-Hemophilia B: deficient of factor IX

-Expected findings:

-Excessive bleeding

-Reports of joint pain and stiffness

-Easy bruising

-Activity intolerance

-Laboratory tests:

-Prolonged PTT

-PLT and PT within expected ranges

-Nursing care:

-Avoid unnecessary skin punctures

-Elevate and apply ice to the affected joints

-Set activity restrictions to avoid injury

-Low-contact sports: bowling, fishing, swimming, and golf

-Use soft-bristled toothbrushes

-Control bleeding episodes using RICE (rest, ice, compress, and elevate)

-Complications:

-Joint deformity

Chapter 22: Acute infectious GI disorders

1. Rotavirus

-Most common cause of diarrhea in children younger than 5 years

-Manifestations:

-Fever

-Diarrhea for 5-7 days

-Vomiting for 2 days

2. Enterobius vermicularis (pinworm)

-Manifestations:

-Perineal itching

-Perform a tape test over anus at night

3. Diarrhea

-Avoid:

-Fruit juices, carbonated sodas, and gelatin

-Caffeine

-Chicken or beef broth

-BRAT diet

-Cleanse toys and childcare areas thoroughly to prevent further spread or

reinfestation

-Avoid undercooked or under-refrigerated food

-Do not share dishes and utensils

4. Dehydration

-Mild:

-Capillary refill greater than 2 seconds

-Possible slight thirst

-Moderate:

-Capillary refill between 2-4 seconds

-Possible thirst and irritability

-Severe:

-Capillary refill >4

-Tachycardia

-Extreme thirst

-Very dry mucous membranes and tented skin

-No tearing with sunken eyeballs

-Sunken anterior fontanel

-Oliguria and anuria

Chapter 23: Gastrointestinal structural and inflammatory disorders

1. Cleft lip and cleft palate

-Cleft lip:

-Results from incomplete fusion of the oral cavity during intrauterine life

-Apply elbow restraints

-Cleft palate:

-Results from the incomplete fusion of the palates during intrauterine life

-Infant may be placed on the abdomen (prone)

-For isolated cleft lip:

-Use a wide-based nipple for bottle-feeding

-For CP or CL and CP:

-Use a specialized bottle with a one-way valve and a

specially cut nipple

-Avoid having the infant suck on a nipple or pacifier

-Complications:

-Ear infections and hearing loss

-Speech and language impairment

-Dental problems

2. GERD

-Expected findings:

-Infants:

-Sitting up or forceful vomiting

-Irritability

-Arching of back

-Children:

-Difficulty swallowing

-Chronic cough

-Non-cardiac chest pain

-Nursing care:

-Small, Frequent Meals

-Thicken infant’s formula with 1 tsp. to 1 tbsp. rice cereal per 1oz formula

-Avoid: Caffeine | Citrus | Peppermint | Spicy or Fried Foods

-Assist with weight control

-HOB elevated during and after meals (at least 30 degrees)

-Therapeutic procedures:

-Nissen fundoplication: wraps the fundus of the stomach around the distal

esophagus to decrease reflux

3. Hypertrophic pyloric stenosis

-Thickening of the pyloric sphincter, which creates an obstruction

-Expected findings:

-Projectile vomiting

-Constant hunger/dehydration

-Olive-shaped mass in the right upper quadrant of the abdomen

-Therapeutic procedures:

-Pylorotomy

4. Hirschprung’s disease

-Lack of ganglionic cells in segments of the colon resulting in decreased motility and

mechanical obstruction

-Expected findings:

-Newborn:

-Failure to pass meconium within 24-48 after birth

-Episodes of vomiting bile

-Refusal to eat

-Abdominal distention

-Child:

-Foul-smelling, ribbon-like stool

-Nursing care:

-High-protein/calorie and low-fiber diet

-Therapeutic Procedures:

-Surgical removal of the aganglionic section of the bowel

-Temporary colostomy can be required

5. Intussusception

-Proximal segment of the bowel telescopes into a more distal segment

-Abdominal mass (sausage-shaped)

-Stools mixed with blood and mucus that resembles the consistency of red currant

jelly

-Therapeutic procedures:

-Air enema

6. Appendicitis

-Inflammation of the vermiform appendix

-Average client age is 10 years

-Expected findings:

-Abdominal pain in the right lower quadrant

-Decrease or absent bowel sounds

-Fever

-Laboratory tests:

-CBC

-Diagnostic procedures:

-CT scans

-Nursing care:

-Avoid applying heat to the abdomen

-Watch for pain: if patient no longer feels pain, appendix ruptured

-Removal of nonruptured appendix:

-Pre-op:

-Give IV fluid replacement/IV antibiotic

-Post-op:

-Place NG tube for decompression

Chapter 24: Enuresis and Urinary tract infections

1. Enuresis

-Must be at least 5 years of age before there’s consideration about diagnosing

enuresis

-Primary enuresis:

-A child has never been free of bed-wetting for any extended periods of time

-Secondary enuresis:

-A child who started bed-wetting after development of urinary control

-Nursing care:

-Have the child empty their bladder before bedtime

-Encourage fluids during the day and restrict fluids in the evening

-Avoid fruit and fruit drink, caffeinated or carbonated drinks after

1600

-Use positive reinforcement

-Avoid punishing, scolding, or teaching the child following an incident

2. UTI

-Physical assessment findings:

-Infants:

-Poor feeding, vomiting, or failure to gain weight

-Increase in thirst

-Frequent urination

-Foul-smelling urine

-Fever

-Seizure

-Pallor

-Laboratory tests:

-Urinalysis and urine culture and sensitivity:

-Nitrates and leukocytes will be increased

-Client education:

-Teach females to wipe the perineal area from front to back

-Suggest the use of cotton underwear

-Instruct avoidance of bubble baths

-Encourage frequent voiding

-Empty complete bladder

Chapter 25: Structural Disorders of the genitourinary tract and Reproductive

system

1. Defects of the genitourinary tract

-Bladder exstrophy:

-Eversion of the posterior bladder through the anterior bladder wall and lower

abdominal wall

-Cover the exposed bladder with sterile, nonadherent dressing

-Prepare the child for immediate surgery

-Hypospadias:

-Urethral opening located just below the glans penis, behind the glans penis, or on the

ventral surface of the penile shaft

-Meatus opening below the glans penis

-Epispadias:

-Urethra opened on dorsal surface of the penis

-Phimosis:

-Inability to retract foreskin of penis

-Testicular torsion:

-Pain is either acute or insidious in onset and radiates to the groin area

Chapter 26: Renal disorders

1. Acute glomerulonephritis

-Associated with GABHS

-Physical assessment findings:

-Cloudy, tea-colored urine

-Decreased urine output

-Periorbital edema

-Facial edema that is worse in the morning but then spreads to extremities and

abdomen with progression of the day

-Mild to severe HTN

-Laboratory:

-Urinalysis:

-Proteinuria, smoke or tea-colored urine, hematuria, increased specific

gravity

-Renal function:

-Elevated BUN and creatinine

-Antistreptolysin O (ASO) titer:

-Positive indicator for the presence of streptococcal antibodies

-Nursing care:

-Possible restriction of sodium and fluid

-Monitor for skin break down (at risk due to edema)

-Encourage frequent turning and repositioning

-Medications:

-Diuretics and antipyretics

2. Nephrotic syndrome

-Alterations in the glomerular membrane allow proteins (especially albumin) to pass

into the urine, resulting in decreased serum osmotic pressure

-Expected findings:

-Facial and periorbital edema: decreased throughout the day

-Decreased frothy urine

-BP within expected range

-Laboratory tests:

-Urinalysis/24-hour urine:

-Proteinuria: protein greater than 2+ on dipsticks

-Serum chemistry:

-Hypoalbuminemia: reduced serum protein and albumin

-Hyperlipidemia: elevated serum lipid levels

-Hemoconcentration: elevated Hgb, Hct, and platelets

-Nursing care:

-Monitor daily weights

-Monitor edema and measure abdominal girth daily

-Salt can be restricted during the edematous phase

-Assess skin for breakdown

-Medications:

-Corticosteroids: prednisone

-Diuretic: furosemide

-25% albumin: increases volume and decrease edema

Chapter 27: Fractures

1. Fractures

-Closed or simple:

-The fracture occurs without a break in the skin

-Open or compound:

-The fracture occurs with an open wound and bone protruding

-Complicated fracture:

-The fracture results in injury to other organs and tissues

2. Nursing care

-Maintain ABC’s

-Stabilize the injured area, avoiding unnecessary movement

-Elevate the affected limb and apply ice packs (not to exceed 20 min)

-Neurovascular assessment:

-Sensation: Assess for numbness or tingling sensation of the extremity

-Loss of sensation can indicate nerve damage

-Skin Temperature: Assess the extremity for temperature.

-It should be warm, not cool, to touch

-Skin Color: Assess the color of the affected extremity

-Check distal to the injury and look for changes of pigmentation

-Capillary Refill: Press the nail beds of the affected extremity until blanching

occurs

-Blood return should be within 3 seconds

-Pulses: Should be palpable and strong

-Pulses should be equal to the pulses of the unaffected extremity

-Movement: The client should be able to move the joints distal to the injury

-Move Fingers or Toes

3. Casting

-Elevate the cast above the level of the heart during the first 24

-Apply ice for the first 24 hours to prevent swelling

-Turn and position every 2 hours (cast dries faster | prevents cast from changing shape)

-Assess for increased warmth or hot spots on the cast surface (infection)

-Plaster Casts: Use Palms of Hands to avoid Denting | Expose the Cast to Air

-Instruct the client not to place any foreign objects inside the cast to avoid trauma to

the skin

4. Traction care

-Maintain body alignment

-Pharmacological and Nonpharmacologic Interventions for Pain and Muscle Spasms

-Assess and monitor neurovascular status

-Assess pin sites for pain, redness, swelling, drainage, or odor

-Weights should hang freely

-Halo device:

-Ensure that the wrench to release the rod is readily available when using halo

traction in the event that CPR is necessary

5. Complications

-Compartment syndrome:

-Compression of nerves, blood vessels, and muscle inside a confined place,

resulting in neuromuscular ischemia

-Findings: 5 P’s:

-Pain: unrelieved with elevation or analgesics, increases with passive

movement

-Paresthesia: numbness (early finding)

-Pulselessness: distal to fracture

-Paralysis: inability to move digits (nerve damage)

-Pale: cold skin and cyanosis to nail beds

-Osteomyelitis:

-Expected findings:

-Fever

-Tachycardia

-Edema

-Pain is constant but increases with movement

-Nursing actions:

-Administer IV and oral ABX therapy

Chapter 28: Musculoskeletal congenital disorders

1. Clubfoot

-A complex deformity of the foot and ankle

-Therapeutic procedures:

-Series of castings

2. Legg-calve-Perthes disease

-Aseptic necrosis of the femoral head can be unilateral or bilateral

-Expected findings:

-Intermittent painless limp

-Hip stiffness

-Limited ROM

-Shortening of the affected leg

-Maintain rest and limited weight bearing:

-Abduction brace

-Casts

-Physical therapy

-Traction

-Surgical intervention:

-Osteotomy of the hip or femur

3. Developmental dysplasia of the hip (DDH)

-Expected findings:

-Infant:

-Asymmetry of gluteal and thigh folds

-Limited hip abduction

-Widened perineum

-Positive Ortolani test:

-Hip is reduced by abduction

-Positive Barlow Test:

-Hip is dislocated by adduction

-Child: -One leg shorter than the other

-Positive Trendelenburg sign:

-While bearing weight on the affected side, the pelvis tilts

downward

-Walk with a limp

-Pavlik harness:

-For newborn to 6 months

-Maintain harness placement for ? to 12 weeks

-Check straps every 1 to 2 weeks for adjustment

-Perform neurovascular and skin integrity checks (2-3 times/day)

-Teach the family not to adjust the straps

-Teach the family skin care:

-Use an undershirt

-Wear knee socks

-Gently massage skin under straps

-Avoid lotions/powders

-Place diaper under the straps

-Hip Spica cast/Bryant traction:

-> 6 months

-Hips flexed at 90-degree angle with buttock raised off of the bed

-Evaluate hydration status frequently

-Assess elimination status daily

4. Osteogenesis imperfecta

-“Brittle bone disease”

-An inherited condition that results in bone fractures and deformity along with

restricted growth

-Expected findings:

-Multiple bone fractures

-Blue sclera

-Early hearing loss

-Small, discolored teeth

-Medications:

-Pamidronate: Increase bone density

-SE: decreases electrolytes

-Nursing care:

-Teach the family and client low-impact exercises

5. Scoliosis

-Characterized by a lateral curvature of the spine and spinal rotation that causes rib

asymmetry

-Have the child bend over at the waist with arms hanging down and observe for

asymmetry of ribs and flank

-Bracing:

-Customized braces slow the progression of the curve

-Spinal fusion with rod placement:

-Used for curvatures >45 degrees

Chapter 29: Chronic Neuromusculoskeletal disorders

1. Cerebral palsy

-Is a non-progressive impairment of motor function, especially that of muscle control,

coordination, and posture

-Abnormal perception and sensation; visual, hearing, and speech impairment; seizures;

and cognitive disabilities

-Risk factors:

-Exact cause is unknown

-Prenatal, perinatal, and postnatal risk factors

-Expected findings:

-Spastic CP (pyramidal):

-Hypertonicity, increased deep tendon reflex; clonus; and poor control of

motion, balance and posture

-Dyskinetic CP (nonspastic, extrapyramidal):

-Involuntary jerking movements that appear slow, writhing, and

wormlike

-Ataxic CP (nonspastic, extrapyramidal):

-Poor ability to do repetitive movements

-Lack of coordination with purposeful movements (ex: reaching for an

object)

-Medications:

-Baclofen/Diazepam

-Complications:

-Aspiration

2. Spina Bifida

-Is failure of the osseous spine to close

-Meningocele:

-The sac contains spinal fluid and meninges

-Myelomeningocele:

-The sac contains spinal fluid, meninges, and nerves

-Risk factors:

-Medications/substances taken during pregnancy

-Insufficient folic acid intake during pregnancy

-Physical assessment findings:

-Protruding sac midline of the osseous spine (cystica)

-Dimpling in the lumbosacral area (occulta)

-Therapeutic procedures:

-Closure of myelomeningocele sac is done as soon as possible to prevent

complications of injury and infection

-Apply a sterile, moist, nonadherent dressing with 0.9% sodium chloride on the sac,

changing it every 2 hr

-Place in the infant in prone position with hips flexed, legs abducted

-Complications:

-Skin ulceration

-Latex allergy:

-Also bananas, avocados, kiwi, and chestnuts

-Increased intracranial pressure:

-Infants:

-High-pitched cry, lethargy, vomiting, bulging fontanels, and

increased head circumference

-Bladder issues

-Orthopedic issues

3. Juvenile idiopathic arthritis

-Chronic autoimmune inflammatory disease affecting joints and other tissues

-Expected findings:

-Joint swelling/stiffness/redness/warmth that tends to be worse in the morning

or after inactivity

-Nursing care:

-Apply heat or warm moist packs to the child’s affected joints prior to exercise

-Encourage warm baths

-Medications:

-NSAIDs: control pain and inflammation

-Ibuprofen, naproxen, diclofenac, indomethacin, and tolmetin

-DMARD: slows joint degeneration and progression of rheumatoid arthritis when

NSAIDs do not work alone

-Methotrexate

-Corticosteroid:

-Prednisone

4. Muscular dystrophy

-Is a group of inherited disorders with progressive degeneration of symmetric

skeletal muscle groups causing progressive muscle weakness and wasting

-Duchenne (psuedohypertrophic) muscular dystrophy (DMD):

-Is the most common form of MD

-Onset between 3 and 5 years

-Expected findings:

-Muscle weakness beginning in the lower extremities

-Unsteady gait, with a waddle

-Lordosis

-Delayed motor skill development

-Frequent falling

-Learning difficulties

-Progressive muscle atrophy

-Respiratory and cardiac difficulties as the disease progresses

-Medications:

-Corticosteroids

-Complications:

-Respiratory complications

Chapter 30: Skin infections and infestations

1. Bacterial skin infections

-Impetigo contagiosa:

-Manifestations:

-Reddish macule becomes vesicular

-Erupts easily leaving moist erosion on the skin, secretions dry forming

crusts

-Spreads by direct

-Pruritus common

-Management:

-Topical bactericidal or triple antibiotic ointment

-Burrow’s solution

-Cellulitis:

-Manifestations:

-Firm, swollen, red area of the skin and subcutaneous tissue

-Fever/malaise

-Management:

-Oral or parenteral ABX

-Warm/moist compress

2. Fungal skin infections

-Tinea capitis (ringworm of the scalp):

-Use selenium sulfide shampoos

-Treat infected pets

-Tinea corporis (Ringworm of the body):

-Round erythematous scaling patch

-Use topical antifungal (tolnaftate, Clotrimazole)

-Tinea pedis (athletes foot):

-Between toes or on the plantar surface of the feet

3. Skin infestations

-Scabies mite (Sarcoptes scabiei):

-Manifestations:

-Itchy, especially at night

-Rash, especially between the fingers

-Thin, pencil-like marks on the skin

-Infants:

-Pimples on the trunk

-Blisters on the palms of the hands and soles of the feet

-Interventions:

-Scabicide such as 5% permethrin all over body

-Treat entire family and persons that have been in contact with

infected person during and 60 days after infection

-Wash underwear, towels, clothing, and sleepwear in hot water

-Pediculosis capitis (Head lice):

-Intense itching

-Nits (white specs) on the hair shaft

-1% permethrin shampoo

-Remove nits with a nit comb; repeat in 7 days after shampoo TX

-Washing clothing, bedding in hot water with detergent

-Client education:

-Teach the parent to bag items that cannot be laundered into tightly sealed bag for 14

days

-Teach the parents to boil combs, brushes and hair accessories for 10 min or soak

in lice-killing products for 1 hr

-Discourage sharing of personal items

Chapter 31: Dermatitis and Acne

1. Dermatitis

-Diaper dermatitis

-Nursing interventions:

-Clean urine in the perineal area with a nonirritating cleanser

-Expose the affected area to air

-Use superabsorbent disposable diapers to reduce skinexposure (no

cloth)

-Apply a skin barrier (zinc oxide)

-Poisonous plant exposure:

-Cleanse exposed area as soon as possible with cold running water,

then soap and water shower

-Apply calamine lotion; burrow solution compresses, or natural

colloidal oatmeal baths

-Use topical corticosteroid gel

-Seborrheic dermatitis: (thick flakes on scalp)

-Treat by gently scrubbing the scalp to remove scales and crusted areas

-Petrolatum, vegetable oil, or mineral oil can be helpful

-Use a fine-tooth comb to remove the loosened crusts from the hair

-Shampoo daily with antiseborrheic shampoo

-Client education:

-Encourage frequent diaper

-Advise parents that their child should avoid bubble baths and harsh soaps

-No talcum powder but cornstarch is okay to prevent friction

-Keep fingernails trimmed short

2. Atopic dermatitis

-Is a type of eczema

-Dress in Cotton Clothing (avoid wool and synthetic fabrics)

-Avoid excessive heat and perspiration (increase itching)

-Avoid irritants (Bubble Baths | Soaps | Perfumes | Fabric Softeners)

-Place gloves or cotton socks over hands for sleeping

-Medications:

-Antihistamines/topical corticosteroids

3. Acne

-Nursing care:

-Teach the child to gently wash the face and other affected areas, avoiding

scrubbing and abrasive cleaners

-Medications:

-Trentinoin:

-Avoid Sun Exposure | Use Sunscreen Daily (SPF 15 or greater)

-Benzoyl peroxide:

-Can bleach clothing but not skin

-Isotretinoin:

-SE:

-Elevated cholesterol/triglycerides

-Depression/suicidal ideation/violent behaviors

-Contraindicated in women who are not taking oral

contraceptives

Chapter 32: Burns

1. Stages of burns

-First degree:

-Superficial:

-Damage to the epidermis (sunburn)

-Pink to red in color with no blisters

-Blanches with pressure

-Painful

-Second degree:

-Superficial partial thickness:

-Damage to the entire epidermis

-Dermal elements are intact

-Painful, moist, red in color with blisters

-Blanches with pressure

-Sensitive to temperature changes, exposure to air, and light touch

-Deep partial thickness:

-Damage to the entire epidermis and some parts of the dermis

-Sweat glands and hair follicles remain intact

-Red to white in color, with blisters

-Blanches with pressure

-Painful

-Sensitive to temperature changes and light touch

-Third degree:

-Full thickness:

-Damage to the entire epidermis and dermis and possible damage to

the subcutaneous tissue

-Red to tan, black, brown, or waxy white in color

-Dry, leathery appearance

-Fourth-degree:

-Deep full thickness:

-Damage to all layers of the skin that extends to muscle, bone, and

fascia

-No pain is present

2. Nursing care

-Check immunization status, and determine the need for immunization

-Administer tetanus vaccine if it has been more than 5 years

-Educate the family to avoid using greasy lotions or butter on burns

-Maintain airway and ventilation

-Initiate IV access with large-bore catheter

-Multiple access points may be necessary

-Fluid replacement is important during the first 24 hours

-Isotonic crystalloid solutions, such as 0.9% sodium chloride or lactated

ringer’s are used during the early stage of burn recovery

-Maintain urine output of 0.5 to 1 ml/kg/hr is <30 kg

-Maintain urine output of 30 ml/hr for >30 kg

-Manage pain:

-Use IV opioid

-Provide nutritional support:

-Increase caloric intake/protein

-Vitamin A, C, and zinc for wound healing

-Maintain active and passive range of motion

3. Medications

-Topical agents:

-Silver sulfadiazine/ Mafenide acetate

-Use with 2nd and 3rd degree burns

-Apply to cleansed, debrided area

-Wear sterile gloves for applications

-Bacitracin:

-Use for prevention of secondary infection

4. Skin coverings

-Biologic skin coverings:

-Allograft (homograft):

-Skin from human cadavers that is used for partial and full thickness

burn wounds

-Xenograft:

-Obtained from animals: pigs (partial thickness burns)

-Permanent skin coverings:

-Autografts:

-Client’s skin

Chapter 33: Diabetes Mellitus

1. Risk factors

-Genetics

-Toxins/viruses: can destroy the beta cells ->type 1 DM

-Obesity/physical inactivity/HTN -> type 2 DM

2. Expected findings

-Hypoglycemia: blood glucose <60

-Hunger, lightheadedness, and shakiness

-Pale, cool skin/diaphoresis

-Decreasing LOC

-Slurred speech

-Headache and blurred vision

-Seizures leading to coma

-Hyperglycemia: blood glucose >250

-Thirst

-Polyuria (early sign)/oliguria (late sign)

-Nausea, vomiting, and abdominal pain

-Skin that is warm, dry, and flushed with poor turgor

-Dry mucous membranes

-Confusion

-Weakness

-Lethargy

-Weak pulse

-Diminished reflexes

-Rapid, deep respirations with acetone/fruit odor due to ketones (Kussmaul

respirations)

3. Laboratory tests

-Diagnostic criteria for diabetes:

-An 8-hr fasting blood glucose level of 126 or more

-Random blood glucose of 200 or more with classic sign of diabetes

-An oral glucose tolerance test of 200 or more in the 2 hr sample

-Glycosylated hemoglobin (HbA1c):

-Expected reference range is 4%-5.9%

-Acceptable target for children who have diabetes: 6.5%-8%

-If >7%: not regulating sugar well

4. Nursing care

-Trimming toenails straight across with clippers and filing edges with a nail file

-Caution the child against wearing sandals, walking barefoot, or wearing socks

without socks

-Dry feet completely

-Can use mild foot powder: cornstarch

-Never use commercial remedies for removing callus/corn

-Sock: cotton or wool

-No heating pads for feet

-Teach the child illness management:

-Monitor blood glucose and urinary ketone levels every 3 hr

-Continue to take insulin or oral Antidiabetic agents

-Encourage sugar-free, noncaffeinated liquids to prevent dehydration

-Call the provider for the following:

-Blood glucose >240

-Fever 102F

-Positive ketones in the urine

-Disorientation or confusion occurs

-Rapid breathing is experienced

-Treat with 10-15 g simple carbohydrates (1tbsp sugar)

-Ex: 4 OZ orange juice/8OZ milk

-If the child is unconscious or unable to swallow:

-Administer glucagon SC or IM

-Administer simple carbohydrates as soon as tolerated

5. Medications

6. Complications

-DKA:

->330 mg/dL

-Expected findings:

-Ketone levels in the blood and urine

-Fruity scent to the breath

-Mental confusion

-Dyspnea

-Nausea and vomiting

-Electrolyte imbalances: Metabolic acidosis/hyperkalemia

-Nursing actions:

-Monitor serum potassium levels

-Administer sodium bicarbonate by slow IV infusion for severe acidosis

(pH <7)

-Have a cardiac monitor

-Kidney disease

-Eye disease

-Neurologic complications

Chapter 34: Growth Hormone deficiency

1. Expected findings

-Short stature but proportional height and weight

-Delayed epiphyseal closure

-Delayed sexual development

2. Medications

-Somatropin:

-Given until epiphyseal plate closes

-Administer SC

1. Contraindications

-DTaP:

Chapter 35: Immunizations

-IPV:

-MMR:

-Occurrence of encephalopathy within 7 days following prior doses of the

vaccine

-Anaphylactic reaction to neomycin, streptomycin or polymyxin B

-Anaphylactic reaction to eggs, gelatin, and neomycin

-Influenza vaccine:

-Hypersensitivity to eggs

-Varicella:

-If taking corticosteroids

-The common cold and other minor illnesses are not contraindications to

immunizations

-Severe febrile illness is a contraindication to all immunizations

-Do not administer live virus vaccines, such as varicella or MMR, to a child who is

severely Immunocompromised

2. Nursing administration

-Give IM immunizations in the Vastus lateralis or ventrogluteal muscle in infants and

young children

-Give IM immunization in the deltoid muscle for older children/adolescents

-Give infants a concentrated oral sucrose solution 2 min prior to, during, and 3 min

after immunization administration

-Document date, route, site of immunization, lot number, manufacturer and exp. Date

Chapter 36: Communicable Diseases

1. Conjunctivitis

-Spread: Direct contact (viral/bacterial

-Expected findings:

-Pink or red color in the sclera of the eyes

-Crusting of the eyelids in the morning

2. Epstein-Barr virus (EBV)/mononucleosis

-Spread: saliva

-Expected findings for infectious mononucleosis:

-Fever

-Swollen lymph glands

-Splenomegaly

-Hepatic involvement

-Complications: ruptured spleen (no contact sports)

3. Erythema infectiosum (fifth disease)/parvovirus B19

-Spread: droplet/blood

-Expected findings:

-Rash (7 days to several weeks):

-Red rash on face (slapped cheek), which appears from day 1 to 4

4. Mumps/paramyxovirus

-Spread: droplet

-Expected findings:

-Painful, swollen parotid glands

5. Pertussis (whooping cough)/Bordetella pertussis

-Spread: direct contact/droplet/indirect contact with freshly contaminated articles

-Expected findings:

-Common cold manifestations:

-Runny nose/congestion, sneezing, mild fever, and mild cough

-Severe coughing starts in 1-2 weeks:

-Coughing fits

-Violent and rapid coughing

-Loud “whooping” sound upon inspiration

6. Rubella (German measles)/rubella virus

-Spread: droplet

-Expected findings:

-Red rash that starts on the face and spreads to the rest of the body, lasting 2- 3 days

-Complications:

-Birth defects (deafness; heart defects; mental, liver, and spleen damage) in fetus

of women infected during pregnancy

7. Rubeola (measles)/rubeola virus

-Spread: droplet

-Expected findings:

-Cough, runny nose, red eyes, and sore throat

-Rash:

-Koplik spots (tiny white spots) appear in mouth 2 days before rash

8. Varicella (chicken pox)/varicella-zoster virus

-Spread: droplet (airborne)

-Expected findings:

-Manifestations 1-2 days prior to rash:

-Fever/fatigue

-Rash: -Macules start in center of trunk, spreading to the face and proximal

extremities

-Progresses from macules, to papules, to vesicles, and crust formations

9. Nursing care

-Do not administer aspirin, due to the risk of Reye Syndrome

-Provide calamine lotion for topical relief

-Keep the child’s fingernails clean and short

10. Medications

-Antihistamine

-Antiviral therapy:

-Acyclovir for high-risk clients who have varicella

Chapter 37: Otitis Media

1. Risk factors

-Most common in the first 24 months of life and again when children enter school

ages (5-6)

2. Medications

-Acetaminophen/ibuprofen:

-For analgesia and reduce fever

-Antibiotics

3. Therapeutic procedures

-Myringotomy and placement of tympanoplasty tubes

-A small incision is made in the tympanic membrane

-The tubes come out spontaneously (usually in 6-12 months)

-Instruct parents to notify the provider when tubes come out

-This is usually does not require replacement of tubes

Chapter 38: HIV/AIDS

1. HIV/AIDS

-HIV infection is a viral infection in which the virus primarily infects a specific subset of

T-lymphocytes, the CD4 T cell causing immune dysfunction

-This leads to organ dysfunction and a variety of opportunistic illnesses in a

weakened host

2. Expected findings

-Mild:

-Lymphadenopathy

-Hepatomegaly

-Splenomegaly

-Dermatitis

-Parotitis

-Severe:

-Multiple serious bacterial infections

-Kaposi’s sarcoma: skin infection

-Pneumocystis carinii pneumonia

-Wasting syndrome

3. Laboratory findings

-Ages >6:

-CD4 T-lymphocyte count= lower than 500=some immunosuppression

-CD4 T-lymphocyte count=lower than 200=severe immunosuppression

4. Nursing care

-Diet high in calories and protein

-Provide good oral care

-Prevent infection using standard precautions

-Does not need special precautions

-Teach the child and parents to avoid individuals who have colds/infections/viruses

-Encourage immunizations:

-Pneumococcal vaccine and yearly influenza vaccine

5. Medications

-Antiretroviral

-Antibiotics

-IV gamma globulin

Chapter 39: Organ neoplasms

1. Wilms’ tumor (Nephroblastoma)

-Is a malignancy that occurs in the kidneys or abdomen

-Tumor is usually unilateral

-Most cases diagnosed between 2-3 years of age

-Metastasis is rare

-Expected findings:

-Painless, firm, nontender abdominal swelling or mass

-Fatigue, malaise, and weight loss

-Fever

-Diagnostic tests:

-Abdominal ultrasonography

-Abdominal and chest CT scan

-Bone marrow aspiration (rule out metastasis)

-Nursing care:

-IF WILM’S TUMOR IS SUSPECTED DO NOT PALPATE THE ABDOMEN (can

cause spread)

2. Neuroblastoma

-Is a malignancy that occurs in the adrenal gland

-Usually manifested during toddler years

-Half of all cases have metastasized before diagnosis

-Expected findings:

-Half of children who have a Neuroblastoma have few findings

-Manifestations of metastasis:

-Ill appearance

-Periorbital ecchymosis

-Bone pain

-Irritability

-Diagnostic procedures:

-Skull, neck, chest, abdominal and bone CT scans

-Bone marrow aspiration (rule out metastasis)

3. Chemotherapy

-Provide an antiemetic prior to administration

-Observe the mouth for mucosal ulcerations

-Educate about the SE of chemotherapy:

-Mouth sores

-Loss of appetite

-Nausea/vomiting

-Hair loss

-Diarrhea/constipation

-Increased risk of infection

-Easy bruising or bleeding

-Fatigue

4. Radiation

-Nurse: wear lead aprons

-Instruct the child and family not to wash off marks on the skin that outline the

targeted areas

-Avoid use of soaps, creams, lotions, and powders unless prescribed

-Keep the areas protected from the sun by wearing a hat and long-sleeved shirts

5. Complications

-Encourage the child to avoid crowds while undergoing chemotherapy

-Avoid fresh fruits and vegetables

-Avoid invasive procedures

-Administer filgrastim:

-Is a granulocyte colony-stimulating factor that stimulates WBC production

-Given SC daily

-Administer epoetin alfa:

-Given SC 2-3 times per week

-Stimulate RBC production

-Administer Oprelvekin

-Given SC daily

-For PLT formation

-Encourage the use of soft toothbrush

-Mucositis and dry mouth:

-Lubricate the child’s lips

-Avoid hydrogen peroxide and lemon glycerin swabs

Chapter 40: Blood Neoplasms

1. Leukemia

-Is the term of a group of malignancies that affect the bone marrow and lymphatic

system

-Diagnostic procedures:

-Bone marrow aspiration or biopsy analysis:

-Topical anesthetic such as EMLA cream 45 min-1 hr prior

-CSF analysis:

-Have the child empty their bladder

-EMLA cream 45 min-1 hr prior

-Side-lying position with the head flexed and knees drawn up toward

the chest, and assist in maintaining the position (during

procedure) -Remain in bed 4-8 hr in a flat position to prevent leakage and a

resulting spinal headache (after)

Chapter 43: Pediatric Emergencies

1. Obstructed airway

-Children/adolescents:

-Use abdominal thrusts

-Infants:

-Combination of back blows and chest thrusts

-Remove any visual obstruction or large debris from the mouth, but do not perform a

blind finger sweep

2. Drowning

-Encourage parents of toddlers to lock toilet seats when their child is at home

-Instruct parents to not leave the child unattended in the bathtub

-Inform parents not to leave the child unattended in a swimming pool, even if the

child can swim

-Encourage parents to provide life jackets when boating

3. SIDS

-Risk factors:

-Maternal smoking during pregnancy

-Co-sleeping with parent or adult

-Prone or side-lying sleeping

-Low birth weight

-Education on risk reduction:

-Place the infant on the back for sleep

-Avoid exposure to tobacco smoke

-Prevent overheating

-Use a firm, tight-fitting mattress in the infant’s crib

-Remove pillows, quilts, and stuffed animals from the crib during sleep

-Offer pacifier at naps and night

-Encourage breastfeeding

-Avoid co-sleeping

4. Poisoning

-1st thing to do is call poison control center

-Acetaminophen: N-acetylcysteine given orally

-Supplemental iron:

-Emesis or lavage

-Chelation therapy using deferoxamine mesylate

Chapter 44: Psychosocial issues of infants, children and adolescents

1. ADHD

-Expected findings:

-Inattention:

-Difficulty in sustaining attention

-Easily distracted

-Forgetfulness

-Hyperactivity

-Impulsivity

-Medications:

-Methylphenidate, Dextroamphetamine:

-Increases dopamine and norepinephrine levels

-Give 30 min before meals

-Give last dose of the day prior to 1800 to prevent insomnia

-Atomoxetine

2. Autism spectrum disorder

-Expected findings:

7-Distress when routines are changed

-Unusual attachment to objects

-Delayed or absent language development

-Withdrawn, labile mood

-Avoiding eye contact

-Nursing care:

-Decrease environmental stimulation

-Introduce the child to new situations slowly

-Encourage support groups for parents

A nurse is collecting data from a 9-month-old infant. Which of the following findings would require further

intervention?

Rationale:

The Babinski reflex disappears after 1 year of age. Therefore, a 9-month-old infant

with a positive Babinski reflex is a finding that does not require further intervention.

Positive Babinski reflex

Rationale:

The Moro reflex disappears approximately at 3-4 months of age. Therefore, a 9-

month-old infant with a positive Moro reflex is a finding that requires further

intervention

Positive Moro reflex

Rationale:

A negative Doll’s eye reflex is a normal finding. Therefore, a 9-month-old infant with

a negative Doll’s eye reflex is a finding that does not require further intervention.

Negative Doll’s eye reflex

Rationale:

A negative Crawl reflex disappears after 6 months of age. Therefore, a 9-month-old

infant with a negative Crawl reflex is a finding that does not require further

intervention.

Negative Crawl reflex

A nurse is reinforcing teaching a parent of a child who has a fracture of the epiphyseal plate. Which of the

following is an appropriate statement by the nurse?

Rationale:

Children heal fractures in less time than adults because of the generous blood

supply to the bone and the epiphyseal plate.

“The blood supply to the bone is disrupted.”

Rationale:

A fracture of the epiphyseal plate can affect growth in a child. Therefore, it needs to

be detected and treated rapidly.

“Normal bone growth can be affected.”

Rationale:

The epiphyseal plate is the cartilage growth plate. Therefore, bone marrow is not

lost through this type of fracture.

“Bone marrow can be lost though the fracture.”

Rationale:

Children heal fractures in less time than adults because of the generous blood

supply to the bone and the epiphyseal plate.

“The healing process will take longer.”

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Homework 8 – Pediatrics

A nurse is planning to speak to a group of adolescents about toxic shock syndrome (TSS). The nurse knows

that TSS is commonly associated with which of the following?

Rationale:

Toxic shock syndrome, a severe disease caused by a toxin made by

Staphylococcus aureus, is characterized by shock and multiple organ dysfunction. It

most often affects menstruating women who use highly absorbent tampons.

High-absorbency tampons

Rationale:

Mosquito bites are not associated with TSS.

Mosquito bites

Rationale:

International travel is not associated with TSS.

International travel

Rationale:

TSS is not associated with multiple sexual partners.

Multiple sexual partners

A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis?

Rationale:

Visible gastric peristaltic waves moving from the left to the right are a clinical

manifestation of pyloric stenosis.

Absent bowel sounds

Rationale:

Vomiting causes a depletion of fluid and electrolytes, therefore a decrease in serum

sodium levels is a clinical manifestation of pyloric stenosis.

Increased sodium level

Rationale:

Pyloric stenosis is a narrowing and thickening of the pyloric canal between the

stomach and the duodenum resulting in projectile vomiting.

Projectile vomiting after feedings

Rationale:

An olive-shaped mass is palpable right of the umbilicus is a clinical manifestation of

pyloric stenosis.

Golf ball-sized mass over the left quadrant

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Homework 8 – Pediatrics

A nurse is planning care for a child who has juvenile rheumatoid arthritis. Which of the following is an

appropriate action for the nurse to take?

Rationale:

NSAIDs are used to control pain. Therefore, administering opioids on a schedule is

not an appropriate action for the nurse to take.

Administer opioids on a schedule.

Rationale:

Physical mobility will assist in preserving function and maintaining mobility.

Therefore, prolonged periods of complete joint immobilization is not an appropriate

action for the nurse to take.

Schedule prolonged periods of complete joint immobilization daily.

Rationale:

Heat is beneficial for relieving pain and stiffness. Therefore, applying cool

compresses for 20 minutes every hour is not an appropriate action for the nurse to

take.

Apply cool compresses for 20 minutes every hour.

Rationale:

Maintaining night splints to the affected joints will assist in range of motion.

Therefore, this is an appropriate action for the nurse to take.

Maintain night splints to the affected joint.

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Homework 8 – Pediatrics

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected

finding? (Select all that apply.)

Symptoms are continuous throughout the day.

Daytime symptoms occur more than twice a week.

Nighttime symptoms occur approximately twice a month.

Minor limitations occur with normal activity.

Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.

Rationale:

Symptoms are continuous throughout the day is incorrect. Continual asthma

symptoms throughout the day are seen with severe persistent asthma.

Daytime symptoms occur more than twice a week is correct. A child with mild

persistent asthma will typically have daytime symptoms more than twice a week,

but not daily.

Nighttime symptoms occur approximately twice a month is incorrect. Nighttime

symptoms occurring approximately twice a month are seen with intermittent

asthma.

Minor limitations occur with normal activity is correct. A child with mild persistent

asthma will have some minor limitations with normal daily activities.

Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value is

correct. A child with mild persistent asthma will have a PEF greater than or equal to

80% of the predicted value.

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Homework 8 – Pediatrics

A nurse working in a pediatric clinic is collecting data on a preschool-age child who has a rash on his arm. The

mother reports that the child was recently exposed to impetigo contagiosa. Which of the following

manifestations should the nurse expect to find with this skin infection?

Rationale:

This finding is associated with tinia corporis (ringworm), not impetigo.

Scaling patches that are clear in the center.

Rationale:

This finding is associated with impetigo contagiosa. Honey-colored crusts develop

when vesicles rupture and the exudate dries.

Honey-colored crusts caused by dried exudate.

Rationale:

This finding is associated with verruca (warts), not impetigo.

Firm papules with a roughened, finely papillomatous texture.

Rationale:

This finding is associated with poison ivy, not impetigo.

Lines of small blisters surrounding one large blister.

During a routine well child check-up, a nurse is reinforcing teaching to a parent who reports having difficulty

getting a preschool-age child to go to bed. Which of the following statements indicates to the nurse that the

parent understands how to foster a consistent bedtime for the preschooler?

Rationale:

While crying for brief periods of time is not harmful to the child, it may promote a

sense of fear and insecurity and discourage the child from going to sleep.

“I will allow my child to cry himself to sleep each night.”

Rationale:

Allowing the child to routinely come into the parent’s bed fosters the idea that this

will be the norm. The child may then be unwilling to sleep alone.

“I will let my child fall asleep with me, and then move him to his own bed.”

Rationale:

Darkened rooms may elicit fear in a preschooler.

“I will make sure the room is dark when placing my child in bed.”

Rationale:

Transitional objects, such as a blanket or toy, will provide a sense of comfort and

allow the child to fall asleep more quickly.

“I will encourage my child to fall sleep with his favorite toy.”

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Homework 8 – Pediatrics

A nurse is collecting data about a 6-year-old client. Which statement by the client’s parent should concern the

nurse?

Rationale:

Squinting to see the board may indicate a vision problem. It is essential to check

children for hearing and vision problems. If not identified and corrected early, they

lead to frustration and a decreased ability to learn.

“The teacher says my child has to squint to see the board.”

Rationale:

Children of this age begin to lose their deciduous teeth to accommodate the

emergence of their permanent teeth. This is an expected finding.

“My child has recently lost both front top teeth.”

Rationale:

Children of this age often cheat to win at games because they feel winning is most

important. This is an expected finding.

“My child often cheats when we play board games.”

Rationale:

Children of this age are often bossy and are learning how to interact with peers.

This is an expected finding.

“Sometimes my child acts bossy with his friends.”

A nurse working at a clinic speaks on the telephone with the parent of a 2-month-old infant. The parent tells

the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following

responses by the nurse is appropriate?

Rationale:

The manifestations of worsening projectile vomiting, which started at about 6 weeks

of age, and the child acting hungry afterwards, are indicative of pyloric stenosis. The

baby needs to be examined in the clinic as soon as possible by the provider.

“Bring your infant into the clinic today to be seen.”

Rationale:

This is not an appropriate response by the nurse.

“Burp your child more frequently during feedings.”

Rationale:

This is not an appropriate response by the nurse.

“Give your infant an oral rehydrating solution.”

Rationale:

This is not an appropriate response by the nurse.

“You might want to try switching to different formula.”

10.

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Homework 8 – Pediatrics

A parent expresses concern to the nurse about his 5-year-old child’s stuttering. Which of the following

statements is an appropriate nursing response?

Rationale:

Taking time to listen attentively to a child who stutters is an appropriate

recommendation.

“Look directly at your son when he is speaking.”

Rationale:

This response is inappropriate, as it calls attention unnecessarily to the child’s

disfluent speech pattern.

“Try encouraging your son to begin saying the word again.”

Rationale:

This response is inappropriate, because it dismisses the parent’s concern without

offering any recommendations for helping the child.

“Many children his age have problems with stuttering.”

Rationale:

This is an inappropriate response, because it calls attention to the child’s problem

and might reinforce feelings of inadequacy.

“Be sure to correct the child’s speech gently and without judgement.”

11.

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Homework 8 – Pediatrics

A nurse is reinforcing teaching with the parent of a child scheduled for the initial surgery to treat

Hirschsprung’s disease. The nurse knows that the parent understands the goal of the surgery when the parent

states,

Rationale:

Hirschsprung’s disease is characterized by an area of the large intestine without

innervation. The child will probably require 2 surgeries over 18 months to 2 years

before normal bowel function is achieved. The initial surgery is for the creation of an

ostomy, which relieves the obstructed area and allows the bowel distal to the

ostomy to rest.

“I’m glad that the ostomy is only temporary.”

Rationale:

It will probably take 18 months to 2 years for the child to achieve normal bowel

function.

“I’m glad my child will have normal bowel movements now.”

Rationale:

Placement of a feeding tube is not a typical part of the treatment plan for

Hirschsprung’s disease.

“I want to learn how to use the feeding tube as soon as possible.”

Rationale:

This statement indicates a lack of understanding of the pathophysiology of this

disease.

“The operation will straighten out the kink in the intestine.”

12.

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Homework 8 – Pediatrics

A nurse is talking to a parent who is concerned about her hospitalized 5-year-old child’s behavior and asks the

nurse if it is “normal.” The nurse explains that regression is common in hospitalized children and may manifest

by which of the following?

Rationale:

Bedwetting by a preschooler who does not usually do so is a sign of regression in

preschoolers.

Bedwetting several times a day

Rationale:

This behavior is expected with preschoolers and is not a sign of regression.

Crying when the parent leaves

Rationale:

Preschoolers are reluctant to make changes in their dietary habits when ill. This is

not a sign of regression.

Eating only food from home

Rationale:

Transitional objects are helpful in any situation where a child feels anxiety or stress.

This is not a sign of regression.

Cuddling a threadbare blanket at bedtime

13.

A nurse is planning care for a child with suspected epiglottitis. Which of the following is an appropriate action

for the nurse to take?

Rationale:

Obtaining a throat culture on a child with suspected epiglottitis could precipitate

obstruction of the airway and should be avoided.

Obtain a throat culture

Rationale:

Placing the child in an upright position will assist in maintaining a patent airway and

is an appropriate action for the nurse to take.

Place client in an upright position

Rationale:

The airway of a child with suspected epiglottitis could become obstructed easily,

therefore transferring for a throat x-ray is not an appropriate action for the nurse to

take.

Transfer for a throat x-ray

Rationale:

Visualizing the epiglottis with a tongue depressor on a child with suspected

epiglottitis could precipitate obstruction of the airway and should be avoided.

Visualize the epiglottis with a tongue depressor

14.

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Homework 8 – Pediatrics

A school nurse is screening an 11-year-old client for idiopathic scoliosis. Which of the following instructions

should the nurse give the client for this examination?

Rationale:

With the client in this position, the nurse might notice some asymmetry due to

scoliosis. However, this position does not exaggerate the manifestations of this

disorder and is not part of the standard scoliosis screening procedure.

“Lie prone on the examination table.”

Rationale:

These movements might help the nurse test flexion and hyperextension of the neck

to evaluate the cervical spine. They are not part of the standard scoliosis screening

procedure.

“Touch your chin to your chest and then look up at the ceiling.”

Rationale:

Scoliosis is a lateral curvature of the spine that the nurse might not detect from a

side view. This position might help the nurse note kyphosis, a convex thoracic

curvature of the thoracic spine, or lordosis, an abnormal lumbar curvature.

“Turn to the side and remain in a relaxed position.”

Rationale:

Called the Adams position, this posture will make any asymmetry of the ribs and

flanks easier for the nurse to recognize.

“Bend forward from the waist with your head and arms downward.”

15.

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Detailed Answer Key

Homework 8 – Pediatrics

A school nurse is talking with a 13-year-old female at her annual health screening visit. Which of the following

client comments should concern the nurse?

Rationale:

This is an expected comment. Adolescence can be a time of great struggle between

independence and dependence for both the child and the parents.

“My parents treat me like a baby sometimes.”

Rationale:

Adolescents constantly compare themselves to their peers and feel very isolated if

there are any differences. Onset of menses varies and this client is still within the

appropriate time frame.

“I haven’t gotten my period yet, and all my friends have theirs.”

Rationale:

This statement should concern the nurse, as the peer group is critical to adolescent

development and sense of self-esteem. This comment needs to be explored in

greater depth.

“None of the kids at this school like me, and I don’t like them either.”

Rationale:

Adolescents constantly compare themselves to their peers and feel very isolated if

there are any differences.

“There’s a pimple on my face, and I worry that everyone will notice it.”

16.

The nurse is caring for a hospitalized adolescent. The nurse understands that which major developmental task

is important during adolescence?

Rationale:

Building a sense of trust is not an appropriate developmental task of adolescence.

Building a sense of trust

Rationale:

Learning to utilize creative energies is not a developmental task of adolescence.

Learning to utilize creative energies

Rationale:

Learning to defer gratification is not an appropriate developmental task of

adolescence.

Learning to defer gratification

Rationale:

Establishing an identity or defining a sense of self is the major adolescent

developmental task.

Defining a sense of self

17.

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Detailed Answer Key

Homework 8 – Pediatrics

A nurse is talking to the parents of an 8-month-old who will be hospitalized for surgery. Which of the following

actions should the nurse explain to the parents will help prepare the infant for the hospital?

Rationale:

This action could be an effective anxiety-reduction strategy with a preschooler or

school-age child, as a new toy could provide the child with distraction. This is not an

appropriate action to take for a hospitalized infant.

Buy a new toy and give it to the infant at the hospital.

Rationale:

Infants of this age have separation anxiety and often need a transitional object, such

as a blanket or toy, that brings them comfort. The transitional object is especially

important when the child is in unfamiliar surroundings, or the parent is not there to

provide comfort. Having the object will help to provide the infant with a sense of

security.

Bring the infant’s favorite blanket to the hospital.

Rationale:

This action could be an effective anxiety-reduction strategy with an older school-age

child or adolescent, as new clothes could help with the child’s anxiety about body

image. This is not an appropriate action to take for a hospitalized infant.

Purchase new loose-fitting, soft pajamas for the child.

Rationale:

This action could be an effective anxiety-reduction strategy with a preschooler or

school-age child because it will help to prepare the child for a new, anxiety-

producing experience. This is not an appropriate action to take for a hospitalized

infant.

Read the child a story about hospitalization.

18.

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Detailed Answer Key

Homework 8 – Pediatrics

A nurse is planning care for a hospitalized 4-year-old child. The nurse should include providing a

Rationale:

Preschool play centers on imitation of adults. Providing a stethoscope allows the

child to imitate the staff and helps ease the fear of unfamiliar equipment.

plastic stethoscope.

Rationale:

A brightly colored mobile is appropriate for a very young infant. It would not meet

the activity needs of a preschooler.

brightly colored mobile.

Rationale:

A jigsaw puzzle is too difficult for most preschoolers and will frustrate rather than

entertain the child.

jigsaw puzzle.

Rationale:

Helium balloons might entertain the child, but the rubber in a deflated latex balloon

presents a choking hazard.

helium-filled latex balloon.

19.

A nurse is caring for an infant with spinal bifida. Which of the following is an appropriate action for the nurse to

take?

Rationale:

Rectal temperature could case rectal prolapse and should be avoided.

Obtain rectal temperature

Rationale:

Placing the infant in prone position will assist in preventing trama to the lesion.

Place in prone position

Rationale:

The lesion should be covered with a moist cloth to prevent drying.

Cover lesion with a dry cloth

Rationale:

Movement of the lower extremities could cause tension on the lesion and should be

avoided.

Perform ROM to lower extremities

20.

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Detailed Answer Key

Homework 8 – Pediatrics

A school-age child is brought to the emergency department with a 2-day history of nausea, vomiting, and

report of severe right lower quadrant pain. The child’s WBC is 17,000/mm3 so appendicitis is suspected.

Which of the following statements made by the child is most concerning to the nurse?

Rationale:

Many children are frightened by the health care setting. Since this is not

unexpected, this is not the most concerning statement to the nurse.

“I am scared and I want to go home.”

Rationale:

A client with a 2-day history of nausea and vomiting might be dehydrated and feel

both hungry and thirsty. Children may report feeling hungry right after vomiting.

Since this is not unexpected, this is not the most concerning statement to the nurse.

“I am hungry and thirsty.”

Rationale:

A client with a 2-day history of nausea and vomiting might be dehydrated and

exhausted. Clients of all ages may sleep when they are ill or in pain. Since this is

not unexpected, this is not the most concerning statement to the nurse.

“I’m tired and want to take a nap.”

Rationale:

The nurse’s findings of a 2-day history of nausea, vomiting, and severe right lower

quadrant pain, along with the laboratory findings of an elevated white blood cell

(WBC) count are highly suspicious of appendicitis. Sudden relief of pain may be an

early indicator of appendix rupture which would be a surgical emergency. Since the

greatest risk to the client is peritonitis secondary to a burst appendix, this statement

by the child is most concerning to the nurse.

“My belly doesn’t hurt anymore.”

21.

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Detailed Answer Key

Homework 8 – Pediatrics

At the preoperative visit before an elective surgery, the nurse is planning to prepare a 9-year-old client for IV

catheter insertion. When reinforcing teaching, the nurse will first

Rationale:

While this is both important and appropriate, this is not the first action the nurse

should take.

explain to the client’s parents what they can expect during and after IV insertion.

Rationale:

While this is important and appropriate, it is best initiated at the conclusion of the

visit.

provide an opportunity for the client to see and touch IV tubing and supplies.

Rationale:

While this is important and appropriate, it is not the first action the nurse should

take.

describe the insertion procedure to the client, emphasizing sensory aspects.

Rationale:

A key principle of teaching/learning theory is to first determine the learner’s prior

knowledge and readiness to learn. The child’s perception of the anticipated

experience illuminates any misconceptions that require clarification. In addition, it is

possible that the child has had experience with IV therapy, and the nurse can build

on this knowledge.

ask the client what he knows about having an IV infusion.

22.

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Detailed Answer Key

Homework 8 – Pediatrics

An assistive personnel (AP) on a pediatric unit brings to the attention of the nurse several client measurements

obtained with the morning vital signs. Which of the following clients should the nurse plan to visit first?

Rationale:

A specific gravity of 1.002 is much lower than the expected reference range (1.005

to 1.030) and indicates urine output that is extremely dilute. The client is losing

excessive water and is in danger of hypovolemia. Therefore, the nurse should plan

to visit this client first.

7-year-old client with diabetes insipidus and a urine specific gravity of 1.002

Rationale:

A fever of 39°C (102.2°F) is an expected finding in a child with roseola; therefore,

this is not the client that the nurse should plan to visit first.

1-year-old client with roseola and a temperature of 39°C (102.2°F)

Rationale:

This value, 95%, is considered within the expected range; therefore, this is not the

client that the nurse should plan to visit first.

4-year-old client with status asthmaticus and a pulse oximetry of 95%

Rationale:

A pain level of 6 is not unexpected or life threatening. Therefore, this is not the client

that the nurse should plan to visit first.

10-year-old client with sickle cell anemia and a pain rating of 6 out of 10

23.

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Detailed Answer Key

Homework 8 – Pediatrics

A nurse is collecting data from an infant. Which of the following is clinical manifestation of a large patent

ductus arteriosus?

Rationale:

A patent ductus arteriosus is failure of the artery connecting the aorta and

pulmonary artery to close after birth causing a left-to-right shunt. Therefore,

cyanosis is not a clinical manifestation of a large patent ductus arteriosus.

Cyanosis with crying

Rationale:

A patent ductus arteriosus is failure of the artery connecting the aorta and

pulmonary artery to close after birth causing a left-to-right shunt. A machinery-like

murmur is a clinical manifestation found in infants with a large patent ductus

arteriosus.

Machinery-like murmur

Rationale:

A patent ductus arteriosus is failure of the artery connecting the aorta and

pulmonary artery to close after birth causing a left-to-right shunt. Therefore,

bounding pulses are a clinical manifestation of a large patent ductus arteriosus.

Weak pulses

Rationale:

A patent ductus arteriosus is failure of the artery connecting the aorta and

pulmonary artery to close after birth causing a left-to-right shunt. Therefore, chronic

hypoxemia is not a clinical manifestation of a large patent ductus arteriosus.

Chronic hypoxemia

24.

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Detailed Answer Key

Homework 8 – Pediatrics

A nurse is caring for an infant who is dehydrated and requires therapy. The nurse should monitor the infant’s

response to therapy by

Rationale:

Weight is the most sensitive indicator of hydration status for clients of all ages.

Weight is the only measurement that reflects both measurable fluid balance

changes and incidental fluid loss.

weighing the infant at the same time every day.

Rationale:

Vital signs are not a reliable indicator of hydration status.

taking the infant’s vital signs every 2 hr.

Rationale:

Measuring head circumference gives no useful information regarding the hydration

status of the infant.

measuring the infant’s head circumference twice a day.

Rationale:

Counting wet diapers is inadequate to accurately determine the hydration status of

the infant.

counting the number of wet diapers every shift.

25.

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End of Test

*items are not administered in this order.

Detailed Answer Key

Homework 8 – Pediatrics

A nurse is caring for a pre-school age child who has a epiglottitis with a barking cough. Which of the following

is an appropriate nursing action?

Rationale:

Encouraging the client to cough is not an appropriate nursing and precipitates a

complete obstruction.

Encourage coughing.

Rationale:

Attempting to obtain a throat culture is not an appropriate nursing action and may

precipitate a complete obstruction.

Attempt to obtain a throat culture.

Rationale:

Trying to visualize the back of the throat is not an appropriate nursing action and

may precipitate a complete obstruction.

Visualize the back of the throat.

Rationale:

Applying high-flow oxygen on the client and keeping the client calm is an

appropriate action by the nurse to improve oxygenation.

Apply oxygen.

A nurse is reinforcing teaching to the parents of a child who has cystic fibrosis and has a prescription for

pancrelipase (Pancrease) capsules. Which of the following should the nurse include in the teaching?

Rationale:

Pancrelipase is a digestive enzyme that must be administered with all snacks or

meals in order for the food to be properly digested.

Administer the medication with meals and snacks.

Rationale:

The medication maybe taken whole or the capsules may be opened up and the

contents sprinkled on soft food.

Capsules must be taken whole.

Rationale:

Pancreatic enzymes will be needed throughout the child’s life.

This medication may be discontinued when symptoms diminish.

Rationale:

With sufficient replacement of the pancreatic enzyme, the client should experience a

decrease in the number of stools.

This medication may cause a diarrhea.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is collecting data from an 11-month-old infant. Which of the following clinical manifestations is

suggestive of a central nervous system infection?

Rationale:

Oliguria is a clinical manifestation of shock or kidney disease. However, it is not a

clinical manifestation of a central nervous system infection.

Oliguria

Rationale:

A central nervous system infection causes increased intracranial pressure.

Therefore, bulging fontanels are a clinical manifestation of a central nervous system

infection.

Bulging fontanel

Rationale:

A positive Brudzinski sign is a clinical manifestation of a central nervous system

infection.

Negative Brudzinski sign

Rationale:

Jaundice is a clinical manifestation liver disease. However, not a clinical

manifestation of a central nervous system infection.

Jaundice

A nurse is caring for a child diagnosed with tinea pedis. The nurse should respond with which of the following

when asked by the parent what the common name for this disorder is?

Rationale:

Shingles is the common name for varicella zoster.

Shingles

Rationale:

Athlete’s foot is the common name for tinea pedis.

Athlete’s foot

Rationale:

Fever blister is the common name for herpes simplex virus type I.

Fever blister

Rationale:

Valley fever is the common name for coccidioidomycosis.

Valley fever

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is reinforcing teaching to an adolescent client regarding administration of Gardasil vaccine. For which

of the following sexually transmitted infections does the vaccine provide immunity?

Rationale:

Gardasil is the only HPV vaccine that helps provide immunity against 4 types of

HPV. These include type 6, 11, 16, and 18. The immunization schedule for Gardasil

is 3 injections over a 6 month period. Clients should receive this vaccine between

the ages of 9 and 26.

Human papillomavirus (HPV)

Rationale:

Gardasil does not provide immunity against HSV-2.

Herpes simplex virus (HSV-2)

Rationale:

Gardasil does not provide immunity against chlamydia trachomatis.

Chlamydia trachomatis

Rationale:

Gardasil does not provide immunity against gonorrhea.

Gonorrhea

A nurse is reinforcing teaching to an assistive personnel to count respiration rate on a newborn. Which of the

following statements indicate understanding of why the respiratory rate should be counted for a complete

minute?

Rationale:

Newborns are abdominal breathers. However, this has no impact on obtaining a

respiratory rate.

“Newborns are abdominal breathers.”

Rationale:

The labor of breathing in a newborn will vary. However, this has no impact on

obtaining a respiratory rate.

“Newborns do not expand their lungs fully with each respiration.”

Rationale:

Activity will increase the respiration rate. However, this has no impact on obtaining a

respiratory rate.

“Activity will increase the respiration rate.”

Rationale:

Newborns have an irregular respiratory rate and rhythm. Therefore, counting the

respiratory rate for a complete minute is recommended to obtain an accurate rate.

“The rate and rhythm are irregular in newborns.”

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is caring for a toddler who has a fractured right femur and is in Bryant’s traction. When monitoring to

determine if the traction is appropriately assembled, the nurse expects to observe which of the following?

Rationale:

Skin straps maintaining the leg in an extended position is appropriate for Buck

extension traction.

Skin straps maintaining the leg in an extended position.

Rationale:

Weights attached to a pin that is inserted in the femur are appropriate for skeletal

traction.

Weights attached to a pin that is inserted in the femur.

Rationale:

A padded sling under the knee of the affected leg is appropriate for Russell traction.

A padded sling under the knee of the affected leg.

Rationale:

The buttocks elevated slightly off of the bed is appropriate for Bryant traction. The

child’s hips are flexed at a 90-degree angle with the legs suspended by pulleys and

weights. The weights must hang freely from the bed to maintain alignment.

The buttocks elevated slightly off of the bed.

A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal

area and his urine is a pink color. Which of the following is the priority action the nurse should take?

Rationale:

While it is important to schedule the child for an ultrasound, this is not the nurse’s

priority action.

Schedule the child for an abdominal ultrasound.

Rationale:

The priority action by the nurse is to instruct the parent to avoid pressing on the

child’s abdominal. These symptoms are associated with Wilm’s tumor, and trauma

to the mass should be avoided to prevent entry of cancer cells into other sites.

Instruct the parent to avoid pressing on the abdominal area.

Rationale:

While it is important to determine if the child is having pain, this is not the nurse’s

priority action.

Determine if the child is having pain.

Rationale:

While it is important to obtain a urine specimen for a urinalysis, this is not the nurse’

s priority action.

Obtain a urine specimen for a urinalysis.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected

finding? (Select all that apply.)

Symptoms are continuous throughout the day.

Daytime symptoms occur more than twice a week.

Nighttime symptoms occur approximately twice a month.

Minor limitations occur with normal activity.

Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.

Rationale:

Symptoms are continuous throughout the day is incorrect. Continual asthma

symptoms throughout the day are seen with severe persistent asthma.

Daytime symptoms occur more than twice a week is correct. A child with mild

persistent asthma will typically have daytime symptoms more than twice a week,

but not daily.

Nighttime symptoms occur approximately twice a month is incorrect. Nighttime

symptoms occurring approximately twice a month are seen with intermittent

asthma.

Minor limitations occur with normal activity is correct. A child with mild persistent

asthma will have some minor limitations with normal daily activities.

Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value is

correct. A child with mild persistent asthma will have a PEF greater than or equal to

80% of the predicted value.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is caring for a preterm newborn who is in an incubator. The nurse should make sure that the

maximum oxygen concentration to deliver to this client is

Rationale:

This is a safe oxygen concentration to deliver to a preterm newborn, but not the

maximum. Of course, the nurse should make sure the newborn receives the oxygen

concentration the provider prescribes.

30%.

Rationale:

Oxygen concentrations higher than 40% can cause retinal damage and visual

impairment. This is the maximum concentration to deliver.

40%.

Rationale:

This is an unsafe oxygen concentration to deliver to a preterm newborn. The nurse

should make sure the newborn receives the oxygen concentration the provider

prescribes.

50%.

Rationale:

This is an unsafe oxygen concentration to deliver to a preterm newborn. The nurse

should make sure the newborn receives the oxygen concentration the provider

prescribes.

60%.

10.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is reinforcing teaching to a parent and a school-age child following application of a fiberglass cast for a

radius fracture. Which of the following statements by the parent or child indicates the need for further

teaching?

Rationale:

The child should move his fingers frequently to promote circulation and maintain

range of motion.

“I will try not to move my fingers very much while I have the cast on.”

Rationale:

The child should keep the injured extremity elevated as often as possible to prevent

swelling and pain.

“I will have my arm in a sling whenever I am walking around.”

Rationale:

The parent should keep an ice bag on the child’s cast for the first 24 to 36 hr to

decrease swelling from the injury.

“I will keep an ice bag on my son’s cast to decrease swelling.”

Rationale:

The parent should immediately report any change in skin color of the fingers that

are distal to the cast as this can indicate neurovascular impairment. Swelling may

have caused the cast to become too tight and intervention is necessary to prevent

permanent tissue and muscle damage.

“I will notify the provider if I notice any discoloration of my son’s fingers.”

11.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is collecting data from a child. Which of the following is a clinical manifestation of nephrotic

syndrome?

Rationale:

The glomerular membrane is permeable to albumin and is excreted thus changing

the colloidal osmotic pressure. Therefore, a decrease in urine is a clinical

manifestation of nephrotic syndrome.

Polyuria

Rationale:

The glomerular membrane is permeable to albumin and is excreted thus changing

the colloidal osmotic pressure. Therefore, facial edema is a clinical manifestation of

nephrotic syndrome.

Facial edema

Rationale:

Urine will consist of proteinuria, hyaline casts, oval fat bodies, and decreased

volume. Therefore, frothy urine is a clinical manifestation of nephrotic syndrome.

Smokey brown urine

Rationale:

The glomerular membrane is permeable to albumin and is excreted thus changing

the colloidal osmotic pressure leading to hypovolemia. Therefore, normal or

hypotension is a clinical manifestation of nephrotic syndrome.

Hypertension

12.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings are

associated with this diagnosis? (Select all that apply.)

Coughing

Apnea

Sunken abdomen

Cyanosis

Frothy saliva

13.

Rationale:

Coughing is correct. Coughing is a finding associated with a tracheoesophageal

fistula.

Apnea is correct. Apnea is a finding associated with a tracheoesophageal fistula.

Sunken abdomen is incorrect. Abdominal distension, not a sunken abdomen, is a

finding associated with a tracheoesophageal fistula.

Cyanosis is correct. Cyanosis is a finding associated with a tracheoesophageal

fistula.

Frothy saliva is correct. Frothy saliva is a finding associated with a

tracheoesophageal fistula.

A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings

should the nurse expect?

Rationale:

Infants with pyloric stenosis have projectile vomiting often ejecting vomitus several

feet.

Projectile vomiting

Rationale:

Infants with pyloric stenosis vomit nonbilious fluid.

Bile colored vomit

Rationale:

Infants with pyloric stenosis have active bowel sounds and visible gastric waves.

Absent bowel sounds

Rationale:

Infants with pyloric stenosis constantly show signs of hunger and are avid nursers.

Indifferent approach to feedings

14.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is caring for a child with acute glomerulonephritis. Which of the following should be the first action by

the nurse?

Rationale:

Placing the child on a no-salt-added diet is an appropriate action; however, it is not

the first action the nurse should take.

Place the child on a no-salt-added diet.

Rationale:

The first action the nurse should take using the nursing process is to collect data

from the client; therefore, checking the child’s daily weight should be the first action

the nurse takes.

Check the child’s daily weight.

Rationale:

Educating the parents about potential complications is an appropriate action;

however, it is not the first action the nurse should take.

Educate the parents about potential complications.

Rationale:

Maintaining a saline-lock is an appropriate action; however, it is not the first action

the nurse should take.

Maintain a saline-lock.

15.

A nurse is caring for a child with Kawasaki disease. Which of the following is the primary system involved with

this diagnosis?

Rationale:

Cardiovascular changes occur in children diagnosed with Kawasaki disease due to

inflammation of the arterioles, venules, and capillaries; therefore, this is the primary

system involved with this diagnosis.

Cardiovascular

Rationale:

The gastrointestinal system is not the primary system involved with the diagnosis of

Kawasaki disease.

Gastrointestinal

Rationale:

The integumentary system is not the primary system involved with the diagnosis of

Kawasaki disease.

Integumentary

Rationale:

The respiratory system is not the primary system involved with the diagnosis of

Kawasaki disease.

Respiratory

16.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is collecting data from a 7-month-old infant. Which of the following would indicate the need for further

evaluation?

Rationale:

A 7-month-old infant should exhibit a unidextrous approach and grasp, therefore this

would not indicate the need for further evaluation.

Uses a unidextrous grasp

Rationale:

A 7-month-old infant should exhibit a fear of strangers, therefore this would not

indicate the need for further evaluation.

Has a fear of strangers

Rationale:

A 7-month-old infant should exhibit a preference towards food likes and dislikes,

therefore this would not indicate the need for further evaluation.

Shows preferences towards foods

Rationale:

A 7-month-old infant should babble in changed syllables, therefore this would

indicate the need for further evaluation.

Babbles one-syllable sounds

17.

A nurse is caring for a 6 month old who is posteroperative following a myringotomy. Which of the following is

an appropriate method to determine the infant’s pain level?

Rationale:

The FLACC pain scale is appropriate to use with infant and children between the

ages of 2 months and 7 years.

FLACC pain scale

Rationale:

The OUCHER pain scale is appropriate to use with children between the ages of 3

and 13 years.

OUCHER pain scale

Rationale:

The faces pain scale is appropriate to use with children as young as 3 years of age.

Faces pain scale

Rationale:

The visual analog pain scale is appropriate to use with children as young as 4½

years of age.

Visual analog pain scale

18.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is assisting with the discharge of a child with sickle cell anemia after an acute crisis episode. Which of

the following should the nurse reinforce with the child’s parents?

Rationale:

The parents only need to check the child’s temperature when they suspect fever,

and when they do, they should report it to the provider immediately. Fever is a

manifestation of acute chest syndrome, a complication of sickle cell anemia.

Monitor the child’s temperature daily.

Rationale:

The child may play as usual.

Restrict outdoor play activity to 1 hr per day.

Rationale:

Preventing dehydration is an important step in preventing a sickle cell crisis. The

nurse should give the parents a specific amount of fluid to make should the child

drinks each day.

Encourage the child to drink lots of fluids.

Rationale:

The child should eat a well-balanced diet, not unusually high in protein.

Have the child eat a high-protein diet.

19.

A nurse is collecting data regarding the pain level of a 4-year-old client on the second postoperative day.

Which of the following actions should the nurse take?

Rationale:

An ordinal scale is not appropriate to use with a 4-year-old client.

Ask the client what number the pain is on a scale from 1 to 10.

Rationale:

The FACES Pain Rating Scale is an age appropriate pain assessment tool for a 4-

year-old client.

Tell the client to point to a face on a FACES Pain Rating Scale.

Rationale:

The nurse should use an age appropriate pain rating scale for a 4-year-old client.

The parent may not be able to accurately report the client’s pain level.

Have the parent report the pain level for the client.

Rationale:

Determining a 4-year-old client’s pain level is not within the scope of practice of an

assistive personnel.

Request an assistive personnel to evaluate the client’s pain level.

20.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is preparing to administer acetaminophen (Tylenol) to a child for fever. The order states to administer

10 mg/kg/dose. The child weighs 28 pounds. The label on the bottle reads 120 mg/5 mL. How many milliliters

should the nurse administer? (Round to the nearest tenth.)

Correct Rationale:

Convert pounds to kilograms:

28 pounds/ 2.2 pounds per kilogram = X

X = 12.7 kg

Desired dose = 12.7 kg X 10 mg/kg/dose = 127 mg/dose

(Desired X Quantity) / Have = Amount to give

(127 mg x 5 mL) / 120 mg = X

X = 5.29 = 5.3 mL

5.3 mL

Incorrect Rationale:

Convert pounds to kilograms:

28 pounds/ 2.2 pounds per kilogram = X

X = 12.7 kg

Desired dose = 12.7 kg X 10 mg/kg/dose = 127 mg/dose

(Desired X Quantity) / Have = Amount to give

(127 mg x 5 mL) / 120 mg = X

X = 5.29 = 5.3 mL

21.

A nurse is monitoring a child for acute signs of lead poisoning. Which of the following should the nurse expect

the client to manifest?

Rationale:

The client may manifest decreased urinary output if the kidneys are affected rather

than increased urinary output.

Increase urinary output

Rationale:

The client may manifest anorexia which is an acute sign of lead poisoning.

Anorexia

Rationale:

The client may manifest constipation not diarrhea as an acute sign of lead

poisoning.

Diarrhea

Rationale:

The client would not manifest jaundice as an acute sign of lead poisoning.

Jaundice

22.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is caring for a school-age child with acute glomerulonephritis who has peripheral edema and is

producing 35 mL of urine per hr. The client should be placed on which of the following diets?

Rationale:

The child will be placed on a low-sodium, fluid-restricted diet to prevent

complications.

Low-sodium, fluid-restricted

Rationale:

A regular diet with no added salt is not an appropriate diet for a client with acute

glomerulonephritis with peripheral edema.

Regular diet, no added salt

Rationale:

A low-carbohydrate, low-protein diet is not an appropriate diet for a client with acute

glomerulonephritis with peripheral edema and 35 mL urinary output per hr.

Low-carbohydrate, low-protein diet

Rationale:

A low-protein, low-potassium diet is not an appropriate diet for a client with acute

glomerulonephritis with peripheral edema and 35 mL urinary output per hr.

Potassium intake is restricted in periods of oliguria.

Low-protein, low-potassium diet

23.

A nurse is reinforcing teaching to the mother of a 2-month-old infant who had a Pavlik harness applied one

week earlier for the treatment of developmental hip dysplasia. Which of the following statements made by the

mother indicates an understanding of the teaching?

Rationale:

The mother should only adjust the straps with medical supervision.

“I adjust the harness straps each day.”

Rationale:

Triple-diapering is not recommended for hip dysplasia as it can worsen

development of the hip.

“I use triple-diapering when his harness is removed.”

Rationale:

The mother should place a shirt under the straps of the harness to prevent the

straps from rubbing and causing skin irritation.

“I put a shirt under the straps of the harness.”

Rationale:

The mother should not use lotions and powders on the skin because they can cake

and irritate the skin.

“I gently massage lotion on his skin around the harness clasps.”

24.

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Detailed Answer Key

Homework 10 – Pediatrics

A nurse is preparing a 4-year-old client for discharge following a bilateral myringotomy with tympanostomy

tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of

the following instructions?

Rationale:

Attempting to reinsert the tubes could cause trauma.

Gently reinsert the tubes.

Rationale:

Dislodgement of the tubes is not an emergency situation.

Take the child to the emergency department.

Rationale:

If the tubes fall out, no immediate intervention is necessary, but the parent should

notify the provider, who might wish to reassess the child at that time.

Call the health care clinic to report that the tubes have fallen out.

Rationale:

It is a reasonable expectation that the tubes will fall out.

Reassure the mother that the tubes will not fall out.

25.

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End of Test

*items are not administered in this order.

Detailed Answer Key

Homework 10 – Pediatrics

A nurse is caring for an infant after surgical repair of a cleft lip. The nurse should comfort the infant by

Rationale:

After a cleft lip repair, the nurse should try to minimize crying. Crying pulls on the

incision line, causing inflammation and increasing the risk of scar tissue formation.

rocking her with a favorite blanket.

Rationale:

A pacifier is contraindicated for this client.

offering her a pacifier.

Rationale:

This intervention is not likely to calm the client.

placing her in a play yard at the nurses’ station.

Rationale:

The infant should be placed on her side when in the crib.

positioning her on her abdomen.

A nurse is caring for a 4-year-old child who had hydrocephalus as an infant and is admitted with a

malfunctioning ventriculoperitoneal shunt. Following new shunt placement, the nurse conducts a postoperative

check. Which of the following findings requires immediate action by the nurse?

Rationale:

The child may be sleepy following surgery but should be easily aroused. Lethargy

could indicate a decreased level of consciousness or increasing intracranial

pressure and should be reported immediately.

Sleepy and very difficult to arouse

Rationale:

The child should be positioned on the unaffected side to avoid pressure on the

shunt valve. Lying flat is often prescribed after initial shunt placement, not

necessarily after elective replacement. If the child has signs of increasing

intracranial pressure, the provider might prescribe upright positioning.

Lying flat on the unaffected side

Rationale:

These vital signs are within the expected range for a 4-year-old child.

BP 100/60, apical pulse rate of 90

Rationale:

A urine output of 50 mL in 2 hr indicates adequate renal function for a 4-year-old

child.

Urine output 50 mL in 2 hr

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse caring for a child who has tetralogy of Fallot and notes that the child is easily fatigued. The nurse

understands that the etiology of the fatigue is which of the following?

Rationale:

This is a result, not the etiology, of the fatigue. The child tires too easily to take in

adequate nutrition.

Inadequate intake of high-calorie foods and vitamins

Rationale:

Poor muscle tone and development are not the cause of the fatigue.

Poor muscular tone and development

Rationale:

Fatigue is a direct result of the child circulating poorly oxygenated blood due to left-

to-right shunting of blood.

Inadequate oxygenation for supporting energy metabolism

Rationale:

This describes aortic stenosis.

Restricted blood flow leaving the heart

A nurse is caring for a toddler scheduled to have a lumbar puncture (LP) to rule out meningitis. The nurse who

is planning to assist with the procedure should

Rationale:

One nurse should be able to assist with the procedure.

have another nurse to help hold the toddler.

Rationale:

This is not an appropriate position for a toddler who is being prepared for a lumbar

puncture.

sit the toddler on the side of bed.

Rationale:

A lumbar puncture (LP) is a procedure in which a small amount of the fluid that

surrounds the brain and spinal cord called the cerebrospinal fluid, or CSF, is

removed and examined. The client is positioned on the side in a fetal position

(knees curled to abdomen and chin tucked to chest).

place the toddler in a side-lying, knee-chest position.

Rationale:

Mummy restraints may be used when performing a procedure such as suturing a

facial laceration, but it would place the child in an inappropriate position when

performing an lumbar puncture.

use a mummy restraint.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse in the emergency department is caring for an infant who ingested lye. Which of the following is an

appropriate action of the nurse?

Rationale:

Infants who have ingested a caustic substance should be observed for increasing

restlessness, which is an accompanying sign of oxygen deprivation. Swelling of the

throat and trachea commonly occur after ingestion of lye.

Observe for increasing restlessness.

Rationale:

Vomiting should not be induced with caustic poisonings due to the risk for additional

burns.

Induce vomiting

Rationale:

Chelating agents are not indicated for caustic poisonings. These agents are used

with iron poisonings because they bind with metals and allow them to be excreted

from the body.

Administer a chelating agent.

Rationale:

Monitoring liver enzymes is not indicated for caustic poisonings. Liver enzymes

should be monitored with acetaminophen (Tylenol) poisoning.

Monitor liver enzymes.

A nurse is caring for a child with Legg-Calve-Perthes disease that is in Buck extension traction. Which of the

following is an appropriate action for the nurse to take?

Rationale:

This is an appropriate action by the nurse. The child should be repositioned every 2

hr to prevent skin breakdown.

Reposition the child every 2 hr.

Rationale:

The traction boot should not be removed. The nurse should assess the device

frequently to ensure circulation is maintained.

Remove traction boot during bath.

Rationale:

Buck extension traction is skin traction, and does not require pins.

Apply antibiotic ointment to pin sites daily.

Rationale:

Fluid intake should be increased, instead of decreased, to minimize risks associated

with immobility.

Reduce fluid intake.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric

stenosis. Which of the following findings should the nurse expect?

Rationale:

The client with pyloric stenosis would experience metabolic alkalosis.

Metabolic acidosis

Rationale:

Effortless regurgitation is a manifestation of gastroesophageal reflux disease

(GERD), which is due to incompetence of the lower esophageal (cardiac) sphincter.

Effortless regurgitation

Rationale:

The client with pyloric stenosis would experience muscle wasting and weight loss

rather than a distended abdomen.

A distended abdomen

Rationale:

Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the

small intestine, which does not allow for emptying of the stomach contents.

Vomiting, which is usually mild at first, becomes more forceful and progresses to

projectile vomiting.

Projectile vomiting

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical

obstruction. Which of the following disorders does the infant have?

Rationale:

Encopresis is constipation with fecal soiling.

Encopresis

Rationale:

Enterocolitis is diarrhea involving the colon and intestines.

Enterocolitis

Rationale:

Pyloric stenosis is a thickening of the pyloric channel resulting in an outlet

obstruction.

Pyloric stenosis

Rationale:

Hirschsprung disease is an inadequate motility of part of the intestine resulting in a

mechanical obstruction.

Hirschsprung disease

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a child who has idiopathic thrombocytopenic purpura and is experiencing a nose bleed.

Which of the following is an appropriate action by the nurse?

Rationale:

The nurse should apply ice, or a cold cloth, to the bridge of the nose instead of the

back of the neck.

Apply ice to the back of the neck.

Rationale:

To prevent aspiration, the nurse should position the child sitting up and leaning

forward, not supine.

Position the child supine.

Rationale:

The nurse should insert cotton into each nostril to assist with controlling the

bleeding.

Insert cotton into each nostril.

Rationale:

The nurse should tilt the child’s head forward, not back.

Tilt the child’s head back.

A nurse is caring for a toddler who is experiencing separation anxiety. Which of the following is an appropriate

action for the nurse to take?

Rationale:

Toddlers have limited concept of time. Therefore, explaining to the toddler that her

parents will return in one hour is not an appropriate action for the nurse to take.

Explain to the toddler that her parents will return in one hour.

Rationale:

Parents are encouraged to tell their toddler that they are leaving to prevent the

uncertainty of their absence. Therefore, assisting the parents to sneak out of the

room is not an appropriate action for the nurse to take.

Assist the parents to sneak out of the toddler’s room.

Rationale:

Telling the parents about the reaction of the toddler will ease the stress of the

separation.

Tell the parents about the reaction of the toddler while they were gone.

Rationale:

Toddlers that experience separation anxiety should not be left alone. Therefore, this

is not an appropriate action for the nurse to take.

Leave the toddler alone for five minutes to cry it out.

10.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a 3-year-old client who has persistent otitis media. To help identify contributing factors,

the nurse should ask the parents which of the following questions?

Rationale:

Hearing loss is a possible outcome of, not a risk factor for, otitis media.

“Has your daughter shown any signs of hearing loss?”

Rationale:

Allergies to common irritants such as smoke can cause congestion and chronic

otitis media.

“Does anyone smoke around or in the same house as your daughter?”

Rationale:

Water in the ears may cause otitis externa (swimmer’s ear).

“Does your daughter get water in her ears when you bathe her?”

Rationale:

A fever is a manifestation of, not a risk factor for, otitis media.

“Has your daughter had a fever recently?”

11.

A nurse is caring for a child with a suspected diagnosis of cystic fibrosis. Which of the following diagnostic

tests will the nurse prepare the child for to confirm the diagnosis?

Rationale:

Clients with cystic fibrosis have an increase of sodium and chloride in both saliva

and sweat. Therefore, a sweat chloride test is a definitive diagnostic test to

determine the diagnosis of cystic fibrosis.

Sweat chloride test

Rationale:

A sputum culture will determine the organism infecting the lungs. However, it is not

a diagnostic test to determine the diagnosis of cystic fibrosis.

A sputum culture

Rationale:

A stool fat content analysis will determine the amount of fat within a stool. However,

it is not a diagnostic test to determine the diagnosis of cystic fibrosis.

A stool fat content analysis

Rationale:

Pulmonary function tests will determine the lung capability. However, it is not a

diagnostic test to determine the diagnosis of cystic fibrosis.

Pulmonary function test

12.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a 3-year-old client whose parents report that she has an intense fear of painful

procedures, such as injections. Which of the following strategies should the nurse contribute to the child’s plan

of care? (Select all that apply.)

Have a parent stay with the child during procedures.

Cluster invasive procedures whenever possible.

Perform the procedure as quickly as possible.

Allow the child to keep a toy from home with her.

Use mummy restraints during painful procedures.

13.

Rationale:

Have a parent stay with the child during procedures is correct. Maintaining parent-

child contact is one of the most supportive interventions for toddlers and

preschoolers undergoing painful procedures.

Cluster invasive procedures whenever possible is incorrect. This creates an

unnecessarily lengthy painful period for the client, which is likely to increase her

fear.

Perform the procedure as quickly as possible is correct. Moving quickly through the

procedure is one of the most supportive interventions for toddlers and preschoolers

undergoing painful procedures.

Allow the child to keep a toy from home with her is correct. Having familiar and

cherished objects nearby are therapeutic for children during their hospitalization.

Use mummy restraints during painful procedures is incorrect. This helps immobilize

very young children and keep them safe during procedures, but it is likely to

increase terror in toddlers and preschoolers.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for an adolescent who is admitted with sickle cell crisis. Which of the following nursing

actions should be performed?

Rationale:

This is not an appropriate nursing action. Narcotics should not be withheld from a

client in sickle cell crisis.

Withhold narcotics to avoid dependence.

Rationale:

This is not an appropriate nursing action. Increasing fluid intake helps prevent

dehydration vaso-occlusion.

Place client on a 2 L/day fluid restriction.

Rationale:

This is not an appropriate nursing action. During a sickle cell crisis, activity should

be minimized. Clients are usually placed on bed rest to decrease the need for

oxygen by the cells.

Encourage exercise.

Rationale:

This is an appropriate nursing action. Hemoglobin S forms a sickled shape in the

presence of low oxygen tension, and oxygen is administered to prevent the

condition of low oxygen tension.

Administer oxygen via nasal cannula.

14.

A nurse is caring for a child who just underwent insertion of a ventriculoperitoneal shunt. Which of the following

positions would be appropriate for the client?

Rationale:

On the operative side is not an appropriate position for this client.

On the operative side

Rationale:

A 45-degree elevation of the head of bed is not the appropriate position for this

client.

A 45-degree head elevation

Rationale:

Lying on the stomach is not the appropriate position for this client.

Prone

Rationale:

Lying flat on the back is the appropriate position for this client. This position keeps

the head level with the body, which reduces the risk of cerebrospinal fluid flowing

too rapidly, leading to rapid decompression, which can result in tearing of the

cerebral arteries.

Dorsal recumbent

15.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a child who is having a seizure. Which of the following is an appropriate action by the

nurse? (Select all that apply.)

Check the client’s airway for patency.

Place a tongue depressor in the client’s mouth.

Place the bed in a low position.

Place the client in prone position.

Restrain the client.

16.

Rationale:

Assess the client’s airway patency is correct. This is an appropriate action by the

nurse.

Place a tongue depressor in the client’s mouth is incorrect. Placing something in the

client’s mouth can cause injury, and is not an appropriate action by the nurse.

Place the bed in a low position is correct. This is an appropriate action by the nurse.

Place the client in prone position is incorrect. The client should be positioned side-

lying to prevent aspiration of secretions or vomit.

Restrain the client is incorrect. Restraining the client can cause injury, and is not an

appropriate action by the nurse.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is collecting data on a child who is descending stairs by placing both feet on each step while holding

on to the railing. This is developmentally appropriate at which of the following ages?

Rationale:

At age 3, children can typically go up stairs using alternating feet, but still descend

by placing both feet on each step.

3 years

Rationale:

By age 4, they descend using alternating feet and holding the railing.

4 years

Rationale:

By age 5, children’s balance improves and they continue going up and down stairs

using alternating feet and holding the railing.

5 years

Rationale:

At age 6, balance is improved and children are proficient at going up and down

stairs.

6 years

17.

A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the

priority action by the nurse?

Rationale:

The priority nursing action is to administer antibiotics when available. Bacterial

meningitis is an acute inflammation of the meninges and the CNS, and antibiotic

therapy has a marked effect on the course and prognosis of the illness.

Administer antibiotics when available.

Rationale:

Reducing environmental stimuli is an appropriate action by the nurse; however, this

is not the priority.

Reduce environmental stimuli.

Rationale:

Documenting intake and output is an appropriate action by the nurse; however, this

is not the priority.

Document intake and output.

Rationale:

Maintaining seizure precautions is an appropriate action by the nurse; however, this

is not the priority.

Maintain seizure precautions.

18.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a 4-year-old client following abdominal surgery. Which of the following statements is

appropriate for the nurse to use to encourage the child to take deep breaths?

Rationale:

This is a punitive remark that the child could perceive as a threat or a challenge.

“You can’t go to the playroom until you finish doing your deep breathing.”

Rationale:

By engaging the child in a form of play, the nurse may distract him from the

discomfort of deep breathing.

“Let’s play a game of blowing cotton balls across your table.”

Rationale:

Since deep breathing will be uncomfortable, it is unlikely that the child will perform it

without coaching.

“I’ll leave your blow bottle here on your table, so you can use it yourself like a big kid.”

Rationale:

This action is going to be painful, and the child may not respond to positive

reinforcement after the pain.

“I will give you a sticker each time you take a deep breath.”

19.

A nurse is caring for a school-age child who has environmental allergies who is scheduled to begin

desensitization therapy. Which of the following statements by the client indicates the teaching has been

effective?

Rationale:

Allergen solutions are injected weekly during the first year of therapy.

“I’ll receive my allergy shots daily for the first two weeks.”

Rationale:

Each allergy shot uses an increased amount of allergen so the client can build up

an immunity to the allergen.

“At each visit, I’ll receive an allergy shot with a little bit less of the allergen than I received the visit

before.”

Rationale:

The recommended course of desensitization therapy is usually 5 years.

“To reduce my symptoms I will need allergy shots for the rest of my life.”

Rationale:

After the allergy shot is administered, observation for a minimum of 30 minutes is

required to monitor the client for any manifestations of an anaphylactic reaction to

the injection.

“I’ll need to remain in the clinic for 30 minutes after each shot.”

20.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a toddler who has laryngotracheobronchitis and is placed in a cool mist tent. Which of the

following findings should the nurse expect as a result of the treatment?

Rationale:

Laryngotracheobronchitis, or croup, is caused by infection of the upper airway

(larynx, trachea, and bronchus) and is characterized by a barking cough. Edema

and obstruction in the upper airways cause the cough and stridor. The cool mist tent

humidifies the inspired air, which will reduces respiratory effort and stridor.

Decreased stridor

Rationale:

The treatment does not affect hydration.

Improved hydration

Rationale:

Edema and obstruction in the upper airways cause the characteristic cough, but this

is a manifestation of the infection, not a result of the treatment.

Barking cough

Rationale:

Reducing the child’s temperature may not occur as a result of the mist tent

treatment.

Temperature stabilization

21.

A nurse is instructing a mother on how to care for a child who has impetigo contagiosa. Which of the following

should the nurse plan to include in her education of the mother?

Rationale:

The mother should know isolation precautions are not needed; however, limiting

contact with others when the wound is weeping will prevent spread of the infection.

Isolate this child from others in his family.

Rationale:

The mother should know to wash the toys with soap and hot water to disinfect and

prevent the spread of the infection.

Wash toys with soap and very hot water.

Rationale:

The mother should know there is no vaccination for the infection

Vaccinated the other family member for disease.

Rationale:

The mother should know to implement universal precautions to prevent the spread

of the infection.

Implement no special precautions.

22.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and

application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions

should the nurse take first?

Rationale:

The incision should be viewed regularly for signs of infection; however, this is not

the first action the nurse should take.

Remove the window and view the incision.

Rationale:

The client should be turned regularly to ensure that all sides of the cast are allowed

to dry; however, this is not the first action the nurse should take.

Turn the client so the cast will dry on all sides.

Rationale:

Medicating the client for pain is an important nursing action; however, this is not the

first action the nurse should take.

Medicate the client for pain.

Rationale:

The greatest risk to this client is injury from impaired circulation due to constriction.

Therefore, the first action the nurse should take is to perform neurovascular checks.

Perform neurovascular checks of the affected extremity.

23.

A nurse is caring for a hospitalized 2-year-old child who has a tantrum when the parent leaves. To help the

child adjust to the stress of the situation, which of the following therapeutic toys is most appropriate for the

nurse to provide?

Rationale:

While a set of building blocks is an age-appropriate toy for a 2-year-old toddler, it is

not the most therapeutic choice.

Set of building blocks

Rationale:

A toy hammer and a pounding board (usually consisting of brightly colored jumbo

pegs that hammer through the board) helps the toddler express anger and

frustration when the parent leaves.

Toy hammer with a pounding board

Rationale:

While a picture book is age-appropriate for a toddler, it is not the most therapeutic

choice.

Picture book about hospitals

Rationale:

While a stuffed animal is age-appropriate for a toddler, it is not the most therapeutic

choice.

Stuffed animal

24.

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Detailed Answer Key

Homework 9 – Pediatrics

A nurse is caring for a hospitalized 14-month-old child. Which of the following lunch choices is appropriate?

Rationale:

These “finger foods” appeal to a 14-month-old child and offer appropriate nutrition

as well.

Chicken nuggets and green beans

Rationale:

Solids should have been introduced to the child at around 6 months of age.

Commercially prepared formula

Rationale:

This may be a nutritious meal, but it offers little variety in texture, and the child

cannot easily feed herself.

Chicken and strained beans

Rationale:

It is best to avoid fried foods when possible. Foods should be poached, broiled, or

baked, rather than fried.

Hamburger and french fries

25.

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End of Test

*items are not administered in this order.

Detailed Answer Key

Homework 9 – Pediatrics

Detailed Answer Key

Com Health Guided Learning_Practice C

1. A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should

concern the nurse?

A. “The teacher says my child has to squint to see the board.”

Rationale: Squinting to see the board may indicate a vision problem. It is essential to assess children for

hearing and vision problems. If not caught early, they lead to frustration and decreased ability to

learn.

B. “My child has recently lost both front top teeth.”

Rationale: This is the age when children begin to lose their deciduous teeth and replace them with their

permanent teeth. This is an expected response.

C. “My child often cheats when we play board games.”

Rationale: Children of 5 to 7 years of age often cheat to win at games because they feel winning is most

important. This is an expected response.

D. “Sometimes my child acts bossy with his friends.”

Rationale: Children of this age are often bossy and are learning how to interact with peers. They have to

learn to appreciate how others feel, but this is a gradual process, as they are still somewhat

egocentric. This is an expected response.

2. A nurse is assessing a toddler in the well-child clinic. At what point in the physical examination should the nurse

examine the tympanic membrane?

A. At the end

Rationale: When examining the toddler, the nurse should follow a modified head-to-toe approach, starting

at the head but deferring anything that the toddler is likely to view as invasive and traumatic to

the very end. The toddler is likely to resist not only having the ears examined, but also anything

that follows.

B. At the beginning

Rationale: The nurse should not examine the tympanic membranes first because the toddler is likely to

view examination of the ear canal as invasive and traumatic. The toddler is likely to resist not

only having the ears examined, but also anything that follows.

C. Before the head and neck are examined

Rationale: The nurse should not examine the tympanic membrane before the head and neck.

D. Before the chest and abdomen are auscultated

Rationale: The nurse should not examine the tympanic membrane before the chest and abdomen are

auscultated.

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Detailed Answer Key

Com Health Guided Learning_Practice C

3. A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products

but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide

the nutrients most likely to be lacking in his diet?

A. Peanut butter and jelly sandwich

Rationale: A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich

beans for meat protein. Peanut butter is an excellent source of protein. A peanut butter and jelly

sandwich, especially if prepared on protein-enriched bread, can provide almost 20 grams of

protein.

B. Baked potato topped with sour cream

Rationale: A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich

beans for meat protein. Potatoes have a minimal amount of protein and, although sour cream

does have some protein, it is a more significant source of fat.

C. Bagel with cream cheese

Rationale: A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich

beans for meat protein. Bagels, if made with enriched flour, may have a minimal amount of

protein, and although cream cheese also has some protein, it is a more significant source of fat.

D. Fruit salad

Rationale: A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich

beans for meat protein. Fruit salad is a healthy side dish for this client. However, it is not a

source of protein.

4. A school nurse identifies that a child has pediculosis capitis and educates the child’s parent about the condition.

Which of the following statements by the parent indicates an understanding of the teaching?

A. “All recently worn clothing, bedding, and towels must be washed in hot water.”

Rationale: Pediculosis capitis is commonly referred to as head lice. All recently worn clothing, bed sheets,

and towels need to be washed in hot water. Anything that cannot be washed should be sealed in

a plastic bag for 10 to 14 days. This might include jackets, sweaters, hats, pillows, bicycle

helmets, and stuffed animals that the child may sleep with. Furniture, carpets, and car seats can

be sprayed with a variety of over-the-counter products.

B. “My child must have a physician’s note to return to school.”

Rationale: The school nurse will examine the child upon returning to determine if the child is free of

infestation.

C. “I will treat all the family members to be on the safe side.”

Rationale: Only family members who actually have lice should be treated because there are side effects

with the treatment, known as pediculicides, as with any medication.

D. “Toys that can’t be dry cleaned or washed must be thrown out.”

Rationale: Items that can’t be dry cleaned or washed can be closed up inside a plastic bag for 10 to 14

days. This might include jackets, sweaters, hats, pillows, bicycle helmets, and stuffed animals

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that the child may sleep with.

5. A charge nurse, following hospital policy, reports an incident of suspected child abuse. The parent of the child

becomes upset and demands to know the reason for the nurse’s action. The appropriate nursing response to the

parent should be which of the following?

A. “As a nurse, I am required by law to report incidents of suspected child abuse.”

Rationale: A nurse is required by law to report suspected child abuse. Therefore, this is a truthful,

non-accusatory response to the parent.

B. “I am unable to discuss this, but you can talk to my supervisor.”

Rationale: The nurse does not need clarification by her supervisor to speak with the parent.

C. “Perhaps you should leave before I call security.”

Rationale: The nurse should not ask the parent to leave in case permission is needed for surgery or a

procedure.

D. “I reported the incident to my supervisor who decided to contact the authorities.”

Rationale: The nurse supervisor does not decide to contact the authorities.

6. A nurse is caring for a young adult client who says he is experiencing increasing anxiety and the inability to

concentrate. Which of the following is an appropriate response by the nurse?

A. “It sounds like you’re having a difficult time.”

Rationale: This therapeutic response is an open-ended empathetic statement that encourages the client to

talk.

B. “Have you talked to your parents about this yet?”

Rationale: This nontherapeutic response is focused inappropriately on the client’s parents. It does not

address the client’s need to communicate or express feelings.

C. “Why do you think you are so anxious?”

Rationale: This nontherapeutic response can make the client feel defensive, and he may not be able to tell

the nurse why.

D. “How long has this been going on?”

Rationale: This nontherapeutic response is a close-ended statement that does not encourage the client to

talk.

7. A nurse is caring for a 4-year-old child who has been newly diagnosed with diabetes mellitus and is distressed after

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an insulin injection. Which of the following play activities should the nurse recognize as therapeutic in helping the

child deal with the injection?

A. A needleless syringe and a doll

Rationale: A needleless syringe and a doll are an appropriate therapeutic activity for the newly diagnosed

diabetic child, since it will allow the child to act out feelings of anger and helplessness.

B. A video game

Rationale: This activity is more of a distraction and is useful for the child with diversional activity deficit

(boredom).

C. A story book about a child with diabetes

Rationale: This activity does not allow an outlet for working out the feelings that the child is unable to

verbalize at the age of 4.

D. A period of play in the playroom

Rationale: This is not a therapeutic activity in this situation.

8. A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse

recognize as an indication of this condition?

A. Firmly attached white particles on the hair

Rationale: Pediculus capitis, or head lice, are tiny parasitic insects that live on the scalp and can be spread

by close contact with other people. Their eggs (nits) appear much like flakes of dandruff, but are

stuck firmly to the hair shaft instead of flaking off of the scalp. Head lice can spread readily

among school children.

B. Itching and scratching of the head

Rationale: There are many other causes of scalp itching, so this is not a definitive symptom of pediculosis.

C. Patchy areas of hair loss

Rationale: Alopecia, or patchy areas of hair loss, is a typical finding in ringworm, a superficial infection of

the scalp by a fungus.

D. Thick, yellow, crusted lesion on a red base

Rationale: Thick, golden yellow, crusted lesions on a red base are a typical finding in impetigo, a superficial

infection of the skin that may often involve the face or scalp.

9. A nurse is admitting a client who has experienced a weight loss of 25 lb (11 kg) in the past 3 months. The client

weighs 88 lb (40 kg) and believes she is fat. Which of the following aspects of care should the nurse consider the

first priority for this client?

A. Identify the client’s nutritional status.

Rationale:

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According to the nursing process, the nurse should perform an assessment first to gather

enough data to plan, implement, and evaluate care.

B. Request a mental health consult.

Rationale: Requesting a mental health consult may be necessary but it is not the first priority.

C. Plan a therapeutic diet for the client.

Rationale: Planning a therapeutic diet for the client may be necessary but it is not the first priority.

D. Talk to family members to find out more about the client’s dietary habits.

Rationale: Including the client’s family when planning care may be necessary but it is not the first priority.

10.A nurse is caring for a client who is receiving chlorpromazine (Thorazine) and is given a pass to attend a family

outing on a sunny day. Which of the following is the most important for the nurse to include in the client’s teaching

about the side effects of chlorpromazine?

A. “Wear a hat and a long-sleeved shirt.”

Rationale: Photophobic skin reactions and damage to the retina of the eye can occur when a client who is

taking chlorpromazine is exposed to direct sunlight. Clients should be reminded to wear

protective clothing, apply sunscreen, and wear sunglasses when they are outside.

B. “Suck on hard candies.”

Rationale: While sucking on hard candies for the dry mouth that often accompanies chlorpromazine

therapy is a good recommendation, it is not the most important side effect for the nurse to

include at this time.

C. “Drink plenty of fluids.”

Rationale: While maintaining fluid and electrolyte balance is important for all clients, this advice is not

critical to clients who take chlorpromazine and is not the most important side effect for the

nurse to include at this time.

D. “Limit alcoholic beverages to one beer only.”

Rationale: Although clients taking chlorpromazine should avoid all alcoholic beverages due to the

potentiation of central nervous system depressant effects and the development of liver

problems, this is not the most important side effect for the nurse to include at this time.

11.A nurse’s sibling had a diagnostic test performed at the facility where the nurse is employed. Now the sibling asks

the nurse to look up the result in the computer. In replying to the sibling, the nurse realizes that disclosing the

result is

A. permissible. Because this is a sibling who has given the nurse permission, the action is allowable.

Rationale: The client’s consent does not make it permissible for the nurse to view or disclose the test

results.

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B. not permissible. Only the physician is allowed to disclose laboratory results or findings to a client.

Rationale: The physician may delegate the disclosure of the results to another member of the health care

staff, such as a nurse in the physician’s office or other facility staff.

C. permissible. Because the sibling has paid for the service, the test results are actually the sibling’s property.

Rationale: These factors do not make it permissible for the nurse to view or disclose the test results.

D. not permissible. Despite the request, there is no nurse-client relationship between the sibling and nurse.

Rationale: There is no legal or professional basis for a nurse-client relationship between them. Therefore,

it is not permissible for the nurse to view or disclose the test results. Even with the sibling’s

permission, to do so is a breach of client confidentiality. The test results may only be disclosed

on the prescribing physician’s authority.

12.A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into

practice by

A. discussing advance directives with the client and family.

Rationale: Discussing advance directives with the client and family is an example of promoting client

autonomy by respecting the client’s right to self-determination.

B. providing comfort care measures to the client.

Rationale: Providing comfort measures to a client who is dying is an example of the principle of

beneficence, which is a moral obligation to act to benefit others.

C. refusing to give a potentially lethal dose of narcotic pain medication.

Rationale: The principle of nonmaleficence is an obligation not to inflict harm intentionally. It is customary

to ease a client’s pain via the administration of narcotics. However, if the nurse believes that

the dose is potentially lethal or may hasten the client’s death, the nurse should refuse to

administer the medication on the grounds of nonmaleficence.

D. allowing the client’s family unlimited visitation at the time of death.

Rationale: Allowing the client’s family unlimited visitation at the time of death is an example of the principle

of beneficence, which is the moral obligation to act in the interest of others.

13.A client becomes very dejected and states, “No one really cares what happens to me. Life isn’t worth living

anymore.” The therapeutic nursing response is

A. “Of course people care. Your family comes to visit every day.”

Rationale: This response is nontherapeutic because it uses the communication blocks of using a cliché

and focusing on inappropriate persons (the client’s family).

B. “Why do you feel that way?”

Rationale:

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This response is nontherapeutic because it asks the client to explain feelings that she may be

unable to explain.

C. “Tell me who you think doesn’t care about you.”

Rationale: This response is nontherapeutic because it uses the communication blocks of challenging the

client and of focusing on inappropriate people (the people the client thinks don’t care).

D. “I care about you, and I am concerned that you feel so sad.”

Rationale: This is an open-ended therapeutic statement that focuses on the client’s feelings, shows

empathy, and allows for further exploration of the client’s belief that life is not worth living.

14.A nurse is caring for a client who is a resident in a facility designed for the care of clients with Alzheimer disease.

The client has been oriented to name and place and is usually cooperative and able to perform activities of daily

living (ADL) with minimal supervision. When the client refuses to take medications, the nurse should

A. notify the provider of the client’s increasing confusion.

Rationale: Before taking this action, the nurse must make a further assessment regarding the reasons for

refusal.

B. crush the pills, if not contraindicated, and mix them in the client’s applesauce.

Rationale: A confused client can still make valid health care choices. This action does not allow the client

to make a choice.

C. explain to the client the possible implications of missing a dose.

Rationale: Being confrontational may cause the client to become argumentative and distrustful.

D. ask the client to express the reasons for refusing the morning medications and document the event.

Rationale: Before making a judgment about the client’s competence, the nurse should complete an

assessment of the client. It is important to document the client’s reasons in his own words,

especially if he is refusing ordered medications and/or treatments.

15.A public health nurse is visiting an older adult client who lives with a family member. The nurse assesses the client

and identifies several bruises in various stages of healing. The client explains that the bruises are a result of

“clumsiness,” and the client’s family member agrees. However, based on the location and distribution of the

bruises, the nurse suspects the client may be abused. Which of the following actions should the nurse should take

first?

A. Document the bruises in the client’s chart.

Rationale: Although documenting the bruises in the client’s chart may be an appropriate action to take, it

is not the initial action to promote the client’s safety.

B. Follow the agency’s guidelines for reporting suspected abuse.

Rationale: Reporting the suspected abuse, according to the guidelines of the agency, is the action most

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likely to promote the client’s safety. According to Maslow’s Hierarchy of Needs, after

physiological needs are met, safety needs take priority. This action will help to ensure the

client’s safety.

C. Institute more frequent visits to the client’s home.

Rationale: Although instituting more frequent visits to the client’s home may be an appropriate action to

take, it is not the initial action to promote the client’s safety.

D. Discuss installing hand rails in the client’s home.

Rationale: Although installing hand rails in the client’s home may be an appropriate action to take, it is not

the initial action to promote the client’s safety.

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1. A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery.

Which of the following statements by the parent indicates an understanding of the teaching?

A. “I’m glad that my child’s ostomy is only temporary.”

Rationale: Hirschsprung disease is also known as aganglionic megacolon and is characterized by an area

of the large intestine without nerve innervation. The child will probably require two surgeries over

an 18- to 24-month period before normal bowel function is obtained. The initial surgery creates

an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest.

B. “I’m glad my child will have normal bowel movements now.”

Rationale: The child will not have bowel movements after the initial surgery.

C. “I want to learn how to use my child’s feeding tube as soon as possible.”

Rationale: The child will not have a feeding tube after the surgery.

D. “I want to learn how to empty my child’s urinary catheter bag.”

Rationale: The child will not have a urinary catheter after the surgery.

2. A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile

vomiting immediately after eating. Which of the following responses should the nurse make?

A. “Bring your baby in to the clinic today.”

Rationale: Projectile vomiting followed by hunger are characteristic of pyloric stenosis. The infant needs to

be examined in the clinic by a provider as soon as possible.

B. “Burp your baby more frequently during feedings.”

Rationale: Burping the infant does not address the cause of the projectile vomiting.

C. “Give your infant an oral rehydration solution.”

Rationale: Administering an oral rehydration solution does not address the cause of the projectile vomiting.

D. “Try switching to a different formula.”

Rationale: Switching to a different formula does not address the cause of the projectile vomiting.

3. A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client

weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the

first priority for this client?

A. Identify the client’s nutritional status.

Rationale: According to the nursing process, the nurse should perform an assessment first to gather

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enough data regarding nutritional status and other findings in order to plan, implement, and

evaluate care. The assessment identifies client nutrition needs as well as complications the

client might be experiencing related to the eating disorder.

B. Request a mental health consult.

Rationale: Requesting a mental health consult might be necessary but another aspect of care is the

priority.

C. Plan a therapeutic diet for the client.

Rationale: Rationale C. Planning a therapeutic diet for the client will be necessary but another aspect of

care is the priority.

D. Provide a structured environment for the client.

Rationale: It is important to provide a structured environment for the client regarding meals, times for

weighing, and monitoring of eating, but another aspect of care is the priority.

4. A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the

following recommendations should the nurse include in the teaching?

A. Limit fluid intake not related to meals.

Rationale: The nurse should recommend consuming liquids between meals rather than with meals to help

reduce abdominal distention.

B. Chew on mint leaves to relieve indigestion.

Rationale: The nurse should instruct the client to avoid items like mint that can increase gastric acid

secretion.

C. Avoid eating within 3 hr of bedtime.

Rationale: The nurse should instruct the client to eat small, frequent meals but to avoid eating with 3 hr of

bedtime.

D. Season foods with black pepper.

Rationale: The nurse should instruct the client to avoid items such as black and red pepper that can

increase gastric acid secretion.

5. A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of

the following instructions should the nurse provide?

A. Take the medication on an empty stomach to decrease gastrointestinal irritation.

Rationale: Taking iron on an empty stomach may increase gastrointestinal side effects.

B. Take the medication with orange juice to enhance absorption.

Rationale:

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Ascorbic acid (vitamin C), which is found in orange juice, will enhance the absorption of iron and

increase its bioavailability. This will also help to decrease the gastrointestinal side effects of iron.

C. Take the medication with milk.

Rationale: Iron should not be taken with milk or antacids, because it decreases the absorption.

D. Rinse the mouth before taking the iron.

Rationale: The client should rinse the mouth after taking the ferrous sulfate liquid to prevent the medication

from staining the teeth.

6. A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which

of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

A. Determine the pH of the gastric secretions.

Rationale: Determining the pH of gastric secretions is one way to determine the correct placement of the

NG tube; however it is not the purpose for the client who has a pyloric obstruction.

B. Supply nutrients via tube feedings.

Rationale: Clients who have difficulty swallowing or at risk for aspiration may receive feedings through an

NG tube. Because of the obstruction however, tube feedings are contraindicated for this client.

C. Decompress the stomach.

Rationale: A pyloric obstruction, also called gastric outlet obstruction, is caused by edema, scarring, or

spasm, often the result of gastritis or peptic ulcer disease. The nurse should inform the client

that because the stomach is dilated and may contain undigested food, it must be decompressed,

necessitating the placement of an NG tube.

D. Administer medications.

Rationale: Medications that are liquid or can be safely crushed may be administered through the NG tube if

a client is at risk for aspiration or unable to swallow. However, the client who has a pyloric

obstruction will not be given any food or medications by mouth until the obstruction is resolved.

7. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the

emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is

suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

A. NPH insulin

Rationale: Isophane NPH insulin is intermediate-acting. It has an onset of action of 1 to 3 hr and is not

appropriate for emergency treatment of ketoacidosis.

B. Insulin glargine

Rationale: Insulin glargine is a long-acting insulin, with an onset of 2 to 4 hr. It is not appropriate for

emergency treatment of ketoacidosis.

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C. Insulin detemir

Rationale: Insulin detemir is an intermediate-acting insulin. It has an onset of action of 1 hr and is not

appropriate for emergency treatment of ketoacidosis.

D. Regular insulin

Rationale: Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset

of action of less than 30 min. This is the insulin that is most appropriate in emergency situations

of severe hyperglycemia or diabetic ketoacidosis.

8. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

A. Dehydration

Rationale: Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration.

B. Polyphagia

Rationale: Polyphagia is a finding of diabetes mellitus, not insipidus.

C. Hyperglycemia

Rationale: Hyperglycemia is a finding of diabetes mellitus, not diabetes insipidus.

D. Bradycardia

Rationale: Tachycardia, not bradycardia, is a manifestation of diabetes insipidus.

9. A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a

hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for

which of the following complications?

A. Dehydration

Rationale: Dehydration is a complication that may occur as a result of a fever, however it is not considered

a complication of the hypothermia blanket therapy.

B. Seizures

Rationale: Seizures are a complication associated with meningitis and should be monitored in this client;

however, it is not considered a complication of the hypothermia blanket therapy.

C. Burns

Rationale: Burns are associated with the improper use of heating pads, not a hypothermia blanket.

D. Shivering

Rationale: The hypothermia blanket, if used improperly (at inappropriately low temperatures, or without skin

protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from

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the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The

body will also try to increase heat production by shivering, which can increase the metabolic rate

by two to five times and in doing so greatly raise oxygen consumption.

10.A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When

the nurse finds the client’s blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the

following?

A. Graham crackers

Rationale: After establishing that the client has hypoglycemia, the nurse should give the client about 15 g

of a rapid-acting, concentrated carbohydrate, such as 4 oz of fruit juice, 8 oz of skim milk, 3 tsp

of sugar or honey, 3 graham crackers, or commercially prepared glucose tablets. The nurse

should recheck the client’s blood glucose level in 15 minutes.

B. 1 tsp sugar

Rationale: This does not contain enough carbohydrate to reverse hypoglycemia. The usual

recommendation is 4 tsp of sugar or 1 tablespoon of honey.

C. 4 oz diet soda

Rationale: The client who has hypoglycemia requires treatment with15g of carbohydrates to raise the

blood glucose level. Diet soda does not contain the required carbohydrates, but has artificial

sweeteners. The nurse can administer 4 oz of regular soda, however.

D. 4 oz skim milk

Rationale: This does not contain enough carbohydrate to reverse hypoglycemia. The usual

recommendation is 8 oz of skim milk in order to provide 15 g of carbohydrates.

11.A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse

include in the teaching?

A. Eat plenty of fresh fruits and vegetables.

Rationale: The nurse should inform a client who is neutropenic to avoid fresh fruits and vegetables due to

the bacteria they can carry.

B. Avoid crowds.

Rationale: The nurse should inform the client to avoid crowds due to his suppressed immune system.

C. Perform mild exercise, such as gardening.

Rationale: The nurse should instruct the client to avoid gardening due bacteria contained in the soil.

D. Take temperature weekly.

Rationale: A client who is neutropenic can experience a 1&deg increase from his baseline temperature,

even in the presence of infection. Therefore, the nurse should recommend the client take his

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temperature at least once daily.

12.A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of

the following positions should the nurse place the client?

A. Trendelenburg

Rationale: Positioning the child in Trendelenburg could result in inadequate functioning of the VP shunt

due to the child’s head being lower than the rest of his body.

B. Semi-Fowler’s

Rationale: Positioning the child in semi-Fowler’s could result in a rapid reduction of intracranial fluid.

C. Prone

Rationale: Positioning the child prone could result in inadequate functioning of the VP shunt due to the

need to position the child’s head to the side.

D. On the unoperated side

Rationale: The nurse should position the child flat on the unoperated side to prevent a rapid reduction of

intracranial fluid and to protect the child for injuring the operative site.

13.A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following actions

should the nurse take?

A. Insert a tongue blade in the client’s mouth.

Rationale: The nurse should never force anything into the mouth of a client who is having a seizure. Doing

so can obstruct the client’s airway or chip the client’s teeth.

B. Place the client on his side.

Rationale: The nurse should place the client on his side. This position drops the tongue to the side of the

client’s mouth and prevents the client’s airway from being obstructed.

C. Hold the client’s arms and legs from moving.

Rationale: The nurse should not try to restrain the client from moving because this could injure the client.

D. Place the client back in bed.

Rationale: The nurse should remove all furniture out of the way from the client during the seizure and

place the client‘s head on a pillow or lap. However, the nurse should avoid moving the client

back into bed until the seizure is completed.

14.A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly

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peds nclex practice

restless and intermittently confused. Which of the following actions should the nurse take to address the client’s

safety needs?

A. Call the family and ask them to stay with the client.

Rationale: It is the nurse’s responsibility, not the family’s, to ensure the client’s during his time in the

facility.

B. Move the client to a room closer to the nurses’ station.

Rationale: This will make it easier for the staff to observe the client, should the client behave in an unsafe

manner.

C. Apply wrist and leg restraints to the client.

Rationale: Restraints are a last resort, plus they can increase the client’s risk for injury.

D. Administer medication to sedate the client.

Rationale: Sedating an older adult client can worsen confusion.

15.A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse

identify as an indication of increased intracranial pressure (ICP)?

A. Tachycardia

Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and

bradycardia (termed Cushing’s triad) are signs of increased ICP.

B. Amnesia

Rationale: The client who has a traumatic brain injury may experience a loss of consciousness along with

a lack of memory of events prior to or following the injury, but does not indicate an increase in

ICP.

C. Hypotension

Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and

bradycardia (termed Cushing’s triad) are signs of increased ICP.

D. Restlessness

Rationale: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or

brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP

include restlessness, irritability and confusion along with a change in level of consciousness, or

a change in speech pattern.

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Module 7 Quiz

1. A child is admitted with a suspected diagnosis of Wilms’ tumor. The nurse should place a sign with which of the

following warnings over the child’s bed?

A. Do not palpate abdomen.

Rationale: Wilms’ tumor is a neoplasm of the kidney (nephroblastoma). This tumor is encapsulated, and

palpation can cause it to rupture, which would allow seeding of the tumor into the pelvic cavity.

B. No venipuncture or blood pressure in left arm

Rationale: There is no contraindication for venipuncture or obtaining blood pressure in either of the child’s

arms.

C. Contact precautions

Rationale: There is no indication to place the child on contact precautions.

D. Collect all urine.

Rationale: There is no indication to collect urine for a 24-hr urine specimen.

2. A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same

room with this child?

A. A child who has nephrotic syndrome

Rationale: A child who has leukemia is at risk for infection. Nephrotic syndrome is not an infectious disorder

poses no risk to a child who has leukemia.

B. A child recovering from a ruptured appendix

Rationale: A child who has leukemia is at risk for infection. A client recovering from a ruptured appendix

can be infectious.

C. A child who has rheumatic fever

Rationale: A child who has leukemia is at risk for infection. A child who has rheumatic fever can still be

infectious from the original causative organism.

D. A child who has cystic fibrosis

Rationale: A child who has leukemia is at risk for infection. A client who has cystic fibrosis is likely to be

infectious.

3. A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the

following statements by the parent indicates a need for further teaching?

A. “I will have my child rest.”

Rationale:

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Module 7 Quiz

Supportive measures to control a minor bleeding episode include resting.

B. “I will elevate the affected part.”

Rationale: Supportive measures to control a minor bleeding episode include elevation.

C. “I will compress the site.”

Rationale: Supportive measures to control a minor bleeding episode include compression.

D. “I will apply heat.”

Rationale: Supportive measures to control a minor bleeding episode include applying cool compresses.

4. A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous

sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of

this medication?

A. Give with a 240 mL (8 oz) glass of milk.

Rationale: Milk binds with iron and interferes with the absorption of this medication.

B. Administer at mealtimes.

Rationale: Iron supplements should be administered between meals.

C. Give with orange juice.

Rationale: Citrus fruit or juice aids absorption of this medication.

D. Administer at bedtime.

Rationale: This medication should be administered at least 1 hr prior to bedtime.

5. A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions

should the nurse initiate?

A. Neutropenic

Rationale: The nurse should initiate neutropenic precautions for a child who has a low WBC level.

B. Bleeding

Rationale: The nurse should initiate bleeding precautions for a child who has a low platelet count. Bleeding

precautions involve specific measures to reduce the risk of bleeding, such as using soft-bristled

toothbrushes, avoiding IM injections, and preventing constipation.

C. Contact

Rationale: The nurse should implement contact precautions for a child who has an illness that is

transmitted through direct contact.

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Module 7 Quiz

D. Droplet

Rationale: The nurse should implement contact precautions for a child who has an illness that is

transmitted through large-particle droplets.

6. A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. Which of the following should

the nurse recommend as a method of preventing iron deficiency anemia?

A. Avoid a diet that consists primarily of milk.

Rationale: Milk is a poor source of iron and a diet that consists primarily of milk places the toddler at risk for

iron deficiency anemia.

B. Administer fat-soluble vitamins daily.

Rationale: It is important to ensure the toddler received adequate amounts of fat-soluble vitamins, but these

do not provide iron and would not prevent iron deficiency anemia.

C. Include fluoridated water in the toddler’s diet.

Rationale: It is important to ensure the toddler receives adequate amounts of fluoride, but fluoridated water

does not provide iron and would not prevent iron deficiency anemia.

D. Limit intake of high-protein foods.

Rationale: High-protein foods—such as meats, green leafy vegetables, and nuts—are good sources of iron

and should not be limited in the toddler’s diet.

7. A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

A. High fever

Rationale: A low grade fever is a manifestation of sickle cell crisis.

B. Bradycardia

Rationale: Tachycardia is more common with sickle cell anemia than bradycardia.

C. Pain

Rationale: A client who is in sickle cell crisis has severe pain resulting from tissue hypoxia and necrosis.

D. Constipation

Rationale: Sickle cell crisis generally affects the lungs and the liver, rather than the gastrointestinal tract.

8. A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following

instructions should the nurse include in the teaching?

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Module 7 Quiz

A. “Monitor your child’s temperature daily.”

Rationale: The parents need to check the child’s temperature only when they suspect fever, and when they

do, they should report it to the provider immediately. Fever is a manifestation of acute chest

syndrome, a complication of sickle cell anemia.

B. “Restrict outdoor play activity to 1 hour per day.”

Rationale: The nurse should instruct the parent to restrict the child from playing contact sports.

C. “Offer fluids to your child multiple times every day.”

Rationale: Preventing dehydration is an important step in preventing a sickle cell crisis. The nurse should

provide the parents with a specific fluid goal for the child to reach each day.

D. “Apply cold compresses when your child expresses pain.”

Rationale: Heat applications can be soothing but cold compresses should be avoided because they cause

vasoconstriction.

9. A nurse is assessing a 1-year-old toddler notices a large abdominal mass and pink-tinged urine on the diaper.

Which of the following disorders should the nurse suspect?

A. Pyloric stenosis

Rationale: Manifestations of pyloric stenosis include projectile vomiting, weight loss, and upper abdominal

distention.

B. Nephritic syndrome

Rationale: Manifestations of nephritic syndrome include facial edema, abdominal swelling, and lethargy.

C. Wilms’ tumor

Rationale: Manifestations of Wilms’ tumor include an abdominal mass, hematuria, fatigue, weight loss, and

fever.

D. Intussusception

Rationale: Manifestations of intussusception include vomiting, abdominal pain, and bloody stools.

10.A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal

area and that his urine is a pink color. Which of the following actions is the nurse’s priority?

A. Schedule the child for an abdominal ultrasound.

Rationale: Although it is important to schedule the child for an ultrasound, this action is not the priority.

B. Instruct the parent to avoid pressing on the abdominal area.

Rationale: The priority action is to instruct the parent to avoid pressing on the child’s abdomen. These

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Module 7 Quiz

symptoms are associated with Wilms’ tumor, and trauma to the mass should be avoided to

prevent movement of cancer cells into other sites.

C. Determine if the child is having pain.

Rationale: Although it is important to determine if the child is having pain, this action is not the priority.

D. Obtain a urine specimen for a urinalysis.

Rationale: Although it is important to obtain a urine specimen for a urinalysis, this action is not the priority.

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ATI Review NSG 440

1. A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands

to know the reason for the nurse’s action. Which of the following responses by the nurse is appropriate?

A. “As a nurse, I am required by law to report suspected child abuse.”

B. “I am unable to discuss this, but I can contact my supervisor to speak with you.”

C. “The provider will be coming to explain the situation.”

D. “I reported the incident to my supervisor who decided to contact the authorities.”

2. A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse

give? (Select all that apply.)

A. Measles, mumps rubella (MMR)

B. Diphtheria, tetanus and acellular pertussis (DTaP)

C. Varicella (VAR)

D. Rotavirus (RV)

E. Human papillomavirus (HPV4)

3. A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should

concern the nurse?

A. “The teacher says my child has to squint to see the board.”

B. “My child has recently lost both front top teeth.”

C. “My child often cheats when we play board games.”

D. “Sometimes my child acts bossy with his friends.”

4. A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse

examine the child’s tympanic membrane?

A. At the end

B. At the beginning

C. Before examining the head and neck

D. Before auscultating the chest and abdomen

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5. A school nurse identifies that a child has pediculosis capitis and educates the child’s parents about the condition.

Which of the following statements by the parents indicates an understanding of the teaching?

A. “All recently used clothing, bedding, and towels must be washed in hot water.”

B. “My child must be free from nits before returning to school.”

C. “I will treat all the family members to be on the safe side.”

D. “Toys that can’t be dry cleaned or washed must be thrown out.”

6. A child is admitted with a suspected diagnosis of Wilms’ tumor. The nurse should place a sign with which of the

following warnings over the child’s bed?

A. Do not palpate abdomen.

B. No venipuncture or blood pressure in left arm

C. Contact precautions

D. Collect all urine.

7. A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the

following actions should the nurse take?

A. Encourage the parents to rock the infant.

B. Offer the infant a pacifier.

C. Administer ibuprofen as needed for pain.

D. Position the infant on her abdomen.

8. A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse

expect?

A. Tugging on the affected ear lobe

B. Clear drainage from the affected ear

C. Pain when manipulating the affected ear lobe

D. Erythema and edema of the affected ear

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9. A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the

following statements by the client should indicate to the nurse a need for further teaching?

A. “I only need to catheterize myself twice every day.”

B. “I carry a water bottle with me because I drink a lot of water.”

C. “I use a suppository every night to have a bowel movement.”

D. “I do wheelchair exercises while watching TV.”

10.A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery.

Which of the following statements by the parent indicates an understanding of the teaching?

A. “I’m glad that my child’s ostomy is only temporary.”

B. “I’m glad my child will have normal bowel movements now.”

C. “I want to learn how to use my child’s feeding tube as soon as possible.”

D. “I want to learn how to empty my child’s urinary catheter bag.”

11.A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should

follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the

steps.)

A. Inspection

B. Superficial palpitation

C. Deep palpitation

D. Auscultation

12.A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which

of the following responses by the parents indicates an understanding of the teaching?

A. “We will give our child pancreatic enzymes with snacks and meals.”

B. “We will restrict the amount of salt in our child’s food.”

C. “I will limit my child’s fluid intake.”

D. “I will prepare low-fat meals with limited protein for my child.”

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13.A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same

room with this child?

A. A child who has nephrotic syndrome

B. A child recovering from a ruptured appendix

C. A child who has rheumatic fever

D. A child who has cystic fibrosis

14.A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next

day, the nurse explains the situation and one of the parents says, “She never wets the bed at home. I am so

embarrassed.” Which of the following responses should the nurse make?

A. “It is expected for children who are hospitalized to regress. The toileting skills will return when your child is

feeling better.”

B. “I know this can really be embarrassing. I have kids myself, so I understand, and it doesn’t bother me.”

C. “Your child did not seem upset, so I wouldn’t worry about it if I were you.”

D. “Why does it bother you that your child has wet the bed?”

15.A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile

vomiting immediately after eating. Which of the following responses should the nurse make?

A. “Bring your baby in to the clinic today.”

B. “Burp your baby more frequently during feedings.”

C. “Give your infant an oral rehydration solution.”

D. “Try switching to a different formula.”

16.A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in

place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the

client?

A. Large building blocks

B. Hanging crib toys

C. Modeling clay

D. Crayons and a coloring book

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17.A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated

temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

A. Body weight

B. Skin integrity

C. Blood pressure

D. Respiratory rate

18.A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items

should the nurse offer the child at this time?

A. Crushed ice

B. Orange juice

C. Vanilla milkshake

D. Cranberry juice

19.A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following

manifestations should indicate to the nurse that the child’s appendix is perforated?

A. Sudden decrease in abdominal pain

B. Absent Rovsing’s sign

C. Flaccid abdomen

D. Low-grade fever

20.A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an

insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child

deal with the injection?

A. A needleless syringe and a doll

B. A video game

C. A story book about a child who has diabetes

D. A period of play in the playroom

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21.A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse

recognize as an indication of this condition?

A. Firmly attached white particles on the hair

B. Itching and scratching of the head

C. Patchy areas of hair loss

D. Thick yellow crusted lesion on a red base

22.A nurse is caring for a child who has Addison’s disease. Which of the following actions should the nurse take?

A. Teach the parents about cortisol replacement therapy.

B. Place the child on a low-sodium diet.

C. Monitor the child for fluid volume excess.

D. Discuss the manifestations of hypoglycemia with the parents.

23.A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

A. A 10-year-old child who has sickle cell anemia who reports severe chest pain

B. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016

C. A 1-year-old toddler who has roseola and a temperature of 39° C (102.2° F)

D. A 4-year-old child who has asthma and a PCO2 of 37 mm Hg

24.A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The

client’s mother insists that the client receive treatment. Which of the following actions should the nurse take?

A. Initiate the IV per the parent’s request.

B. Notify the provider of the situation.

C. Administer a sedative to calm the client.

D. Offer the client an antiemetic.

25.A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler’s mother

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leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When

the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these

behaviors indicate which of the following developmental reactions?

A. An anxiety reaction

B. Regression

C. Resentment toward the mother

D. Developing autonomy

26.A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an

anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses

should the nurse make?

A. “This test will indicate if your child has rheumatic fever.”

B. “This test will confirm if your child had a recent streptococcal infection.”

C. “This test will indicate if your child has a therapeutic blood level of an aminoglycoside.”

D. “This test will confirm if your child has immunity to streptococcal bacteria.”

27.A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod

instrumentation. Which of the following interventions should the nurse include in the plan of care?

A. Keep the head of the bed at a 30° angle.

B. Reposition the client by log rolling every 4 hr.

C. Place the client in protective isolation.

D. Initiate the use of a PCA pump for pain control.

28.A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse

expect?

A. Closed posterior fontanel

B. Uses thumb and index fingers in a pincer grasp

C. Lateral incisors

D. Sitting steadily without support

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29.A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should

the nurse clarify?

A. Maintain NPO status.

B. Monitor oral temperature every 4 hr.

C. Medicate the client for pain every 4 hr as needed.

D. Administer sodium biphosphate/sodium phosphate.

30.A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following

actions should the nurse plan to take to prevent aspiration?

A. Place a bedside humidifier at the head of the client’s bed.

B. Suction the nasopharynx as needed.

C. Withhold fluids until the client demonstrates a gag reflex.

D. Perform chest physiotherapy.

31.A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of

the following positions should the nurse place the client?

A. Trendelenburg

B. Semi-Fowler’s

C. Prone

D. On the unoperated side

32.A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations

should the nurse anticipate administering?

A. Pneumococcal polysaccharide vaccine

B. Bacille Calmette-Guérin (BCG) vaccine

C. Meningococcal polysaccharide vaccine

D. Influenza vaccine

33.A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of

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the following toys should the nurse provide to alleviate the child’s stress?

A. Set of building blocks

B. Toy hammer and pounding board

C. Picture book about hospitals

D. Stuffed animal

34.A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse’s priority?

A. Respiratory rate

B. Burns of the mouth

C. Bowel sounds

D. Visual acuity

35.A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of

the following actions should the nurse include in the plan of care to meet the client’s psychosocial needs according

to Erikson?

A. Arrange for a teacher to provide lesson plans.

B. Allow the client to select his own food from the menu.

C. Discourage visits from the client’s friends.

D. Provide a daily session with a play therapist.

36.A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse

expect? (Select all that apply.)

A. Hypotension

B. Bradycardia

C. Clubbing of the nail beds

D. Weak pulses

F. Murmur

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37.A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the

nurse’s priority immediately after admission?

A. Auscultating the rate and characteristics of the child’s heart sounds

B. Using a pain-rating tool to determine the severity of the joint pain

C. Identifying the degree of parental anxiety related to the diagnosis

D. Assessing the client’s erythematous rash

38.A parent of a toddler asks a nurse at a well-child visit how the child’s frequent temper tantrums can best be

handled. Which of the following actions should the nurse suggest to the parent?

A. Restrain the child physically.

B. Ignore the temper tantrums.

C. Tell the child that temper tantrums are not acceptable.

D. Distract the child by offering to play a game.

39.A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations

should the nurse expect?

A. Red currant jelly stools

B. Distended neck veins

C. Projectile vomiting

D. Ridged abdomen

40.A nurse is assessing a female child in an area struck by an earthquake. The child, who is crying, walks well, can

state her first name, and repeatedly says “All done” and “Go bye-bye now” during the assessment. The child has

24 deciduous teeth and her anterior fontanel is closed. Based on these observations, the nurse should estimate

that the child is how many months old?

A. 12

B. 18

C. 24

D. 30

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41.A nurse is providing nutritional teaching to the mother of a preschooler and is recommending food options to

provide 1 oz of grains. Which of the following foods should the nurse recommend?

A. 1 cup ready-to-eat cereal flakes

B. ½ slice whole wheat bread

C. 1 cup cooked rice

D. ½ flour tortilla

42.A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing

interventions is unnecessary in the client’s plan of care?

A. Place the client in a semi-Fowler’s position.

B. Admit the client to a private room.

C. Measure head circumference every shift.

D. Implement seizure precautions.

43.A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

A. Weight loss

B. Increased urine output

C. Bradycardia

D. Orthopnea

44.A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization.

Which of the following instructions should the nurse include?

A. Keep the child home for 1 week.

B. Give the child acetaminophen for discomfort.

C. Offer the child clear liquids for the first 24 hr.

D. Assist the child to take a tub bath for the first 3 days.

45.A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis.

Which of the following actions should the nurse include in the plan of care?

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A. Keep the infant NPO for 6 hr prior the procedure.

B. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure.

C. Place the infant in an infant seat for 2 hr following the procedure.

D. Hold the infant’s chin to his chest and knees to his abdomen during the procedure.

46.A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent.

Which of the following findings indicates that the treatment has been effective?

A. Barking cough

B. Improved hydration

C. Decreased stridor

D. Decreased temperature

47.The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at

bedtime. Which one of the following statements should the nurse make?

A. “Let your child sleep in your bed with you.”

B. “Keep a night light on in your child’s room.”

C. “Tell your child that monsters are not real.”

D. “Stay with your child until the child is asleep.”

48.A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin,

1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child’s fluid intake?

______ mL

49.A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse

measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than

what rate?

______ /min

50.A nurse participating in lead screening at a community center. The nurse should instruct parents to bring their

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children back for rescreening in a year for which of the following laboratory values?

A. 4 mcg/dL

B. 10 mcg/dL

C. 18 mcg/dL

D. 44 mcg/dL

51.A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the

following goals is the priority for the nurse to include in the plan of care?

A. Provide respite services for the parents.

B. Improve the client’s communication skills.

C. Foster self-care activities.

D. Modify the environment.

52.A nurse is teaching a parent of an infant who has heart failure about meeting the infant’s nutritional needs. Which

of the following statements by the parent indicates an understanding of the teaching?

A. “I will feed my baby on a schedule every 4 hours.”

B. “I will add Polycose to each of my baby’s bottles.”

C. “I will allow my baby to take as much time as needed to finish the bottle.”

D. “I will limit my babies crying to 15 minutes prior to each feeding.”

53.A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take

first?

A. Administer 0.9% sodium chloride IV solution.

B. Place the child on droplet precautions.

C. Initiate IV antibiotics.

D. Assist with obtaining an x-ray of the child’s neck.

54.A school nurse conducting a screening for pediculosis capitis identifies several children who require treatment.

Which of the following instructions should the nurse give the children’s parents?

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A. Soak all combs and hairbrushes in alcohol.

B. Inspect any dogs or cats at home for lice.

C. Seal nonwashable items in airtight plastic bags.

D. Spray countertops and sinks with insecticide.

55.A nurse is developing a health program for the parents of school-age boys. Which of the following information

about pubescent changes should the nurse include in the program?

A. Changes in the voice signal the beginning of puberty.

B. Gynecomastia commonly occurs during late puberty.

C. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years.

D. Growth spurts in height occur toward the end of midpuberty.

56.A nurse is providing teaching to a 17-year-old female client who has severe acne about the use of isotretinoin.

Which of the following adverse effects should the nurse instruct the client is the priority to report to the provider?

A. Frequent nosebleeds

B. Itching of skin

C. Back pain

D. Feelings of isolation

57.A nurse is preparing to measure an infant’s vital signs. The nurse should use which of the following sites to assess

a heart rate?

A. Carotid artery

B. Apex of the heart

C. Brachial artery

D. Radial artery

58.A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?

A. Report the suspected abuse to the authorities.

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B. Obtain a detailed history.

C. Ask a psychiatrist to talk with the parents.

D. Separate the child from the parents.

59.A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse

take?

A. Obtain a throat culture.

B. Place the child in an upright position.

C. Transport the child to radiology for a throat x-ray.

D. Visualize the epiglottis with a tongue depressor.

60.A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

A. Attempt to stop the seizure.

B. Restrain the child’s arms.

C. Use a padded tongue blade.

D. Position the child laterally.

61.A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in

the plan?

A. Initiate standard precautions.

B. Initiate airborne precautions.

C. Initiate droplet precautions.

D. Initiate contact precautions.

62.A nurse is teaching an assistive personnel to measure a newborn’s respiratory rate. Which of the following

statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

A. “Newborns are abdominal breathers.”

B. “Newborns do not expand their lungs fully with each respiration.”

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C. “Activity will increase the respiratory rate.”

D. “The rate and rhythm of breath are irregular in newborns.”

63.A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions

is the nurse’s priority?

A. Prepare the child for a lumbar puncture.

B. Administer an intravenous antibiotic.

C. Obtain blood cultures.

D. Place the child in isolation.

64.A nurse is caring for a child who has red marks across his cheeks. Which of the following actions should the nurse

take?

A. Assess the rest of the child’s body for a rash.

B. Refer the family to child protective services.

C. Question the parents about how the marks occurred on the child’s cheeks.

D. Obtain the child’s temperature.

65.A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the

following statements by the parent indicates a need for further teaching?

A. “I will have my child rest.”

B. “I will elevate the affected part.”

C. “I will compress the site.”

D. “I will apply heat.”

66.A nurse is caring for a child who has pertussis. The child’s parent asks the nurse what the common name for this

disease is. The nurse should respond with which of the following common names?

A. Chickenpox

B. Whooping cough

C. Mumps

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D. Fifth disease

67.A nurse is caring for a child who has tinea pedis. The child’s parent asks the nurse what this infection is commonly

called. The nurse should respond with which of the following common names?

A. Shingles

B. Athlete’s foot

C. Fever blister

D. Valley fever

68.A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the

nurse’s priority?

A. Place a pillow under the child’s head.

B. Position the child side-lying.

C. Loosen restrictive clothing.

D. Clear the area of hazards.

69.A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is

characterized by which of the following?

A. Imaginary playmates

B. Erikson’s stage of initiative versus guilt

C. Demonstrations of sexual curiosity

D. Negative behaviors characterized by the need for autonomy

70.A nurse is providing health promotion teaching to an adolescent. Which of the following information should the

nurse include in the teaching?

A. “Share piercing needles only with close friends you trust.”

B. “Limit your caloric intake to avoid becoming overweight.”

C. “Your need for sleep will increase during periods of growth.”

D. “Tanning beds are much safer then lying in the sun.”

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71.A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information

should the nurse include in the teaching? (Select all that apply.)

A. Management of tantrums

B. How to establish trust

C. How to encourage cooperative play

D. Dental care

E. Need for increased caloric intake

72.A nurse is providing health promotion teaching to the parents of an infant. Which of the following conditions should

the nurse identify as the leading cause of death among this age group?

A. Congenital anomalies

B. Respiratory distress

C. Low birth weight

D. Sudden infant death syndrome

73.A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place

Erikson’s stages of psychosocial development in order from birth to adolescence. (Move the steps into the box on

the right, placing them in the selected order of performance. Use all the steps.)

A. Autonomy vs. shame and doubt

B. Industry vs. inferiority

C. Identity vs. role confusion

D. Initiative vs. guilt

E. Trust vs. mistrust

74.A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to

the railing. The nurse should understand that these actions are developmentally appropriate at which of the

following ages?

A. 3 years

B. 4 years

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C. 5 years

D. 6 years

75.A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically

doubles by what age?

A. 3 months

B. 6 months

C. 9 months

D. 12 months

76.A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The

nurse should include which of the following statements in a discussion with the mother?

A. “Placing your child on her back when sleeping will decrease the risk of SIDS.”

B. “SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines.”

C. “SIDS rates have been rising over the last 10 years.”

D. “Sleep apnea is the main cause of SIDS.”

77.A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures,

such as injections. Which of the following strategies should the nurse add to the child’s plan of care? (Select all

that apply.)

A. Have a parent stay with the child during procedures.

B. Cluster invasive procedures whenever possible.

C. Perform the procedure as quickly as possible.

D. Allow the child to keep a toy from home with her.

E. Use mummy restraints during painful procedures.

78.A nurse in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her

son is a “picky eater.” Which of the following instructions should the nurse include in the teaching?

A. Have the child remain at the table after meals to increase food intake.

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B. Add fruit juice to the child’s diet to increase vitamin intake.

C. Emphasize the quantity, rather than the quality, of food consumed.

D. Expect that food consumption might not decrease significantly.

79.A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation?

A. Uses a unidextrous grasp

B. Has a fear of strangers

C. Shows preferences towards foods

D. Babbles one-syllable sounds

80.A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should

the nurse expect?

A. Dry, sticky mucous membranes

B. Polyuria

C. Negative Chvostek’s sign

D. Muscle tremors

81.A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions

should the nurse include in the teaching?

A. Apply a topical corticosteroid ointment to the affected area.

B. Launder the child’s clothing with fabric softener.

C. Give the child a bubble baths every day.

D. Dress the child in woolen clothes during cold months.

82.A nurse is providing discharge instructions to a parent and his school-age child who has juvenile idiopathic

arthritis. Which of the following instructions should the nurse include?

A. Encourage the child to take a 45 min nap daily.

B. Allow the child to stay at home on days when her joints are painful.

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C. Apply cool compresses for 20 min every hour.

D. Administer prednisone on an alternate-day schedule.

83.A nurse is teaching a parent of a 2-year-old child about safe food choices. Which of the following foods should the

nurse recommend?

A. Grapes

B. Bananas

C. Celery

D. Raw carrots

84.A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention?

A. Positive Babinski reflex

B. Positive Moro reflex

C. Negative Doll’s eye reflex

D. Negative Crawl reflex

85.A nurse is assessing an adolescent who has an exacerbation of Graves’ disease. Which of the following findings

should the nurse expect?

A. Weight gain

B. Bradycardia

C. Lethargy

D. Heat intolerance

86.A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and

concentrating on the questions the nurse is asking. The nurse checks the adolescent’s blood glucose level and

identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?

A. Dry, flushed skin

B. Deep, rapid respirations

C. Tachycardia

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D. Polyuria

87.A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of

the following interventions should the nurse include in the plan of care?

A. Allow for adjustment of rules to correlate with the child’s behavior.

B. Provide a flexible schedule that adjusts to the child’s interests.

C. Allow for imaginative play with peers without supervision.

D. Establish a reward system for positive behavior.

88.A nurse is caring for a child who has been physically abused by a family member. Which of the following

statements should the nurse to say to the child?

A. “I promise I won’t tell anyone about this.”

B. “Let’s discuss what happened with your family.”

C. “Your family is bad for doing this to you.”

D. “It is not your fault that this happened.”

89.A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the

client’s history, the nurse should determine that which of the following is the priority risk factor for suicide

completion?

A. Active psychiatric disorder

B. Previous suicide attempt

C. Loss of a parent

D. History of substance abuse

90.A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the

following behaviors by the adolescent should the nurse anticipate because it is most common reaction?

A. Identity crisis

B. Body image changes

C. Feelings of displacement

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D. Loss of privacy

91.A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output

should indicate to the nurse that the treatment has corrected the fluid imbalance?

A. 0.5 mL/kg/hr

B. 2 mL/kg/hr

C. 7.5 mL/kg/hr

D. 15 mL/kg/hr

92.A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an

intussusception. Which of the following fluids should the nurse select for the infant?

A. Oral electrolyte solution

B. Half-strength infant formula

C. Half-strength orange juice

D. Sterile water

93.A parent tells a nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The

nurse should explain that the toddler is at risk for which of the following disorders?

A. Iron deficiency anemia

B. Rickets

C. Diabetes mellitus

D. Obesity

94.A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of

the condition?

A. Tracks an object with eyes

B. Sits with pillow props

C. Smiles when a parent appears

D. Uses a pincer grasp to pick up a toy

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95.A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider?

A. Inability to raise head when in prone position

B. Inability to sit without support

C. Inability to pick up an object with her fingers

D. Inability to bring an object to her mouth

96.A nurse is teaching the parents of a toddler about temper tantrums. Which of the following statements should the

nurse include in the teaching?

A. “You should leave the room while the tantrum is happening.”

B. “Temper tantrums are the toddler’s attempt to gain control of a situation.”

C. “You should get a psychological consult for the temper tantrums.”

D. “Temper tantrums are a type of learning disability.”

97.A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following

pain scales should the nurse use to determine the infant’s pain level?

A. FLACC

B. Oucher

C. FACES

D. Visual Analog Scale

98.A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should

anticipate providing which of the following types of fluid?

A. Broth

B. Water

C. Diluted apple juice

D. Oral rehydration solution

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99.A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse

should understand that further teaching is necessary when the mother states which of the following?

A. “I will give my son the enzymes between meals.”

B. “The enzymes probably won’t cause many adverse effects.”

C. “The enzymes help him digest fat.”

D. “I will put the enzyme crystals in his applesauce.”

100.A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes

three times per day. Which of the following statements indicates that the mother understands the teaching?

A. “My child will take the enzymes to improve her metabolism.”

B. “My child will take the enzymes following meals.”

C. “My child will take the enzymes to help digest the fat in foods.”

D. “My child will take the enzymes 2 hours before meals.”

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a nurse is assessing a 12 month old infant during a well child visit. which of the following findings should the nurse report to the provider

a. closed anterior fontanel
b. eruption of six teeth
c. birth weight doubled
d. birth length increased by 50%

a nurse is performing a developmental screening on a 10 month old infant. which of the following fine motor skills should the nurse expect the infant to perform? (select all that apply)

a. grasp a rattle by the handle
b. try building a 2 block tower
c. use a crude pincer grasp
d. place objects into a container
e. walk with one hand held

A
C

B (@ 12months)
D (@ 11 months)
E (@ 12 months)

a nurse is conducting a well-baby visit with a 4 month old infant. which of the following immunizations should the nurse plan to adminiter to the infant (select all that apply)

a. MMR
b. polio (IPV)
c. pneumococcal vaccine (PCV)
d. varicella
e. rotavirus (RV)

B C E

A (1st MMR is given between 12-15 months)
D (given at minimum 12 months)

a nurse is providing education about introducing new foods to the parents of a 4 month old infant. the nurse should recommend that the parents introduce which of the following foods first

a. strained yellow vegetables
b. iron fortified cereals
c. pureed fruits
d. whole milk

B

A (6 months)
C (6 months)
D (12 months)

a nurse is providing teaching about dental care and teething to the parent of a 9 month old infant. which of the following statements by the parents indicate an understanding of the teaching?

a. I can give my baby a warm teething ring to relieve discomfort

b. I should clean my baby’s teeth with a cool, wet wash cloth

c. I can give Advil for up to 5 days while my baby is teething

d. I should place a diluted juice in the bottle my baby drink while falling asleep

a nurse is assessing a 2.5 year old toddler at a well child visit. which of the following findings should the nurse report to the provider

a. height increased by 7.5 (3″) in the past year
b. head circumference exceeds chest circumference
c. anterior and posterior fontanels are closed
d. current weight equals four times the birth weight

a nurse is performing a developmental screening on an 18 month old. which of the following skills should the toddler be able to perform (select all that apply)

a. build a tower with 6 blocks
b. throw a ball overhand
c. walk up and down the stairs
d. draw circles
e. use a spoon without rotation

B E

A (@ 2 years)
C (@ 2 years)
D (@ 2.5 years)

a nurse is providing teaching about age-appropriate activities to the parent of a 2 year old. which of the following statements by the parent indicates an understanding of the teaching?

a. I will send my child’s favorite stuffed animal when she will be napping away from home

b. my child should be able to stand one foot for a second

c. the soccer team my child will be playing on starts practicing next week

d. I should expect my child to be able to draw circles

a nurse is providing anticipatory guidance to the parents of a toddler. which of the following should the nurse include (select all that apply)

a. develop food habits that will prevent dental caries
b. meeting caloric needs results in an increased appetite
c. expression of bedtime fears is common
d. expect behaviors associated with negativism and tribalism
e. annual screening for phenylketonuria are important

A C D

a nurse is providing teaching to the parent of a preschool age child about methods to promote sleep. which of the following statements by the parent indicates an understanding of the teaching

a. I will sleep in the bed with my child if she wakes up during the night

b. I will let my child stay up an additional 2 hours on weekend nights

c. I will let my child watch TV for 30 minutes just before bedtime each night

d. I will keep a dim lamp on in my child’s room during the night

a nurse is conducting a well child visit with a 5 year old. which of the following immunizations should the nurse plan to administer to the child (select all that apply)

a. DTaP
b. IPV
c. MMR
d. PCV
e. Hib

A B C

a nurse is preparing an education program for a group of parents of preschool-age children about promoting optimum nutrition. which of the following information should the nurse include in the teaching?

a. saturated fats should equal 20% of total daily caloric intake

b. average calorie intake should by 1800 calories per day

c. daily intake of fruits and vegetables should total 2 servings

d. healthy diets include a total of 8 G protein each day

a nurse is performing a developmental screening on a 3 year old child. which of the following skills should the nurse expect the child to perform

a. ride a tricycle
b. hop on one foot
c. jump rope
d. throw a ball overhead

a nurse is caring for a preschool age child who says she needs to leave the hospital because her doll is scared to be at home alone. which of the following characteristics of pre-operational thought is the child experiencing

a. egocentrism
b. centration
c. animism
d. magical thinking

a nurse is discussing pre-pubsecence and pre-adolescence with a group of parents of school aged children. which of the following information should the nurse include in the discussion

a. initial physiologic changes appear during early childhood

b. changes in height and weight occur slowly during this period

c. growth differences between boys and girls become evident

d. signs of sexual maturation become highly visible in boys

a nurse is conducting a well child visit with a child who is scheduled to receive the recommended immunizations for 11-12 years old. which of the following immunizations should the nurse administer (select all that apply)

a. trivalent inactivated influenza (TIV)
b. PCV
c. Meningococcal (MCV4)
D. Tdap
e. RV

A C D

a nurse is providing education about age appropriate activities for the parents of a 6 year old child. which of the following activities should the nurse include in teaching>

a. jumping rope
b. playing card games
c. solving jigsaw puzzles
d. joining competitive sports

a nurse is teaching a course about safety during the school age years to a group of parents. which of the following information should the nurse include in the course (select all that apply)

a. gating stairs at the top and bottom
b. wearing helmets when riding bicycles or skateboarding
c. riding safely in bed of pickup trucks
d. implementing firearm safety
e. wearing seat belts

B D E

a nurse is providing teaching about expected changes during puberty to a group of parents of early adolescent girls. which of the following statements by one of the parents indicates an understanding of the teaching

a. girls usually stop growing about 2 years after menarche

b. girls are expected to gain about 65 pounds during puberty

c. girls experience menstruation prior to breast development

d. girls typically grow more than 10″ during puberty

a nurse is providing anticipatory guidance to the parent of a 13 year old. which of the following screenings should the nurse recommend for the adolescent (select all that apply)

a. BMI
b. blood lead level
c. 24 hr dietary recall
d. weight
e. scoliosis

A D E

a nurse is caring for an adolescent whose mother expresses concerns about her child sleeping such long hours. which of the following conditions should the nurse inform the mother as requiring additional sleep during adolescence

a. sleep terrors
b. rapid growth
c. elevated zinc levels
d. slowed metabolism

a nurse is teaching a class about puberty in boys. which of the following should the nurse include as the first manifestation of sexual maturation

a. pubic hair growth
b. vocal changes
c. testicular enlargement
d. facial hair growth

a nurse is planning to administer the influenza vaccine to a toddler. which of the following actions should the nurse take

a. administer SQ in abdomen
b. use a 20 gauge needle
c. divide the medication into 2 injections
d. place the child in the supine position

D (to get to the vastus lateralis location)

a nurse is teaching a parent of an infant about administration of oral medications. which of the following should the nurse include in the teaching (select all that apply)

a. use a universal dropper for medication admin
b. ask the pharmacy to add flavoring
c. add the med to formula
d. use the nipple of a bottle to admin
e. hold the infant in a semireclining position

B D E

a nurse is preparing to administer medication to a toddler. which of the following actions should the nurse take (select all that apply)

a. identify the toddler by asking the parent
b. tell the parent to administer the med
c. calculate safe dosage
d. ask the toddler what toy he wants to hold
e. offer juice after the medication

C D E

a nurse is caring for an infant who needs otic medication. which of the following is an appropriate action for the nurse to take

a. hold the infant in an upright position
b. pull the pinna down and straight back
c. hyperextend the infants neck
d. ensure that the med is cool

a nurse is reviewing the medical record of a newborn who has necrotizing entercolitis (NEC). which of the following findings is a risk factor for NEC

a. macrosomia
b. transient tachypnea of the newborn (TTN)
c. maternal gestational hypertension
d. gestational age 36 weeks

a nurse is assessing a newborn who has congenital hypothyroidism. which of the following findings should the nurse expect (select all that apply)

a. hypotonicity
b. cool extremities
c. short neck
d. tachycardia
e. hyperreflexia

B C

a nurse is teaching the parent of a newborn how to treat the newborns plagiocephaly. which of the following statements by the parent indicates an understanding of the teaching

a. I should put my baby to sleep on her belly during her afternoon nap

b. a should ensure my baby’s head is in the same position each time she sleeps

c. I should have my baby wear the prescribed helmet 23 hours a day

d. I should allow my baby to sleep in her infant swing

a nurse is developing a plan of care for a newborn who has hyperbilirubinemia and is to undergo phototherapy. which of the following actions should the nurse include in the plan of care

a. reposition the newborn q4h
b. lotion the newborns skin twice daily
c. check the newborns temp q8
d. remove the newborns eye mask during feedings

a nurse is providing preconception teaching with a client who has PKU. which of the following information should the nurse include in the teaching

a. follow a low phenylalanine diet once pregnancy is confirmed

b. the client will undergo testing of phenylalanine levels one to two times per week throughout pregnancy

c. increase intake of dietary proteins prior to conception

d. the client will require a C section due to the likelihood of having a fetus with macrosomia

a nurse is caring for a child who is experiencing respiratory distress. which of the following findings are early manifestations of respiratory distress (select all that apply)

a. bradypnea
b. peripheral cyanosis
c. tachycarida
d. diaphoresis
e. restlessness

C D E

a nurse in the ED is caring for a child whose parent reports that the child has swallowed paint thinner. the child is lethargic, gagging, and cyanotic. which of the following actions should the nurse take

a. induce vomiting with syrup of ipecac
b. insert NG and administer activated charcoal
c. prepare for intubation with a cuffed endotracheal tube
d. administer chelation therapy using deferoxamine mesylate

a nurse in the ED is admitting the infant who experienced a life threatening event. which of the following prescriptions by the provider should the nurse anticipate (select all that apply)

a. electroencephalogram
b electrocardiogram
c. urine culture
d. arterial blood gas
e. blood culture

A B C E

a nurse is providing teaching to a parent about acetaminophen poisoning. which of the following information should the nurse include in the teaching

a. nausea begins 24 hours after injection
b. pallor can appear as early as 2 hours after ingestion
c. jaundice will appear in 12 hours if the child is toxic
d. children can have 4 g / day of acetaminophen

a nurse in a community center is providing an in service to a group of parents on management of airway obstructions in toddlers. which of the following responses by the parents indicates understanding? (select all that apply)

a. I will push on my child’s abdomen
b. I will hyperextend my child’s head to open his airway
c. I will listen over my child’s mouth for sounds of breathing
d. I will use my finger to check my child’s mouth for objets
e. I will place my child in my car and take hm to the closest ER facility

A C

a nurse is teaching a group of parents about characteristics of infants who have failure to thrive. which of the following characteristics should the nurse include in teaching>

a. intense fear of strangers
b. increased risk for childhood obesity
c. inability to form close relationships with siblings
d. developmental delays

a nurse is providing instruction to the teacher of a child who has ADHD. which of the following strategies should the nurse include in the teaching (select all that apply)

a. eliminate testing
b. allow for regular breaks
c. combine verbal instruction with visual cues
d. establish consistent classroom rules
e. increase stimuli in the environment

B C D

a nurse is teaching a parent about post-traumatic stress disorder (PTSD). which of the following information should the nurse include in the teaching (select all that apply)

a. children who have PTSD can benefit from psychotherapy
b. a manifestation of PTSD is phobias
c. personality disorders are a complication of PTSD
d. PTSD develops following a traumatic event
e. there are 6 stages of PTSD

A B D

a nurse is teaching the parent of a child about risk factors for ADHD. which of the following should the nurse include in the teaching

a. formula feeding as an infant
b. history of head trauma
c. history of preterm birth
d. child of a single parent

a nurse is caring for a child who has depression. which of the following findings should the nurse expect (select all that apply)

a. preferring being with peers
b. weight loss or gain
c. report low self esteem
d. sleeping more than usual
e. hyperactivity

B C D

A nurse is completing an admission assessment on an adolescent child who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide nutrients most likely to be lacking in his diet?
Peanut Butter and Jelly Sandwich

A nurse is caring for a 1-month old infant who weighs 3540 g and is prescribed a dose of cefazolin 50mg/kg IV bolus TID. How many mg should the nurse administer per dose?

A nurse is preforming a pre-college assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?
Meningococcal polysaccharide vaccine

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Nocturia at night

A nurse is caring for a client who has active TB and is to be started on IV rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects?
Body sections turning a red orange color

A nurse is caring for a 6-week-old infant who as a pyloric stenosis. Which of the following manifestations should the nurse expect?
Projectile vomiting

A nurse receives a call from a parent of a child who has von Willebrand disease and has having a nosebleed. Which of the following instructions should the nurse give to the parents?
“Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes.”

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?
Pain

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?
Place her hands on the sides of her rib cage

A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (select all that apply).
-Hypotension
-Weak pulses
-Murmur

A nurse is planning care for a client who has idiopathic thrombocytopenic purpur (ITP). Which of the following manifestations is the most appropriate for the nurse to monitor?
Bleeding

A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements indicates an understanding of the teaching?
I’m glad that my child’s ostomy is only temporary

A school nurse identifies that a child has pediculosis capitis and educates the child’s parents about the condition. Which of the following statements by the parents indicated an understanding of the teaching?
All recently used clothing, bedding, and towels must be washed in hot water.

A nurse is providing dietary teaching to the parents of a newborn who is being breastfed. The nurse should instruct that the transition to whole milk can occur at which of the following ages?
12 months

A nurse is assessing a 6-month old patient at a well-child visit. Which of the following findings should the nurse expect?
Closed posterior fontanel

A nurse is caring for a 2-year old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?
Shake the container vigorously.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client’s plan of care?
Obtain a order for an in and out catheter

A nurse is planning care for a child who has suspected epiglottis. Which of the following actions should the nurse take?
Place the child on droplet precautions

A nurse is instructing a group of clients regarding calcium rich food. Which of the following should the nurse include in the teaching as the best source of calcium?
1 cup of milk

A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says ” I don’t understand why my child is so upset. I’ve never seen my child act this way around others before.” Which of the following statements should the nurse make?
This is a normal, expected reaction for a child of this age

A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child’s cooperation?
Offer the child a choice of crushed pills or elixir

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the meal tray?
Mask

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?
The client holds his breath for 10 seconds after inhaling the medication.

A nurse is caring for a 2-month-old infant who is post-operative following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Encourage the parents to rock the infant

A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis?
Cardiovascular

A nurse is providing teaching to a client who has oral candidiasis and a new script for nystatin suspension. Which of the following statements by the client indicates an understanding of the teaching?
“I will store the medication at room temperature”

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply).
-An increase in neutrophils
-Localized edema

A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following must be removed first?
Gloves

A nurse is assessing a client who is receiving a unit of RBC. Which of the following findings is a manifestation of acute hemolytic reaction?
Client reports lower back pain

A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching?
Immobilize the limb at the level of the heart.

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?
Hepatomegaly

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client’s plan of care?
Measure head circumference every shift

A nurse is caring for a pre-school child who has epiglottitis with a barking cough. Which of the following actions should the nurse take?
Monitor O2 sat

A nurse is caring for a child who 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?
Crushed Ice

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following assessment should indicate to the nurse that the client could be developing a serious complication?
Dyspnea

A nurse is providing discharge teaching to a client who has SLE. Which of the following instructions should the nurse include?
I should wear gloves when it is cold outside

A nurse is caring for an infant who has congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow?
Patent ductus arteriosus

A community health nurse in a pediatric clinic is reviewing a history of a 12-year-old client. Which of the following immunizations should the nurse expect to administer?
Meningococcal conjugate

A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant?
Trendelenburg

A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. The amount available is 0.125mg tab. The client’s current vital signs are: BP 144/96, hear rate 54/min, respirations 18/min, and temperature 98.6 F. Which of the following actions should the nurse take?
Withhold the digoxin dose for decreased pulse rate

A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?
The teacher says my child has to squint to see the board

A nurse is reinforcing teaching about food choices with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?
I will give my child peanut butter and mashed egg whites

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Inspect the mouth for sings of inhalation injuries

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
A private room

A nurse is reviewing the lab findings for a client who has ITP. Which of the following findings should the nurse expect to be decreased?
Platelets

A nurse is assessing a client who has SLE. Which of the following findings should the nurse expect?
Decreased urine output.
Butterfly rash.
Joint inflammation.

A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
TB

A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication?
Sedation

A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?
A child who has nephrotic syndrome

A nurse is instructing the parents of a client who has a new prescription for methylphenidate. Which of the following instructions should the nurse include?
Take the medication orally once daily in the morning.

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of PCN. Which of the following meds should the nurse administer first?
Epinephrine

A nurse is providing teaching to a parent of a toddler about appropriate snacks. Which of the following foods should the nurse include?
A: Graham crackers are appropriate snack foods for toddlers
B:Apple slices are appropriate snack foods for toddlers
E: Cheese cubes are appropriate snack foods for toddlers

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (select all that apply).
Avoid ventipucture

A nurse is admitting a toddler who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take?
Keep thermometer in the toddler’s room.

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?
Recombinant

A nurse is assessing a school-aged child whose blood glucose level is 280. Which of the following findings should the nurse expect?
Lethargy

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?
Conjunctiva, lips, and oral mucous.

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following action should the nurse take first?
Check the clients vital signs.

A nurse is teaching a client who has a new prescription for prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication?
Decreases inflammation

A nurse is caring for a client who just had a cardiac catherization. Which of the following nursing interventions should the nurse include in the clients plan of care?
Notify the provider of the client’s allergy.

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse’s highest priority?
Administering a nebulizer beta- adrenergic

A nurse is assessing a 9-month-old infant. Which of the following findings require further interventions?
Positive Moro reflex

A nurse is caring for a client who has HIV. Which of the following lab values is the nurse’s priority?
CD4-T- cell count less than 180 cells/mm

A nurse is providing dietary teaching to a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing?
One cup of lentils

A nurse is caring for a client who has hemophilia A and hemarthrosis of the left knee. Which of the following actions should the nurse take?
Prepare for replacement of the missing clotting factor

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider?
Dyspnea

A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following lab values gives the nurse an assessment of the adequacy of the client’s protein uptake and synthesis?
Albumin

A child is admitted with suspected diagnosis of Wilms’ tumor. The nurse should place a sign with which of the following warnings over the child’s bed?
Do not palpate abdomen.

A nurse in the ER is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Airway obstruction

A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur?
Indicates turbulent blood flow through a valve.

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?
Tell the client to blow her nose gently before the instillation.

A nurse is caring for an 8-year-old who has acute rheumatic fever. Which of the following assessments is the nurse’s priority immediately after admission?
Auscultating the rate and characteristics of the child’s heart sounds.

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