Peds Pot of Gold (w answers) PDF

lOMoARcPSD|15235676 Peds Pot of Gold (w answers) Primary Care of Children I: Health Promotion (Rutgers University) Studocu is not sponsored or endorsed by any college or university Downloaded by Gabriela Gamonski (...

lOMoARcPSD|15235676 Peds Pot of Gold (w answers) Primary Care of Children I: Health Promotion (Rutgers University) Studocu is not sponsored or endorsed by any college or university Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February 1. A nurse is collecting data from a 6-year-old child at a well-child visit. Which of the following statements by the child's parent should the nurse report to the provider? A. "The teacher says my child has to squint to see the board." Rationale: Squinting is a manifestation of strabismus, which must be diagnosed early in order to prevent vision loss. B. "My child has recently lost both front top teeth." Rationale: Children of this age begin to lose their deciduous teeth to accommodate the emergence of their permanent teeth. C. "My child often cheats when we play board games." Rationale: Children of this age often cheat to win at games because they find it difficult to lose. This behavior should disappear as the child matures. D. "Sometimes my child has temper tantrums." Rationale: Children of this age do have occasional temper tantrums. The nurse should provide the parent with guidance on how to react to the tantrum and ensure the child is not causing self-harm. 2. A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take? A. Perform a neurovascular check of the lower extremities. Rationale: The client is at risk for compartment syndrome following the application of a cast because the extremity can continue to swell inside the cast resulting in obstruction to circulation. Therefore, the nurse should perform a neurovascular check following cast application to check circulation, motion, and sensation of the lower extremities. B. Keep the client's leg in a dependent position. Rationale: The nurse should keep the client's leg elevated to promote venous return and minimize swelling. C. Discourage the client from ambulating. Rationale: After the cast dries, the nurse should assist the client to ambulate using crutches to promote general circulation and prevent complications of immobility. D. Use a hair dryer on a hot setting to dry the cast. Rationale: The nurse should not expose the cast to heat, such as from a dryer or a fan, because heat conduction can result in skin burns under the cast. 3. A nurse is caring for a 4-year-old child who refuses to take his medication because of the bad taste. Which of the following strategies should the nurse use to elicit the child's cooperation? Created on:02/16/2022 Page 1 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February A. Offer the child an ice pop prior to administering the medication. Rationale: Giving the child an ice pop prior to administering the medication will help numb the tongue. This technique also helps to alleviate the bad taste, making it easier for the child to take the medication orally. B. Tell the child the medicine tastes like candy. Rationale: This is not an appropriate action for the nurse to take. Telling the child that medicine tastes like candy can create the misconception that medicine is candy, which increases the risk of accidental poisoning. C. Hide the medication in apple slices. Rationale: This is not an appropriate action for the nurse to take. The child will likely taste the hidden medication and might not trust the nurse in the future. The experience could also cause the child to refuse apples in the future, an essential food item. D. Inform the child that if he does not take the medication he will need a shot. Rationale: This is not an appropriate action for the nurse to take. Threatening a child with painful medication alternatives decreases the trust the child has with the nurse. 4. A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings? A. Tugging on the affected ear lobe Rationale: Otitis media is a middle ear infection that causes fever and pain and can be indicated by the infant tugging at the affected ear. B. Bluish-green discharge from the ear canal Rationale: Drainage is not an expected finding of otitis media, unless the tympanic membrane ruptures. If so, the drainage associated with otitis media is typically purulent. A bluish-green or gray discharge occurs with otitis externa. C. Increase in appetite Rationale: An infant who has otitis media will have a loss of appetite due to pain that occurs in the ear from moving the jaw. D. Erythema and edema of the affected auricle Rationale: Erythema and edema of the affected ear are associated with trauma to the external ear or otitis externa. 5. A nurse is reinforcing teaching with a parent of a 1-month-old-infant who is to undergo the initial surgery to treat Hirschsprung's disease. Which of the following statements should indicate to the nurse that the parent understands the goal of the surgery? Created on:02/16/2022 Page 2 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February A. "I'm glad that the ostomy is only temporary." Rationale: A child who has Hirschsprung's disease is missing ganglion cells in a portion of the intestine. The disease usually requires two surgical procedures. The first results in the creation of an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest. B. "I'm glad my child will have normal bowel movements now." Rationale: The child will usually have the second surgery at 12 to 18 months of age. The child will not have normal bowel function until after the bowel repair that occurs during the second surgery. C. "I want to learn how to use the feeding tube as soon as possible." Rationale: A child who has Hirschsprung's disease does not typically require a feeding tube postoperatively. D. "The operation will straighten out the kink in the intestine." Rationale: The surgery will remove the portion of the bowel that is not functioning correctly. 6. A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect? A. Diarrhea Rationale: The nurse should expect a client who has an elevated calcium level to have constipation. B. Muscle hypotonicity Rationale: The nurse should expect a client who has an elevated calcium level to have muscle hypotonicity. C. Tachycardia Rationale: The nurse should expect a client who has an elevated calcium level to have bradycardia, which can lead to cardiac arrest. D. Positive Chvostek's sign Rationale: The nurse should expect a client who has a decreased calcium level to have a positive Chvostek sign and tetany. 7. A nurse is planning care for a 4-year-old child who has been admitted to the hospital. Which of the following toys should the nurse plan to provide the child? A. Modeling clay Rationale: Preschool-age children enjoy molding clay with their fingers. This activity provides an opportunity for creativity and entertainment, as well as a chance for fine motor development. B. Brightly-colored mobile Rationale: Created on:02/16/2022 Page 3 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February A brightly-colored mobile is appropriate for a very young infant. It does not meet the activity needs of a pre-school age child. C. 100-piece jigsaw puzzle Rationale: A 100-piece jigsaw puzzle is too difficult for a pre-school age child and will lead to frustration, rather than providing entertainment for the child D. Checkerboard and checkers Rationale: A checkerboard and checkers are appropriate for a school-age child. 8. A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Apply an antibiotic ointment to the suture site. Rationale: The nurse should apply an antibiotic ointment to the suture site to help prevent a postoperative infection. B. Clear oral secretions using a bulb syringe. Rationale: Suctioning in the infant's mouth can cause suture damage. C. Feed the infant using a spoon. Rationale: The nurse should feed the infant with a syringe or bottle or allow the infant to breastfeed. Placing objects, such as a spoon, in the infant's mouth can cause suture damage. D. Position the infant on her abdomen. Rationale: Positioning the infant on her abdomen can cause suture damage. 9. A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will make sure my child washes her hands before eating." Rationale: Clients who have cystic fibrosis are at high risk for infection and should use good hand washing techniques before eating. B. "I will restrict the amount of salt in my child's meals." Rationale: Cystic fibrosis does not cause a child's sodium requirements to decrease. Adequate sodium intake is required for electrolyte balance. C. "I will put my child in daycare to ensure that she socializes with other children." Rationale: Clients who have cystic fibrosis are at high risk for infection. The parent should avoid daycare settings because of the high risks that the exposure to illnesses has. Created on:02/16/2022 Page 4 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February D. "I will provide low-fat meals for my child." Rationale: A diet that is high in calories and protein, and unrestricted in fats and salt, is recommended to meet the nutritional needs of children who have cystic fibrosis. 10. A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching? A. "I need to catheterize myself twice a day." Rationale: In most cases, paralysis from waist down affects bladder and bowel control. Catheterization should be performed every 4 to 6 hr, and as needed. Infrequent emptying of the bladder can result in urinary tract infections. B. "I carry a water bottle with me because I drink a lot of water." Rationale: A client who is paralyzed from the waist down is at increased risk for urinary tract infections. Therefore, drinking plenty of water is appropriate. C. "I use a suppository every night to have a bowel movement." Rationale: Using a suppository to stimulate a bowel movement every 1 to 2 days is appropriate. D. "I do my wheelchair exercises sitting in my chair." Rationale: Wheelchair exercises are appropriate to prevent skin breakdown and increase upper body strength. 11. A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate? A. "Bring your infant into the clinic today to be seen." Rationale: The nurse should recognize that projectile vomiting, followed by the child acting hungry afterwards, are indicative of pyloric stenosis. The infant needs to be examined in the clinic as soon as possible by the provider. B. "Burp your child more frequently during feedings." Rationale: The nurse should recognize that projectile vomiting followed by hunger is a clinical manifestation of pyloric stenosis. C. "Give your infant an oral rehydrating solution." Rationale: The nurse should recognize that projectile vomiting followed by hunger is a clinical manifestation of pyloric stenosis. D. "You might want to try switching to different formula." Rationale: Created on:02/16/2022 Page 5 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February The nurse should recognize that projectile vomiting followed by hunger is a clinical manifestation of pyloric stenosis. 12. A parent asks a nurse about toys to provide for a 10-month-old infant. Which of the following toys should the nurse suggest? A. Push-pull toy Rationale: A push-pull toy will assist the 10 month-old infant to develop muscles and gross motor skills needed to walk unaided. B. Crib gym Rationale: Although a crib gym encourages the development of fine motor skills, this toy is not appropriate for a 10-month-old infant. It presents safety issues, such as the infant using the gym to pull up to standing and falling or strangling on the pieces of the gym when no one is watching. C. Large-piece puzzles Rationale: A 10-month old does not have the fine motor skills needed to manipulate puzzle pieces. D. Coloring book with crayons Rationale: A 10-month old does not have the fine motor skills needed to manipulate crayons in order to color a picture. 13. A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client? A. Orange ice pop Rationale: Clear, cold fluid helps decrease swelling and pain in the operative area. B. Hot tea Rationale: After a tonsillectomy, the client will not be comfortable drinking hot fluids. C. Ice cream Rationale: Dairy products increase the viscosity of mucus, which can stimulate throat clearing and thus precipitate bleeding. D. Cranberry juice Rationale: Cranberry juice is acidic and can irritate the incision and increase pain. In addition, cranberry juice is red; red fluids make it difficult to determine if vomitus is red due to the fluid or is blood from a hemorrhage. Created on:02/16/2022 Page 6 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February 14. The mother of a 4-year-old child tells a nurse that her child is reluctant to go to bed at night. Which of the following responses should the nurse make? A. "Allow your child an additional 30 minutes of play time before bed." Rationale: The mother should have the child to participate in soothing activities prior to bed and not allow the child to stay up past a reasonable hour. Playtime just before bed can make it more challenging for the child to go to sleep and staying up too late can result in inadequate sleep. B. "Let your child sleep in your bed with you." Rationale: The mother should not allow the child to sleep in her bed because this action can lead to a habit for the child and result in inadequate sleep for the mother. C. "Keep a night light on in your child's room." Rationale: The mother should leave a night light on in the child's room so the child can see the room if he becomes afraid. Other measures the mother can try include allowing the child to sleep with a favorite toy, following the same ritual each night at bedtime, and leaving a drink of water by the child's bed. D. "Stay with your child until he is asleep if he begins to cry." Rationale: The mother should offer the child reassurance if he begins to cry at bedtime but should not remain with the child until he is asleep. The mother should ignore attention-seeking behaviors. 15. A nurse is collecting data from a child who has ß-thalassemia. Which of the following findings should the nurse expect? A. Hyperactivity Rationale: Listlessness and decreased exercise tolerance are manifestations of ß-thalassemia. B. Increased appetite Rationale: Anorexia is a manifestation of ß-thalassemia. C. Fever Rationale: An unexplained fever is a manifestation of ß-thalassemia. D. Flushed skin Rationale: Pallor is a manifestation of ß-thalassemia. 16. A parent expresses concern to a nurse about his 5-year-old child's stuttering. Which of the following statements should the nurse make? A. "Look directly at your son when he is speaking." Rationale: Taking time to listen attentively to a child who stutters is an appropriate recommendation. Created on:02/16/2022 Page 7 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February B. "Try encouraging your son to speak more slowly." Rationale: A child who stutters will stutter at any pace. Slowing down does not resolve the child's disfluent speech pattern. C. "Promise a reward to your son when he does not stutter." Rationale: A child is unable to control stuttering; therefore, a promise of a reward is not an appropriate action for the parent to take. D. "Complete your son's sentences when he begins to stutter." Rationale: Parents should avoid completing the child's sentences because it can appear as impatience and lead to further stress for the child. 17. A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching? A. Drink eight glasses of fluid daily. Rationale: Hydration decreases the viscosity of the blood. A decreased viscosity helps lower the risk for sickling as a result of venous stasis. B. Avoid playground activities at school. Rationale: Although strenuous activity should be avoided, mild activity is encouraged to maintain muscle tone and build activity tolerance. C. Maintain an updated haemophilus influenza type B immunization. Rationale: An immunization for haemophilus influenza type B is given to infants. This immunization is not given after 6 years of age. D. Assume postural drainage positions every 6 hr. Rationale: Postural drainage does not benefit the child who has sickle cell anemia. 18. A nurse is reinforcing teaching with the mother of a 14-month-old child about safe food choices. Which of the following food choices should the nurse recommend? A. Mashed potatoes Rationale: Mashed potatoes is a safe food choice for the nurse to recommend because it is soft and has a low risk of choking. B. Raw carrots Rationale: Raw carrots can cause choking in children younger than 4 years of age. C. Popcorn Rationale: Created on:02/16/2022 Page 8 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February Popcorn can cause choking in children younger than 4 years of age. D. Watermelon with seeds Rationale: Watermelon with seeds can cause choking children younger than 4 years of age. 19. A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority? A. Lethargy Rationale: Lethargy is the priority finding because can indicate a decreased level of consciousness or increasing intracranial pressure. B. Lying flat on the unaffected side Rationale: The child should lie flat on the unaffected side to avoid pressure on the shunt valve. C. Respiratory rate 20/min Rationale: A respiratory rate of 20/min is within the expected reference range for a 4-year-old child. D. Urine output 50 mL in 2 hr Rationale: A urine output of 50 mL in 2 hr indicates adequate renal function for a 4-year-old child. 20. A nurse is caring for a 4-year-old child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make? A. "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better." Rationale: A recently learned skill, such as toilet training, is often temporarily lost due to the stress of hospitalization. It is appropriate to reassure the parents that regression is an expected behavior in children who are hospitalized, and that they regain bladder control when their health improves. B. "I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me." Rationale: This is not therapeutic communication since it offers no information about the cause or treatment of bedwetting. The nurse is using a sympathetic response that discourages the parents' thoughts and feelings. C. "Why is she wetting the bed in the hospital? She must wet the bed at home." Rationale: This is not an appropriate response by the nurse because asking a why question places the parents in a defensive position. This response also does not address the parents' concern. D. "I will discuss your child's loss of bladder control with the provider." Rationale: This is not an appropriate response. Hematuria, abdominal pain, or pain during urination, warrant a follow-up. Bedwetting episodes are not unusual for a child under 4 years of age, Created on:02/16/2022 Page 9 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February especially in a stressful situation. 21. A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents? A. "You should expect your child to be upset when you leave." Rationale: Children between 4 and 8 months of age can have separation anxiety and become upset when the parents leave. B. "Your child is responding to an overstimulating environment." Rationale: The child is not responding to an overstimulating environment. The child's response is caused by separation anxiety. C. "Your child needs to rest." Rationale: This statement is does not provide reassurance or offer an explanation. D. "I will notify the provider of his behavior." Rationale: The child's behavior is an expected reaction and does not warrant a notification of the provider. 22. A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first? A. Remove the window and view the incision. Rationale: The incision should be viewed regularly for signs of infection; however, this is not the first action the nurse should take. B. Turn the client so the cast will dry on all sides. Rationale: The client should be turned regularly to ensure that all sides of the cast are allowed to dry; however, this is not the first action the nurse should take. C. Medicate the client for pain. Rationale: Medicating the client for pain is an important nursing action; however, this is not the first action the nurse should take. D. Perform neurovascular checks of the affected extremity. Rationale: The greatest risk to this client is injury from impaired circulation due to constriction. Therefore, the first action the nurse should take is to perform neurovascular checks. 23. A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the Created on:02/16/2022 Page 10 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February nurse monitor to detect airway obstruction? A. Decreased stridor Rationale: The nurse should monitor for increased stridor to detect an impending airway obstruction. B. Decreased restlessness Rationale: The nurse should monitor for increased restlessness to detect an impending airway obstruction. C. Increased heart rate Rationale: The nurse should monitor for an increased heart rate as an early manifestation of an impending airway obstruction. D. Decreased temperature Rationale: A child who has laryngotracheobronchitis can have a low-grade fever, but this is not an expected manifestation of an impending airway obstruction. 24. A nurse in a clinic is preparing to administer pre-kindergarten vaccines to a 5-year-old child whose medical record indicates that his immunizations are up to date. Which of the following vaccines should the nurse plan to administer? A. Measles, mumps, and rubella (MMR) Rationale: The MMR vaccine is given by an injection in two doses. The first dose is administered at 12 to 15 months of age; the second is typically given prior to school entry at 4 to 6 years of age. B. Haemophilus influenzae type B (Hib) Rationale: The Hib vaccine is given at 2 months, 4 months, and 6 months of age. C. Pneumococcal conjugate vaccine (PCV) Rationale: The PCV vaccine is given at 2 months, 4 months, 6 months, and 12 to 18 months of age. D. Hepatitis B (HBV) Rationale: The HBV vaccine is given at birth, 2 months, and 6 to 18 months of age. 25. A nurse in an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler? A. Activated charcoal Rationale: The nurse should assist with administering activated charcoal to a toddler who has ingested aspirin because it will decontaminate the toddler's gastrointestinal tract. B. Acetylcysteine Rationale: Created on:02/16/2022 Page 11 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February The nurse should assist with administering acetylcysteine to a child who has life-threatening acetaminophen overdose. C. A chelating agent Rationale: The nurse should assist with administering a chelating agent to a child who has a life-threatening iron level. D. Digoxin immune FAB Rationale: The nurse should assist with administering digoxin immune FAB to a child who has a life-threatening digoxin level. 26. A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect? A. Metabolic acidosis Rationale: A client who has pyloric stenosis exhibits metabolic alkalosis. B. Effortless regurgitation Rationale: Effortless regurgitation is a manifestation of GERD, which is due to incompetence of the lower esophageal (cardiac) sphincter. C. Distended abdomen Rationale: A client who has pyloric stenosis experiences muscle wasting and weight loss, rather than a distended abdomen. D. Projectile vomiting Rationale: Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine, which does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting. 27. The father of a toddler asks a nurse at a well-child clinic what to do when his child kicks and screams during temper tantrums. Which of the following responses should the nurse make? A. "Tell your toddler that temper tantrums are not acceptable." Rationale: Telling the child that temper tantrums are not acceptable is not a developmentally appropriate response to the child's behavior. B. "You should punish your toddler when the tantrum stops." Rationale: The parent should act as if the temper tantrum didn't occur and offer comfort to the child after the temper tantrum ends. C. "You should ignore your toddler's temper tantrums." Rationale: Created on:02/16/2022 Page 12 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February The parent should ignore the toddler's attention-seeking behavior, so the child realizes that expressing himself in this method is not effective way to communicate. D. "You should offer your child a reward if he stops the tantrum." Rationale: The parent should not provide positive reinforcement for this type of behavior. Positive reinforcement encourages the toddler to continue engaging in temper tantrums. 28. A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take? A. Ask another nurse to assist with holding the toddler in a prone position. Rationale: One nurse should be able to maintain the toddler in a side-lying position during the procedure. B. Restrain the toddler for 1 hr after the procedure. Rationale: There is no need to restrain the toddler for 1 hr following the procedure. C. Place the toddler in a side-lying, knee-chest position. Rationale: A lumbar puncture is a procedure in which a small amount of the fluid that surrounds the brain and spinal cord called the cerebrospinal fluid is removed and examined. The nurse should position the toddler on his side in a fetal position with his knees curled to his abdomen and his chin tucked to his chest. D. Swaddle the toddler in a warm blanket. Rationale: Swaddling the toddler in a warm blanket would cover the lumbar area where the provider is going to be performing the procedure. 29. A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first? A. Explain to the child's parents what role they will have during the procedure. Rationale: The nurse should explain to the parents what role they will have during the procedure to ensure they comfort the child and do not interfere with the procedure, but there is another action the nurse should take first. B. Allow the child to see and touch IV tubing and supplies. Rationale: The nurse should allow the child to see and touch IV tubing and supplies in order to reduce the child's anxiety, but there is another action the nurse should take first. C. Describe the procedure using visual aids. Rationale: The nurse should describe the procedure using visual aids in order to reduce the child's anxiety, but there is another action the nurse should take first. D. Ask the child what he knows about the procedure. Rationale: Created on:02/16/2022 Page 13 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February The first action the nurse should take when using the nursing process is to collect data. By determining what the child already knows the nurse can determine how to better direct the remaining preparations. 30. A nurse is planning to speak to a group of adolescents about toxic shock syndrome (TSS). The nurse include that TSS is commonly associated with which of the following? A. High-absorbency tampons Rationale: TSS is a severe disease caused by a toxin made by Staphylococcus aureus and can lead to shock and multiple organ dysfunction. It most often affects menstruating women who use highly absorbent tampons. B. Mosquito bites Rationale: Mosquito bites contribute to vector-borne diseases, such as West Nile virus, but are not associated with TSS. C. International travel Rationale: International travel can lead to diseases endemic to the area of travel, such as malaria, but is not associated with TSS. D. Multiple sexual partners Rationale: Multiple sexual partners increase the risk of contracting sexually transmitted infections but are not associated with TSS. 31. A nurse is checking a school-age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition? A. Itching and scratching of the head Rationale: There are many causes of scalp itching, so this is not a definitive manifestation of pediculosis. B. Firmly attached white particles on the hair Rationale: Pediculus capitis, or head lice, are tiny parasitic insects that live on the scalp and are spread by close contact with other people. Their eggs (nits) appear much like flakes of dandruff, but stick firmly to hair shafts instead of flaking off the scalp. C. Patchy areas of hair loss Rationale: Patchy areas of hair loss are a manifestation of ringworm, which is a superficial infection that can occur on the scalp. D. Thick, yellow-crusted lesions on a red base Rationale: Thick, golden-yellow, crusted lesions on a red base is a manifestation of impetigo, which is a superficial infection of the skin that can occur on the face or scalp. Created on:02/16/2022 Page 14 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February 32. A nurse is caring for a 3-year-old client who has persistent otitis media. To help identify contributing factors, the nurse should ask the parents which of the following questions? A. "Has your daughter been drinking 6 glasses of water a day?" Rationale: Hydration status is not a risk factor for otitis media. Causes of otitis media are viral or bacterial in nature. B. "Does anyone smoke in the same house as your daughter?" Rationale: Allergies to common irritants such as smoke can cause congestion and chronic otitis media. C. "Does your daughter get water in her ears when you bathe her?" Rationale: Water in the ears can cause otitis externa (swimmer's ear), but it is not a contributing factor to otitis media. D. "Has your daughter had a lot of earwax in her ears over the last month?" Rationale: Earwax helps protect the ear from the invasion of viruses. It is not a contributing factor to otitis media. 33. A nurse is collecting data from a 2-year-old toddler who has AIDS. The nurse should inspect inside the toddler's mouth for which of the following opportunistic infections? A. Candidiasis Rationale: Candidiasis, or oral thrush, is caused by the overgrowth of Candida albicans, an opportunistic fungus that typically infects the oral cavity of clients who have immature or compromised immune systems. Thrush is often the initial opportunistic infection noted in children who have AIDS. B. Gingivitis Rationale: Gingivitis is not an opportunistic infection commonly associated with AIDS. C. Canker sores Rationale: Canker sores are shallow ulcers that often associated with minor trauma and dietary deficiencies. D. Koplik spots Rationale: Koplik spots are oral lesions characteristic of measles (rubeola). 34. A nurse is caring for a child who has disseminated intravascular coagulation and is experiencing epistaxis. Which of the following actions should the nurse take? A. Insert cotton into both of the child's nostrils. Rationale: Created on:02/16/2022 Page 15 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February The nurse should insert cotton into both the child's nostrils and apply continuous pressure to reduce bleeding. B. Apply a warm cloth to the bridge of the child's nose. Rationale: The nurse should apply an ice pack to the bridge of the child's nose in order to decrease bleeding and improve clot formation. C. Ask the child to gently blow his nose. Rationale: The nurse should tell the child avoid blowing his nose, as this could delay clot formation and result in additional bleeding time. D. Place the child in a supine position. Rationale: The nurse should have the child sit up and tilt his head forward in order to reduce blood pressure in the nasal vessels and to prevent blood from entering the nasopharynx. 35. A nurse is caring for a 4-year-old child who is postoperative following abdominal surgery. Which of the following statements should the nurse make to encourage the child to take deep breaths? A. "You can't go to the playroom until you finish doing your deep breathing." Rationale: This is a punitive remark that the child could perceive as a threat or a challenge. B. "Let's play a game of blowing cotton balls across your table." Rationale: By engaging the child in a form of play, the nurse can distract him from the discomfort of deep breathing. Therefore, this is an appropriate statement for the nurse to make. C. "Do you want to take deep breaths for me now?" Rationale: Asking the child this type of question can lead the child to believe there is a choice and provides the child with an opportunity to refuse or delay the procedure. D. "This will not be painful, just a little uncomfortable." Rationale: This statement can damage trust between the nurse and the child because the deep breaths might cause pain. 36. A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority? A. Blood glucose 110 mg/dL Rationale: The expected reference range for a fasting blood glucose level is 70 to 110 mg/dL. B. Potassium 2.5 mEq/L Rationale: The expected reference range for a potassium level is 3.4 to 4.7 mEq/L. The nurse should identify this finding as the priority because hypokalemia can lead to cardiac dysrhythmias or Created on:02/16/2022 Page 16 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February cardiac arrest. C. Sodium 142 mEq/L Rationale: The expected reference range for a child's potassium level is 136 to 145 mEq/L. D. Urine specific gravity 1.025 Rationale: The expected reference range for urine specific gravity is between 1.015 and 1.025. 37. A nurse is attempting to obtain information from a child who is hearing impaired. Which of the following actions should the nurse take? A. Talk directly into the child's impaired ear. Rationale: Speaking directly into the client's ear prevents the client from seeing the nurse's mouth move. B. Stand above the child's eye level when speaking. Rationale: The nurse should be positioned at the child's eye level to enable the child to hear better and to allow the child to watch the nurse's mouth move. C. Speak loudly to the child. Rationale: The nurse should not speak loudly because it can distort sounds that the child needs to interpret. The nurse should speak at a normal volume. D. Speak slowly while facing the child. Rationale: The nurse should always face a client who is hearing impaired during conversation and speaking slowly makes it easier for the client to interpret the sounds. 38. A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take? A. Withhold opioids to avoid dependence. Rationale: An adolescent who is having a sickle cell crisis is likely to have severe pain that the nurse should manage with opioids. B. Initiate a 2 L/day fluid restriction. Rationale: The adolescent will likely require oral and IV fluids to maintain an adequate hydration status to prevent further sickling, vasoocclusion, hypoxia, and ischemia. C. Encourage exercise. Rationale: An adolescent who is having a sickle cell crisis should rest to minimize oxygen consumption. D. Assist with administering a blood transfusion. Rationale: Created on:02/16/2022 Page 17 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February An adolescent who is having a sickle cell crisis can receive a blood transfusion to treat anemia and to decrease the viscosity of the blood. 39. A nurse is caring for a child who is postoperative following the insertion of a ventriculoperitoneal shunt. The nurse should place the child in which of the following positions? A. On the nonoperative side Rationale: The nurse should place the child flat on the nonoperative side to prevent pressure on the shunt valve. B. A 45&deg head elevation Rationale: The child should lie flat to prevent rapid intracranial fluid reduction. C. Prone Rationale: Lying on the stomach can cause the child's head to hang over the edge of the bed and create a kink in the shunt at the neck. D. Supine Rationale: Lying flat on the back can result in pressure on the shunt valve. 40. A nurse is talking with a 13-year-old female client who is having her annual health-screening visit. Which of the following comments by the client should concern the nurse? A. "My parents treat me like a baby sometimes." Rationale: Adolescence can be a time of great struggle between independence and dependence for both the child and the parents. A comment expressing frustration about a lack of independence should not concern the nurse. B. "I start taking ibuprofen a few days before my period starts." Rationale: Adolescents can experience painful periods that can require NSAIDS. It is appropriate for the client to take ibuprofen a few days before menses to help alleviate the pain. C. "None of the kids at my school like me, and I don't like them either." Rationale: This statement should concern the nurse, as developing a peer group is critical to adolescent development and self-esteem. The nurse should explore this comment in greater depth. D. "There's a pimple on my face, and I worry that everyone will notice it." Rationale: It is expected for adolescents to compare themselves to their peers and to feel isolated if they find differences. Created on:02/16/2022 Page 18 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February 41. A nurse is caring for a 17-year-old client who has a terminal illness and refuses treatment. The client's mother wants to proceed with treatment. Which of the following actions should the nurse take? A. Notify the charge nurse of the situation. Rationale: The nurse should consult with the charge nurse before proceeding with any treatments. Although a parent or legal guardian can give the consent for a minor, the nurse should facilitate a discussion between the parent and the adolescent in an effort to resolve their difference in opinion regarding treatment. B. Start the prescribed treatment per the parent's request. Rationale: The legal requirement for informed consent from an adolescent varies from state to state; therefore, the nurse should encourage discussion between the parent and the adolescent and should not initiate treatment without following the chain of command to clarify legal concerns. C. Administer a prescribed sedative to calm the client. Rationale: Administering a sedative to the adolescent can alter judgment and make decision-making difficult. The nurse should not administer a sedative until the legal concerns are clarified because the adolescent should be coherent to discuss informed assent with the provider. D. Inform the adolescent that parental assent is required. Rationale: The nurse should ensure that older children and adolescents assent to a treatment or procedure, even if the parent or guardian must give informed consent. Assent means that an adolescent has been given the necessary information about a treatment and agrees to the proposed treatment. Parents do not assent to a procedure or treatment for the minor. 42. A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. The nurse should recognize that the infant's fatigue is caused by which of the following? A. Lack of adequate ventricle strength to pump blood to the body Rationale: An infant who has hypoplastic left heart syndrome will have a lack of strength to pump blood into the body because the left ventricle is not working appropriately. B. Increased circulation pressure to the lungs Rationale: An infant who has patent ductus arteriosus will have increased pulmonary circulation. C. Inadequate oxygenation for supporting energy metabolism Rationale: Fatigue is a direct result of the infant circulating poorly oxygenated blood, which is caused by right-to-left shunting of blood. D. Restricted blood flow leaving the heart Rationale: An infant who has Tetralogy of Fallot will have decreased pulmonary blood flow that causes fatigue. An infant who has aortic stenosis can have fatigue from restriction of blood flow leaving the heart. Created on:02/16/2022 Page 19 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February 43. A nurse is collecting data from a 10-year-old child during a well-child visit. Which of the following statements by the child indicates he is meeting the psychosocial development expectations of a school-age child? A. "I really want to do well in school." Rationale: Erikson's stage of psychosocial development for a 10-year-old client is industry vs. inferiority. Children at this age want to perform well in school to develop a sense of accomplishment. B. "I like to collect rocks." Rationale: A collection of rocks is an example of Piaget's cognitive development. Children at this age want to classify objects into groups. C. "My parents set rules that I need to follow." Rationale: Following rules and moral standards is an example of Kohlberg's moral development. Children at this age understand that rules are in place and should be followed. D. "I can do simple math problems in my head." Rationale: The ability to perform simple math problems without writing them down is an example of Piaget's cognitive development. Children at this age are able to perform actions mentally without needing to write the problem down. 44. A nurse on a pediatric unit is receiving report from an assistive personnel (AP). Which of the following clients should the nurse plan to visit first? A. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002 Rationale: A specific gravity of 1.002 is much lower than the expected reference range (1.005 to 1.030) and indicates urine output that is extremely dilute. The child is losing excessive water and is in danger of hypovolemia. Therefore, the nurse should plan to visit this child first. B. A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F) Rationale: A fever of 39°C (102.2°F) is an expected finding in a child who has roseola. C. A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95% Rationale: This value, 95%, is within the expected reference range. D. A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale Rationale: A pain level of 6 is not unexpected for this child's condition or life threatening. 45. A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions? A. Weighing the infant at the same time every day Rationale: Weight is the most sensitive indicator of hydration status for clients of all ages. Weight is the Created on:02/16/2022 Page 20 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February only measurement that reflects both measurable fluid balance changes and incidental fluid loss. B. Taking the infant's vital signs every 2 hr Rationale: Vital signs are not a reliable indicator of hydration status. C. Measuring the infant's head circumference twice per day Rationale: Measuring head circumference gives no useful information regarding the hydration status of an infant. D. Counting the number of wet diapers every shift Rationale: Counting wet diapers is an inadequate method for accurately determining the hydration status of an infant. 46. A nurse is caring for a 6-month-old child. The child's provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine? A. Afebrile otitis media Rationale: A mild childhood illness without a fever, and in the absence of other manifestations, is not a reason to withhold the DTaP vaccine. B. Evidence of sensitivity to egg antigens Rationale: This is not a contraindication for this vaccine. C. Temperature of 40.5° C (104.9° F) after last DTaP Rationale: The DTaP vaccine is a 3-in-1 vaccine that protects against diphtheria, pertussis, and tetanus. A high fever is a serious side effect. If a dose of DTaP vaccine were to be given again, it might cause a serious or life-threatening adverse reaction. D. New onset of seizure disorder in the child’s sibling Rationale: Only if the child to be immunized has manifestations of a neurologic disorder should this be considered a potential contraindication for the administration of the DTaP vaccine. 47. A nurse is reinforcing teaching with the parents of a child who has cystic fibrosis and a prescription for pancrelipase capsules. Which of the following instructions should the nurse include in the teaching? A. "Administer the medication with meals and snacks." Rationale: The child should take pancrelipase with meals and snacks to promote digestion of fats, carbohydrates, and proteins. B. "Tell your child to chew the capsules thoroughly." Rationale: Created on:02/16/2022 Page 21 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February Chewing the capsules damages the protective coating that prevents inactivation of the enzymes and damage to the oral mucosa. C. "Discontinue the medication when the child's symptoms resolve." Rationale: There is no cure for cystic fibrosis, so the child will require pancreatic enzymes throughout his life to promote digestion. D. "Observe for signs of bleeding." Rationale: Pancrelipase has few adverse effects and does not affect blood coagulation. 48. A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take? A. Call the parent to return to the child's room. Rationale: When a child is having a temper tantrum, the nurse should not give in to the child's demands. Parents need time away from the hospital room, and it is not appropriate for the nurse to call a parent back to the room each time the child has a tantrum. B. Leave the child alone in the room for 5 min. Rationale: The nurse should not leave a child alone during a temper tantrum. The nurse should be present to provide security for the child. C. Inform the child that her parent will be back in 2 hr. Rationale: Children at this age have no concept of time. The nurse should translate lengths of time into how many cartoons will be on before the parent returns. D. Give the child a stuffed animal. Rationale: A nurse should provide a transitional object for a child who is experiencing separation anxiety and exhibiting temper tantrum behaviors. This object can aid the child in feeling safe. 49. A nurse is working with several clients on an acute care pediatric unit. Which of the following clients requires the nurse's immediate attention? A. An 8-year-old client who had a tonsillectomy and is swallowing frequently Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that this client has priority needs. Frequent swallowing is an indication of blood in the throat and requires immediate intervention to prevent worsening hemorrhage. B. A 12-year-old client who had an appendectomy and refuses to ambulate Rationale: The nurse should encourage the client to ambulate to help prevent postoperative complications such as atelectasis; however, another client has priority needs. C. A 15-year-old client who has an IV infusion and reports pain at the insertion site Rationale: Created on:02/16/2022 Page 22 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February The nurse should evaluate the client’s IV access site to identify signs of infection or infiltration; however, another client has priority needs. D. An 18-month-old client who had a cleft palate repair and is crying in pain Rationale: The nurse should determine the client’s need for pain medication and help relieve her pain; however, another client has priority needs. 50. A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include? A. Provide low-calorie snacks. Rationale: The nurse should provide high-calorie, high-protein snacks to help replace calories and proteins lost by increased metabolism. B. Maintain medical asepsis during dressing changes. Rationale: The nurse should maintain surgical asepsis during dressing changes to prevent infection. C. Administer pain medication 30 min before physical therapy. Rationale: The nurse should administer pain medication 30 min before physical therapy to decrease the pain caused by moving tight skin at joints, which will encourage the child to participate in therapy. D. Allow the child to set her own schedule for care. Rationale: The nurse should set up a daily schedule to provide predictability and a sense of control for the child. The nurse should encourage the child to participate as much as possible in her care to gain a sense of accomplishment and improve self-esteem. 51. A nurse is caring for a school-age child who has seasonal allergies and has been taking diphenhydramine. The provider recommends fexofenadine for the child. The child's parent asks the nurse about the advantage of taking fexofenadine. Which of the following responses should the nurse make? A. "Fexofenadine is less sedating." Rationale: Fexofenadine is a second generation antihistamine that causes much less sedation than diphenhydramine, if any. B. "Fexofenadine is available without a prescription." Rationale: The parent can obtain both diphenhydramine and fexofenadine without a prescription. C. "Fexofenadine can be taken nasally." Rationale: Neither diphenhydramine nor fexofenadine is available in a nasal preparation. D. "Fexofenadine has decongestant properties." Rationale: Created on:02/16/2022 Page 23 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February Neither diphenhydramine nor fexofenadine has decongestant properties; however, both are available in formulations that contain decongestants. 52. A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks? A. Building a sense of trust Rationale: An infant meets Erickson's developmental task of trust vs. mistrust. B. Learning to use creative energies Rationale: A school-age child meets Erickson's developmental task of industry vs. inferiority. C. Learning to perform tasks independently Rationale: A toddler meets Erickson's developmental task of autonomy vs. shame or doubt. D. Defining a sense of self Rationale: An adolescent is working to meet Erickson's developmental task of identity vs. identity confusion. This stage is defined by the establishment of an identity or a sense of self. 53. A nurse is reinforcing teaching with the parents of an adolescent about expected development. Which of the following developmental tasks should the nurse instruct the parents to expect the adolescent to achieve? A. Trust Rationale: The infant should achieve the developmental task of trust. B. Initiative Rationale: The preschooler should achieve the developmental task of initiative. C. Identity Rationale: The adolescent should achieve the developmental task of establishing an identity. D. Autonomy Rationale: The toddler should achieve the developmental task of autonomy. 54. A nurse is selecting a toy for a 7-month-old infant. Which of the following toys should the nurse choose? A. A set of blocks to build a block tower Rationale: A set of blocks is appropriate for an infant of 9 to 12 months of age who is learning to manipulate, sort, and stack objects. At 9 to 12 months of age, an infant is able to stack two Created on:02/16/2022 Page 24 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February blocks. B. A colorful crib mobile that plays music Rationale: Crib mobiles are appropriate for an infant up to 6 months of age. C. A soft toy that squeaks or crackles when squeezed Rationale: Toys for a 7-month-old infant should be light, soft, and easy to handle. The most popular toys for infants this age include toys that respond to manipulation. D. A wooden farm animal puzzle with large pieces Rationale: Simple puzzles with large, easy-to-place pieces are appropriate for an infant of 12 to 18 months of age. 55. During a routine well-child visit, a nurse is reinforcing teaching with the parents of a preschool-age child whom they have difficulty getting to sleep. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will allow my child to watch TV to help him go to sleep." Rationale: Media use can contribute to sleep disturbances. Viewing media before bedtime can increase nightmares and night waking. B. "I will let my child fall asleep with me, and then move him to his own bed." Rationale: Allowing the child to routinely come into the parent's bed fosters the idea that this behavior will be the norm. The child might then become unwilling to sleep alone. C. "I will make sure the room is dark when placing my child in bed." Rationale: Darkened rooms can elicit fear in a preschooler. The nurse should encourage the parents to keep a light on in the child's room to foster good sleep. D. "I will encourage my child to fall asleep with his favorite toy." Rationale: Transitional objects, such as a blanket or toy, provide a sense of comfort, which allows the child to fall asleep more quickly. 56. A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching? A. "You will need to go home when It is not visiting hours." Rationale: Parents of an infant should plan to spend a great deal of time in the hospital including rooming-in with the infant at night. B. "You should bring the infant's favorite blanket to the hospital." Rationale: Infants of this age have separation anxiety and often need a transitional object, such as a Created on:02/16/2022 Page 25 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February blanket or toy that brings them comfort. The transitional object is especially important when the child is in unfamiliar surroundings, or the parent is not there to provide comfort. C. "You should begin to manipulate the infant's bedtime based on the hospitals visiting hours." Rationale: Nurses should encourage the infant's parents to continue with their bedtime rituals and times while in the hospital setting. D. "You should read the child a story about hospitalization." Rationale: This action could be an effective anxiety-reduction strategy with a preschooler or school-age child because it will help to prepare the child for a new, anxiety-producing experience. This is not an appropriate action to take for an infant. 57. A nurse is assisting with a parenting class and is approached by a parent of a 2-year-old toddler who asks what to do when the toddler throws a tantrum. Which of the following instructions should the nurse give? A. Place the child in time-out for 3 min. Rationale: Time-out is a form of punishment for unacceptable behavior. A rule for the length of a time-out is 1 min per year of age. Therefore, 3 min is too long of a time-out for a 2-year-old child. B. Distract the child by buying a toy. Rationale: Distracting the child with a toy positively rewards the behavior. C. Calmly tell the child to stop. Rationale: Once a tantrum has started, parental interference rarely will stop it. Asking the child to stop, even calmly, rewards the child with attention. D. Appear to ignore them. Rationale: Temper tantrums are an immature expression of frustration, typically manifested by both verbal outbursts, such as screaming and/or crying, and physical outbursts, such as flailing of the arms and legs. Temper tantrums tend to be self-limiting, and it is important for the parent remain calm. These outbursts are most effectively dealt with by ignoring the behavior. After the child loses an audience, the tantrum usually stops. 58. A nurse is collecting data regarding the pain level of a 3-year-old child on the second postoperative day following an appendectomy. Which of the following actions should the nurse take? A. Use a numeric scale to assess the child's pain level. Rationale: A numeric scale is an effective pain assessment tool to use with children who are 5 years of age and older. B. Use the FACES scale to assess the child's pain level. Rationale: The FACES Pain Rating Scale is an age-appropriate pain assessment tool for a 3-year-old child. Created on:02/16/2022 Page 26 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February C. Use a color tool to assess the child's pain level. Rationale: A color tool is an effective pain assessment tool to use with children who are 4 years of age and older. D. Use the Visual Analog Scale to assess the child's pain level. Rationale: The Visual Analog Scale is an effective pain assessment tool to use with children who are 4 ½ years of age and older. 59. A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning? A. "I am scared and I want to go home." Rationale: Many children are frightened by health care settings; therefore, this statement is not the most concerning. B. "I am hungry and thirsty." Rationale: A child who has a 2-day history of nausea and vomiting might be dehydrated and feel both hungry and thirsty; therefore, this statement is not the most concerning. C. "I’m tired and want to take a nap." Rationale: A child who has a 2-day history of nausea and vomiting might be dehydrated and exhausted. A common symptom of appendicitis is lethargy; therefore, this statement is not the most concerning. D. "My belly doesn’t hurt anymore." Rationale: Sudden relief of pain can be an early indication of appendix rupture, which is a surgical emergency. Because the greatest risk to the client is peritonitis secondary to a ruptured appendix, this statement is the most concerning. 60. A nurse is caring for a child who has idiopathic thrombocytopenic purpura and is experiencing a nosebleed. Which of the following actions should the nurse take? A. Apply warm pack to the bridge of the child’s nose. Rationale: The nurse should apply ice, or a cold cloth, to the bridge of the nose to help decrease the bleeding. A warm pack will encourage vasodilation and cause further bleeding. B. Move the child into a supine position. Rationale: To prevent aspiration, the nurse should position the child sitting up and leaning forward. C. Insert cotton into each of the child's nostrils. Rationale: The nurse should insert cotton into each nostril to assist with controlling the bleeding. Created on:02/16/2022 Page 27 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February D. Tilt the child’s head back. Rationale: The nurse should tilt the child’s head forward to prevent stomach upset. 61. A nurse in a pediatric clinic is collecting data from a preschool-age child who has suspected impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection? A. Scaly patches that have clear centers Rationale: Scaly patches that have a clear center are associated with tinea corporis (ringworm). B. Red macule with honey-colored crusts Rationale: Red macule with honey-colored crusts are associated with impetigo contagiosa. Honey-colored crusts develop when vesicles rupture and the exudate dries. C. Firm brown papules with a roughened, finely papillomatous texture Rationale: Firm brown papules are associated with verruca (warts). D. Reddened areas with white exudate Rationale: Reddened areas with white exudate are associated with Candida albicans. 62. A nurse is reinforcing teaching with the mother of a 2-month-old infant whose provider applied a Pavlik harness 1 week earlier for the treatment of developmental hip dysplasia. Which of the following statements by the mother indicates an understanding of the teaching? A. "I will adjust the harness straps every day." Rationale: The mother should only adjust the straps with medical supervision. B. "I will place the diaper over the harness." Rationale: The mother should always place the diaper under the harness. C. "I will check my baby's skin three times each day." Rationale: The mother should check the infant's skin under the straps and at skin folds for irritation and skin breakdown two to three times per day. D. "I will gently massage lotion on his skin around the harness clasps." Rationale: Lotions and powders on the skin can build up and irritate the skin. 63. A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? Created on:02/16/2022 Page 28 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February A. "Administer a bronchodilator to the child after chest percussion therapy." Rationale: The child should use a bronchodilator before chest percussion therapy in order to open the bronchi, which allows for easier expectoration. B. "A pigeon-shaped chest might become evident as the disease progresses." Rationale: A barrel-shaped chest might become evident as the disease progresses. C. "Bradycardia is an early indicator of a pneumothorax." Rationale: Tachycardia is a manifestation associated with a pneumothorax. An early indicator of a pneumothorax is a subtle decline in the oxygen saturation. D. "Engage the child in daily aerobic exercise." Rationale: Engaging the child in daily aerobic exercise stimulates mucous excretion, enhances self-esteem, and is recommended as a daily adjunct to chest percussion therapy. 64. A nurse is caring for a pre-school age child who has croup. Which of the following findings should the nurse report to the provider? A. Barky cough Rationale: A barky cough is expected finding of croup. B. Paroxysmal attacks of laryngeal spasm at night Rationale: Laryngeal spasms occur with acute spasmodic laryngitis and are usually a self-limiting. C. Hoarseness Rationale: Hoarseness is an expected finding of croup. D. Drooling Rationale: The presence of drooling can indicate epiglottitis, which requires immediate medical attention. 65. A nurse administers subcutaneous NPH insulin at 0700 to a child who has diabetes. At which of the following times should the nurse observe for hypoglycemia caused by the onset of the medication? A. 0715 Rationale: Insulin lispro, a rapid-acting insulin, has an expected onset of 15 min. NPH insulin is not a rapid-acting insulin; therefore, the nurse should not observe for hypoglycemia caused by the onset of the medication beginning at 0715. B. 0730 Rationale: Regular insulin, a short-acting insulin, has an expected onset of 30 to 60 min. NPH insulin is not a short-acting insulin; therefore, the nurse should not observe for hypoglycemia caused by Created on:02/16/2022 Page 29 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February the onset of the medication beginning at 0730. C. 0900 Rationale: NPH insulin is an intermediate-acting insulin, and has an expected onset of 1½ to 4 hr with a peak of 4 to 12 hours. Therefore, the nurse should observe for hypoglycemia caused by the onset of the medication beginning at 0900. D. 1200 Rationale: NPH insulin is an intermediate-acting insulin, and has an expected onset of 1½ to 4 hr. Therefore, the nurse should observe for hypoglycemia caused by the onset of the medication before 1200. 66. A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? A. Projectile vomiting Rationale: Infants who have pyloric stenosis have projectile vomiting, often ejecting vomitus several feet. B. Bile-colored vomit Rationale: Infants who have pyloric stenosis vomit non-bilious fluid. C. Absent bowel sounds Rationale: Infants who have pyloric stenosis have active bowel sounds and visible gastric waves. D. Fever Rationale: Infants who have pyloric stenosis do not have a fever. 67. A nurse is reinforcing teaching with an adolescent regarding administration of the Gardasil vaccine. The vaccine provides immunity against which of the following sexually transmitted infections? A. Human papillomavirus (HPV) Rationale: Gardasil is the only vaccine that provides immunity against 4 types of HPV: types 6, 11, 16, and 18. The immunization schedule for Gardasil requires three injections over a 6-month period. Clients should receive this vaccine between the ages of 9 and 26. B. Herpes simplex virus (HSV-2) Rationale: There is currently no vaccine available for HSV-2. C. Chlamydia trachomatis Rationale: There is currently no vaccine available for C. trachomatis. D. Gonorrhea Rationale: Created on:02/16/2022 Page 30 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February There is currently no vaccine available for gonorrhea. 68. A nurse is reinforcing teaching about cast care to a school-age child following application of a fiberglass cast for a radius fracture. Which of the following statements by the child indicates an understanding of the teaching? A. "I can put an ice pack on the areas of my cast that itch." Rationale: An ice pack placed over areas of the cast that itch can help alleviate this problem. The child may also use a blow dryer on the cool setting to blow into the cast to help with itching. B. "I can let my arm hang down for 1 hour at a time every 4 hours." Rationale: The child should keep the injured extremity elevated as often as possible to prevent swelling and pain. The child should not allow the affected limb to hang in a dependent position longer than 30 min. C. "I should expect some tingling in my fingertips the first few days." Rationale: Tingling in the child's fingertips can indicate paresthesia. Paresthesia is a possible sign of compartment syndrome and should be reported to the child's provider immediately. D. "I should expect the cast to be dry in 2 days." Rationale: Fiberglass casts dry within a few minutes following application. A plaster cast can take 24 to 48 hr to dry. 69. A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination? A. "Lie prone on the examination table." Rationale: With the client in this position, the nurse might notice some asymmetry due to scoliosis. However, this position does not exaggerate the manifestations of this disorder and is not part of the standard scoliosis screening procedure. B. "Touch your chin to your chest, and then look up at the ceiling." Rationale: These movements might help the nurse test flexion and hyperextension of the neck to evaluate the cervical spine, but they are not part of the standard scoliosis screening procedure. C. "Turn to the side, and remain in a relaxed position." Rationale: Scoliosis is a lateral curvature of the spine that the nurse might not detect from a side view. This position might help the nurse note kyphosis, a convex thoracic curvature of the thoracic spine, or lordosis, an abnormal lumbar curvature. D. "Bend forward from the waist with your head and arms downward." Rationale: Called Adams position, this posture will make any asymmetry of the ribs and flanks easier for the nurse to recognize. Created on:02/16/2022 Page 31 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February 70. A nurse is reinforcing discharge instructions with a parent of a 6-year-old child who has just had a tonsillectomy. Which of the following statements by the parent indicates an understanding of postoperative care? A. "I'll call the doctor if my child is swallowing continuously." Rationale: Frequent swallowing is a sign of hemorrhage following a tonsillectomy. The parent should report this finding immediately. B. "It's okay for my child to have plenty of ice cream." Rationale: Although the child should have soft foods for the first few postoperative days, ice cream and other dairy products can coat the throat and make the child cough or clear his throat, which can result in bleeding. C. "I'll help my child gargle with salt water a few times a day." Rationale: Gargling and vigorous toothbrushing can lead to bleeding. D. "It's okay for my child to ride his bike in a few days." Rationale: Most children can return to their usual activities in 1 to 2 weeks. They remain at risk for hemorrhage for up to 10 days, so parents must proceed cautiously with activities. 71. A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching? A. Headache Rationale: A headache is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include nervousness, dizziness, tachycardia, and sweating. B. Acetone breath Rationale: Acetone breath is a manifestation of hyperglycemia. A client who has hypoglycemia will have a normal breath odor. C. Rapid respirations Rationale: Rapid respirations, or Kussmaul breathing, is a manifestation of hyperglycemia. A client who has hypoglycemia will have shallow breathing. D. Diminished reflexes Rationale: Diminished reflexes is a sign of hyperglycemia. A client who has hypoglycemia will have tremors. 72. A nurse is collecting data from a 7-month-old infant. Which of the following findings should indicate to the nurse a need for further evaluation? Created on:02/16/2022 Page 32 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February A. Uses a unidextrous grasp Rationale: A 7-month-old infant should exhibit a unidextrous approach and grasp. Therefore, this finding does not indicate a need for further evaluation. B. Has a fear of strangers Rationale: A 7-month-old infant should exhibit a fear of strangers. Therefore, this finding does not indicate a need for further evaluation. C. Sits leaning forward on both hands Rationale: A 7-month-old infant should sit leaning forward on both hands. Therefore, this finding does not indicate a need for further evaluation. D. Babbles one-syllable sounds Rationale: A 7-month-old infant should babble in sounds that contain multiple syllables. Therefore, this finding indicates a need for further evaluation. 73. A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first? A. Report the suspected abuse to the authorities. Rationale: The bruises might be the result of injury or a medical diagnosis. Therefore, reporting suspected abuse to the authorities is not the first action the nurse should take. B. Obtain a detailed history. Rationale: The nurse should first obtain a history in order to determine possible causes of the bruises. While collecting additional data, the nurse should observe the parent and child for other indicators of abuse. C. Request a social services referral. Rationale: The bruises might be the result of injury or a medical diagnosis. Therefore, requesting a social services referral is not the first action the nurse should take. D. Tell the child what will happen to her when the abuse is reported. Rationale: The bruises might be the result of injury or a medical diagnosis. Therefore, telling the child what will happen to her when the abuse is reported is not the first action the nurse should take. 74. A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take? A. Feed the infant through an NG tube. Rationale: An infant born who has spina bifida is able to suck and swallow. B. Place the infant in prone position. Rationale: Created on:02/16/2022 Page 33 Downloaded by Gabriela Gamonski ([email protected])  lOMoARcPSD|15235676 Detailed Answer Key Pediatric February Placing the infant in prone position will help prevent trauma to the lesion. C. Cover the infant's lesion with a dry cloth. Rationale: The nurse should cover the lesion with a moist cloth to prevent drying. D. Perform range-of-motion (ROM) exercises to the infant's hips. Rationale: The nurse should avoid performing ROM exercises on the infant's hip joints. The hips might have tight hip flexors and adductor muscles and this movement could lead to subluxation of the hips. 75. A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take? A. Obtain a throat culture. Rationale: The nurse should not obtain a throat culture from a child who has epiglottitis because this procedure can cause an airway obstruction. B. Prepare the child for a neck radiograph. Rationale: The nurse should prepare the child for a lateral radiograph of the neck. A health care professional who has advanced skills with airway management should remain with the child at all times. C. Initiate airborne precautions. Rationale: The nurse should initiate droplet precautions for a child who has epiglottis. D. Visualize the epiglottis using a tongue depressor. Rationale: The nurse should not use a tongue d