ATI Pediatric FULL BANK PDF

ATI Pediatric FULL BANK written by SmartStudySolutions www.stuvia.com Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? ...

ATI Pediatric FULL BANK written by SmartStudySolutions www.stuvia.com Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric 1. A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect? A. Bulging anterior fontanel Rationale: A sunken anterior fontanel is a manifestation of severe dehydration in an infant. B. Bradypnea Rationale: Hyperpnea is a manifestation of severe dehydration in an infant. C. 13% weight loss Rationale: A weight loss greater than 10% is a manifestation of severe dehydration in an infant. D. Capillary refill 3 seconds Rationale: A capillary refill greater than 4 seconds is a manifestation of severe dehydration in an infant. 2. A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include? A. Breast tenderness Rationale: Breast tenderness, a presumptive sign of pregnancy, can have other causes, such as premenstrual changes or as an adverse effect of oral contraceptives. B. Fatigue Rationale: Fatigue, a presumptive sign of pregnancy, can have other causes, such as stress or illness. C. Fetal heart tones detected by ultrasound Rationale: Fetal heart tones are a positive sign of pregnancy because the presence of fetal heart tones can only be explained by pregnancy. D. Positive urine pregnancy test Rationale: A positive urine pregnancy test, a probable sign of pregnancy, can have other causes, such as a pelvic infection or a tumor. 3. A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? A. Attempt to stop the seizure. Rationale: Attempting to stop the seizure can cause further injury to the child. B. Restrain the child's arms. Rationale: Created on:04/09/2023 Page 1 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric Restraining the child's arms can cause further injury to the child. C. Use a padded tongue blade. Rationale: Using a padded tongue blade can cause further injury to the child. D. Position the child laterally. Rationale: Positioning the child laterally facilitates airway patency. 4. A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition? A. Tracks an object with eyes Rationale: An infant who has cerebral palsy does not track objects with the eyes and shows little interest in her surroundings. B. Sits with pillow props Rationale: Infants who have cerebral palsy require support when sitting upright. C. Smiles when a parent appears Rationale: An infant smiling when a parent appears is an expected developmental finding. D. Uses a pincer grasp to pick up a toy Rationale: A pincer grasp is an expected developmental finding in an infant and is not an indication of cerebral palsy 5. 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. Explain the source of the toddler's fears. Rationale: Although a toddler's cognitive skills are developing rapidly, reasoning skills remain immature. Toddlers are aware of a causal relationship, such as turn on a light switch and light will appear. However, they are not able to transfer this knowledge to new situations. B. Turn off the room light. Rationale: Sleep disturbances are common and a night light is an appropriate intervention. During this developmental stage, fears can be provoked by stress, experiences of loss, or separation from parents. C. Provide bedtime rituals. Rationale: Establishing a bedtime routine is important. Reading a familiar book or providing a favorite stuffed toy or blanket will help decrease the child's insecurity and fears. Created on:04/09/2023 Page 2 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric D. Encourage play exercises in the evening. Rationale: Play allows children to express feelings and fears and is encouraged during hospitalization, but a child should have stimulating physical activity during the daytime, not in the evening before bedtime. 6. A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel Rationale: The infant's posterior fontanel should close by about 8 weeks of age. B. Uses thumb and index fingers in a pincer grasp Rationale: A 9-month-old infant should be able to use his thumb and index fingers in a crude pincer grasp. C. Lateral incisors Rationale: An infant should develop upper lateral incisors between 9 and 13 months of age and lower lateral incisors at 10 to 16 months of age. D. Sitting steadily without support Rationale: At 6 months of age, most infants can sit only with support. An 8-month-old infant should be able to sit without support. 7. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress. Answers cannot be displayed for this alternate item format. 8. A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings? A. Place the infant in a prone position. Rationale: Prone position can decrease episodes of reflux. However, it is not recommended by the American Academy of Pediatrics. B. Place the infant in an infant seat. Rationale: An infant seat provides elevation and decreases the risk of aspiration. C. Place the infant on his left side. Rationale: Placing the infant on his left side can increase the risk of reflux and aspiration. Created on:04/09/2023 Page 3 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric D. Place the infant on his right side. Rationale: Placing the infant on the right side can increase the risk of reflux and aspiration. 9. 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. Rationale: There is another action that the nurse should perform first. B. Position the child side-lying. Rationale: This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position. C. Loosen restrictive clothing. Rationale: There is another action that the nurse should perform first. D. Clear the area of hazards. Rationale: There is another action that the nurse should perform first. 10. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Answers cannot be displayed for this alternate item format. Rationale: The nurse should assess the apical pulse for 1 full min and assess the rhythm strip for a prolonged P-R interval because the infant is most likely experiencing digoxin toxicity. The manifestations of digoxin toxicity that are seen in infants most commonly include vomiting, poor feeding, and bradycardia. The P-R interval is also prolonged if digoxin toxicity is occurring. It is critical the nurse quickly identifies and reports these symptoms to the provider for treatment of digoxin toxicity. Furosemide is a potassium wasting diuretic and can cause hypokalemia. Hypokalemia increases the potential for digoxin toxicity.The nurse should continue to monitor the infant's heart rate and withhold digoxin per the provider's prescription. It may be necessary to treat the digoxin toxicity with the antidote digoxin immune fab fragment. It is important to continue to monitor digoxin level as treatment is initiated. 11. A nurse is preparing to teach about communicable diseases. During which of the following stages is the period in which a disease is contagious? A. ?Communicability period Rationale: ?The communicability period is the time when a disease is contagious and can be transmitted to others. Created on:04/09/2023 Page 4 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric B. ?Convalescent period Rationale: The convalescent period is the time between when the disease manifestations disappear and the client becomes well. C. ?Incubation period Rationale: The incubation period is the time between when the organism infects the client and the onset of the illness. D. ?Prodromal period Rationale: The prodromal period is the time between the onset of nonspecific manifestations and the onset disease-specific manifestations. 12. A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider? A. Inability to raise head when in prone position Rationale: A 3-month-old infant should be able to raise her head and shoulders from prone position; therefore, the nurse should report this finding to the provider. B. Inability to sit without support Rationale: An 8-month-old infant should be able to sit without support. C. Inability to pick up an object with her fingers Rationale: A 6-month-old infant should be able to grasp objects with her fingers. D. Inability to bring an object to her mouth Rationale: A 4-month-old infant should be able to bring objects to her mouth. 13. A nurse receives a call from a parent of a child who has von Willebrand disease and has having a nosebleed. Which of the following instructions should the nurse give to the parent? A. "Place your child in a sitting position with her head tilted back." Rationale: This position puts the child at risk for aspiration of blood. B. "Apply ice at the base of the nose for 5 min and then check for bleeding." Rationale: ?If bleeding persists, the parent should apply ice across the bridge of the nose. C. "Place your child in a supine position with a pillow under her back." Rationale: ?This position puts the child at risk for aspiration of blood. D. "Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes." Rationale: Created on:04/09/2023 Page 5 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric The nurse should instruct the parent to have the child sit up with her head tilted forward to reduce the risk of aspiration. The parent should apply pressure with the thumb and forefinger to the child's nose for 10 min and then check for further bleeding. 14. A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply.) A. The preschooler stutters when speaking. B. The preschooler mispronounces words. C. The preschooler speaks in three word sentences. D. The preschooler talks to himself when reading. E. The preschooler speaks in a nasally tone. Rationale: The preschooler stutters when speaking is incorrect. Stuttering is expected in the preschooler. Stuttering or stammering is common for a preschool-age child who is learning to form new words into sentences.The preschooler mispronounces words is correct. Language begins to increase with toddlers as development progresses towards two to three word phrases. Mispronounced vowels and consonants occur between ages 24 and 36 months. The nurse should expect a toddler to mispronounce words.The preschooler speaks in three word sentences is incorrect. Three to four word sentences (telegraphic speech) is expected for preschoolers. Preschoolers ask many questions and often continue talking when no-one is listening. The preschooler talks to himself when reading is incorrect. During preschool development, the child experiences a vivid imagination that is expressed through imitative and dramatic play. In discovering books, the child becomes engaged in the story and might talk to himself. Speaking in a nasally tone is correct. A child who speaks with a nasally tone might have a neurogenic speech disorder that is caused by weakened muscles of the tongue, soft palate, and face. A speech therapist can evaluate the child and determine exercises to improve the articulation, voice, pitch quality, and volume. 15. A nurse is caring for an adolescent who was admitted with anorexia nervosa. Which of the following finding should the nurse expect? A. ?Diarrhea Rationale: Constipation, rather than diarrhea, is associated with anorexia nervosa. B. ?Hypertension Rationale: Hypotension, rather than hypertension, is associated with anorexia nervosa. C. ?Tachycardia Rationale: Bradycardia, rather than tachycardia, is associated with anorexia nervosa. D. ?Bloating Rationale: ?Bloating is a finding associated with anorexia nervosa. Created on:04/09/2023 Page 6 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric 16. Drag words from the choices below to fill in each blank in the following sentence. Answers cannot be displayed for this alternate item format. Rationale: Hypokalemia is correct.The client is receiving furosemide every 6 hr. Furosemide causes potassium depletion. Therefore, the client is at risk for hypokalemia.Digitalis toxicity is correct.The client is receiving digitalis every 12 hr. The margin of safety is very small, 0.8 to 2 mcg/L. Therefore, the client is at risk for digitalis toxicity. Dependent rubor is incorrect. Heart failure causes decreased perfusion, which results in cool extremities.Hypercyanotic spells is incorrect.Hypercyanotic spells are seen in children who have tetralogy of Fallot.Murmur is incorrect. A murmur is not a sign of heart failure for this child.Fever is incorrect. Fever is typically seen with infections and is not a sign of heart failure. Carditis is incorrect. Carditis is inflammation of the heart and is not a sign of heart disease.Hypertension is incorrect.With an exacerbation of heart failure, the blood pressure is decreased. 17. A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse to say to the child? A. "I promise I won't tell anyone about this." Rationale: The nurse should not promise not to tell, as it is legally required to report child abuse. B. "Let's discuss what happened with your family." Rationale: The nurse should discuss the occurrence privately with the child. C. "Your family is bad for doing this to you." Rationale: The nurse should not criticize or talk negatively about the child's family. D. "It is not your fault that this happened." Rationale: The nurse should reinforce to the child that the abuse is not his fault. 18. A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck extension traction. Which of the following actions should the nurse take? A. ?Reposition the child every 2 hr. Rationale: The nurse should reposition the child should be repositioned every 2 hr to prevent skin breakdown. B. Remove the traction boot during baths. Rationale: The nurse should assess the traction boot frequently to ensure circulation is maintained but should not remove it. C. ?Apply antibiotic ointment to pin sites daily. Rationale: Created on:04/09/2023 Page 7 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric Buck extension traction is skin traction and does not require pins. D. ?Reduce fluid intake. Rationale: The nurse should increase the child's fluid intake to minimize the risks associated with immobility. 19. A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse? A. A child who has frequent visitors Rationale: Parents of abused children often control interactions with peers and try to seclude children. Abused children often do not have many friends or frequently change friends. B. A child who has a BMI indicating obesity Rationale: An abused child is likely to show failure to thrive and a low body weight. C. A child who uses the call light frequently Rationale: A child who is abused is often numb or emotionless. The child does not talk much or show signs of curiosity. The child often tries to disappear to avoid notice and decrease the risk of additional abuse. This child is not likely to use the call light frequently. D. A child whose parents answer questions for the child Rationale: Often the perpetrator of abuse is controlling and will talk for the child to avoid the risk of the child saying something that could expose the abuse. A school-age child should be able to answer most questions. The nurse should gather information when the parents are absent and to determine if the child interacts differently. 20. A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority? A. Schedule the child for an abdominal ultrasound. Rationale: Although it is important to schedule the child for an ultrasound, this action is not the priority. B. Instruct the parent to avoid pressing on the abdominal area. Rationale: The priority action is to instruct the parent to avoid pressing on the child’s abdomen. These symptoms are associated with Wilms' tumor, and trauma to the mass should be avoided to prevent movement of cancer cells into other sites. C. Determine if the child is having pain. Rationale: Although it is important to determine if the child is having pain, this action is not the priority. D. Obtain a urine specimen for a urinalysis. Rationale: Created on:04/09/2023 Page 8 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric Although it is important to obtain a urine specimen for a urinalysis, this action is not the priority. 21. A nurse is providing teaching to the parents of a child who has iron deficiency anemia and is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching? A. "The medication should be administered in one large dose every day." Rationale: Red blood cell production is maximized by supplying the bone marrow with small, frequent doses throughout the day rather than one large dose. B. "Restricting fiber from our child's diet will help absorption of the iron." Rationale: Iron supplements often cause constipation. The parents should increase the child's fiber and fluids in an effort to prevent constipation. C. "The medication will be more effective if it is administered with meals." Rationale: The medication is most effective if it is given on an empty stomach. If the child cannot tolerate it on an empty stomach, it can be administered after meals. Oral iron supplements are best administered on an empty stomach and 2 hr after consuming milk or antacids. D. "Our child's blood count will need to be monitored routinely for several weeks." Rationale: The child's response to treatment will be determined by monitoring hemoglobin and hematocrit levels through routine blood tests. Treatment can take up to 3 months to be effective. 22. 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 child? A. Putting a large-piece puzzle together Rationale: A child who requires airborne precautions must remain in her room. Appropriate activities for a 4-year old child include putting together large-piece puzzles, using paints and crayons, playing ball, riding tricycles, playing pretend and dress up, sewing cards and beads, and reading books. B. Watching a video game in the playroom Rationale: A child who requires airborne precautions can transmit infectious agents by small-particles of evaporated droplets that can stay in the air for long periods of time. To prevent infection transmission, the child must remain in an airborne infection isolation room. C. Pulling a wagon with toys in the hallway Rationale: A child who requires airborne precautions can transmit infectious agents by small-particles of evaporated droplets that can stay in the air for long periods of time. To prevent infection transmission, the child must remain in an airborne infection isolation room. D. Constructing a model airplane Rationale: A 4-year old child is developing fine motor skills—such as using scissors to cut out a picture, Created on:04/09/2023 Page 9 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric copying squares, and tracing crosses and diamonds—but has neither the cognitive ability to read directions nor the fine motor skills to put a model together. 23. A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take? A. Use a 20-gauge needle. Rationale: When administering an immunization to a preschooler, the nurse should use a 22- to 25-gauge needle to minimize discomfort. B. Use a 1.8 mm (0.5 in) needle. Rationale: The nurse should use the smallest size needle that will allow the medication to pass through the subcutaneous tissue and enter the muscle. For a preschooler, a 1.8 mm (0.5 in) needle is adequate in length. C. Insert the needle just below the acromion process. Rationale: When administering the medication, the nurse should use the upper third of the muscle, which is approximately two finger breadths below the acromion process. Using this location, the nurse can avoid the radial and axillary nerve. D. Insert the needle at a 15&deg angle. Rationale: The nurse should insert the needle at a 90&deg angle, pointing the needle slightly toward the shoulder to ensure that the medication enters the muscle. 24. A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching? A. Apply a topical corticosteroid ointment to the affected area. Rationale: The child might require a topical corticosteroid ointment to use during flare-ups to decrease inflammation. B. Launder the child's clothing with fabric softener. Rationale: The parent should wash the child's clothing and sheets in a mild detergent and then rinse them in clear water. The parent can also put the clothing through a second wash cycle without detergent to further reduce harmful substances. C. Give the child a bubble baths every day. Rationale: The parent should give the child a bath in tepid water with mild soap and should not use bubble baths, oils, or powders. The parent can also give the child a colloidal bath and then apply an emollient to the skin. D. Dress the child in woolen clothes during cold months. Rationale: The parent should dress the child in synthetic fabrics, rather than wool, for outerwear during Created on:04/09/2023 Page 10 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric cold weather and dress the child in soft cotton fabrics at night to prevent pruritus. 25. A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? A. "My morning blood glucose should be between 90 and 130." Rationale: The child's fasting blood glucose should be between 80 and 120 mg/dL. B. "I should eat a snack half an hour before playing soccer." Rationale: Exercise lowers blood glucose levels. The child should eat a snack half an hour prior to physical activity. If the exercise is prolonged, the child might require a snack during the activity. C. "I should not take my regular insulin when I am sick." Rationale: A child who has type 1 diabetes mellitus can experience hyperglycemia during illness. The nurse should encourage the child to monitor glucose levels more frequently on sick days than on healthy days and adjust insulin doses as needed. D. "I can store unopened bottles of insulin in the freezer." Rationale: Insulin should be stored at room temperature or in a refrigerator. Freezing insulin causes it to become inactive. 26. A nurse is caring for a pre-school age child who has epiglottitis with a barking cough. Which of the following actions should the nurse take? A. Initiate airborne precautions. Rationale: The nurse should implement and maintain droplet precautions for 24 hr after a child who has epiglottitis begins antibiotic therapy. B. Obtain a throat culture. Rationale: Attempting to obtain a throat culture can cause an airway obstruction. C. Use a tongue depressor to observe the epiglottis. Rationale: Using a tongue depressor to observe the epiglottis can cause an airway obstruction. D. Monitor oxygen saturation. Rationale: The nurse should monitor the child's oxygen saturation levels to check for indications of respiratory distress or a decline child's condition. 27. A nurse is caring for a child on the oncology unit. The child's parents are asking the nurse about the cancer diagnosis. Which of the following information should the nurse provide the parents about the most common Created on:04/09/2023 Page 11 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric malignant renal and intra-abdominal tumor of childhood? A. ?Ewing sarcoma Rationale: ?Ewing sarcoma is the second most common malignant bone tumor in children and adolescents. It arises in the marrow spaces of the bones, such as the femur, tibia, fibula, ulna, humerus, pelvis, ribs, and skull. B. ?Osteosarcoma Rationale: ?Osteosarcoma is the most frequent malignant bone cancer in children with a peak incidence between 10 to 25 years of age. C. ?Neuroblastoma Rationale: ?Neuroblastoma is the most common malignant extracranial solid tumor in children. D. Wilms' tumor Rationale: Wilms' tumor, or nephroblastoma, is the most common malignant renal and intra-abdominal tumor of childhood. 28. A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.) A. Symptoms are continuous throughout the day. B. Daytime symptoms occur more than twice a week. C. Nighttime symptoms occur approximately twice a month. D. Minor limitations occur with normal activity. E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value. Rationale: Symptoms are continual throughout the day is incorrect. Continual asthma symptoms throughout the day are seen with severe persistent asthma.Daytime symptoms occur more than twice per week is correct. A child who has mild persistent asthma will typically have daytime symptoms more than twice per week, but not daily.Nighttime symptoms occur approximately twice per month is incorrect. Nighttime symptoms occurring approximately twice per month is typical of intermittent asthma.Minor limitations occur with normal activity is correct. A child who has mild persistent asthma will have some minor limitations with normal daily activities.Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value is correct. A child who has mild persistent asthma will have a PEF greater than or equal to 80% of the predicted value. 29. Which of the following assessment findings at 1600 indicate that the expected outcomes have been met?Click to highlight the statements in the nurse's notes which show achievement of the expected outcomes. To deselect a statement, click on the statement again. Answers cannot be displayed for this alternate item format. Rationale: Created on:04/09/2023 Page 12 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric Temperature 36.5°C (97.7°F) is correct. The child's temperature was 35.6°C (96°F) upon returning from the cardiac catheterization. This value is below the expected reference range of 36-38°C (96.8-100.4°F). The child's temperature has increased to the expected range.Right groin pressure dressing is intact and has a small amount of dried blood on the dressing is correct. The nurse is assessing the c site dressing to note for bleeding. The dressing should also remain occlusive to maintain pressure to cannulization site to prevent bleeding and to prevent contamination of the site. This statement shows the bleeding has not increased and the outcome has been met.Right leg is warm to touch and equal in color to the left leg is correct. This assessment shows the outcome is achieved. The nurse assesses the color and temperature of the affected leg to determine if there is any arterial or venous obstruction. The outcome is to have the affected leg return to pre-catheterization assessment.Pedal and popliteal pulses strong and equal in bilateral lower extremities is correct.This assessment shows the outcome is achieved. The nurse assesses the presence and strength of the pulses in the lower extremities of the affected leg to determine if there is an arterial obstruction. The outcome is to have the affected leg return to pre-catheterization assessmentApical heart rate is strong and regular is correct. This assessment shows the outcome is achieved. During a catheterization a complication may include injury to a heart vessel or valve. Blood may collect in the pericardial space which would cause the apical heart rate to sound distant or faint. Another complication the nurse assess for is dysrhythmias or bradycardia. Child continues refusing PO fluids is incorrect.An outcome that should be met is that the child will be able to maintain adequate oral fluid intake. Children undergoing a cardiac catheterization are at risk for dehydration due to pre-procedure NPO, procedural dyes or contrast material and blood loss. Child reports pain at the right groin is a 4 on the Faces Pain Rating scale is incorrect.The outcome of pain management has not been met. Discomfort at the cannulation site should be treated with the administration of acetaminophen or ibuprofen. 30. A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect? A. Dry, flushed skin Rationale: A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to be diaphoretic and have pale skin. B. Deep, rapid respirations Rationale: A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to have shallow or normal respirations. An adolescent who has a blood glucose level above the expected reference range is likely to have deep, rapid respirations, known as Kussmaul respirations. C. Tachycardia Rationale: A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to have tachycardia due to increased circulating catecholamines and increased adrenergic activity. D. Polyuria Rationale: A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to a normal urine output. An adolescent who has a blood glucose level above the expected reference range is likely to have polyuria as the body responds to the increased glucose in the blood. Created on:04/09/2023 Page 13 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric 31. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress. Answers cannot be displayed for this alternate item format. 32. A nurse is providing teaching to a parent of a child who has acute group A ß-hemolytic streptococci. Which of the following information should the nurse include in the teaching? A. ?Avoid the use of warm compresses around the head or neck. Rationale: Both warm and cold compresses can provide pain relief and should not be avoided. B. ?Intramuscular injections will be required monthly. Rationale: Monthly intramuscular injections are not required for an acute group A ß-hemolytic streptococci infection. C. ?Replace the child’s toothbrush after 24 hr on antibiotics. Rationale: ?The child’s toothbrush should be replaced after 24 hr on antibiotics to prevent the spread of infection or re-infection. D. ?Keep the child home from school for at least 1 week. Rationale: After taking antibiotics for 24 hr and remaining free of fever, the child can return to school. 33. A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Offer fluids through a straw. Rationale: To avoid trauma to the surgical site, objects such as tongue depressors, thermometers, syringes, spoons, or straws should not be placed in the mouth of the infant who is 24 hr postoperative following a cleft palate repair. B. Apply bilateral wrist restraints. Rationale: The nurse should apply bilateral elbow restraints to prevent the toddler from placing his hands in and around his mouth, which can result in trauma. C. Administer opioids for pain. Rationale: Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN. D. Implement a soft diet. Rationale: The toddler should receive clear liquids for 24 hr following surgery, after which the nurse should Created on:04/09/2023 Page 14 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric implement a liquid diet for 2 weeks, followed by a soft diet for 6 weeks following the repair. 34. A nurse is caring for an infant who has gastroesophageal reflux. The nurse should recognize that which of the following findings are associated with this condition? (Select all that apply.) A. Vomiting B. Weight loss C. Rigid abdomen D. Wheezing E. Fever Rationale: Vomiting is correct. Vomiting is associated with gastroesophageal reflux.Weight loss is correct. Weight loss is associated with gastroesophageal reflux.Rigid abdomen is incorrect. A rigid abdomen is associated with appendicitis.Wheezing is correct. Wheezing is associated with gastroesophageal reflux.Fever is incorrect. Fever is associated with appendicitis. 35. 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. Rationale: The nurse should consider the developmental age before the cast is applied. A preschooler might fear bodily harm and fantasize about the loss of an extremity. Using a doll or stuffed animal helps to explain the procedure. During this stage of development, the child is a "magical thinker" and might believe stuffed animals are alive. This action shows the child that it does not hurt the doll or stuffed animal, and, in turn, will not hurt the child. B. Tell the child, "This will make your arm feel better." Rationale: A preschooler would not be comforted by these words. A child in this age group is unable to associate a "cause and effect" and has a limited understanding of the cause, but knows what it feels like. It would be more appropriate to tell the child that the cast might feel "warm." The child would be able to understand this information, and it would provide reassurance and alleviate the preschooler's fear of bodily harm. C. Place a heated fan at the bedside to facilitate drying. Rationale: Heated fans or dryers should not be used. These promote drying from the outside to the inside. The heat conduction could also cause a burn. The cast should remain uncovered and allowed to dry from the inside out. D. Support the casted arm with a firm grasp. Rationale: The nurse might need to provide support but should not use a firm grasp. A wet plaster cast should be supported by a pillow that is covered in plastic and held by using the palms of the hands. This will prevent indentions, which can cause pressure areas. Created on:04/09/2023 Page 15 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric 36. A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets? A. ?Low-sodium, fluid-restricted Rationale: A low-sodium, fluid-restricted diet will prevent complications. B. ?Regular diet, no added salt Rationale: A regular diet with no added salt is not an appropriate diet for a client who has acute glomerulonephritis with peripheral edema. C. ?Low-carbohydrate, low-protein diet Rationale: A low-carbohydrate, low-protein diet is not an appropriate diet for a client who has acute glomerulonephritis with peripheral edema and a urinary output of 35 mL/hr. D. ?Low-protein, low-potassium diet Rationale: A low-protein, low-potassium diet is not an appropriate diet for a client who has acute glomerulonephritis with peripheral edema and a urinary output of 35 mL/hr. Potassium intake is restricted in periods of oliguria. 37. A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect? A. Lethargy Rationale: A blood glucose of 280 mg/dL is above the expected reference range indicating hyperglycemia. The nurse should expect the child to appear lethargic, leading to a decreased level of consciousness and confusion. B. Pallor Rationale: The nurse should expect a child who has a blood glucose level below the expected reference range to have pallor and sweating. This child is more likely to have flushed, dry skin and mucous membranes. C. Tremors Rationale: The nurse should expect a child who has a blood glucose level below the expected reference range to have tremors, leading to hyperreflexia and possibly seizures. This child is more likely to have diminished deep tendon reflexes. D. Shallow respirations Rationale: The nurse should expect a child who has a blood glucose level below the expected reference range to have shallow or normal respirations. This child is more likely to have deep rapid respirations. Created on:04/09/2023 Page 16 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric 38. A nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names? A. ?Shingles Rationale: Shingles is the common name for varicella zoster. B. Athlete's foot Rationale: Athlete's foot is the common name for tinea pedis. C. Fever blister Rationale: ?Fever blister is the common name for herpes simplex virus type I. D. Valley fever Rationale: ?Valley fever is the common name for coccidioidomycosis. 39. Complete the following sentence by using the list of options. Answers cannot be displayed for this alternate item format. Rationale: Dropdown 1Pulmonary embolism is correct. Immobility from traction decreases venous return and causes pooling of blood, which increases the risk of clot formation. The child is receiving traction therapy for management of femur fracture and is experiencing a change in respiratory status with their respirations being slightly labored. These findings put the child at great risk for developing an embolus. Fecal impaction is incorrect.The child has limited mobility from traction, which increases the child's risk for developing constipation and fecal impaction. However, the child's assessment findings indicate a soft-formed bowel movement 2 days ago; therefore, this is not a high risk.Paralytic ileus is incorrect.While a child who is immobile has an increased chance of a paralytic ileus, this is not the highest risk. The child has active bowel sounds and had a bowel movement two days ago. Hypotension is incorrect.The effects of immobility can cause an increase in blood pressure; therefore, this is not a great risk for the child.Renal calculi are incorrect. Immobility increases urine stasis and possibly bladder distention and increases the risk for calculi formation; however, the child is having urinary output. Therefore, this is not a great risk for the client.Dropdown 2Oxygen saturation level is correct. The child's oxygen saturation level has decreased, which indicates hypoxia. This finding can be related to pulmonary embolism.Blood pressure is incorrect. The child's blood pressure is within the expected reference range for a school-age child.Bowel sounds is incorrect. The child has hypoactive active bowel sounds and had a bowel movement two days ago. Stool characteristics is incorrect.The child had a soft formed stool 2 days ago; therefore, there is no indication that the child is at risk for impaction.Urine characteristics is incorrect.The child's genitourinary assessment revealed no unexpected findings. The child was able to void 200 mL of clear, yellow urine, which is an expected finding. 40. A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention? A. Positive Babinski reflex Rationale: The Babinski reflex disappears after 1 year of age. Therefore, a 9-month-old with a positive Babinski reflex is a finding that does not require further intervention. Created on:04/09/2023 Page 17 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric B. Positive Moro reflex Rationale: The Moro reflex disappears at approximately 3 to 4 months of age. Therefore, a 9-month-old who has a positive Moro reflex is a finding that requires further intervention C. Negative Doll’s eye reflex Rationale: A negative Doll’s eye reflex is a normal finding. A 9-month should have the ability to fix his eyes on objects as he turns his head. Therefore, a 9-month-old with a negative Doll’s eye reflex is a finding that does not require further intervention. D. Negative Crawl reflex Rationale: The Crawl reflex is positive when an infant is placed on his abdomen and makes crawling movements with his arms and legs. This reflex disappears at about 6 weeks of age. A 9-month old infant should be able to crawl about on his hands and knees and pull himself up to a standing position. Therefore, a 9-month-old with a negative Crawl reflex is a finding that does not require further intervention. 41. A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Administer antibiotics when available. Rationale: The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS. Antibiotic therapy has a marked effect on the course and prognosis of the illness. B. ?Reduce environmental stimuli. Rationale: Reducing environmental stimuli is an appropriate action, but it is not the priority. C. ?Document intake and output. Rationale: Documenting intake and output is an appropriate action, but it is not the priority. D. ?Maintain seizure precautions. Rationale: Maintaining seizure precautions is an appropriate action, but it is not the priority. 42. A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect? A. Irritability Rationale: An infant who is dehydrated will exhibit irritability. B. Slow, bounding pulse Rationale: An infant who is dehydrated will exhibit tachycardia, rather than a slow, bounding pulse. Created on:04/09/2023 Page 18 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric C. Decreased temperature Rationale: An infant who is dehydrated will exhibit an increased, rather than a decreased, temperature. D. Tetany Rationale: Tetany is a manifestation of hypoglycemia. 43. The nurse is reviewing the assessment findings and diagnostic results.For each assessment finding, click to specify if the finding is consistent with leukemia, sickle cell anemia, or hemophilia. Each finding may support more than one disease process. Answers cannot be displayed for this alternate item format. Rationale: Temperature is consistent with leukemia and sickle cell anemia.The child has an elevated temperature. A child who has leukemia can present with a fever and a persistent mild infection. A low-grade fever can be present in a child experiencing a sickle cell crisis due to inflammation.Bruising is consistent with leukemia and hemophilia. A child who has leukemia often presents with bruising and petechia related to a low production of platelets. A child who has hemophilia can present with bruising related to an alteration in clotting from a factor VIII deficiency.Bleeding is consistent with leukemia and hemophilia.Due to low platelet production, children who have leukemia can have increased bleeding. Hemophilia can result in excessive bleeding from even slight trauma due to a deficiency of the clotting factor VIII.WBC count is consistent with leukemia and sickle cell anemia.The child's WBC count is elevated. A WBC count greater than 10,000/mm³ is a typical manifestation of leukemia. It is related to infiltration of the bone marrow by immature WBCs. WBC count in a child who has sickle cell anemia can be as high as 12,000 to 20,000/mm³ due to chronic inflammation.Pain is consistent with leukemia, sickle cell anemia, and hemophilia. The child reported generalized pain of the extremities. Children who have leukemia might report bone pain related to infiltration of the bones with nonfunctional immature WBCs. During a sickle cell crisis, a child could experience painful bones and joints of the hands and feet due to decreased blood flow. With hemophilia, hemorrhages can occur into the joints, which causes stiffness and aching in the affected joints. 44. Drag words from the choices below to fill in each blank in the following sentence. Answers cannot be displayed for this alternate item format. Rationale: Dehydration is correct. The client has been running a low-grade fever and has not eaten for past 2 days, BUN and sodium are slightly above expected reference ranges. Increased BUN and sodium may be indicative of dehydration. Client also reports not having an appetite; all these manifestations place the client at risk for dehydration.Anemia is incorrect. The client’s hemoglobin is slightly below the expected reference range, the hematocrit is within the expected reference range. There is no indication that the client is at risk for anemia.Muscle cramps is incorrect.The client’s potassium is within the expected reference range. There is no indication in client’s data collection that indication the client is at risk for developing muscle cramps.Pleural effusion is correct. The client has pneumonia with bilateral crackles auscultated in the lungs and chest x-ray indicates that the client has infiltrates and consolidation in the lungs. Created on:04/09/2023 Page 19 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric 45. Which of the following actions should the nurse take? Answers cannot be displayed for this alternate item format. 46. 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. Keep the child home for 1 week. Rationale: The child should avoid strenuous activity but can attend school. B. Give the child acetaminophen for discomfort. Rationale: The child might have minor discomfort at the puncture site. The parent should offer either acetaminophen or ibuprofen due the risk of Reye syndrome associated with taking aspirin. C. Offer the child clear liquids for the first 24 hr. Rationale: The child should begin fluid intake with sips of clear liquids but can resume her regular diet as soon as she desires. D. Assist the child to take a tub bath for the first 3 days. Rationale: The child should keep the site clean and dry and therefore avoid tub baths for at least 3 days. The parent can remove the dressing the day after the procedure and then cover the site with an adhesive bandage strip for the next 2 days. The child can shower if she is able to keep the site dry. 47. A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following? A. "I will give my son the enzymes between meals." Rationale: The parent should give the child pancreatic enzymes with every meal and snack. B. "The enzymes probably won't cause many adverse effects." Rationale: Pancreatic enzymes rarely cause adverse effects. In inappropriately large doses, they can cause nausea and diarrhea. C. "The enzymes help him digest fat." Rationale: Pancreatic enzymes improve digestion, particularly of fats. D. "I will put the enzyme crystals in his applesauce." Rationale: The parent can sprinkle the contents of the pancreatic enzyme capsules on a variety of foods, including applesauce. Created on:04/09/2023 Page 20 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric 48. Which of the following actions should the nurse plan to take? Answers cannot be displayed for this alternate item format. Rationale: Educate the parents to increase the toddler’s daily fiber intake is incorrect. There is no indication that the toddler is constipated. Monitor color of stools is correct.The passage of a normal brown stool indicates resolution of the intussusception. The nurse should notify the provider of this occurrence. Insert an NG tube is correct.An intussusception is a bowel obstruction caused by the intestines telescoping in on itself. The nurse should plan to insert an NG tube to provide gastric decompression until the obstruction is resolved. Administer pancreatic enzymes before meals is incorrect.Pancreatic enzymes are indicated for children who have cystic fibrosis and pancreatic insufficiency due to blocked pancreatic ducts. Administer intravenous antibiotics is correct. Children who are experiencing an intussusception are at risk for developing bowel necrosis and a resulting perforation. The nurse should plan to administer intravenous antibiotics until the intussusception has resolved.Initiate contact precautions is incorrect. The toddler’s manifestations of abdominal pain and currant jelly stools is due to a bowel obstruction caused by intussusception, not a contagious infection.Collect a urine specimen for culture and sensitivity is incorrect. There is no indication that the toddler is experiencing a urinary tract infection. 49. A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect? A. High fever Rationale: A low grade fever is a manifestation of sickle cell crisis. B. ?Bradycardia Rationale: ?Tachycardia is more common with sickle cell anemia than bradycardia. C. ?Pain Rationale: A client who is in sickle cell crisis has severe pain resulting from tissue hypoxia and necrosis. D. ?Constipation Rationale: Sickle cell crisis generally affects the lungs and the liver, rather than the gastrointestinal tract. 50. 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. Candidiasis Rationale: Manifestations of oral candidiasis include white patches that adhere to the inner cheeks, tongue, and palate that are painful and can cause the child to refuse to eat. B. Dermatitis Rationale: Manifestations of dermatitis include a red, itchy rash of the skin. Created on:04/09/2023 Page 21 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric C. Herpes simplex Rationale: Manifestations of herpes simplex include a cluster of blisters, usually around the nose or mouth. D. Squamous cell carcinoma Rationale: Manifestations of squamous cell carcinoma include a firm, nodular lesion with a crust located in a sun-exposed areas of the skin. 51. A nurse is reviewing data for four children. Which of the following children should the nurse assess first? A. A 10-year-old child who has sickle cell anemia who reports severe chest pain Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the 10-year-old child who has sickle cell anemia and reports severe chest pain should be assessed first. This finding is a medical emergency because it is a manifestation of acute chest syndrome. B. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016 Rationale: A specific gravity of 1.016 is nonurgent because it is within the expected reference range for a 7 year-old child. There is another child the nurse should assess first. C. A 1-year-old toddler who has roseola and a temperature of 39° C (102.2° F) Rationale: A temperature of 39° C (102.2° F) is nonurgent because it is an expected finding of roseola. There is another child the nurse should assess first. D. A 4-year-old child who has asthma and a PCO2 of 37 mm Hg Rationale: A PCO2 of 37 mm Hg is a nonurgent finding because it is within the expected reference range for a 4 year-old child. There is another child the nurse should assess first. 52. A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect? A. Red currant jelly stools Rationale: Red currant jelly stools is a clinical manifestation of intussusception. B. Distended neck veins Rationale: Distended neck veins is a clinical manifestation of fluid overload. C. Projectile vomiting Rationale: Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine. The narrowing does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting. Created on:04/09/2023 Page 22 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric D. Ridged abdomen Rationale: A ridged abdomen is a clinical manifestation of appendicitis. 53. A nurse is assessing a toddler who has acute nephrotic syndrome. Which of the following findings should the nurse report to the provider? A. ?Yellow nasal discharge Rationale: Yellow or green nasal discharge is an indication of an upper respiratory infection. Children who have nephrotic syndrome are at constant risk for infection. The nurse should report this manifestation to the provider so the child can receive appropriate and prompt treatment. B. ?Facial edema Rationale: ?Facial edema is an expected manifestation of nephrotic syndrome. C. ?Poor appetite Rationale: ?Poor appetite is an expected manifestation of nephrotic syndrome. D. ?Irritability Rationale: ?Irritability is an expected manifestation of nephrotic syndrome. 54. Complete the following sentence by using the list of options. Answers cannot be displayed for this alternate item format. Rationale: Dropdown 1Scarlet fever is incorrect. The nurse should recognize that scarlet fever is a type of group A streptococcal infection, which involves a sore throat and a red, rough-feeling rash.Acute streptococcal infection is incorrect. The nurse should recognize that acute streptococcal pharyngitis is a group A β-hemolytic streptococci that involves pain, redness, inflammation of the throat.Respiratory syncytial virus is correct. The nurse should recognize that respiratory syncytial virus is a viral infection of the respiratory system. As the illness progresses, the client may develop infections of the lower airway, such as bronchiolitis and pneumonia.Dropdown 2Retractions are correct. The nurse should recognize that clients who have respiratory syncytial virus can develop retractions when the lower airway becomes affected and the effort to breathe becomes difficult.Bradypnea is incorrect. The nurse should recognize that clients who have respiratory syncytial virus develop tachypnea, an increased rate of breathing, as the illness progresses. Bradypnea, a decreased rate of breathing is not a finding associated with RSV.Hyperactivity is incorrect. The nurse should recognize that clients who have respiratory syncytial virus will experience lethargy and listlessness. Hyperactivity is not a finding associated with RSV. 55. A nurse is preparing to collaborate with interdisciplinary team about the child’s care. After reviewing the child's information, which of the following potential provider's prescriptions should the nurse identify as anticipated, nonessential, or contraindicated? For each potential provider's prescription, click to specify if the potential Created on:04/09/2023 Page 23 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric prescription is anticipated, nonessential, or contraindicated for the child. Answers cannot be displayed for this alternate item format. Rationale: Oral steroids is anticipated.Steroids are indicated in the treatment of ALL.Cranial radiation is contraindicated.Cranial radiation is only indicated for those patients with high risk ALL.Fluid restriction is contraindicated. Children with ALL require aggressive IV hydration to prevent tumor lysis syndrome.Viscous lidocaine oral rinse is contraindicated. Viscous Lidocaine may increase the risk of aspiration in children.Varicella vaccine is contraindicated. Children with any cancer diagnosis should not receive any live vaccines during treatment.Ondansetron is anticipated. Ondansetron is commonly administered to assist in the prevention of chemotherapy-induced nausea and vomiting during cancer treatments. 56. A nurse is providing care to a child who has an allergy to eggs. The nurse should question a prescription for which of the following immunizations? A. Influenza, live attenuated (LAIV) Rationale: An egg allergy is a contraindication for receiving the LAIV vaccine. Severe anaphylactic reactions can occur and pose life-threatening conditions for the child. B. Inactivated poliovirus (IPV) Rationale: An egg allergy is not a contraindication for receiving the IPV vaccine. A severe allergic reaction to a previous dose or to a component of the vaccine is a contraindication for receiving the IPV vaccine. The nurse can delay administering the vaccine if the child has a moderate or severe acute illness with or without a fever. C. Haemophilus influenza type b (Hib) Rationale: An egg allergy is not a contraindication for receiving the Hib vaccine. A severe allergic reaction to a previous dose or to a component of the vaccine is a contraindication for receiving the Hib vaccine. The nurse can delay administering the vaccine if the child has a moderate or severe acute illness with or without a fever. D. Hepatitis B (HepB) Rationale: The HepB vaccine is contraindicated in individuals who have an allergy to baker's yeast. 57. Which of the following assessment findings should the nurse report to the provider?Select the 4 findings that the nurse should report to the provider. Answers cannot be displayed for this alternate item format. Rationale: Sputum is incorrect. The child's sputum was thick and yellow with streaks of blood on admission and now has no blood streaks. This is an improvement; therefore, this finding does not need to be reported to the provider.Respiratory effort is correct. The child’s respiratory rate is above the expected reference range, along with the presence of accessory muscle use. The child also reports worsening of the dyspnea. This finding should be reported to the provider.Temperature is incorrect. There has been a decrease in the child's temperature from admission; therefore, this finding does not need to be reported to the provider.Oral intake is incorrect. The child’s appetite Created on:04/09/2023 Page 24 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric has improved and intake has increased; therefore, this finding does not need to be reported to the provider.Gastrointestinal status is incorrect. Large, frothy, foul-smelling stools are consistent with steatorrhea, which is an expected finding for a child who has cystic fibrosis; therefore, this finding does not need to be reported to the provider.Oxygenation is correct. The child’s oxygen saturation is below the expected reference range. A decrease in oxygen saturation, along with increased shortness of breath, labored respirations, tachycardia, and hypotension, can indicate the occurrence of a pneumothorax. Therefore, this finding should be reported to the provider.Pain is correct. New onset of chest pain in a child who has cystic fibrosis and pneumonia can indicate the occurrence of a pneumothorax. Additional indicators of a possible pneumothorax include increased shortness of breath, decreased oxygen saturation, labored respirations, tachycardia, and hypotension. Therefore, this finding should be reported to the provider.Blood pressure is correct. The child’s blood pressure is below the expected reference range. Hypotension, along with respiratory distress, decreased oxygenation, and chest pain in a child who has pneumonia and cystic fibrosis, is indicative of a possible pneumothorax. Therefore, this finding should be reported to the provider. 58. 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. ?Oral electrolyte solution Rationale: After gastrointestinal surgery, infants should receive clear liquids that contain glucose and electrolytes, such as an oral electrolyte or rehydration solution. They should then advance to formula or breast milk as they demonstrate tolerance. B. ?Half-strength infant formula Rationale: ?Half-strength formula is not a clear liquid. C. Half-strength orange juice Rationale: ?Half-strength orange juice is not a clear liquid. D. ?Sterile water Rationale: Sterile water does not contain nutrients and is not appropriate to include in a clear liquid diet for an infant who is postoperative. 59. A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care? A. Keep the infant NPO for 6 hr prior the procedure. Rationale: Fasting is not required prior to a lumbar puncture. B. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure. Rationale: The nurse should apply a eutectic mixture of lidocaine and prilocaine cream topically 60 min prior to the procedure. C. Place the infant in an infant seat for 2 hr following the procedure. Rationale: Created on:04/09/2023 Page 25 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric The nurse should position the infant flat following the procedure to prevent postural drainage. D. Hold the infant's chin to his chest and knees to his abdomen during the procedure. Rationale: During the procedure, the infant is positioned on her side in a fetal position (knees curled to abdomen and chin tucked to chest) to open up the subarachnoid space. 60. A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development? A. Tie colorful latex balloons to the side of the crib. Rationale: Toys that are tied to the side or strung across the crib are a safety hazard that could cause the infant to suffocate. The nurse should keep latex balloons out of the infant's reach. B. Provide a small electronic toy. Rationale: Small electronic toys are a safety hazard. Electronic toys often have small batteries that can be ingested. Electronic toys can also have heating elements and sharp edges that can cause injury to the skin. C. Change the infant's diaper as soon as soiling occurs. Rationale: Maintaining hygiene is important because it promotes health, but it does not promote growth and development. The nurse should keep the diaper area and cast clean without using lotions or powders. These actions help maintain integrity of the skin. D. Allow the infant to stand in the crib. Rationale: Allowing the child to participate in normal developmental activities promotes growth and development. The infant can be held and allowed to walk in a cast or orthotic device. 61. A nurse is reviewing the laboratory results of an adolescent who has chronic glomerulonephritis. Which of the following findings should the nurse expect? A. BUN 50 mg/dL Rationale: The nurse should expect the adolescent to have a BUN above the expected reference range due to kidney injury and the inability to filter and excrete urea nitrogen from the blood. B. Serum potassium 3.8 mEq/L Rationale: A serum potassium of 3.8 mEq/L is within the expected reference range. The nurse should expect the adolescent to have an increased potassium level due to the kidney injury and the inability to filter and excrete potassium from the blood. C. Absence of proteinuria Rationale: The nurse should expect an adolescent who has chronic glomerulonephritis to have proteinuria due to injured glomerular membranes allowing protein molecules to pass into the urine for excretion. Created on:04/09/2023 Page 26 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric D. Serum phosphorus 4.0 mg/dL Rationale: A serum phosphorus of 4.0 mg/dL is within the expected reference range. The nurse should expect the adolescent to have an increased phosphorus level due to the kidney injury and the inability to filter and excrete phosphorus from the blood. 62. A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client? A. Trendelenburg Rationale: Positioning the child in Trendelenburg could result in inadequate functioning of the VP shunt due to the child's head being lower than the rest of his body. B. Semi-Fowler's Rationale: Positioning the child in semi-Fowler's could result in a rapid reduction of intracranial fluid. C. Prone Rationale: Positioning the child prone could result in inadequate functioning of the VP shunt due to the need to position the child's head to the side. D. On the unoperated side Rationale: The nurse should position the child flat on the unoperated side to prevent a rapid reduction of intracranial fluid and to protect the child for injuring the operative site. 63. A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this condition? A. Firmly attached white particles on the hair Rationale: Pediculus capitis, or head lice, are tiny parasitic insects that live on the scalp and can be spread by close contact with other people. Their eggs (nits) appear much like flakes of dandruff but stick firmly to the hair shaft instead of flaking off of the scalp. B. Itching and scratching of the head Rationale: There are many causes of scalp itching, so this is not a definitive indication of pediculosis capitis. C. Patchy areas of hair loss Rationale: Alopecia, or patchy areas of hair loss, is a typical finding in ringworm, a superficial infection of the scalp by a fungus. D. Thick yellow crusted lesion on a red base Rationale: Thick golden yellow crusted lesions on a red base are a typical finding in impetigo contagiosa, a superficial infection of the skin that often involves the face or scalp. Created on:04/09/2023 Page 27 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric 64. A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.) A. Assess the client’s airway patency. B. Place a tongue depressor in the client’s mouth. C. Remove objects from the client's bed. D. Place the client in a side-lying position. E. Restrain the client. Rationale: Assess the client's airway patency is correct. The nurse should continually assess the client's airway during a seizure.Place a tongue depressor in the client's mouth is incorrect. Placing something in the client's mouth can cause injury.Remove objects from the client's bed is correct. The nurse should remove objects that can cause injury to the client during a seizure.Place the client in a side-lying position is correct. The client should be positioned side-lying to prevent aspiration of secretions or vomit.Restrain the client is incorrect. Restraining the client can cause injury. 65. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Answers cannot be displayed for this alternate item format. Rationale: The nurse should place the child in a quiet, softly lit room, and prepare the child for an MRI. The child is most likely experiencing a CNS tumor because of the history of irritability, emesis upon waking, positive Romberg and finger/nose test, and unsteady gait. The nurse should monitor the child's neurologic status and paint rating because they will determine any worsening intracranial pressure or growth of the tumor. 66. 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." Rationale: The child should drink plenty of fluids, but this will not prevent transmission of the infection. B. "We'll take his temperature every 4 hours." Rationale: Monitoring the child's temperature will not prevent transmission of the infection. C. "We'll give him Tylenol for the pain." Rationale: The parents can give the child acetaminophen for pain and fever, but this will not prevent transmission of the infection. Created on:04/09/2023 Page 28 Downloaded by: tilbury_sonar0n | [email protected] Want to earn $1.236 Distribution of this document is illegal extra per year?  Stuvia.com - The Marketplace to Buy and Sell your Study Material Detailed Answer Key Pediatric D. "We'll discard his toothbrush and buy another." Rationale: Children who have positive throat cultures for streptococcal infection should replace their toothbrush after they have been taking antibiotics for 24 hr. Using a contaminated toothbrush can re-introduce the bacteria and spread it to others if others handle the toothbrush. 67. A home health nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching? A. Apply suction when inserting the catheter. Rationale: The nurse should instruct the parents to apply suction when withdrawing the catheter and not when inserting it. B. Apply suction for less than 10 seconds. Rationale: Prolonged suctioning can cause damage to tissues and induce hypoxia. Hypoxia can interfere with stages of respiration, cellular absorption, and blood transport. C. Set the suction pressure to 110 mm Hg. Rationale: The nurse should instruct the parents to set the suction pressure between 60 and 100 mm Hg. D. Allow the child to rest for 10 to 15 seconds after each suctioning attempt. Rationale: The nurse should instruct the parents to give the child 30 to 60 seconds to rest after each suctioning attempt to allow oxygen saturation to return to baseline. 68. A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care? A. Keep the head of the bed at a 30° angle. Rationale: The nurse should plan to maintain the client in a supine position to prevent bending of the spine. B. Reposition the client by log rolling every 4 hr. Rationale: The nurse should plan to log roll the client every 2 hr to promote respiratory status. C. Place the client in protective isolation. Rationale: The nurse sh