NC of Children 1 Flashcards
(269 cards)
1
Q
NC of Children 1
A
From ATI
2
Q
A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain?
Ask the parents.
Use the FACES scale.
Use the numeric rating scale.
Check the child’s temperature.
A
Pain is a subjective experience even for a 3-year-old child. Asking the parents is not appropriate as pain is considered a personal experience.
The FACES scale can be used to accurately determine the presence of pain in children as young as 3 years of age.
The numeric rating scale is appropriate for children who are 5 years of age or older.
The child’s temperature is not an indicator of pain. While changes in heart rate, BP, and respiratory rate can be indicators of pain, these are not reliable, because pain is a subjective manifestation.
3
Q
The FACES scale can be used to accurately determine the presence of pain in children as young as
A
3 years of age.
4
Q
The numeric rating scale is appropriate for children who are
A
5 years of age or older.
5
Q
The child’s temperature is not an
A
indicator of pain.
6
Q
While changes in heart rate, BP, and respiratory rate can be indicators of pain, these are not reliable, because
A
pain is a subjective manifestation.
7
Q
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client’s pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take?
Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication.
A PCA device allows the adolescent to be in charge of pain management and is an effective method to control pain.
Suggest the client’s parent push the button for the client if the parent thinks the adolescent is having pain.
Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10.
Reinforce teaching with the client about how to push the button to deliver the medication.
A
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client’s pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take?
Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication.
A PCA device allows the adolescent to be in charge of pain management and is an effective method to control pain.
Suggest the client’s parent push the button for the client if the parent thinks the adolescent is having pain.
Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10.
Reinforce teaching with the client about how to push the button to deliver the medication.
8
Q
One of the principles of PCA is that
A
no one other than the client or nurse pushes the button to deliver the medication.
9
Q
An adolescent is capable of maintaining effective pain control using a
A
PCA.
10
Q
Moderate (5 to 6) or severe pain (7 to 10) requires the use of ______ for effective pain management.
A
opioids
11
Q
A PCA delivers an appropriate amount of opioid to treat
A
moderate pain and the client should be encouraged to push the PCA button to deliver medication at this time.
12
Q
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion?
“The absence of oral burns excludes the possibility of esophageal burns.”
“Treatment focuses on neutralization of the chemical.”
“Injury by a corrosive liquid is more extensive than by a corrosive solid.”
“Immediate administration of activated charcoal is warranted.”
A
Injury by a corrosive liquid is more extensive than by a corrosive solid.
13
Q
The absence of oral or pharyngeal burns does not eliminate the possibility of
A
esophageal burns.
14
Q
The existence and extent of burns depend on
A
the substance and the length of time it has been in contact with tissues.
15
Q
It is possible to have a burn in the esophagus without the existence of WHAT?
A
a burn in the mouth.
16
Q
Neutralization can result in heat injury to tissues due to an _____?
This might result in both
A
exothermic reaction.
chemical and thermal burns of tissues.
17
Q
The coating action of liquids permits larger areas of
A
contact with tissues and results in more extensive injury.
18
Q
Activated charcoal is not administered to an adolescent who has ingested a corrosive substance, because
A
it can infiltrate any tissue that is burned.
19
Q
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take?
A
Give the medication at the side of the infant’s mouth.
20
Q
Administering the medication to the infant while she is supine can cause the infant to
A
choke and aspirate.
21
Q
When administering medications to an infant, a needleless oral syringe or medicine dropper is placed WHERE? WHY?
A
in the side of the mouth (buccal cavity alongside the tongue)
to prevent gagging and aspiration.
22
Q
Medication should never be mixed into an infant’s what?
Why?
A
regular formula given through a bottle.
Cannot ensure all medication has been administered
might cause infant not to take bottle / formula in future (associates unpleasant taste or activity.)
23
Q
An infant’s nasal passages should never be blocked to assure that oral medications are swallowed because
A
Young infants are obligatory nose breathers and holding the nares closed can increase an infant’s distress. This method of administration increases the risk of aspiration.
24
Q
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child’s parent?
The PICC line will last several weeks with proper care.
The public health nurse will rotate the insertion site every 3 days.
You will need to make certain the arm board is in place at all times.
Your child will go to the operating room to have the line placed.
A
“The PICC line will last several weeks with proper care.”
25
PICC lines are the preferred venous access device for
short to moderate term IV therapy. They can remain in place for long periods with proper care.
26
The PICC line is meant to remain in place for how long?
the duration of therapy.
27
What is the main advantace of PICC lines over traditional IV lines
The PICC line is meant to remain in place for the duration of therapy.
28
The catheters designed for use as PICC lines are highly flexible, so it is not necessary to
immobilize the client’s arm or limit movement.
29
PICC lines are inserted using what type of anesthetic
local anesthetic by trained personnel.
30
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation?
The child prefers playmates of the same sex.
The child is competitive when playing board games.
The child complains daily about going to school.
The child enjoys spending time alone.
The child complains daily about going to school.
31
Male and female children who are 7 years old prefer to play with peers who are
the same gender.
32
School-age children enjoy engaging in various types of ________ games and are learning about the concept of ________
competitive
winning
33
Complaining every day about going to school is an _______finding for a 7-year-old child.
unexpected
34
What stage of Ericksons psychosocial development - seven year old child
The child is in Erikson’s psychosocial development stage of industry vs. inferiority.
35
in Erikson’s psychosocial development stage of industry vs. inferiority. Children want to
learn and master new concepts. If the child complains daily about going to school, it warrants further evaluation.
36
A 7-year-old child doesn't require the same amount of what as older school-age children; therefore, the fact that this child enjoys spending time alone is an expected finding.
companionship
37
A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include?
Follow a nightly routine and established bedtime.
Encourage active play prior to bedtime.
Let the child remain awake until tired enough to go to sleep.
Reward the child with a food treat just prior to sleep if the child goes to bed on time.
Follow a nightly routine and established bedtime.
38
Preschool-age children test what?
limits. Consistency in approach to bedtime is very important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night.
39
Active play at bedtime is likely to promote the preschool-age child’s resistance to
sleep rather than to promote fatigue.
40
Active Play at bedtime is likely to result in an
overtired child who is awake and unpleasant.
41
Children taught to maintain a bedtime routine at an early age will
make the evening more pleasant for everyone, including themselves, and avoid sleep disturbances.
42
Part of a preschool-age child’s bedtime routine should be
nightly oral care. Following this with a food treat is inappropriate.
43
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching?
Decrease the child's vitamin C intake until the blood lead level decreases to zero.
Administer a folic acid supplement to the child each day.
Give pancreatic enzymes to the child with meals and snacks.
Ensure the child's dietary intake of calcium and iron is adequate.
Ensure the child's dietary intake of calcium and iron is adequate.
44
Vitamin C does not influence ________ or _______ of lead, and intake does not need to be reduced for a child who has a blood lead level of 3 mcg/dL. Over time, this can result in a vitamin C deficiency.
absorption or excretion
45
A 3-year-old child does not need a folic acid supplement. This will not influence absorption or excretion of
lead.
46
Pancreatic enzymes are administered to children who have
cystic fibrosis, not an elevated blood lead level.
47
A child who has an elevated blood lead level should have an adequate intake of
calcium and iron to reduce the absorption and effects of the lead. Dietary recommendations should include milk as a good source of calcium.
48
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play?
Brightly colored mobile
Plastic stethoscope
Small piece jigsaw puzzle
A book of short stories
Plastic stethoscope
49
A brightly colored mobile is appropriate for what age?
young infant. It does not meet the activity needs of a preschool-age child.
50
Preschool play centers on wha type of activities?
imitative activities. Providing a stethoscope allows the child an opportunity for therapeutic play. Imitating health care personnel helps to ease the fear of unfamiliar equipment.
51
A small piece jigsaw puzzle is too difficult for what age children?
most preschool-age children and can frustrate them rather than entertain them.
52
A 4-year-old child is not able to do what independently.
read independently. The nurse should provide the child with a picture book instead.
53
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group?
Copies a circle
Cuts foods using a table knife
Begins writing in cursive
Prints first and last name clearly
Copies a circle
54
The nurse should explain that copying a circle is a skill achieved by what age?
age of 4 years.
55
The nurse should explain that cutting food using a table knife is a fine-motor skill expected of what age?
7-year-old children.
56
Initial use of cursive writing is an expected skill for what age?
an 8- to 9-year-old child.
57
The nurse should explain that children will print their first name around what age?
the age of 5 years.
58
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following highlight reflexes should the nurse expect to find?
Stepping
Babinski
Extrusion
Moro
Babinski
59
The stepping reflex, in which the infant does what?
takes reflexive steps when placed on his or her feet in an upright position,
60
The stepping reflex, disappears by what age?
disappears by the age of 4 weeks.
61
The Babinski reflex, which is elicited by
stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex,
62
The Babinski reflex, should be present until the age of
1 year.
63
Persistence of neonatal reflexes might indicate
neurological deficits.
64
The extrusion reflex, which causes the infant to
spit out food placed on the tongue rather than moving it to the back of the mouth,
65
The extrusion reflex, is absent by what age?
is absent by the age of 4 months.
66
The Moro reflex is an extension of the
arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities.
67
The Moro reflex should disappear by what age?
at the age of 3 to 4 months.
68
A nurse is preparing to administer recommended highlight immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer?
Human papillomavirus (HPV) and hepatitis A
Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP)
Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
Varicella (VAR) and live attenuated influenza vaccine (LAIV)
Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
69
The HPV immunization series is started at what age?
the age of 11 years,
70
The hepatitis A immunization series is started at what age?
the age of 12 months.
71
The first dose of the MMR immunization is administered at what age?
12 to 15 months of age,
72
The TDaP immunization is administered at wehat age?
11 to 12 years of age.
73
The recommended immunizations for a 2-month-old infant include
Hib and IPV.
74
The Hib immunization series consists of
3 to 4 doses, depending on the immunization used, and at a minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months.
75
The IPV immunization series consists of
4 doses and is administered at the ages of 2 months, 4 months, 6 to 18 months, and 4 to 6 years.
76
Varicella is not administered to children younger than
12 months,
77
LAIV immunization is not administered to children under what age?
2 years of age.
78
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child?
Hand-eye coordination
Sense of trust
Object permanence
Egocentrism
Object permanence
79
Playing peek-a-boo does not further refine which skills?
the infant’s fine-motor skills unless the infant is using his hands to locate the hidden object himself.
80
This is necessary for fine motor skills.
Hand-eye coordination
81
Playing peek-a-boo does not serve to establish what?
a sense of trust.
82
Trust is developed by what?
the consistent care given in the first year of life.
83
Object permanence refers to what skill
cognitive skill of knowing an object still exists even when it is out of sight. In discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.
84
Egocentrism refers to the fact that infants are
self-centered and cannot see things from a point of view other than their own.
85
An 8-month-old infant is considered
egocentric.
86
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
Observe the parents' actions when feeding the child.
Maintain a detailed record of food and fluid intake.
Follow the child's cues as to when food and fluids are provided.
Sit beside the child's high chair when feeding the child.
Play music videos during scheduled meal times.
Observe the parents' actions when feeding the child.
Maintain a detailed record of food and fluid intake.
87
Inappropriate feeding techniques and meal patterns provided by parents can contribute to
a child’s growth failure.
88
A nutritional goal for the child who has suspected FTT is to
correct nutritional deficiencies, which can be identified by recording all food and fluid intake.
89
A consistent structured routine of feeding the child at the same time and place is used to
promote weight gain.
90
A child who has failure to thrive might not offer
feeding cues.
91
Caregivers should sit where during feeding and promote eye contact. The emphasis is on encouraging feeding.
directly in front of the child to maintain a face-to-face position
92
A quiet, stimulation-free environment should be provided at meal times to avoid
distractions and focus attention on food intake.
93
A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.)
Use a wheeled infant walker.
Place soft pillows around the edge of the infant's crib.
Position the car seat so it is rear-facing.
Secure a safety gate at the top and bottom of the stairs.
Maintain the water heater temperature at 49° C (120° F).
Position the car seat so it is rear-facing.
Secure a safety gate at the top and bottom of the stairs.
Maintain the water heater temperature at 49° C (120° F).
94
Wheeled infant walkers can
quickly move across uneven surfaces and result in injury.
95
Soft pillows and cushions should not be used in cribs due to
the increased risk of suffocation.
96
Infants and children should remain in the rear-facing position when in a car seat until the age of __ years or until they reach the what?
2
recommended height and weight per the manufacturer’s guidelines.
97
As the infant begins to crawl and becomes more mobile, the risk of falls increases. These should be used at the stairs?
safety gate at the top and bottom of the stairs
98
To prevent a burn injury, the temperature of the water heater should not exceed
49° C (120° F).
99
A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse?
Presence of sparse, fine pubic hair
Decreased head circumference compared to full height
Increased leg length related to height
Presence of a loose, central incisor
Presence of sparse, fine pubic hair
100
The development of sexual characteristics prior to what age in in boys, and girls, is an indication of precocious puberty and requires further evaluation.
9 in boys and 8 in girls
101
precocious puberty
??
102
The head circumference of a school-age child decreases when compared to full height due to
skeletal lengthening.
103
Body proportion varies with a slimmer appearance and longer legs in what age children?
the school-age child.
104
At what age are deciduous teeth are being shed at this age, starting with the lower central incisors
approximately the age of 6.
105
What happens to leg length and waist circumference in school age children?
Leg length increases and waist circumference decreases when related to height in this age group.
106
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care?
Assign an assistive personnel to feed the child.
Explain sounds the child is hearing.
Have the child use a cane when ambulating.
Rotate nurses caring for the child.
Explain sounds the child is hearing.
107
Children who experience a loss of vision should be encouraged to participate in self-care activities, such as
feeding, as much as possible. Items on the meal tray should be organized and the child oriented to their location. Finger foods should be offered.
108
The noises in a facility can be frightening to a child who is experiencing what?
sensory loss. It is important to explain these noises to allay the child’s fears.
109
Children who have a temporary vision loss are not accustomed to
using a cane.
110
A child who has permanent vision loss can use a cane for
ambulation and activities during hospitalization.
111
Providing consistency in the child’s environment promotes what for the child?.
safety and security
112
The same nurse offers
comfort and reassurance to the child, and promotes increasing independence by building upon the child’s skills and abilities during hospitalization.
113
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory?
Pneumococcal polysaccharide
Meningococcal polysaccharide
Rotavirus
Herpes zoster
Meningococcal polysaccharide
114
The pneumococcal polysaccharide immunization is administered to children between what ages?
the ages of 2 and 18 years who have a specific high-risk condition that places them at risk for an infection with Streptococcus pneumococci,
115
Streptococcus pneumococci, a bacterium that causes
meningitis, otitis media, and pneumonia in clients who have chronic illnesses.
116
The meningococcal polysaccharide immunization is used to
prevent infection by certain groups of meningococcal bacteria.
117
Meningococcal infection can cause life-threatening illnesses, such as
meningococcal meningitis, which affects the brain, and meningococcemia, which affects the blood. Both of these conditions can be fatal.
118
College freshmen, particularly those who live in dormitories, are at an increased risk for
meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention has issued a recommendation that all incoming college students receive the meningococcal immunization.
119
The final dose of the rotavirus immunization is administered at what age?
prior to the age of 8 months. An additional booster dose is not recommended.
120
The herpes zoster immunization is recommended for what age?
adults over the age of 60 to prevent an episode of shingles.
121
A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse?
Primary dentition is complete
Unable to hop on one foot
Birth weight is tripled
Able to state first and last name
Birth weight is tripled
122
Primary dentition is complete is an expected finding in what age child?
30-month-old toddler. At this age, the toddler should have all 20 deciduous teeth.
123
The skill of hopping on one foot is not developed until what age?
around the age of 4 years.
124
The birth weight should quadruple by what age?
By 30 months of age,
125
The birth weight should triple by what age?
12 months of age.
126
At what age should a child be able to state his first and last name.
toddler at the age of 30 months.
127
A nurse on a pediatric unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization?
Age 10
Frequent hospitalizations
Parent bonding with child
Calm, quiet demeanor
Frequent hospitalizations
128
Children between the ages of 6 months and 5 years are more vulnerable to what than a 10-year-old child.
the stress of hospitalization
129
Children who experience multiple and frequent hospitalizations are at an increased risk for
stress-related reactions to hospitalization.
130
A child's stress and anxiety with hospitalization are reduce when
parents are highly involved with their children and have close bonds.
131
Children who are hospitalized are at risk for increased stress if
there is a lack of cohesion between the parent and the child.
132
Children who demonstrate irritable and difficult temperaments are at increased risk for
stress-related reactions to hospitalization.
133
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take?
Ask the child to hold his breath and then blow it out slowly.
Ask the child to describe a pleasurable event.
Bounce the child gently while holding him upright.
Rock the child in long rhythmic movements.
Rock the child in long rhythmic movements.
134
Ask the child to hold his breath and then blow it out slowly is an example of what type of strategy?
distraction strategy.
135
Ask the child to describe a pleasurable event is an example of what strategy?
guided imagery.
136
Evidence-based practice indicates that this is not an appropriate action.
bouncing
137
The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest, and then
rocking or swaying back and forth in long, wide movements.
138
A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering?
Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine
A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT)
Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine
Adult tetanus booster (Td)
Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine
139
DTaP is used to provide immunity against
diphtheria, tetanus, and pertussis in infants and children under the age of 7 years.
140
DTaP is not recommended for
wound prophylaxis.
141
Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is given at what age?
under the age of 7 years.
142
TIG and DT may be given concurrently for
wound prophylaxis,
143
DT is given as wound prophylaxis to children under the age of what
7 years.
144
TIG and DT may be given concurrently for wound prophylaxis, but????
but the nurse should administer these separately using different muscles.
145
Tdap is given to whom and at what age?
adults/adolescents who have completed the initial DTaP immunization series, but have not yet received an adult tetanus booster (Td). The minimum age for Tdap is 10 years; however, children between the ages of 7 and 10 years who have not received all recommended doses of DTap should be given a dose of Tdap. Tdap is not recommended for wound prophylaxis.
146
Tdap is recommended for what and at what age?
wound prophylaxis in children ages 7 years and older.
147
Tdap is also recommended every 10 years after what age?
18 years of age.
148
A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take?
Wash and dry the infant's genitalia and perineum thoroughly.
Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area.
Avoid placing the scrotum inside the collection bag.
Wait several hours after positioning the device before checking it.
Wash and dry the infant's genitalia and perineum thoroughly.
149
This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained.
urine collection bag
150
When using a urine collection bage, the skin should be washed and dried to promote
application of the adhesive of the collection device.
151
The adhesive on the collection device will not stick to the infant's skin if it is
moistened with lubricant. Oil and powder should not be used.
152
It is acceptable for the nurse to place the infant’s penis and ____ inside the collection bag in order to ensure a snug fit and prevent leaking.
scrotum
153
The urine collector should be checked how often>
frequently and removed when urine is obtained. If the infant is active, the adhesive might loosen.
154
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take?
Have the toddler wear a disposable gown when in the unit's playroom.
Wear sterile gloves when changing the toddler's diapers.
Wear a mask when assisting the toddler with meals.
Ask visitors to wear an N-95 mask when entering the room.
Wear a mask when assisting the toddler with meals.
155
A toddler who requires droplet precautions should not play where and why?
in common areas, due to the risk of transmitting the infection.
156
The toddler should dow what when being transported through public areas.
wear a surgical mask
157
W/ droplet precautions, clean gloves are worn to prevent
contact with contaminated body fluids
158
Urine or stool in the diaper does not
carry pathogens that are spread via droplets.
159
The nurse should wear a mask when within what distance?
3 to 6 feet of the toddler to prevent the transmission of infections that are spread via large droplet particles expelled in the air.
160
An N-95 mask is worn when caring for a client who requires ____ precautions.
airborne
161
A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include?
"Your child should be referring to himself using the appropriate pronoun by 18 months of age."
"A toddler's interest in looking at pictures occurs at 20 months of age."
"A toddler should have daytime control of his bowel and bladder by 24 months of age."
"Your child should be able to scribble spontaneously using a crayon at the age of 15 months."
Your child should be able to scribble spontaneously using a crayon at the age of 15 months.
162
A toddler’s use of the appropriate pronoun when referring to self does not occur until what age?
30 months of age.
163
A toddler develops an intense focus and interest in pictures at what age?
15 months of age.
164
Most toddlers have bowel and bladder control during the daytime by what age?
30 months of age. The nurse should teach the parent not to expect the toddler to accomplish this task by the age of 24 months.
165
The nurse should teach the parent that at the age of 15 months, the toddler should be able to do what
scribble spontaneously
166
at what age should the toddler be able to make strokes imitatively.
age of 18 months,
167
A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching?
"I can give my baby 4 ounces of juice to drink each day."
"I will offer my baby dry cereal and chilled banana slices as snacks."
"I am introducing my baby to the same foods the family eats."
"My infant drinks at least 2 quarts of skim milk each day."
I will offer my baby dry cereal and chilled banana slices as snacks.
CONFIRM THIS ANSWER, MAY BE MORE THAN ONE CHOICE
168
It is recommended to not exceed what amount of juice in children between the ages of 1 and 6 years.
4 to 6 oz
169
It is not recommended to give juice to infants under what age
4 to 6 months of age.
170
At 12 months of age, infants should be offered what type of foods?
finger foods.
171
Finger foods stimulate what
the pincer grasp, which helps with fine motor development.
172
Cereal is small, but it dissolves with infants’ saliva and would not cause what
an airway obstruction.
173
Chilled banana slices are an appropriate food choice and help w/
teething.
174
Introducing infants to foods prepared for the rest of the family is appropriate and helps them feel
included.
175
Home-cooked foods also provide infants with what
the nutrients they need.
176
At 12 months of age, infants are able to eat what types of foods
soft table foods such as mashed potatoes, green beans, bread, and finely chopped meats.
177
As the infant transitions into toddlerhood, whole milk intake should average what amount?
24 to 30 oz per day.
178
Too much milk can affect
intake of solid foods and result in iron deficiency anemia.
179
Skim milk is not recommended until after what age
age 2 since it lacks essential fatty acids which are needed for growth and development.
180
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child?
Cutting figures from colored paper
Drawing stick figures using crayons
Riding a tricycle
Building towers of blocks
Building towers of blocks
181
Most 2-year-old children do not have the coordination abilities to do what
cut with scissors.
182
cutting with scissors is appropriate for what age
the 3 year old child
183
The ability to draw stick figures is an appropriate activity for what age child
a 4-year-old child.
184
The 2-year-old child will draw what
vertical lines and make circular strokes.
185
Riding a tricycle is an appropriate activity for what age child
a 3-year-old child.
186
Most 2-year-old children do not have the strength or the gross motor ability to do what
ride a tricycle.
187
Building towers of blocks is an appropriate activity for what age child
a 2-year-old child.
188
Building towers of blocks promotes what
It promotes fine-motor development, and knocking blocks down provides a means of dealing with the stress of hospitalization.
189
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching?
"I lock my medications in the medicine cabinet."
"I keep my child's crib mattress at the highest level."
"I turn pot handles to the side of my stove while cooking."
"I will give my child syrup of ipecac if she swallows something poisonous."
I lock my medications in the medicine cabinet.
190
Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow for
further exploration of the environment and possible access to hazardous substances.
191
The parent should keep the child’s crib mattress at what level?
at the lowest level to prevent the child from climbing or falling from the crib.
192
The parent should turn pot handles how?
to the back of the stove while cooking to prevent the toddler from pulling the hot pans off and receiving burns.
193
Syrup of ipecac is not recommended for the treatment of what
poisoning in the home.
194
Caustic substances can cause more damage when
vomiting is induced.
195
A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children?
Cow's milk
Wheat bread
Corn syrup
Eggs
Cow's milk
196
According to evidence-based practice, the nurse should instruct the parent that cow’s milk is
the most common food allergy in children.
197
Some children are sensitive to the protein, called
casein, found in cow’s milk. They have difficulty metabolizing the casein and are, therefore, allergic to cow’s milk.
198
The nurse should instruct the parent that some children have an allergy or sensitivity to
wheat;
corn syrup
eggs
199
The nurse should instruct the parent that some children have an allergy or sensitivity to corn syrup, especially among what group of children?
children who have eczema;
200
The nurse should instruct the parent that some children have an allergy to eggs because
they contain albumin, which is a protein that some clients are unable to metabolize;
201
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse?
Remove the child's contaminated clothing.
Check the child's respiratory status.
Administer an antidote to the child.
Establish IV access for the child.
Check the child's respiratory status.
The nurse observes that the child’s lips are edematous and inflamed and that he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway.
202
The nurse should remove the child’s contaminated clothing to prevent what
further exposure to the substance
203
ABC priority-setting framework emphasizes the basic core of human functioning:
having an open airway,
being able to breathe in adequate amounts of oxygen, and
circulating oxygen to the body's organs via the blood.
204
When applying the ABC priority setting framework, airway is always the highest priority because
the airway must be clear and open for oxygen exchange to occur.
Breathing is the second highest priority- adequate ventilatory effort is essential in order for oxygen exchange to occur.
Circulation is the third highest priority - delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them.
205
The nurse should establish IV access because
shock is a complication of some poisons;
206
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.)
The child views death as similar to sleep.
The child is interested in what happens to his body after death.
The child recognizes that death is permanent.
The child believes his thoughts can cause death.
The child thinks death is a punishment.
The child views death as similar to sleep.
The child believes his thoughts can cause death.
The child thinks death is a punishment.
207
Preschool-age children views death how
as similar to sleep is correct.
208
A school-age child is interested in post-death services and what happens to the body after death due to
an improved ability to comprehend what is happening.
This would not readily be comprehended by a preschool aged child
209
Preschool-age children have difficulty understanding the concept of time and are therefore not likely to believe
that death is permanent.
210
Preschool-age children perceive death as
reversible
211
Preschool-age children believe that their thoughts and wishes can
make things happen since they are egocentric. This is one reason why the death of a family member can be very difficult for a child at this age.
212
Preschool-age children sometimes believe that death is the result of
guilt or punishment due to something they have done, said, or thought.
213
A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider?
Heart rate 175/min
Respiratory rate 26/min
Blood pressure 88/40 mm Hg
Temperature 37.6° C (99.7° F)
Heart rate 175/min
214
A heart rate of 175/min is
above the expected reference range for a 12-month-old infant;
215
ERR heart rate for an infant
??
216
ERR respiratory rate of an infant?
??
217
A respiratory rate of 26/min is
within the expected reference range for a 12-month-old infant.
218
ERR Blood pressure of an infant
??
219
A blood pressure of 88/40 mm Hg is
within the expected reference range for a 12-month-old infant.
220
Temperature 37.6° C (99.7° F) ERR for an infant
??
221
A temperature of 37.6° C (99.7° F) is
within the expected reference range for a 12-month-old infant.
222
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
25
223
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay?
Creeps on hands and knees
Inability to vocalize vowel sounds
Uses crude pincer grasp
Stands by holding onto support
Inability to vocalize vowel sounds
224
The infant should creep on her hands and knees by what age?
9 months,
225
The infant should begin to stand while holding onto furniture by what age?
10 months.
226
The infant should begin vocalizing vowel sounds by what age?
7 months
227
The infant should be able to say at least one word. By what age?
10 months,
228
Most infants demonstrate a crude pincer grasp by what age?
at 9 months of age
229
and the use of a dominant hand is evident by what age?.
at 9 months of age
230
The ability to stand holding onto support is typically present by what age?
at 10 months of age.
231
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions?
Side-lying
Semi-recumbent
Flexed sitting
Supine
The client is placed in the supine position, with the client's legs in a frog position.
232
The side-lying position may be used during what procedure for a toddler?
a lumbar puncture.
233
A semi-recumbent position is used when performing what procedure for a toddler?
a gavage feeding. The client's head and chest should be elevated.
234
The flexed sitting position may be used during what procedure for a toddler?
a lumbar puncture.
235
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?
Head lags when pulled from a lying to a sitting position
Absence of startle and crawl reflexes
Inability to pick up a rattle after dropping it
Rolls from back to side
Head lags when pulled from a lying to a sitting position
236
At the age of 5 months, the infant should have no
head lag when pulled to a sitting position; therefore, the nurse should report this finding to the provider.
237
The startle reflex disappears by what age?
the age of 4 months,
238
crawl reflex disappears by around what age?
around the age of 6 weeks.
239
At the age of 5 months, the infant can visually follow what
a dropped object,
240
infant is unable to pick the object up until around what age?
the age of 6 months.
241
The infant should be able to roll from her back to her side by what age?
at the age of 4 months.
242
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment?
Grabs feet and pulls them to her mouth
Posterior fontanel is closed
Legs remain crossed and extended when supine
Birth weight has doubled
Legs crossed and extended when supine is an unexpected finding and requires further assessment.
243
Infants are able to grab feet and pull them to their mouth by what age?
at the age of 6 months of age.
244
At this age, the infant should also be able to pick up a dropped object and hold her own bottle.
at the age of 6 months of age.
245
This is an expected finding in a 6-month old infant.
Posterior fontanel is closed
246
The posterior fontanel closes at approximately what age?
2 months of age.
247
The anterior fontanel is closed by what age?
18 months of age.
248
At 6 months of age, the legs flex at the knees when
the infant is supine.
249
Crossed and extended legs when supine is a finding associated with
cerebral palsy.
250
Infants should triple their birth weight by what age?
12 months
251
Infants should double their birth weight by what age?
6 months
252
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?
Perform the assessment in a head to toe sequence.
Minimize physical contact with the child initially.
Explain procedures using medical terminology.
Stop the assessment if the child becomes uncooperative.
Minimize physical contact with the child initially.
253
The head to toe approach is recommended for what age child
preschool-age and older children.
254
It is recommended to start with what type of interventions?
the least invasive interventions and proceed to the more invasive.
255
The nurse should handle contact w/ a toddler how?
initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures.
256
The nurse should describe procedures using what type of language?
age-appropriate language the child can understand.
257
If the child becomes uncooperative, the nurse should perform the procedure how?
perform the procedures more quickly.
258
A nurse is providing education to the parent of a toddler who is about to receive an MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching?
"My child should not play with other children for 2 days."
"I will need to return in 2 weeks for my child to receive the varicella immunization."
"I will help my child to blow bubbles during the injection."
"My child may have some drainage from the injection site."
I will help my child to blow bubbles during the injection.
259
A child who receives an MMR immunization is not considered what?
contagious. The child can play with other children as usual.
260
If MMR and varicella immunizations are not administered during the same visit, they must be administered during what time frame?
at least 1 month apart from each other.
261
MMR and varicella immunizations can be administered during what time frame?
the same visit by using separate syringes and different injection sites.
262
Providing distraction, such as helping or allowing a child to blow bubbles while receiving an injection, is a technique that can
minimize pain and discomfort for the child.
263
MMR immunizations are administered by what route?
subcutaneously; therefore, the nurse would not expect any drainage from the injection site.
264
A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance?
Give the toddler milk.
Go to an emergency department.
Call the poison control center.
Induce vomiting.
Call the poison control center.
265
The nurse should instruct the parents that it might be recommended to give the toddler milk to drink, but this will depend on
the poison that is ingested.
266
The nurse should instruct the parents that it might be recommended that they take the toddler to the emergency department, but this will depend on
the poison and amount that is ingested.
267
According to evidence-based practice, the nurse should instruct the parents to do what first?
first call the poison control center, which will then identify what further actions the parents should take.
268
The nurse should instruct the parents that it might be recommended to induce vomiting, but this will depend on
the poison that is ingested.
269
For many poisons, such as corrosives, inducing vomiting is an inappropriate action because
it can cause additional harm by causing burns.
