Deck 2: Child Health

Question 1

The nurse is caring for an infant with a diagnosis of hydrocephalus and is monitoring the infant for signs of increased intracranial pressure (ICP). The nurse suspects increased ICP if which of the following is noted?

A) Proteinuria
B) Bradycardia
C) A drop in blood pressure
D) A bulging anterior fontanel

Answer 1

A bulging anterior fontanel

Question 2

The nurse is caring for a child who has sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse monitors for the earliest sign of increased ICP by assessing for:

A) Apnea
B) Posturing
C) Tachycardia
D) Changes in level of consciousness (LOC)

Answer 2

Changes in level of consciousness (LOC)

Question 3

The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse includes which of the following instructions?

A) Call the physician if the infant is fussy.
B) Expect an increased urine output from the shunt.
C) Call the physician if the infant has a high-pitched cry.
D) Position the infant on the side of the shunt when the infant is put to bed.

Answer 3

Call the physician if the infant has a high-pitched cry.

Question 4

The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for:

A) Signs of hyperglycemia
B) Signs of a bacterial infection
C) The presence of protein in the urine
D) Signs of increased intracranial pressure

Question 5

The nurse is providing home care instructions to the mother of a child who is recovering from Reye's syndrome. Which of the following home instructions should the nurse provide to the mother?

A) Increase the stimuli in the environment.
B) Give the child frequent small meals, if vomiting occurs.
C) Avoid daytime naps so that the child will sleep at night.
D) Check the child's skin and eyes every day for a yellow discoloration.

Question 6

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure:

A) Safety with activities
B) Activities providing verbal stimulation
C) Social interactions with other children in the same age group
D) Familiarity with all activities and providing orientation throughout the activities

Question 7

The nurse is providing instructions to an adolescent who is taking phenytoin (Dilantin) for the control of seizures. Which of the following statements, if made by the adolescent, indicates a need for further teaching regarding the medication?

A) "The medication may cause oily skin."
B) "Drinking alcohol may affect the medication."
C) "If my gums become sore I need to stop the medication."
D) "Birth control pills may not be effective when I take this medication."

Question 8

The nurse is collecting data on a 7-year-old child who is suspected of having episodes of absence seizures. Which of the following questions to the mother will assist in providing information that will identify the symptoms associated with these types of seizures?

A) "Does twitching occur in the face and neck?"
B) "Does the muscle twitching occur on one side of the body?"
C) "Does the muscle twitching occur on both sides of the body?"
D) "Does the child have a blank expression during these episodes?"

Question 9

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing were present?

A) Rigid extension and tremors of all extremities
B) Flaccid paralysis of all extremities
C) Flexion of the upper extremities and extension of the lower extremities
D) Abnormal extension of the upper and lower extremities with some internal rotation

Question 10

The nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which of the following positions on return from the operating room?

A) Supine
B) Side-lying
C) High-Fowler's and on the left side
D) Trendelenburg's and on the right side

Question 11

The nurse provides discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which of the following statements, if made by the mother, indicates a need for further education?

A) "My child should not swim in deep water."
B) "I need to prevent my child from blowing the nose."
C) "My child can swim in the lake as long as the water is not deep."
D) "My child can take a shower or bath as long as I place Vaseline on cotton balls or earplugs in the ears."

Question 12

The pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which of the following items would the nurse offer to the child?

A) Cola with ice
B) A glass of milk
C) Cool cherry-flavored drink
D) Green gelatin

Question 13

The nurse is providing home care instructions to a mother of a 9-year-old child diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. The nurse would instruct the mother that the child:

A) Can return to school immediately
B) Cannot return to school until seen by the physician in 1 week
C) Should be kept at home until the antibiotic eye drops have been administered for 1 week
D) Should be kept at home until the antibiotic eye drops have been administered for 24 hours

Question 14

The nurse is providing instructions to a mother of a child with strabismus of the right eye. The physician has prescribed "patching" for the child, and the parent is instructed in the procedure. Which of the following, if stated by the parent, indicates an understanding of the procedure?

A) "I will place the patch on the left eye."
B) "I will place the patch on both eyes."
C) "I will place the patch on the right eye."
D) "I will alternate the patch from the right to left eye daily."

Question 15

The nurse is reviewing the physician's prescriptions on a child following a tonsillectomy. Which of the following physician prescriptions would the nurse question?

A) Suction the child if coughing.
B) Discharge to home when alert and tolerating fluids.
C) Provide clear cool liquids to the child when awake.
D) Instruct the parent to avoid giving the child milk or milk products.

Question 16

The nurse is caring for a 2-year-old child with an ear infection who requires the administration of antibiotic ear drops. The nurse observes the mother administering the ear drops to the child. Which of the following observations, if made by the nurse, indicates that the mother is performing the procedure correctly?

A) The mother pulls the earlobe down and back.
B) The mother must wear gloves when administering the medication.
C) The mother pulls the earlobe up and back to administer the drops.
D) The mother holds the child in a sitting position when administering the ear drops.

Question 17

The ambulatory care nurse makes a follow-up telephone call to the mother of a child who underwent a myringotomy with insertion of tympanostomy tubes on the previous day. The mother of the child tells the nurse that the child is complaining of discomfort. The nurse would instruct the mother to:

A) Call the physician immediately.
B) Give the child acetaminophen (Tylenol) for the discomfort.
C) Give the child children's aspirin, and call the physician if i t does not help.
D) Call the local pharmacist regarding a stronger over-the-counter analgesic.

Question 18

The nurse is assisting in providing an educational session to new mothers regarding the methods that will decrease the risk of recurrent otitis media in infants. Which of the following statements, if made by a mother in the group, indicates a need for further instruction?

A) "I need to feed the infant in an upright position."
B) "I should not provide the infant with a bottle during naptime."
C) "Bottle-feeding should be discontinued as soon as possible."
D) "I need to discontinue breast-feeding as soon as possible."

Question 19

A nursing student is preparing a clinical conference. The topic of the discussion is caring for the child with cystic fibrosis (CF). Which of the following comments by the student would indicate that the student needs further review of information about cystic fibrosis?

A) It is transmitted as an autosomal recessive trait.
B) It is a disease that causes mucus that is formed to be abnormally thick.
C) It is a disease that causes dilation of the passageways of many organs.
D) It is a chronic multisystem disorder affecting the exocrine glands.

Question 20

The nurse reviews the health record of a 2-year-old child and notes that the physician has documented that the results of a Mantoux test have indicated an area of induration measuring 5 mm. The nurse would interpret these results as:

A) Positive
B) Negative
C) Inconclusive
D) Definitive, requiring a repeat test

Question 21

The nurse has provided instructions to the mother of a child with cystic fibrosis (CF) about appropriate dietary measures. Which of the following statements, if made by the mother, indicates an understanding of the diet that should be provided to the child?

A) "The diet needs to be low in fat."
B) "The diet needs to be low in protein."
C) "The diet needs to be high in calories."
D) "The diet needs to be low in calories."

Question 22

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse positions the infant:

A) In a supine, side-lying position
B) Prone, with the head of the bed elevated 15 degrees
C) With the head at a 60-degree angle with the neck slightly flexed
D) With the head and chest at a 30-degree angle, with the neck slightly extended

Question 23

The nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which of the following statements, if made by the mother, indicates a need for further instruction?

A) "I will take the child out into the cool, humid night air."
B) "I should place a steam vaporizer in the child's room."
C) "I need to place a cool mist humidifier in the child's room."
D) "I can bring the child into a closed bathroom and have the child inhale steam from running water."

Question 24

The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:

A) Extreme fatigue
B) The presence of pain
C) An airway obstruction
D) The presence of dehydration

Question 25

The nurse is preparing for administering ribavirin (Virazole) to a child with respiratory syncytial virus (RSV). Which of the following supplies will the nurse obtain for the administration of this medication?

A) An intravenous (IV) pole
B) A pair of goggles
C) A protective isolation gown
D) An intramuscular (IM) syringe

Question 26

A nursing student is conducting a clinical conference about measures that assist in preventing sudden infant death syndrome (SIDS). The student plans to write on a handout that it is best to place an infant in which of the following positions for sleep?

A) On the back or prone
B) On the back or supine
C) On the stomach or prone
D) On the stomach or supine

Question 27

A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L. The nurse interprets that this finding is indicative of:

A) A negative test
B) A positive test
C) An unrelated finding
D) Suggestive of CF and requires a repeat test

Question 28

The nursing student is caring for an infant with a respiratory infection and is monitoring for signs of dehydration. The nursing instructor asks the student to identify the most reliable method of determining fluid loss. The instructor determines that the student understands this method when the student states that the plan is to:

A) Monitor output.
B) Monitor body weight.
C) Assess the mucous membranes.
D) Obtain a temperature every 2 hours.

Question 29

The nurse is developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse includes to monitor the child for signs of:

A) Bleeding
B) Failure to thrive
C) Congestive heart failure (CHF)
D) Decreased tolerance to stimulation

Question 30

The nurse is reviewing the physician's prescriptions for a child with rheumatic fever (RF) who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which of the following nursing actions is most appropriate?

A) Administer the aspirin if the child's temperature is elevated.
B) Administer the aspirin if the child experiences any joint pain.
C) Consult with the physician to verify the prescription.
D) Administer acetaminophen (Tylenol) instead of the aspirin for temperature elevation.

Question 31

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. The initial nursing action is to:

A) Call a code.
B) Place the infant in a prone position.
C) Place the infant in a knee-chest position.
D) Contact the respiratory therapy department.

Question 32

The nurse is caring for an infant with congenital heart disease. Which of the following signs, if noted in the infant, would alert the nurse to the early development of congestive heart failure (CHF)?

A) Pallor
B) Strong sucking reflex
C) Diaphoresis during feeding
D) Slow and shallow breathing

Question 33

The nurse reviews the physician's prescriptions for a child with a streptococcal infection. The physician prescribes an antistreptolysin O titer. Based on this prescription, which of the following would the nurse suspect in the child?

A) Rheumatic fever (RF)
B) Aortic valve disease (AVD)
C) Pulmonic valve disease (PVD)
D) Congestive heart failure (CHF)

Question 34

The nurse is caring for a child with congestive heart failure (CHF). The nurse provides instructions to the mother regarding the procedure for administration of the prescribed digoxin (Lanoxin). Which of the following statements, if made by the mother, indicates a need for further education?

A) "I can mix the medication with food."
B) "If more than one dose is missed, I need to call the physician."
C) "I need to take the child's pulse before administering the medication."
D) "If the child vomits after being given the medication, I should not repeat the dose."

Question 35

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse would expect to note documentation of which of the following most common assessment findings?

A) Cyanosis
B) Severe bradycardia
C) Asymptomatic findings
D) Higher than normal body weight

Question 36

The nurse is collecting data on a child with a diagnosis of rheumatic fever (RF). Which of the following questions would the nurse initially ask the mother of the child?

A) "Has the child been vomiting?"
B) "Has the child had any diarrhea?"
C) "Does the child complain of chest pain?"
D) "Has the child complained of a sore throat within the past few months?"

Question 37

The nurse is reviewing the health record of an infant with a diagnosis of congenital heart disease. The nurse notes documentation in the record that the infant has clubbing of the fingers. The nurse understands that this finding is caused by:

A) Chronic fatigue
B) Poor oxygenation
C) Poor sucking ability
D) Consistent sucking on the fingers

Question 38

The nurse is admitting a child who arrived from the emergency department after treatment for acetaminophen (Tylenol) overdose. The nurse reviews the child's record and expects to note that the child received which of the following for the acetaminophen overdose?

A) Epoetin alfa (Epogen)
B) Protamine sulfate
C) Acetylcysteine (Mucomyst)
D) Ethylenediaminetetraacetic acid (EDTA)

Question 39

The nurse is monitoring a child who is receiving EDTA with BAL (British anti -Lewisite) for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which of the following laboratory test results?

A) Cholesterol level
B) Blood urea nitrogen (BUN) level
C) Complete blood cell (CBC) count
D) Hemoglobin and hematocrit (H&H) levels

Question 40

The mother of a child with an umbilical hernia calls the clinic and reports to the nurse that the child has been vomiting and is complaining of pain in the abdominal area. The nurse would most appropriately instruct the mother to:

A) Contact the physician.
B) Keep the child on clear liquids.
C) Apply an ice pack to the abdomen.
D) Administer acetaminophen (Tylenol) suppositories to the child.

Question 41

The nurse is reviewing the physician's documentation in the record of a child admitted with a diagnosis of intussusception. The nurse expects to note that the physician has documented the presence of:

A) Scleral jaundice
B) Projectile vomiting
C) Currant jelly-type stools
D) Pale-colored and hard stools

Question 42

The nurse is preparing to care for a newborn infant following creation of a colostomy for the treatment of imperforate anus. In the immediate postoperative period, the nurse plans to inspect the stoma, knowing that it is expected to be:

A) Bleeding
B) Gray in color
C) Dark blue in color
D) Red and edematous

Question 43

The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which of the following questions to the mother will most specifically elicit information regarding this disorder?

A) "Does your infant have diarrhea?"
B) "Is your infant constantly vomiting?"
C) "Does your infant constantly spit up feedings?"
D) "Does your infant have foul-smelling, ribbon-like stools?"

Question 44

The nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table, with the knees pulled up toward the chest. The nurse assists the physician with further assessment of the progression of the child's pain, knowing that the physician will palpate the abdomen:

A) Midway between the liver and the gallbladder
B) Midway between the left iliac crest and the umbilicus
C) Midway between the left inguinal area and the acetabulum
D) Midway between the right anterior superior iliac crest and the umbilicus

Question 45

The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that the mother understands the instructions when the mother states to include which of the following in the child's diet?

A) Corn
B) Wheat cereal
C) Rye crackers
D) Oatmeal biscuits

Question 46

The nurse is developing a plan of care for an infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, the nurse suggests to document in the plan of care to position the child:

A) In an infant seat placed in the crib
B) Prone with the head of the bed elevated
C) Supine with the head at a 90-degree angle
D) Supine with the head of the bed at a 30-degree angle

Question 47

The nurse is assigned to care for an infant following a cleft lip repair. The nurse is asked to observe the parent in the procedure for cleaning the lip repair site. The nurse determines that the parent is performing the procedure correctly if the parent uses which of the following solutions to clean the site?

A) Ice water
B) Sterile water
C) Half-strength alcohol
D) Full strength hydrogen peroxide

Question 48

The nurse is preparing a plan of care for an infant who will be returning from the recovery room following the surgical repair of a cleft lip located on the right side of the lip. On return from the recovery room, the nurse plans to position the infant:

A) Prone and flat
B) Supine and flat
C) On the left side
D) On the right side

Question 49

The nursing student is asked to administer a tepid bath to a child with a fever. The student avoids which of the following when performing this procedure?

A) Applies alcohol-soaked cloths over the child's body
B) Uses a water toy to distract the child during the bath
C) Places lightweight pajamas on the child after the bath
D) Squeezes water over the child's body, using the washcloth

Question 50

A nurse is caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The nurse monitors the child closely and notifies the physician if which of the following is noted?

A) Weight increase of 0.5 kg
B) Temperature of 100.8º F rectally
C) Blood pressure (BP) unchanged from baseline
D) A decrease in urine output to 0.5 mL/kg/hr

Question 51

A female adolescent with type 1 diabetes mellitus has been chosen for her school's cheerleading squad. She visits the school nurse to obtain information regarding adjustments needed in her treatment plan for diabetes. The school nurse instructs the student to:

A) Eat half the amount of food normally eaten.
B) Take two times the amount of prescribed insulin on practice and game days.
C) Take the prescribed insulin 1 hour prior to practice or game time rather than in the morning.
D) Eat six graham crackers or drink a cup of orange juice prior to practice or game time.

Question 52

The nurse has been caring for an adolescent newly diagnosed with type 1 diabetes mellitus. The nurse provides instructions to the adolescent regarding the administration of insulin. The nurse tells the adolescent to:

A) Use only the stomach and thighs for injections.
B) Rotate each insulin injection site on a daily basis.
C) Use the same site for injections for 1 month before rotating to another site.
D) Use one major site for the morning injection and another site for the evening injection for 2 to 3 weeks before changing major sites.

Question 53

The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and would expect to note which of the following?

A) A normal T₄ level
B) An elevated T₄ level
C) An elevated thyroid-stimulating hormone (TSH) level
D) A decreased TSH level

Question 54

A nursing student is caring for a hospitalized child who has hypotonic dehydration. The nursing instructor asks the student to describe this type of dehydration. The instructor determines that the nursing student understands the physiology associated with this type of dehydration if the student states which of the following?

A) "It causes the serum sodium level to rise above 150 mEq/L."
B) "It occurs when the loss of electrolytes is greater than the loss of water."
C) "It occurs when the loss of water is greater than the loss of electrolytes."
D) "It occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body."

Question 55

The nurse is caring for an infant with gastroenteritis who is being treated for dehydration. The nurse reviews the health record and notes that the physician has documented that the infant is mildly dehydrated. Which of the following assessment findings would the nurse find in a child with mild dehydration?

A) Anuria
B) Pale skin color
C) Sunken fontanels
D) Dry mucous membranes

Question 56

The nurse is talking to the parents of a child newly diagnosed with diabetes mellitus. The nurse determines that the parents have a proper understanding of preventing and managing hypoglycemia if the parents state that they will:

A) Administer glucagon immediately if shakiness is felt.
B) Give the child 8 oz of diet cola at the first sign of weakness.
C) Report to the emergency department if the blood glucose level is 65 mg/dL.
D) Carry a glucose source when leaving home in case a hypoglycemic reaction occurs.

Question 57

The nurse provides instructions to the parent of a newborn to bring the infant to the well -baby clinic for a phenylketonuria (PKU) rescreening blood test. The parent brings the infant to the clinic, and the blood test is drawn. The results of the test indicate a serum phenylalanine level of 1.0 mg/dL. The nurse interprets these results as:

A) Positive
B) Negative
C) Inconclusive
D) Requiring rescreening at age 6 weeks

Question 58

The nurse is reviewing the physician's prescriptions for a child hospitalized with nephrotic syndrome. Which of the following dietary prescriptions would the nurse expect to be prescribed for the child?

A) A low-fat diet
B) A full liquid diet
C) A high-protein, high-salt diet
D) A normal protein, mild sodium diet

Question 59

A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. The student collects the specimen by:

A) Attaching a urinary collection device to the infant's perineum for collection
B) Catheterizing the infant using the smallest available Foley catheter
C) Obtaining the specimen from the diaper by squeezing the diaper after the infant voids
D) Noting the time of the next expected voiding and preparing to collect the specimen intoa cup when the infant voids

Question 60

The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which of the following questions to the mother would elicit data associated with the cause of this disease?

A) "Has your child had any diarrhea?"
B) "Have you noticed any rashes on your child?"
C) "Did your child recently complain of a sore throat?"
D) "Did your child sustain any injuries to the kidney area?"

Question 61

The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse would expect to note which of the following findings documented in the child's record?

A) Polyuria
B) Weight gain
C) Hypotension
D) Grossly bloody urine

Question 62

The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which of the following is a priori ty in the plan of care?

A) Wound care
B) Pain control measures
C) Measurement of intake
D) Cold and heat applications

Question 63

A nursing student is assigned to care for a child following surgery to correct cryptorchidism. The nursing instructor reviews the plan of care developed by the student and determines that the student is adequately prepared to care for the child if the student identifies which priority in the plan of care following this type of surgery?

A) Prevent tension on the suture.
B) Force oral fluids, and monitor I&O.
C) Monitor urine for glucose and acetone.
D) Encourage coughing and deep breathing every hour.

Question 64

A nurse is developing a plan of care for a 4-year-old child scheduled for a renal biopsy. Based on the developmental level of the child the nurse considers which of the following?

A) Masturbation is common in this age group.
B) Body image may be a concern for the child.
C) Fears of mutilation may be present in the child.
D) The urination pattern will cause embarrassment for the child.

Question 65

The mother of a newborn male infant with hypospadias asks the nurse why circumcision cannot be performed. The most appropriate response by the nurse is which of the following?

A) "Circumcision will cause an infection."
B) "Circumcision is not performed in a newborn."
C) "Circumcision will cause difficulty with urination."
D) "Circumcision has been delayed to save tissue for surgical repair."

Question 66

The nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by:

A) Covering the bladder with a sterile gauze dressing
B) Covering the bladder with a dry sterile dressing
C) Applying sterile water soaks to the bladder mucosa
D) Covering the bladder with a sterile, nonadhering dressing

Question 67

The nurse is developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. The nurse determines that which of the following is a priority for the child?

A) Promoting bed rest
B) Restricting oral fluids
C) Encouraging visits from friends
D) Allowing the child to play with the other children in the playroom

Question 68

The nurse is collecting data on a child brought to the health care clinic by the mother with a one - week-old cat scratch. While assessing the scratch the nurse notes redness, heat, swelling, and red streaking surrounding the area. The child states that the scratch hurts. Cellulitis is diagnosed. Whenproviding home care instructions, which of the following statements made by the mother indicates a need for further education?

A) "The child should rest in bed."
B) "I should apply cool, moist soaks every 4 hours."
C) "I should take the child's temperature and watch for a fever."
D) "The affected extremity should be elevated and immobilized."

Question 69

The nurse is providing instructions to the mother of a child with herpetic gingivostomatitis. Which of the following responses, if stated by the mother after teaching, would indicate that further instruction is required?

A) "I will offer my child soft, bland foods."
B) "I will encourage my child to drink fluids."
C) "I will give my child frozen ice pops to assist with fluid intake."
D) "I will not give my child anything to eat for 2 days to allow the lesions to heal and crust over."

Question 70

The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation?

A) Heart rate
B) Lung sounds
C) Level of consciousness
D) Amount of edema at the site of the burn injury

Question 71

A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which of the following will be prescribed initially?

A) Insertion of a Foley catheter
B) Insertion of a nasogastric tube
C) Administration of an anesthetic agent for sedation
D) Application of an antimicrobial agent to the burns

Question 72

The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin 1% (Nix) has been prescribed. Which of the following statements, if made by the mother regarding the use of the medication, indicates a need for further education?

A) "I need to purchase the medication from the pharmacy."
B) "After rinsing out the medication, I need to avoid washing my child's hair for 24 hours."
C) "I need to shampoo my child's hair, apply the medication, and leave it on for 10 minutes and then rinse it out."
D) "I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours."

Question 73

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which of the following assessment findings would the nurse expect to note documented in the infant's record regarding this condition?

A) Full range of motion in the affected hip
B) An apparent short femur on the unaffected side
C) Asymmetrical adduction of the affected hip when placed supine, with the knees and hips flexed
D) Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

Question 74

The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip (DDH). The child will be placed in the Pavlik harness. Which of the following statements by the family would indicate that they understand the care of their child while placed in the Pavlik harness?

A) "I know that the harness must be worn continuously."
B) "I will bring my child back to the orthopedic office in a month so the straps can be checked."
C) "I realize that I will also need to put two diapers on my child so that the harness does not get soiled."
D) "I will watch for any redness or skin irritation where the straps are applied and call the doctor if there is any irritation."

Question 75

The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which of the following nursing actions would be most appropriate?

A) Report the findings to the physician.
B) Document the findings, and reassess the situation in 4 hours.
C) Encourage the child to keep the arm elevated for the next 24 hours.
D) Tell the child that this is normal and will disappear when the cast is dry.

Question 76

An adolescent is seen in the emergency department following an athletic injury. It is suspected that the child has sprained an ankle. X-rays have been obtained, and a fracture has been ruled out. The nurse is providing instructions to the adolescent regarding home care for treatment of the sprain. Which of the following instructions would the nurse provide to the adolescent?

A) Elevate the extremity, and maintain strict bed rest for a period of 7 days.
B) Immobilize the extremity, and maintain the extremity in a dependent position.
C) Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice.
D) Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.

Question 77

The nurse is reinforcing instructions to the mother of a child who has a plaster cast applied to the left arm. Which of the following statements, if made by the mother, indicates a need for further education?

A) "I should use a heat lamp to help the cast dry."
B) "I should cover the cast with plastic when the child bathes or showers."
C) "I should call the physician if the cast feels warm or hot or has an unusual smell or odor."
D) "I should keep small toys and sharp objects away from the cast and be sure that my child does not put anything inside the cast."

Question 78

The nurse is assisting a physician during the examination of an infant with developmental hip dysplasia. The physician performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which of the following is noted?

A) A shrill cry from the infant
B) Asymmetry of the affected hip
C) Reduced range of motion in the affected hip
D) A palpable click during abduction of the affected hip

Question 79

The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which of the following statements, if made by one of the parents, indicates an understanding of the use of the harness?

A) "I can remove the harness to bathe my infant."
B) "I need to remove the harness to feed my infant."
C) "I need to remove the harness to change the diaper."
D) "My infant needs to remain in the harness at all times."

Question 80

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which of the following statements, if made by one of the parents, indicates a need for further instructions?

A) "I cannot place powder under the brace."
B) "I need to place a soft shirt on my child under the brace."
C) "I need to encourage my child to perform prescribed exercises."
D) "I need to be sure to apply lotion on the skin under the brace."