The nurse is assessing a 9 -year old boy who has been admitted to the hospital with possible acute poststreptococcal glomenrulonephritis (ASPGN).In obtaining his history what information is most significant?
A sore throat last week
The nurse is measuring the frontal occipital circumference (FOC)for a 3- month old infant and notes that the FOC has increased 5 inches (12.7cm)since birth and the childs head appears large in relation to body size which action is the most important for the nurse to take next
Palpate the anterior fontanel for tension and bulging
A female infant recently admitted with vomiting and diarrhea now weighs 10kg. Her weight at a previous well-baby visit was 11kg. What is the percentage of body weight loss for this infant?
9%
A male highschool student with Type1 diabetes tests his blood glucose level before playing a game of soccer and he obtains a reading of 180mg/dl(10mmol/L). Based on this reading which action should the nurse take?
Tell him to eat a sandwhich and fruit before beginning the game
A 7 year old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the childs mother the recent occurence of which illness is most significant
Sore throat
A mother brings her 2 month old son to the clinic for a well baby exam.During the assessment the nurse finds that the right testicle is not descended into the scrotum but the left is palpable which action should the nurse take?
Ask if the testis has been seen in the scrotum before
The nurse is assessing a 6 month old infant which response requires further evaluation by the nurse
demonstrates startle reflex
A 4 year old girl returns to the pediatrician office for a postoperative what following hospitalization for minor surgery when observing the child in the waiting area which behavior should the nurse consider normal for this age
Talks to an imaginary friend
A preschool aged child is experiencing respiratory distress is brought to the emergency department by the parents the child is anxious has a temperature of 102.8 F(39.3 C) and is drooling form the mouth while leaning forward when sitting which action should the nurse prepare the child for next
obtain bedside trays for intubation or tracheotomy by the healthcare provider
The nurse is caring for a preschool aged child with a congenitial heart defect who is admitted with intermittent low grade fever, fatigue and weight loss. Further phyiscal assessment findings include a new murmur splinter hemmorrhages under the nails and painless red lesions on the palms of the hands which diagnostic procedure should the nurse preapare the parents to expect the healthcare provider to prescribe?
Echocardiogram
A 6 year old male with a body mass index(BMI) in the 95th percentile for gender and age arrives at the clinic after a referral from the school nurse his laboratory findings include hemoglobin A1C of 5.5%(0.06). blood pressure (BP)in the 50th percentile for age height in the 75th percentile and an LDL cholesterol of 90 mg/dL(2.33 mmol/L) which lifestyle modification should the nurse discuss with the parents
Recommend increasing daily fruits and vegetables and daily exercise
when administering indomethacin to a premature infant who has patent ductus arteriosus the nurse should anticipate which outcome
Decreased cardiac murmur
A 2 year old boy had hyposadias repair yesterday goes to the hospital playroom with his mother which activity should the nurse recommend?
using a large piece puzzle
A male child is being prepared for a computed tomography(CT) scan when he begins to have tonic clonic seizure his mother is hysterical and is trying to hold the child down what actions should the nurse take?(SATA)
Place pillows inside the side rails
Ask the mother to release the child
Monitor the childs airway and tongue
A child diagnosed with kawasaki disease is brought to the clinic the mother reports that her child is irritable refuses to eat and has skin peeking on both hands and feet which intervention should the nurse instruct the mother to implement first?
Place the child in a quiet environment
The nurse is caring for a school age child who has laboratory results that reveal the presence of anti gliadin and anti endomysial immunoglobulin G and immunoglobulin A antibodies the nurse should identify with the parent and child which food to avoid after discharge to home?
wheat bread
The nurse is giving an intramuscular injection of an antibiotic to a 16 month old toddler with pneumonia the toddler does not have any known allergies and has been walking without assistance for one month which technique should the nurse select for administration
Administer the injection into the middle of the lateral aspect of the thigh
While administering the final dose of oral amoxicillin to a preschool aged boy he tells the nurse that his throat hurts which intervention is most important for the nurse to implement
Inspect the childs oropharynx
The mother of a 14 month old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition for her child but us concerned about the cost how should the nurse respond
Reassure the mother that these foods will only be needed until the growth spurt of the toddler years is complete
Which nursing intervention is most important to assist in detecting hypopituarism and hyperpituitarism in children
carefully recording the height and weight of children to detect inappropriate growth rate
The nurse is communicating with a 12 year old who is hearing impaired which action is best for the nurse to use when attempting to communicate with this child
Emphasize emotions with facial expressions
During the physical exam of an 11 year old girl the nurse observes budding breasts and scant pubic hair which tanner stage should the nurse choose when documenting these findings
III
A 9 year old with leukemia is admitted with a ruptured appendix a nasogastric tube is inserted and attached to low intermittent suction which finding is most important for the nurse to report to the healthcare provider
Absolute neutrophil count of 400/mm3
A 2 year old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta prior to administering the next dose of digoxin the nurse obtains an apical heart rate of 128 beats/min what action should the nurse implement?
Administer the scheduled dose
A mother brings her preteen daughter to the clinic for her first female examination during the health assessment the nurse should implement which technique to determine if the client has reached the age of menarche
Use the Tanner staging to determine sexual maturity
The nurse is administering a nebuilized albuterol treatment to a young girl who is having an asthmatic exacerbation the client is unable to hold her lips tightly around the mouthpiece which intervention should the nurse implement
Replace the mouthpiece with a mask
A breastfeeding infant screened for congenital hypothyriodism is found to have low levels of thyroxine(T4) and high levels of thyroid stimulating hormone (TSH)what is the best explanation for this finding
The TSh is high because of the low production of T4 by the thyroid
The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. which finding should the nurse report to the healthcare provider immediately
Jaundice
An adolescent with seasonal allergies asthma and eczema is obtaining a physical and medical clearance for an overnight week long summer camp which action should the nurse prioritize?
Remind to pack a rescue inhaler with adequate doses of medication
An infant is admitted for surgery who has a Wilms' tumor which nursing intervention should the nurse implement during the preoperative period?
Careful bathing and handling that avoids abdominal manipulation
One week after removing a tick a student arrives at the school nurses office with reports of flu like symptoms which intervention should the school nurse implement first?
Measure the students oral temp
A one month old male infant is brought to the clinic by his mother who states that her son has been vomiting forcefully after each meal for the last three days the infant is afebrile dehydrated and pyloric stenosis is suspected what other findings should the nurse identify that are consistent with pyloric stenosis
A olive shaped mass in the abdominal area
The school nurse is assessing a child who reports having an itchy scalp the nurse has sent home care instructions for pediculosis capititis for several children in the school which assessment should the nurse implement to this child?
Inspect hair follicle shafts for adherence of nits
The nurse plans to conduct a physical assessment of a toddler which protocol is best for the nurse to implement?
Prior to helping the child remove his/her clothing use a paper doll to demonstrate removal of clothing
During a well baby clinic visit the mother of a 6 month old infant asks the nurse if she can have a prescription for poly Vi Sol with flouride though the infant is still breast feeding the mother provides the with supplemental formula feedings. Which assessment is most important for the nurse to obtain
Water source used with supplemental feedings
The nurse is performing a routine assessment of a 3 year old at a community health center which behavior by the child alert the nurse to request a follow up for a possible autistic spectrum disorder(ASD)
Performs odd repetitive behaviors
The mother of an 11 year old boy who has juvenile iodiopathic arthritis tells the nurse I really dont want my son to become dependent on pain medication so I only allow him to take it when he is really hurting which information is most important for the nurse to provide this mother
Giving pain medication around the clock helps control the pain
The mother of three young children calls the clinic concerned about the recent exposure of her oldest child to chickenpox the nurse should provide the mother with information about the contagious period for chickenpox what is the contagious period
Two days prior to the onset of the rash until all lesions are crusted
A 3 year old child with HIV infection is staying with a foster family who is caring for three other foster children in their home when one of the children acquires pertussis the foster parent calls the clinic and asks the nurse what they should do which action should the nurse take first
Review immunization records of the child with an HIV infection
A 6 month old diagnosed with short bowel syndrome began enteral feedings yesterday to maintain normal growth and development of the child during this period what action should the nurse include in the infants plan of care
Give the infant a pacifier during feedings
The parents of a 3 year old boy who has Duchenne muscucular dystrophy (DMD) ask How can our son have this disease we are wondering if we should have anymore children which information should the nurse provide to these parents
This is an inherited X- linked recessive disorder which primarily affects male children in the family
A 9 year old boy with celiac disease is admitted to the pediatric unit following an appendectomy which food should the nurse remove from this childs meal tray
Crackers
The nurse is preparing a 10 year old child for suturing of a lacerated forehead Both parents and a 12 year old sibling are at the childs bedside which instruction best supports this family
Please decide who will stay when the healthcare provider begins suturing
A male infant is admitted to the pediatric unit with pertussis and is exhibiting a "whooping-like cough." The mother brings the infant to the nurses' station to seek assistance. Which intervention should the nurse implement first?
Cover the infant's mouth and assist the mother to take the infant back to the room.
The caregiver of a preschooler learns about long-term endocrine dysfunction resulting from their child's craniospinal radiation. Which statement made by the caregiver should the nurse recognize as needing additional education?
Make plans for growth hormone injections to enhance growth.
A nurse is teaching a class for mothers of premature infants, and is asked about "a shot for respiratory virus." What information about palivizumab is correct?
It is recommended for infants who meet established high-risk criteria.
A 10- year old is diagnosed with inflammatory bowel disease (IBD). Her mother is concerned that she will experience developmental delays as the result of this disorder. How should the nurse respond?
Growth failure is a concern, but developmental delays are not likely to occur.
The nurse is caring for a 3-year-old child who is 2 hours postop from a cardiac catheterization via the femoral artery. Which assessment finding is an indication of arterial obstruction?
Right foot is cool to the touch and appears pale and blanched.
An infant with Tetralogy of Fallot becomes acutely cyanotic and heperpneic. Which action should the nurse implement first?
Place the infant in a knee-chest position.
A child adnitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration.
Metabolic Acidosis
Patient with diarrhea for 3 days-what does this cause?
Metabolic Alkalosis
Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia understands dietary considerations related to the disease?
Lemonade
The HR for a 3-year-old with CHF has steadily decreased over the last few hours, now is 76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider?
BP 70/40
2- year old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?
Describe the side-lying, knees to chest position that must be assumed during the procedure.
Patient has low platelets.
Bleeding precaution.
The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of the infant's clinical picture?
Metabolic Acidosis
A month old girl is brought to the clinic by her mother because she has had a cold for 2 to 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
During a well-baby visit the parents explain that the soft bulge appears in the groin of their 4 month old son when he cries or strains with stool. The infant is scheduled for surgical repair of he inguinal hernia in 2 weeks. The parent should be instructed to take which measure if the hernia becomes incarcerated prior to surgery?
Gently manipulate the hernia for reduction.
The nurse is developing the plan of care for a hospitalized child with Von Willebrand disease. What priority nursing intervention should be included in the child's plan of care?
Guard against bleeding injuries.
How should then nurse instruct the parents of a 4-month-old with seborrheic dermatitis (cradle cap) to shampoo the child's hair?
Use a soft brush and gently scrub the area.
The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat . How should the nurse respond?
Position the infant on the stomach occasionally when awake and active