Download PN NURSING CARE OF THE CHILDREN 2020-2021 RETAKE GUIDE TEST BANK 100% complete .pdf and more Exams Nursing in PDF only on Docsity!
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Assessment_Nursing_Care_of_Children
1. A home health nurse is providing teaching about post seizure management to the parents of a school age child who has epilepsy and experiences tonic-clonic seizures.Which of the following instructions should the nurse include in the teaching? (Selectall that apply.)
"Hyperextend your child's head for 5 minutes following a seizure." "Immediately following a seizure, give your child 6 ounces of water." "Following a seizure, record the length and characteristics of your child's seizure.""Administer rectal diazepam to your child following a seizure." "Call for emergency medical services if the size of your child's pupils are unequal after aseizure."
2. A nurse in a pediatric clinic is discussing the pathophysiology of Reye syndrome with a newly licensed nurse. Which of the following statements by the newly licensednurse indicate an understanding of the disorder?
"Reye syndrome causes fatty changes in the liver." "Reye syndrome leads to venous thrombus formation." "Reye syndrome is associated with misuse of acetaminophen.""Reye syndrome is linked to decreased serum ammonia levels
3. A nurse is teaching the parents of a toddler about strategies to manage tempertantrums. Which of the following instructions should the nurse include in the teaching?
"Honor the child's request if she holds her breath.""Establish a structured daily routine for the child." "Place the child in her room alone until the temper tantrum
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ends.""Comfort the child during the temper tantrum."
4. A nurse is completing an assessment following suctioning of a child who has a tracheostomy. Which of the following findings should the nurse
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Decreased oxygen saturationClear breath sounds Increased oral secretions
5. A nurse is developing a plan of care for a 4-year-old child who has hemophilia and isexperiencing acute hemarthrosis. Which of the following interventions should the nurse include in the plan?
Have the child perform passive range-of-motion exercises.Administer aspirin as needed for pain. Place ice packs on the affected joints.
Position the lower extremities below the level of the heart.
6. A nurse in the emergency department is caring for a preschooler who hasepiglottitis. Which of the following actions should the nurse take?
Place the child in a left lateral position.
Obtain a specimen from the child's throat for a culture. Inspect the child's throat with a padded tongue depressor.Initiate droplet precautions for the child.
7. A nurse is providing teaching to the parent of a child about home care following a cardiac catheterization. Which of the following statements should the nurse include?
"You should give your child aspirin if they report pain at the site." "You can remove the pressure dressing 8 hours after the procedure.""Your child can soak in the bathtub 24 hours after the procedure." "Your child should avoid strenuous physical activities for several days."
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8. A nurse is admitting a child who has pertussis. Which of the following isolationprecautions should the nurse initiate?
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Protective environment
9. A nurse on a pediatric unit is receiving change-of-shift report for a group of clients.Which of the following clients should the nurse see first?
A child who is postoperative following a tonsillectomy and reports moderate throat pain
A child who had a cardiac catheterization using the femoral artery and has blanching of the toesA child who has bacterial pneumonia and is due for their initial dose of IV antibiotics A child who has juvenile idiopathic arthritis and needs assistance with application of prescribedsplints
10. A nurse in a pediatric clinic is performing a history and physical for a toddler who isscheduled to receive a measles, mumps, and rubella (MMR) immunization. Which of the following findings indicate that the immunization should be withheld?
Temperature of 38° C (100.4° F)
Family history of sudden infant death syndrome (SIDS)Taking an antihistamine for seasonal allergies Receiving prednisone for nephrotic syndrome
11. A nurse is instilling optic drops into an 18-month-old child's ears. Which of the followingmethods should the nurse use?
Pull the pinna down and back. Insert the dropper into the ear canal. Administer the ear drops at 5.5° C (42° F).Massage the area behind the ear.
12. A nurse is providing teaching to an adolescent who has a new prescription for cefazolin. For which of the following adverse effects should the nurse instruct
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theadolescent to monitor and report to the provider?
Dry mouth
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Urticaria
13. A nurse is providing discharge teaching to the parents of a child who has sickle cellanemia and was hospitalized after experiencing a vasoocclusive crisis. Which of thefollowing instructions should the nurse include in the teaching?
"Avoid immunizing your child with the meningococcal vaccine.""Restrict the time your child spends playing outdoors." "Increase your child's intake of oral fluids." "Provide your child with a high-protein diet."
14. A nurse is providing teaching to the parent of a school-age child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching?
"Seal no washable items in a plastic bag for 2 days.""Soak hair brushes in boiling water for 10 minutes." "Apply permethrin 1 percent cream rinse every day for 5 days."
"After washing bed linens, place them in a dryer on a cool setting for 30 minutes."
15. A nurse is admitting a childs who has bacterial meningitis. Which of the followingactions should the nurse take first?
Initiate antibiotic therapy for the child. Minimize the child's environmental stimuli.Place the child in a side-lying position. Administer pain medication to the child
16. A nurse is assessing a 12-month-old infant who is immediately postoperative following hernia repair surgery. Which of the following pain measurement
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toolsshould the nurse use to determine if the infant is experiencing pain?
FACES
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17. A nurse is caring for a school-age child who has metastatic osteosarcoma. The childasks the nurse, "Am I going to die?" Which of the following responses should the nurse make?
"What is your pain level right now?"
"Your doctor will be able to answer your questions tomorrow." "It sounds like you are worried. Tell me what you have been told." "It's natural to worry about death, but you should focus your energy on getting better."
18. A nurse is caring for a toddler who drinks 946 mL (32 oz) of whole milk per day andhas a poor appetite. The nurse should identify the toddler as being at risk for whichof the following conditions?
Iron deciency anemiaVitamin A toxicity Impaired carbohydrate metabolismLactose intolerance
19. A nurse is providing teaching to the parent of a child who has a new prescription formethylphenidate. Which of the following instructions should the nurse include?
"Monitor your child for excessive sleepiness." "Administer the medication with a caffeinated beverage." "Administer the second dose of the medication at lunch time.""Monitor your child for weight gain."
20. A nurse is planning care for an infant who has congenital talipes equinovarus. Which of the following referrals should the nurse expect the provider to make?
Ophthalmologist
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Nutrition counselor Speech
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Obtain a daily weight.Strain the urine. Monitor blood glucose level every 4 hr.Recommend strict bed rest.
22. A nurse is teaching a school-age child and their parents about managing diabetes mellitus during illness. The nurse should determine that the teaching has been effective when the parents indicate they will provide which of the following when thechild is ill?
Decreased calories Increased fluids Blood glucose monitoring every 8 hrUrine testing for leukocytes
23. A nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5° C(101.3° F). Which of the following findings should the nurse recognize as an indication of a urinary tract infection (UTI)?
Steatorrhea Jaundice Incontinence Rebound tenderness
24. A nurse on a pediatric unit is reviewing the laboratory results for a group of clients.Which of the following results should the nurse identify as the priority?
An adolescent who has iron-deciency anemia and an Hgb level of 11 mg/dLA school-age child who has diabetes mellitus and an HbA1c of 8% A toddler who has moderate dehydration and an RBC count of 5.6/mm
A preschooler who has cystic fibrosis-related diabetes and a WBC count of 15,000/mm
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25. A nurse is assessing a child who has received the first 50 mL of a blood transfusion. Which of the following findings indicates that the child might be
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Sharp pain in middle of the chestSevere itching of the hands Distended neck veins Decreased temperature
26. A nurse is assessing a child who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following clinical manifestations should the nurseexpect?
Weight gain Bradypnea Pain Diarrhea
27. A charge nurse is assisting a newly licensed nurse with the preoperative assessmentof a 2-year-old child who has a Wilms' tumor. Which of the following actions by the newly licensed nurse indicates an understanding of the needed care?
Measuring the child's abdominal circumferencePalpating the child's abdomen Providing clear liquids up to 1 hr prior to surgery Continuously monitoring the child's oxygen saturation
28. A nurse is creating a plan of care for a child who is awake and responsive following an acute head injury. Which of the following interventions should the nurse include?
Place the child in a room with bright uorescent lighting.Initiate seizure precautions for the child. Use the COMFORT scale to rate the child's pain.
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Suction the child's nares to determine the presence of fluid.
29. A nurse is providing teaching to the parent of an infant about car seat
