Creating a plan of care for an infant who has an epidural hematoma with a skull fracture. Appropriate action to include?
Implement seizure precautions for the infant
Providing teaching about car seat use to the mother of a 6-month-old infant. Statement that indicates understanding of the teaching?
"I should secure the car seat using lower anchors and tethers instead of the seat belt."
Planning care for a toddler who has a serum lead leverl of 4 mcg/dL. Appropriate action to take?
Schedule the toddler for a yearly rescreening.
Assessing a school-age child immediately postop following a perforated appendix repair. Expected findings?
Absence of peristalsis
Preparing an adolescent for lumbar puncture. Appropriate action?
Apply topical analgesic cream to the site 1 hr prior to the procedure.
Providing anticipatory guidance to the mother of a toddler. Expected behavior characteristics of the toddler to be included in the teaching?
Expresses likes and dislikes
Providing teaching to the parents of a preschooler who has heart failure and who is beginning to take digoxin twice daily. Appropriate instructions to include?
"Brush the child's teeth after giving the medication."
A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?
Withhold the influenza vaccine
A school nurse is assessing a school-age child's BP while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Appropriate action to take first?
Assist the child to a side-lying position on the floor
A nurse in an ED is performing a physical assessment on a 2-wk-old male infant. Manifestation that is the priority to report to the provider?
Substernal retractions
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Instructions to be included in the teaching?
"Encourage the child to perform independent self-care"
A nurse is caring for a hospitalized preschooler. The child's mother is going home for a few hrs while another relative stays with the child. Statement that the nurse should make to explain to the child when her mother will return?
"Your mommy will be back after you eat."
A nurse is assessing the pain lvl of a 3-yr-old toddler. Appropriate pain assessment scale to use?
FACES pain rating scale.
Creating a plan of care for a newly-admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?
For 24 hr following initiation of antimicrobial therapy
A nurse is assessing the vital signs of a 10-year-old child following a burn injury. Clinical manifestation that indicate early septic shock?
Temperature 39.1*C (102.4*F)
Receiving change-of-shift report on 4 children. Which should be assessed 1st?
A toddler who has a concussion and an episode of forceful vomiting
A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for temps. above 38.0*C (100.5*F) to an infant who weights 17.6 lbs. The infant has a temp. of 38.4*C (101.2*F). Available is ibuprofen liquid 100 mg/5mL. How many mL should the nurse administer to the infant per dose? (Nearest whole #)
2 mL
A nurse is creating an educational plan to teach parents about protecting their children from sunburns. Instructions to be included?
"Choose a waterproof sunscreen with an SPF of at least 15."
A nurse is providing teaching to the parents of a toddler about the administration of prescribed eye drops and eye ointment. Instructions to include?
"Administer the eye drops 3 minutes before the ointment."
A nurse is creating a plan of care for a toddler who has minimal change nephrotic syndrome (MCNS) and 3+ pitting edema. Interventions to be included in the plan of care?
Administer corticosteroids to the toddler.
A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration as a result of acute diarrhea. Statement by the parent that indicates and understanding of the teaching?
"I will monitor my child's # of wet diapers"
A nurse is caring for a 10-year-old child following a head injury. Findings that indicate the development of diabetes insipidus?
Sodium 155 mEq/L
A nurse is teaching the parent of a newborn about ways to prevent SIDS. Instructions to be included?
"Give the infant a pacifier at bedtime."
A nurse is assessing a pt. who has a new diagnosis of celiac disease. Expected clinical manifestations?
Steatorrhea
A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. Instructions to include in the teaching?
"Award the child with a sticker when he sits on the potty chair."
Providing discharge teaching to the parents of a 3-month-old infant following cheiloplasty. Appropriate instructions to include?
"Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."
A nurse in the ED is caring for a toddler who has partial-thickness burns on his right arm. Which action should the nurse take?
Cleanse the affected area with mild soap and water.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following?
Tachypnea
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of iron?
1/2 cup of raisins
A nurse in a provider's office is caring for a school-age child who has varicella. The parent asks the nurse when her child will no longer be contagious. Appropriate response by the nurse?
"When your child's lesions are crusted, 6 days after they appear."
A nurse in the ED is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? (Hotspot)
A. the lower R. quadrant of the abdomen between the umbilicus and the anterior iliac crest.
A nurse is providing dietary teaching to the parent of a school-age child who has cystic fibrosis. Appropriate statement to make?
"You should offer your child high-protein meals and snacks throughout the day."
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Appropriate action to take?
Perform a finger stick
A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
Playing dress-up
A charge nurse in an ED is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following clinical manifestations should the charge nurse include as suggestive of potential physical abuse?
Symmetric burns of the lower extremities
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?
"My child will receive antibiotics for several weeks."
A nurse is caring for a 15-year-old pt following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate anitidiuretic hormone secretion (SIADH)?
Mental confusion
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to MD?
Nasal flaring
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?
An infant who is 8 months old and is not yet making babbling sounds.
A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take?
Provide the child with a book about adventure.
A nurse is assessing an adolescent who received a sodium polystryrene sulfonate enema. Which of the following findings indicates effectiveness of the medication.
The adolescent's serum potassium level is 4.1 mEq/L
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take?
Turn of the IV pump
Occlude the IV tubing
Remove the tape securing the catheter
Apply pressure over the catheter insertion site.
A nurse in an ED is caring for a school-age child who is experiencing an anaphylactic rxn. Priority action by the nurse?
Administer IM epinephrine to the child.
A nurse is reviewing the lab report of an infant who is receiving tx for severe dehydration. The nurse should identify that which of the following lab values indicates effectiveness of the current tx?
Sodium 140 mEq/L
A nurse is caring for a preschooler who is scheduled for hydrotherapy tx for wound debridement following a burn injury. Appropriate action to take prior to the procedure?
Administer an analgesic to the child.
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Expected clinical manifestations? (select all)
Ankle clonus
Exaggerated stretch reflexes
Contractures
A nurse in an ED is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Manifestations that indicate moderate to severe dehydration?
Sunken anterior fontanel
A nurse is caring for a school-age child who has peripheral edema. Following assessments that confirm peripheral edema?
Palpate the dorsum of the child's feet
A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should the nurse include?
"Pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy."
A nurse at an urgent care clinic is assessing an adolescent client who has an upper respiratory tract infection. Which of the following findings should the nurse recognize as a manifestation of pertussis?
Dry, hacking cough
A nurse in the ED is caring for a school-age child who has epiglottis. Which of the following actions should the nurse take?
Monitor the child's O2 saturation
A nurse is reviewing the lab report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?
Hematocrit 28%
A nurse in an ED is caring for an adolescent who reports painful urination. Behaviors that suggest possible child maltreatment?
Uses mood-elevating substances.
A nurse is creating a plan of care for a preschooler who has Wilm's tumor and is scheduled for surgery. Which of the following interventions should the nurse include?
Avoid palpating the abdomen when bathing the child before surgery
A nurse is assessing a 3-yo toddler at a well-child visit. Which of the following manifestations should the nurse report to the MD?
Respiratory rate 45/min
A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 wk of tx, which of the following clinical manifestations indicates to the nurse that the medication is effective?
Decreased edema
A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the paretn offer which of the following foods to the child?
Rice pudding
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?
"I should wear sandals as much as possible."
A nurse is preparing to administer an immunization to a 4-yo child. Which of the following actions should the nurse plan to take?
Administer the immunization using a 24-gauge needle
A nurse is providing teaching to the parent of a school-age child who has oral candidiasis and is to begin taking oral nystatin. Which of the following instructions should the nurse include?
"Shake the medication prior to administration."
