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Hesi Exam Pediatric II Questions and Answer Solutions | Download To Score An A.

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The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's repeated hospitalizations. Which is the best response that the nurse should offer? ... Encourage the mother to have the children visit the hospitalized sibling Ⓒ When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it a. D- Stresses the fracture. Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying causes (increased salvation, leads to vomiting, stresses the suture line) these conditions do not create a problem for the child with a cleft lip repair Ⓒ The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift? Tympanic and oral temperatures are equally accurate. Ⓒ A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? Consistently follow a set mealtime routine. Ⓒ What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? Observe for projectile vomiting. Ⓒ The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits? Half of child's speech is understandable. Ⓒ The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take? Pass the information on in the report. Ⓒ A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? Children need to retain a sense of initiative without impinging on the rights and privileges of others. Ⓒ A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? Apical heart rate of 60. Ⓒ Which restraint should be used for a toddler after a cleft palate repair? a. Elbow a.i. Elbow restraints prevent children from bending their arms and brining their hands to the oral surgical site, (A) restrains the hands but the child can bend and bring their head to their ands. (B) is used during procedures (mummy). (D)-jacket, restrains the body torso and is not appropriate Ⓒ When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children? Cessation of growth in a child that had been normal. Ⓒ The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruc Do not give if the child has chickenpox, the flu, or any other viral illness. Ⓒ Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant? A thin stratum corneum that increases topical absorption. Ⓒ The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction? a. B- store all toxic agents and medicines in locked cabinets. a.i. The only reliable way to prevent poisoning in young children is to make them inaccessible Ⓒ A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take? a. C- administer the tetanus toxoid booster. a.i. After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult if every 10 years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds fr. missiles, burns or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered Ⓒ During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement? a. Stop the infusion immediately and notify the healthcare provider a.i. The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be stopped immediately and the healthcare provider notified ©. After the transfusion is discontinued, IV access should be maintained. (A) with fluids that do not introduce any more cellular products. (B & D) place the child @ risk for further blood reactions Ⓒ A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client's social interaction, what intervention is best for the nurse to initiate? Arrange for an Internet connection in the client's room for email communication. Ⓒ The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication? Changes in level of consciousness. Ⓒ The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider? a. A- Pale bluish coloration of the toes a.i. Russell's skin traction is used for fractures of the femur in young children and adolescents whose growth plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can compress the perineal nerve and arteries that supply the foot. Assessment of adequate circulation, movement, & sensation of the toes and skin distal to the application is make to identify compromised blood flow, so cyanosis should be reported immediately Ⓒ Which class of antiinfective drugs is contraindicated for use in children under 8 years of age? a. B- tetracyclines a.i. Tetracyclines cause enamel hypoplasia & tooth discoloration in children under 8 yrs of age Ⓒ The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit? Clubbed fingers. Ⓒ The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which Advice should the nurse give? Walk away from him and ignore the behavior. A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child's care? Plenty of fluids should be consumed daily. When assessing a child with asthma, the nurse should expect intercostal retractions during a. A-inspiration a.i. Intercostals retractions result fr. respiratory effort to draw air into restricted airways The nurse is planning the care of a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis? Place elbow restraints on the child's arms. A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis? Sequestration A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan? a. A- Use sunscreen when lying by the pool a.i. Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) therapy. Severe sunburn can occur with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child's cooperation? Use a colorful straw. The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? I understand that I will be in a body cast and I will show you how you taught me to turn. Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? A trial of human chorionic gonadotrophic hormone Ⓒ A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? Have a bulb syringe readily available to remove secretions. Ⓒ The nurse is planning care for school-aged children at a community care center. Which activity is best for the children? a. B- playing follow the leader a.i. School aged children strive for independence and productivity (ericksons industry vs. inferiority) & enjoy individual & group activities r/t real life situation, such as playing follow the leader Ⓒ Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.) Child's height and weight. Body surface area of child. Nomogram determined mathematical constant. Ⓒ During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next? a. B- Ask the child if he/she has had cold, runny nose, or any ear pain lately. a.i. More information is needed to interpret these finding, the tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of hx and related s/s is indicated for accurate interpretation of the finding. Ⓒ Which finding in a 19-year-old female client should trigger further assessment by the nurse? Menstruation has not occurred. Ⓒ In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? Process of glucose testing Ⓒ The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication? a. A- engage the child through drawing pictures a.i. Drawing pictures is a valuable fr. non verbal communication. As the nurse & child look at the drawings, a verbal story can be told that projects the child's thinking Ⓒ The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that a. B- a tympanic measurement of temperature will provide the most accurate reading a.i. A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or nonsuppurative otitis media does not effect measurement. RULE OF THUMB: for managementsterile procedures should be assigned to licensed personnel. Management skill will tested on the NCLEX. An RN is not required to do: rectal temp Ⓒ A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? Wash the hair and skin frequently with soap and hot water. Ⓒ When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline? a. A- parental control should be consistent a.i. Discipline should be a positive and necessary component of childrearing that is started in infancy & should teach socially acceptable behavior, help children protect themselves fr. danger, and channel undesirable behavior into constructive activity. Misbehavior may result fr. inconsistent rules or messages, so parental attention should be clear, reasonable, and consistent. Ⓒ A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first? Wash the wound gently with mild soap and water Ⓒ The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? Are you experiencing any type of nervousness? Ⓒ A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization? Explain hospital schedules to the child, such as mealtimes. Ⓒ At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she Administer PRN prescription of nifedipine (Procardia) sublingually. Ⓒ A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child? Remove restraints one at a time and provide range of motion exercises. Ⓒ Which action by the nurse is most helpful in communicating with a preschool-aged child? Use a doll to play and communicate. Ⓒ A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care? Apply pressure and ice for bleeding while elevating and resting the extremity. Ⓒ The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? Type of reaction to loud noises. Ⓒ A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? Choking, coughing, and cyanosis. Ⓒ The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? Description of vomiting episodes in past 24 hours. Ⓒ Which behavior should the nurse expect a two-year-old child to exhibit? a. C- display possessiveness of toys a.i. Two year old children are egocentric and unable to share with other children and behaviors of a preschooler. Ⓒ A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The nurse determines the daily caloric need for this child is approximately 600 calories per day Ⓒ The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child? Risk for infection Ⓒ A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding? Steatorrhea Ⓒ The nurse observes a 4-year-old boy in a daycare setting. Which behavior would the nurse consider normal for this child? Demonstrates aggressiveness by boasting when telling a story. Ⓒ An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? Prevent the return of oxygenated blood to the lungs. a.i. a. Closure of VSDs stops oxygenated blood fr. being shunted fr. the left ventricle to the right ventricle. VSDs are acyanotic defects, which means that no deoxygenated blood enters the systemic circulation is common with tetralogy of Fallot, which is a cyanotic defects. Ⓒ The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first? a. B- Start an IV infusion of normal saline a.i. The current VS readings and the decreased peripheral pulse volume indicate that the child is experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume. Ⓒ A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is calculated as a larger percentage of total body surface than an adult's? a. A-Head & Neck a.i. A child's head & neck are proportionately larger to their body than and adult's. The standard "Rule of nines" is inaccurate for determining burned body surface areas with children, and must be modified for use with children. Specially designed charts for children and are commonly used to determine body surface are involvement Ⓒ A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first? Determine the child's pulse and respirations. Ⓒ To assess the effectiveness of an analgesic administered to a 4- year-old, what intervention is best for the nurse to implement? Use a happy-face/sad-face pain scale. Ⓒ Preoperative nursing care for a child with Wilms' tumor should include which intervention? a. D-put a sign on the bed reading, "DO NOT PALPATE ABDOMEN" a.i. Prevention of abdominal palpation minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis. Ⓒ A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome? Congenital heart disease. Ⓒ A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder? Nystatin (Mycostatin). Ⓒ A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior? Concern for body integrity. Ⓒ A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? Call the healthcare provider immediately if his nail beds appear blue. Ⓒ A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD) Monitor the the infant's weight and number of wet diapers per day. Use a softer nipple or increase the size of the nipple opening. Increase the infant's intake per feeding by 1 to 2 ounces per week. Allow the infant to rest and refeed on demand or every 2 hours. Ⓒ During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing? a. B- eye exams a.i. Visual changes leading to blindness an occur in children with JRA/ Regular eye exams can help to prevent this complication Ⓒ As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? a. A- a 6 moth old with failure to thrive that has a closed anterior fontanel a.i. @ 6 months of age the anterior fontanel should be open, and it should not be closed until approx 18 months Ⓒ To take the vital signs of a 4-month-old child, which order provides the most accurate results? Respiratory rate, heart rate, then rectal temperature. Ⓒ A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first? Assess the child's respiratory status Ⓒ A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82 Tell the student to proceed directly to his regularly scheduled class. Ⓒ The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family? Polyuria and polydipsia. Ⓒ The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching? Using a teaspoon will help me measure this correctly. Ⓒ When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement? Record weight daily. Ⓒ A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide? Explain that menarche varies and occurs between the ages of 12 and 18 years. Ⓒ The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement? Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there. Ⓒ All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old child? Assessing fontanels. Ⓒ The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate? 12 to 15 months. Ⓒ A 6-month-old boy and his mother are at the healthcare provider's office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today? All the immunizations with the influenza vaccine given at a separate site from any other injection Ⓒ A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding? Serum BUN and creatinine levels. Ⓒ A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents? The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her. Ⓒ The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand? Administer aerosol therapy followed by postural drainage before meals. Ⓒ Preoperative nursing care for a child with Wilms' tumor should include which intervention? Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." Ⓒ Which behavior should the nurse expect a two-year-old child to exhibit Display possessiveness of toys. Ⓒ The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." (aspirin) Do not give if the child has chickenpox, the flu, or any other viral illness. Ⓒ A nurse who is working in the Poison Control Center receives several telephone calls from parents whose children have ingested possible poisons. The nurse should recommend inducing vomiting for which child? 16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir. Ⓒ The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. What should she do? Walk away from him and ignore the behavior. Ⓒ When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement? Record weight daily. Ⓒ When taking the health history of a child, the nurse know what which finding is an early indication of hypothyroidism in children? a. Cessation of growth in a child that had been normal a.i. Since the thyroid gland is responsible for metabolism, cessation of growth which as previously with in normal range, is the most common for hypothyroidism in children. The child with hypothyroidism is likely to be HYPOactive not (HYPERactive), although there is delay in the eruption of permanent teeth & slow sexual development happen with hypothyroidism, they are LATE signs.. (NOT EARLY indications) and are signs more often assoc with lack of growth hormone Ⓒ The nurse received a lab report stating a child with asthma has theophylline level of 15 mcg/dl. What action will the nurse take? Hold the next dose of theophylline a.i. Therapeutic levels of theophylline is 10-10 mcg/dl, so the child's level is with in the therapeutic rage. Ⓒ Surgery is being delayed for an infant with undescended testes. In collaboration with the health care provider and the family, which prescription should the nurse anticipapte? A trial of HCG may aid in testicular descent, but does not replace surgical repair for true undescended testes. (cryptorchidism: may be found in the inguinal canal due to exaggerated cremasteric reflex Ⓒ Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations? a. Oven baked potato chips & cola a.i. Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat, and barley. The child should avoid any produces containing these ingredients to avoid symptoms such as diarrhea. Ⓒ The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother? a. Walk away from him and ignore the behavior a.i. The best approach for a toddler is to ignor the attention- seeking behavior. The parents should be somewhat nearby, within view of the child but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs Ⓒ The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's hospitalizations. Which is the best response that the nurse should offer? a. Encourage the mother to have the children visit the hospitalized sibling. a.i. Needs of a sibling will be better met with factual information and contact with the ill child, so siblings visitation should be encouraged (D). Parents are experts on their children and should determine when their children are old enough to visit. (A) in the hospital/ Separation fr. a family & home (B) may intensify fear & anxiety (suggest that the child visit a grandmother until the sibling returns home. Children may have difficulty expressing questions (C) ask the mother if the child asks when the sibling will be discharged, so the support of parents & other caregivers are needed to help alleviate their fears. Ⓒ The nurse is giving preoperative instruction to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? a. I understand that I will be in a body cast and I will show you how you taught me to turn a.i. Outcome of learning is best demonstrated when the client not only verbalizes an understand, but can also provide a return demonstration Ⓒ The clinic nurse is taking the hx for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? a. Type of reaction to loud noises a.i. Ototoxicity diminishes hear acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing the infant's reation to loud noises (A) helps to determine an infant's risk for hearing deficit r/t to a hx of the mother taking ototoxic drug, such as aspirin, while pregnancy (B,C,D are not assoc with the exposure to aspirin in utero Ⓒ The mother of a preschool aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he has a "tummy ache" After reminding the mother to check the label of all OTC drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? Do not give if the child has chickenpox, the flu, or any other viral illness a.i. Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (a) is a common effect of pepto bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D) complication of antacids containing calcium Ⓒ A 3 moth old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder? a. Nystatin (Mycostatin) a.i. Nystatin (mycostatin) (A) is an antifungal drug that is effective in treating thrush, an oral fungal infection Ⓒ The nurse is developing a plan of care for a 3 yr old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement? a. C-give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there a.i. Familizaring the child and mother with the department will help decrease anxiety of the child and mother (who may have more anxiety than the child). Three is a difficult age to undergo a procedure that requires cooperation. Restraints and possible sedation may be required Ⓒ A 3 yr old boy is brought to the ER because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first? a. B-determine the child's pulse and respirations a.i. The most important principle in dealing with a poisoning is to treat the child first, not the poison. Initiate immediate life support measures with assessment of VS (B), in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to A. (C & D after assessing the airway.) Ⓒ A 4- year- old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? a. A- children need to retain a sense of initiative with out impinging on the rights and privileges others a.i. Children aged 3-6 are in Erickson's initiative vs. guilt stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others Ⓒ The nurse is planning the care of a 2 year old with severe eczema on the face, next, and scalp fr. scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the purities? a. C- place elbow restraints on the child's arms. a.i. Elbow restraints prevent arm flexion and scratching of involved area, but do not inhibit use of the nads for play activities. Others can be removed easily Ⓒ a 6- year old admitted to the pediatric unit after falling of a bicycle. Which intervention should the nurse implement to assist the child's adjustments to hospitalization? a. Altered daily schedules and loss of rituals are upsetting to children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules (A) and establishing an individual schedule familiarizes the child to the hospital environment and decreases anxiety. Ⓒ The nurse is caring for a 12 year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication? a. B- changes in LOC a.i. The child must be monitored for S/S of hypontremia, which creates secondary central nervous system alterations such as changes in LOC, seizure coma. Ⓒ A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first? a. C-Wash the wound gently with mild soap and water a.i. A small, superficial laceration to the skin should be washed gently with mild soap and water for several minutes, followed by thorough rinsing. Ⓒ A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? a. A- Apical heart rate of 60 a.i. A heart rate of 60 is much lower than normal for a 6-month old and warrants immediate intervention. The normal heart rate for a 6 month old is 80-150 when awake, and a rate of 70 while sleeping is considered within normal limits. Ⓒ To assess the effectiveness of an analgesic administered to a 4-yr old, what intervention is best for the nurse to implement? a. A- use a happy-face/sad face pain scale. a.i. A 4 year old can readily identify with simple picures to show the nurse how he/she is feeling. Could be used to validate what the child is telling the nurse via the "faces" pain scale, but it is best to elicit the child's assessment of his/her pain level (C-assess for changes in the child's vs), may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables, such as fear Ⓒ The nurse is assessing an 8 month old child who has a medical diagnosis of tetrology of Fallot. Which symptom is the client most likely to exhibit? a. D-clubbed fingers a.i. Tetrology of fallot, a cyanotic heart defect, causes clubbing of fingers and toes due to tissue hypoxia Ⓒ Which action by the nurse is most helpful in communicating with a preschool aged child? a. B- use a doll to play and communicate a.i. Communicating through play with a doll or other toy gives time for the child to feel comfortable with a stranger Ⓒ The nurse observes a 4 yr old boy in a daycare setting. Which behavior would the nurse consider normal for this child? a. C- demonstrates aggressiveness by boasting when telling a story a.i. C- 4yr old children are aggressive in their behavior and enjoy "tale telling" Ⓒ A 2 yr old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome? a. A- congenital heart disease a.i. Is the most common assoc with defect in children with Down Syndrome Ⓒ In developing a teaching plan for a 5 year old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? a. C-process of glucose testing a.i. Developmentally a 5 yr old has the cognitive and psychomotor skills to use a glucometer and to read the number (it is especially helpful if the nurse presents this activity as a game The nurse is assessing a 13 yr old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? a. B-are you experiencing any type of nervousness? a.i. Assessing the client's physiological state upon admission is priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism, but assessing loss (even with a hearty appetite) (A) occurs in those with hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid Ⓒ The mother of a 6 month old asks the nurse when her baby will get the first MMR vaccine. Based on the recommended childhood immunization schedule published by the CDC, which response is accurate? a. (b) the MMR vaccine should be given no sooner than 12 months of age, and ideally between 12 & 15 months of age. (a) 3-6 months should not receive the MMR vaccine due to the presence of maternal antibodies. MMR is not routinely administered @ 18-24, but others like dTaP and Hep B may be given at that time. Ⓒ A 6 month old returns fr. surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child? a. B- remove restraints one at a time and provide range of motion exercises a.i. Removing restraints one at a time (B) is safer than removing all of them at once. The child needs to exercise and should not be kept in restraints at all times Ⓒ A 17 yr old male student reports to the school clinic one morning ofr a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assess his VS: temp 100, pulse, 80, RR 20, and BP is 122/82. What is the best action for the nurse to take? a. A- tell the student to proceed directly to his regularly scheduled class. a.i. The student has just completed football practice, and increased muscle activity increases body heat production. A temp of 100F is NORMAL for this student @ this time. The student should attend class Ⓒ A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have esophageal atresia. Which symptoms are this newborn likely to exhibit? a. A- choking, coughing, and cyanosis a.i. Includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea. Ⓒ A 5 month old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCL/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding? a. B - Serum BUN & Creatinine levels a.i. Regardless of a client's age, adequate renal function must be present before adding potassium ot IV fluids, is important in determining the need for fluid replacement Ⓒ A hospitalized 16 yr old male refuses all visits fr. his classmates because he is concerned about his distorted appearance. To increase the clients social interaction, what intervention is best for the nurse to initiate? a. C- Arrange for an internet connection in the client's room for email communication a.i. Body image and peer acceptance are key concerns for the adolescent © allows for social interaction without face to face contact, thus protecting his self image while also promoting social interaction Ⓒ The parents of a 3 week old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? a. A- description of vomiting episodes in past 24 hrs a.i. A description of the vomiting episodes will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant. Ⓒ A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus PDA and placed under an oxygen good at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents? a. B- oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her. a.i. The baby is at 35% which is must more than room air (21%) and at this time the baby should not be moved fr. under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant. Ⓒ To take the VS of a 4 month old child, which order provides the most accurate results? a. A- respiratory rate, heart rate, then rectal temperature a.i. The respiratory rate should be take first in infants, since touching them or performing unpleasant procedures usually makes the cry, elevating the heart rate and making respirations difficult to count. Rectal temp is the most invasive procedure, and is most likely to precipitate crying, so should be done last Ⓒ A preschool-aged child who is hospitalized fy hypospadias repair is most strongly influenced by which behavior? a. C- the preschoolers major stressor is concern for his body integrity. He fears that his "insides will leak out" A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality Ⓒ All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20 month old child? a. B-assessing fontanels a.i. All of these interventions evaluate fluid status in infants (weight diapers, checking skin turgor, observing mucous membranes for moisture and checking for fluid status) Ⓒ The nurse assigning care for 5 yr old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift? a. B- tympanic and oral temps are equally accurate a.i. A tympanic membrane sensor approximates core temps because the hypothalamus and eardrum are perfused by the same circulation. Tympanic readings obtained using proper technique correlated moderately to strongly with oral temperatures in recent research studies. Ⓒ At 8am the unlicensed assistive personnel (UAP) informed the charge nurse that a female adolescent client with acute glomerulonephritis has a BP of 210/110. The 4am BP reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first? a. -Administer PRN prescription of nifedipine (Procardia) sublingually a.i. Sublingual procardia lowers blood pressure very quickly, and this should be done first Ⓒ A 12-month-old is admitted with a respiratory infection and possible pneumonia. He is placed in a tent with oxygen. Which nursing intervention has the greatest priority for this infant? a. C- a patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making having a bulb syringe the highest priority Ⓒ A three month old boy weighing 10 lbs 15 oz an axillary temp of 98.8. The nurse determines the daily caloric need for this child is approximately a. C- 10 lbs 15 oz = 10.9. Convert lbs by dividing 2.2; 10.9/2.2=4.59kg, rounded to 5kg. An infant requires 108 calories/kg/day (108 x 5=540 calories/day.) However this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 and 540 + 54= 594. This infant will require approx 600 calories/day. Ⓒ The nurse is teaching the parents of a 5 yr old w. cystic fibrosis about respiratory treatment. Which statement indicates to the nruse that the parents understand? a. C- administer aerosol therapy followed by a postural drainage before meals. a.i. Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and before meals or at least 1 hour after eating to prevent nausea & vomiting. Postural drainage uses gravity to promote mucous removal after nebulization (which open airways).. Pulmonary toileting or respiratory treatment should be given 3-4 times daily, not episodically Ⓒ A 4 year old boy was admitted to the emergency room with fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? a. A- call the healthcare provider immediately if his nail beds appear blue. a.i. A- Cyanosis indicates impaired circulation to fingers and should be reported immediately. Although the actions described may be indicated, they are implemented rather excessively & might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days. Ⓒ A 3 week old newborn is brought to the clinic for a follow up after a home birth. The mother reports that her child bottle feeds for 5 min only and falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with respiratory rate of 64 breaths per min. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply) A- Monitor the infant's weight and # of wet diapers per day B- Increase the infant's intake per feeding by 1-2 ounces per week d. allow the infant to rest and reefed on demand or every 2 hrs E. use a softer nipple or increase the size of the nipple opening Rationale: Correct responses are A,B,D, E. neonates who have VSD may fatigue quickly during feeding and ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day. A one month old should ingest 2-4 ounces of formula per feeding and progress to about 30 ounces per day by 4 months of age. Due to fatigue, the infant should rest, but feed at least every 2 hours to ensure adequate intake. A softer (preemie) nipple or a larger slit in the nipple helps to reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more with less effort. Antibiotic prophylaxis is recommended for infants with VSD's, but should not be mixed in a bottle of formula because it is difficult to ensure that the total dose is consumed Ⓒ The nurse is teaching a mother to give 4 mL of a liquid antibiotic to a 10 month old infant. Which statement by the parent indicates a need for further teaching? a. B- using a teaspoon will help me measure this correctly a.i. The prescribed medication is 4 mL dosage and is measured with the most accuracy using a syringe, so if the parent uses teaspoon which is equivalent to 5 mL, further teaching is indicated Ⓒ A 3 yr old client with sickle cell anemia is admitted to the ER with abdominal pain. The nurse palpates an enlarged liver, and x ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis? a. B- sequestration this support a sequestration crisis where blood pools in the spleen, and is characterized by abdominal pain anemia Ⓒ A 14 yr old female client tells the nurse that she is concerned about the acne she has recently developed/ Which recommendation should the nurse provide? a. C- wash the hair and skin frequently with soap and hot water a.i. Washing the hair & skin with soap & hot water removes oil debris fr. the skin and helps prevent & treat acne. Oily skin especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne is contraindicated. Cosmetics "medicated" or not should be used sparingly to avoid further blocking sebaceous gland ducts. Might be indicated at a later time, if healthcare recommendations are not successful. Ⓒ An 18 month old is admitted to the hospital with possible Hirschsprung's disease. When obtaining a nursing hx the nurse asks about bowel habits. What description of the disease? D- Ribbon-like and brown a.i. Hirschsprung's disease is a mechanical obstruction caused by inadequate motility in a part of the intestines. The condition results fr. failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis in the affected bowel segment causes constipation and smaller diameter, brown colored stools Ⓒ A 15 yr old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide? a. C- explain that menarche varies and occurs between the ages of 12-18 years Ⓒ A 2 yr old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parent's teaching plan? a. D- a 2- year old child is comforted by consistency Ⓒ The nurse is assessing a 2 year old. What behavior indicates that the child's language development is within normal limits? a. D- half of a child's speech is understandable a.i. Between approximately 15 & 24 months of age, a child's speech is only ½ understandable Ⓒ What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? a. D- observe for projectile vomiting a.i. Projectile vomiting, which contributes to metabolic alkalosis is the classic sign of pyloric stenosis Ⓒ When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement? a. A- record weight daily a.i. The most definitive measure of improved nutrition is an infant is obtaining the child's daily weight Ⓒ Which finding in a 19 yr old female client should trigger further assessment by the nurse? a. A- menstruation has not occurred a.i. Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically occurs by age 18, so A should prompt further investigation to determine the cause of this primary amenorrhea. Children receive tetanus as part of the DPT childhood immunization series, and a booster is not typically given until age 16. Ⓒ A 6 month old boy and his mother are at healthcare provider's office for a well-baby check up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today? a. B- all the immunizations with the influenza vaccine given at a separate site fr. any other injection a.i. At 6 months of age, the routine immunizations should HEP B, DTaP, Hib, PCV (pneumococcal) , IPV (inactivated poliovirus) and influenza. The influenza vaccine should be given at a separate site fr. any other injection. [Show More]

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