Final

Question 1

A nurse is caring for an adolescent who presents to the emergency department.

The nurse reassesses the adolescent at 1930. For each assessment finding, click to specify if the finding indicates that the adolescent’s condition has improved or has not changed.

Assessment Finding :
Heart rate
Oxygen saturation
Blood pressure
Oral intake
Dyspnea
Lung sounds
Respiratory rate

Answer 1

Improved:
- RR
- O2 sat
- oral intake
- HR
- BP

Not changed:
- lung sounds
- dyspnea

Question 2

A nurse is caring for an adolescent in an emergency department.
History of rheumatic fever with resulting cardiac valve damage.
Manifestations presented a few days after having dental work performed. Now they are worse.

Which of the following should the nurse anticipate the provider will prescribe? For each potential provider’s prescription, specify if the potential prescription is anticipated or contraindicated for the client.

Obtain blood cultures x 3.
Administer antibiotic therapy.
Obtain an echocardiogram.
Restrict dental hygiene.
Perform strenuous exercise regimen twice daily.

Answer 2

Anticipated:
- Obtain blood cultures x 3.
- Administer antibiotic therapy.
- Obtain an echocardiogram.

Contraindicated:
- Restrict dental hygiene.
- Perform strenuous exercise regimen twice daily.

Question 3

2 year old toddler admitted into ER. TEMP 102.2, HR 148, RR 42, BP 87/44, O2 89. Now → TEMP 100.3, HR 150, RR 28, BP 86/42, O2 95. Initially came in due to breathing problem. History of asthma. Currently restless and crying, clinging to parents. What would indicate that respiratory treatment has been effective?

Answer 3

• decreased RR
• increased O2 sat
• breath sounds in both bases
• decreased cough
• decreased nasal flaring

Question 4

A nurse is caring for a school-age child who has leukemia.
Which of the following assessment findings should the nurse report to the provider?
Select the 6 findings that should be reported to the provider.

Respiratory rate
WBC count
Hemoglobin
Retractions
Breath sounds
Skin assessment
Upper respiratory infection
Oxygen saturation

Answer 4

Respiratory rate
WBC count
Retractions
Skin assessment
Upper respiratory infection
Oxygen saturation

Question 5

A nurse is caring for a 2-month-old in the emergency department. infant is displaying nasal flaring, retractions, and diminished breath sounds in the left lobe, as well as poor feeding. the nurse places the patient on contact and droplet precautions. What is the most likely diagnosis, as evidenced by what?

Answer 5

RSV as evidenced by retractions

Question 6

A nurse in the provider’s office is assisting with the care of a child.
Upon review of the child’s electronic medical record (EMR), the nurse should determine the child is at risk for developing which of the following conditions as evidenced by what?

Answer 6

seizures as evidenced by phenytoin level

Question 7

A child was brought in for unexplained bruising, and red spots on shoulders/thighs/back. Has had cold for 2 months with no OTC relief. Lungs clear, moves all extremities with some swelling in knees and elbows. Patient had small nosebleed a few min ago, reports “my arms and legs hurt all over” nosebleed resolved with only a small amount of blood on tissues.

Differentiate the assessment findings for each diagnosis Leukemia, sickle cell or hemophilia

Answer 7

Temp- leukemia and sickle cell
Bruising- leukemia and hemophilia
Bleeding- leukemia and hemophilia
Elevated WBC- leukemia and sickle cell
Pain- ALL 3

Question 8

What are the characteristics of duchenne muscular dystrophy?

Answer 8

Waddling gait
Lordosis
Calf muscle hypertrophy

Question 8

The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot?

a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

Answer 8

a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy

Question 9

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

A. Lateral incisors
B. Closed posterior fontanel
C. Sitting steadily without support
D. Uses thumb and index fingers in a pincer grasp

Answer 9

B. Closed posterior fontanel

Question 10

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

Answer 10

a. FLACC

Question 11

A nurse is caring for a school-age child who has a systemic disorder and is
receiving antibiotics, immunosuppressants, and corticosteroids. Both of the child’s parents have a smoking history.
The child reports soreness in his mouth and refuses to eat.
Inspection of his mouth reveals a white, milky plaque that does not come off with
rubbing.
The nurse should suspect which of the following conditions?

A. Dermatitis
B. Candidiasis
C. Herpes simplex
D. Squamous cell carcinoma.

Answer 11

B. Candidiasis

Question 12

A provider is caring for a preschool age child who has been diagnosed with pinworm infection. Which of the following symptoms is the child expected to exhibit?

Answer 12

perineal itching

Question 13

A school-age child is admitted in vasoocclusive sickle cell crisis (pain episode). The child’s care should include which therapeutic interventions?

a. Hydration and pain management
b. Oxygenation and factor VIII replacement
c. Electrolyte replacement and administration of heparin
d. Correction of alkalosis and reduction of energy expenditure

Answer 13

a. Hydration and pain management

Question 14

During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this?

a.Projectile vomiting
b.Hypoactive bowel activity
c.Palpable olive-sized mass in the right lower quadrant
d.Pronounced peristaltic waves crossing from right to left

Answer 14

a.Projectile vomiting

Question 15

A nurse is preparing to assist with applying a cast to a preschooler’s arm. Which of the following actions should the nurse take?

A. Wrap the arm of the child’s doll or toy prior to the procedure
B. Tell the child, “this will make your arm feel better”
C. Place a heated fan at the bedside to facilitate drying
D. Support the casted arm with a firm grasp

Answer 15

A. Wrap the arm of the child’s doll or toy prior to the procedure

Question 16

A school-age child has been diagnosed with Kawasaki disease. What teaching should the nurse provide the family about the pharmacological management of Kawasaki disease?

A. Inactivated vaccines are permissible while receiving IV immunoglobulin for Kawasaki disease
B. The benefits of taking aspirin for Kawasaki disease outweigh the risk for Reye syndrome
C. Corticosteroids are often needed to control inflammation in Kawasaki disease
D. Platelet infusions are needed with Kawasaki disease to prevent internal bleeding

Answer 16

B. The benefits of taking aspirin for Kawasaki disease outweigh the risk for Reye syndrome

Question 17

What is a clinical manifestation of bed bugs?

Answer 17

red rash

Question 18

What does the surgical closure of the ductus arteriosus do?

a. Stop the loss of unoxygenated blood to the systemic circulation
b. Decrease the edema in legs and feet
c. Increase the oxygenation of blood
d. Prevent the return of oxygenated blood to the lungs

Answer 18

d. Prevent the return of oxygenated blood to the lungs

Question 19

Which defect results in increased pulmonary blood flow?

a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries

Answer 19

c. Atrial septal defect

Question 20

An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to:

A. Explain procedures and routines.
B. Provide for privacy.
C. Encourage the parents to room in.
D. Encourage contact with children the same age.

Answer 20

C. Encourage the parents to room in.

Question 21

A nurse is administering a steroid to a child diagnosed with idiopathic thrombocytopenic purpura (ITP); which of the following should the nurse monitor?

A. Infection
B. Anemia
C. Bleeding
D. Bruising

Answer 21

A. Infection

Question 22

A 13-year-old girl asks the nurse how much taller she will become. She has been growing about 2 inches per year but grew 4 inches this past year. Menarche recently occurred. The nurse should base her response on knowing that:

a. Growth cannot be predicted.
b. The pubertal growth spurt lasts about 1 year.
c. Mature height is achieved when menarche occurs.
d. Approximately 95% of mature height is achieved when menarche occurs.

Answer 22

d. Approximately 95% of mature height is achieved when menarche occurs.

Question 23

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.”

Answer 23

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

Question 24

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

Answer 24

a. Body weight

Question 25

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. Discourage visits from the client's friends B. Provide a daily session with a play therapist C. Encourage the client to complete school work D. Vary the child's schedule each day

Answer 25

C. Encourage the client to complete school work

Question 26

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. Improve the client's communication skills. B. Provide respite services for the parents. C. Foster self-care activities. D. Modify the environment.

Answer 26

D. Modify the environment.

Question 27

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? A. Position the child laterally B. Use a padded tongue blade. C. Attempt to stop the seizure D. Restrain the child's arms,

Answer 27

A. Position the child laterally

Question 28

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. Mumps B. Whooping cough C. Fifth disease D. Chickenpox

Answer 28

B. Whooping cough

Question 29

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.

Answer 29

B: Position the child side-lying.

Question 30

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. Negative behaviors characterized by the need for autonomy C. Demonstrations of sexual curiosity D.Erikson's stage of initiative versus guilt

Answer 30

B. Negative behaviors characterized by the need for autonomy

Question 31

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. "Tanning beds are much safer than lying in the sun." D. “Your need for sleep will increase during periods of growth."

Answer 31

D. “Your need for sleep will increase during periods of growth."

Question 32

Eriksons stages in order

Answer 32

Trust vs mistrust (infants) Autonomy vs shame (toddlers) Initiative vs guilt (preschool) Industry vs inferiority (school age) Identity vs role confusion (adolescent)

Question 33

A four month old is losing weight vomiting has a distended abdomen hypoactive bowel sounds not tolerating formula feeding meconium was past 56 hours after birth. What would the nurse suspect? What will the nurse do (action)? What will the nurse monitor?

Answer 33

Hirschsprung's dx action: - rectal biopsy - rectal pull through monitor: - abdominal circumference - temp

Question 34

5 year in acute care setting with sickle cell anemia. Admitted for vaso occlusive crisis. Tylenol is given to decrease pain but pain is getting worse. Recent upper respiratory infection 2 weeks ago. VS → TEMP 100, HR 120, RR 24, BP 90/48, O2 98. Pain in both knees and elbows 10 out of 10. Mucous membrane is dry. Has not been drinking or eating much last few hours. On 2L of O2. IV fluids are now infusing, and IV morphine given for pain. What assessment findings require additional action by the nurse?

Answer 34

- retractions/nasal flaring - wheezing - joint and chest pain of 4 - uncooperative/agitated - O2 decreased

Question 35

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 C. 5 years D. 6 years

Answer 35

A. 3 years

Question 36

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 stranger c. Shows preferences towards foods d. Babbles one-syllable sounds

Answer 36

d. Babbles one-syllable sounds

Question 37

A nurse in a special education program is planning care for a child who has autistic disorder. Which of the following interventions is appropriate to include in the plan of care? a) Allow for adjustment of rules to correlate with the child’s behavior. b) Provide a flexible schedule to adjust to the child’s interests. c) Allow for imaginative play with peers without supervision. d) Establish a reward system for positive behavior.

Answer 37

d) Establish a reward system for positive behavior.

Question 38

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 fluid should a nurse select for the infant? A. Oral electrolyte solution B. Half-strength infant formula C. Half-strength orange juice D. Sterile water

Answer 38

A. Oral electrolyte solution

Question 39

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. Obesity B. Diabetes mellitus C. Iron deficiency anemia D. Rickets

Answer 39

C. Iron deficiency anemia

Question 40

A nurse is assessing an 8 month old infant for Cerebral palsy. Which finding 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

Answer 40

b. Sits with pillow props

Question 41

A nurse is obtaining the length and weight of a 6-month-old infant. Which of the following actions should the nurse take? (Select all that apply.) A. Ensure the scale is balanced prior to use B. Place a disposable covering on the scale C. Use a stadiometer to measure the infant D. Weigh the infant in a diaper

Answer 41

A. Ensure the scale is balanced prior to use B. Place a disposable covering on the scale D. Weigh the infant in a diaper

Question 42

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will keep my baby in an upright position after feedings." B. "My baby's formula can be thickened with oatmeal." C. "I will have to feed my baby formula rather than breast milk." D. "I should position my baby side-lying during sleep."

Answer 42

A. "I will keep my baby in an upright position after feedings."

Question 43

A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings? a.) transesophageal fistula b.) inguinal hernia c.) hypertrophic pyloric stenosis d.) intussusception

Answer 43

d.) intussusception

Question 44

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? A. Gastrointestinal B. Respiratory C. Cardiovascular D. Integumentary

Answer 44

C. Cardiovascular

Question 45

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? (select all that apply). A. coughing B. apnea C. sunken abdomen D. cyanosis E. frothy saliva

Answer 45

A. coughing B. apnea D. cyanosis E. frothy saliva

Question 46

A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect? A. Irritability B. Tetany C. slow, bounding pulse D.Decreased temperature

Answer 46

A. Irritability

Question 47

A nurse is planning care for a 4-year-old child who requires airborne precautions. Which of the following activities should the nurse plan for the child? A. Constructing a model airplane B. Pulling a wagon with toys in the hallway C. Putting a large-piece puzzle together D. Watching a video game in the playroom

Answer 47

C. Putting a large-piece puzzle together

Question 48

A nurse is caring for a 6-month-old infant. Which of the following findings would indicate to the nurse that the client is experiencing pain following the procedure? A. Decreased Heart Rate B. Decreased respiratory rate C. Increased formula consumption D. Increased crying episodes

Answer 48

D. Increased crying episodes

Question 49

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. Offer the child clear liquids for the first 24 hr. B. Give the child acetaminophen for discomfort. C. Assist the child in taking a tub bath for the first 3 days. D. Keep the child home for 1 week.

Answer 49

B. Give the child acetaminophen for discomfort.

Question 50

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. Radial artery B. Brachial artery C. Apex of the heart D. Carotid artery

Answer 50

C. Apex of the heart

Question 51

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.” C. “Activity will increase the respiratory rate.” D. “The rate and rhythm of breath are irregular in newborns.”

Answer 51

D. “The rate and rhythm of breath are irregular in newborns.”

Question 52

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 the most common reaction? A. Body image changes. B. Loss of privacy. C. Feelings of displacement. D. Identity crisis.

Answer 52

A. Body image changes.

Question 53

A nurse is caring for a child who has influenza. The nurse should identify which of the following statements by the parent indicates the child has an increased risk for Reye syndrome. A. "I give my child ibuprofen when his muscles are aching." B. "I am encouraging my child to drink grapefruit juice." C. "I am leaving a humidifier on in my child's room when he naps." D. "I give my child aspirin to reduce his fever."

Answer 53

D. "I give my child aspirin to reduce his fever."

Question 54

A school nurse identifies that a child has pediculosis capitis (head lice) and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching? A. "My child must be free from nits before returning to school.” B. "Toys that can't be dry cleaned or washed must be thrown out.” C. "I will treat all the family members to be on the safe side.” D. "All recently used clothing, bedding, and towels must be washed in hot water.”

Answer 54

D. "All recently used clothing, bedding, and towels must be washed in hot water.”

Question 55

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 restrict the amount of salt in our child's food." B. I will limit my child's fluid intake." C. "I will prepare low-fat meals with limited protein for my child." D. "We will give our child pancreatic enzymes with snacks and meals."

Answer 55

D. "We will give our child pancreatic enzymes with snacks and meals."

Question 56

A nurse is caring for a fussy 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Position the infant on its abdomen. B. Offer the infant a pacifier. C. Encourage the parents to hold and comfort the infant. D. Administer Ibuprofen as needed for pain.

Answer 56

C. Encourage the parents to hold and comfort the infant.

Question 57

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 d. Hanging crib toys c. Modeling clay d. Crayons and a coloring book

Answer 57

a. Large building blocks

Question 58

A nurse is collecting data from an infant at a well-child visit. The nurse should expect the infant to double his birth weight by which of the following ages? A. 3 months. B. 6 months. C. 9 months. D. 12 months.

Answer 58

B. 6 months.

Question 59

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. Diluted apple juice C. Oral rehydration solution D. Water

Answer 59

C. Oral rehydration solution

Question 60

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 B. Droplet C. Bleeding D. Contact

Answer 60

C. Bleeding

Question 61

A nurse is reinforcing teaching with a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding of the teaching? A. "Impetigo is caused by a virus." B. "Impetigo is contagious for 48 hours after vesicles rupture." C. "I will wash my child's clothes in hot water." D. "My child now has immunity against impetigo."

Answer 61

C. "I will wash my child's clothes in hot water."

Question 62

A nurse is planning care for a 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain? A. PANAD scale B. OUCHER scale C. FLACC scale D. FACE Scale

Answer 62

C. FLACC scale

Question 63

A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot jump with both feet. B. The toddler cannot build a tower of six to seven cubes C. The toddler cannot stand upright without support D. The toddler cannot turn a doorknob

Answer 63

C. The toddler cannot stand upright without support

Question 64

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take? A. Percuss each lung segment for 15 min. B. Perform CPT immediately after the child eats. C. Administer albuterol prior to CPT. D. Perform vibration during the client’s inspirations.

Answer 64

C. Administer albuterol prior to CPT.

Question 65

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased Intracranial pressure? A. Brisk pupillary reaction to light B. Tachycardia C. Increased sleeping D. Depressed fontanelles

Answer 65

C. Increased sleeping

Question 66

A nurse is admitting a toddler who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take? A. Allow the toddler to play in the common room. B. Keep thermometer in the toddler's room. C. Initiate airborne precautions. D. Place the toddler in a room that has negative air pressure.

Answer 66

B. Keep thermometer in the toddler's room.

Question 67

A 3-year-old has just returned from surgery in a hip spica cast. The priority nursing intervention is to A. elevate the head of the bed. B. offer sips of water. C. check circulation, sensation, and motion of toes. D. turn the child to the right side, then the left side every 4 hours.

Answer 67

C. check circulation, sensation, and motion of toes.

Question 68

While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should: a) notify the doctor b) look for other signs of abuse c) recognize this as a normal finding d) ask about a family history of Tay-Sachs disease

Answer 68

a) notify the doctor

Question 69

A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching? A. “We’ll continue to encourage him to drink lots of fluids.” B. “We’ll take his temperature every 4 hours.” C. “We’ll give him Tylenol for the pain.” D. “We’ll discard his toothbrush and buy another.”

Answer 69

D. “We’ll discard his toothbrush and buy another.”

Question 70

What is the patient at risk for with hematopoietic stem cell transplantation?

Answer 70

Graft vs host disease

Question 71

A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching? A. "Take cromolyn sodium at the first sign of breathing difficulty." B. "Use the peak expiratory flow meter once per week." C. "Avoid triggers that cause an attack." D. "You should stop playing basketball, but you can swim instead."

Answer 71

C. "Avoid triggers that cause an attack."

Question 72

A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions should the nurse take to promote sleep? A. Turn off the room light. B. Explain the source of the toddler's fears. C. Encourage play exercises in the evening. D. Provide bedtime rituals.

Answer 72

D. Provide bedtime rituals.

Question 73

A nurse providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as an expected finding of the toddler? A. Explains the difference between right and wrong. B. Print letters and numbers. C. separates easily from primary caregiver for short periods of time D. Cooperates and doing simple chores.

Answer 73

C. separates easily from primary caregiver for short periods of time

Question 74

A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection? A. Oliguria. B. Jaundice. C. Bulging fontanel. D. Negative Brudzinski sign.

Answer 74

C. Bulging fontanel.

Question 75

What is the complication of near drowning in a child?

Answer 75

Aspiration

Question 76

What assessment findings will be seen in a patient with Hodgkin’s disease?

Answer 76

Fatigue Weakness Enlarged lymph nodes

Question 77

What labs should be monitored for hemophilia?

Answer 77

PTT PT

Question 78

The medical chart states that the parents are requesting withdrawal of care for a child with terminal leukemia. The nurse understands this request to mean: A. To keep support measures which sustain life for the child. B. To keep providing comfort care for the child. C. To stop life-saving measures and allow the child to die naturally. D. To stop providing comfort measures for the child.

Answer 78

C. To stop life-saving measures and allow the child to die naturally.

Question 79

What are the expected findings of a child with severe combined immunodeficiency (SCID) who is taking steroids?

Answer 79

Oral thrush

Question 80

A patient diagnosed with acute lymphocytic leukemia (ALL) has a basic understanding of the treatment options. The patient asks the nurse, "What is the difference between an allogeneic and autologous bone marrow transplant?" Which response by the nurse is accurate? a) "You do not have to wait for the reestablishment of bone marrow function after an allogeneic transplant like you do after an autologous transplant." b) "Chemotherapy is used before allogeneic transplants, but not autologous transplants." c) "Bone marrow cells are transplanted before radiation therapy in allogeneic transplants and after radiation therapy in autologous transplants." d) "Your own bone marrow cells are used in an autologous transplant, while a matched donor's cells are used in an allogeneic transplant."

Answer 80

d) "Your own bone marrow cells are used in an autologous transplant, while a matched donor's cells are used in an allogeneic transplant."

Question 81

Why do children deserve the right to proper healthcare?

Answer 81

To become productive adult and function in society

Question 82

A nurse is caring for 17-year-old client who is experiencing relapse of leukemia and is refusing treatment. The clients mother insist that the client received treatment. Which of the following actions should take? A. Initiate the IV per the patient’s request. B. Notify the provider of the situation. C. Administer sedative to calm the client. D. Offer the client an antiemetic

Answer 82

B. Notify the provider of the situation.

Question 83

What will a nurse monitor for a child with a skull fracture?

Answer 83

monitor for increased hemorrhage or edema on the head

Question 84

Caring for a 4 month old infant in the ER. difficulty to arrouse. Pupils are slightly sluggish. Assessing the child with the growth chart (birth at 3.18kg and now at 5.9kg, length was 50, now 60). Head circumference was 34.2, now 43.6. 1030 VS → temp 37.4, HR 148, RR 34, BP 78/36. 1100 → HR 110, RR 26, BP 72/32. Difficulty to awake this morning. Currently have bulging fontanelles and lethargic and difficulty to console when awake. Retinal hemorrhage is seen. Clear CSF. What will the nurse suspect? What will the nurse do (action)? What will the nurse monitor?

Answer 84

abuse of head trauma action: - watch interactions of caregiver - assess child for signs of abuse - elevate head of bed monitor: - HR - RR

Question 85

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. Half-strength orange juice B. Sterile water C. Half-strength infant formula D. Oral electrolyte solution

Answer 85

D. Oral electrolyte solution

Question 86

Adolescent brought into ER for pain in left arm that began last night. history of sickle cell anemia. Prescription for oral morphine and took a dose this morning. No relief with pain 9 out of 10. Appears moderately distress with throbbing and stabbing in left hand. Not moving extremity very much due to pain. What is anticipated, contraindicated and nonessential?

Answer 86

anticipated: - fluids - ketorolac contraindicated: - demerol - ambulate - ice packs nonessential: - oxygen

Question 87

Toddler in the ER. 600pm VS → TEMP 99, HR 120, RR 26, O2 98. Parents report episodes of vomiting and crying for the past hour. Abdomen nontender but is uncomfortable when palpating abdomen. The ultrasound determines its intussusception. What would be the plan of action?

Answer 87

monitor stool consistency NG tube IV antibiotics

Question 88

2 year old with congential heart disease. Feeding poorly with poor weight gain. Diagnosis is TOF. pale, unlabored respiratory. Tachypnic and fatigues easily when feeding. Experiencing a tet spell. What is a nursing intervention for this patient?

Answer 88

position knees to chest oxygen morphine

Question 89

11 year old diagnosed 2 years ago with tonic clonic seizure. 3 months ago changed med to include phenytoin due to increased number of seizures. History of asthma. WBC 8500, RBC 4.2, HEM 11, HEMATOCRIT 40, PLATELETS 216000, PHENYTOIN 6 (10-20). What condition would you focus on? a. seizures b. SJS c. pneumothorax d. pneumonia e. liver failure

Answer 89

a. seizures

Question 90

2 month old infant in ER. arrived irritated and agitated. Has rhinorrhea with copious clear 
secretions. Mild expiratory wheezing, crackles, moderate retractions, nasal flaring, poor feeding. Start on contact and droplet precaution. 12pm → diminished breath sounds, cough is present, listless, IV inserted in forearm. Initial VS → TEMP 101.8, HR 172, RR 56, BP 85/50, O2 93. Current VS → 101.6, HR 168, RR 48, BP 90/52, O2 90. The nurse now knows the child is presenting with Manifestations of what disease? acute streptococcal pharyngitis, RSV, or scarlet fever?

Answer 90

RSV (due to copious clear secretions)

Question 91

2 month old infant in ER. arrived irritated and agitated. Has rhinorrhea with copious clear 
secretions. Mild expiratory wheezing, crackles, moderate retractions, nasal flaring, poor feeding. Start on contact and droplet precaution. 12pm → diminished breath sounds, cough is present, listless, IV inserted in forearm. Initial VS → TEMP 101.8, HR 172, RR 56, BP 85/50, O2 93. Current VS → 101.6, HR 168, RR 48, BP 90/52, O2 90. The nurse now knows the child is presenting with Manifestations of what disease? acute streptococcal pharyngitis, RSV, or scarlet fever?

Answer 91

RSV (due to copious clear secretions)

Question 92

Child with TOF. what are the anatomical defects SATA

Answer 92

○  Pulmonary stenosis 
 ○  Overriding aorta 
 ○  Shunting of blood right to left