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Evolve: Pediatric exam
Terms in this set (90)
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.)
A. Monitor the the infant's weight and number of wet diapers per day. - child should at least have 6 wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per week.- child is always fatigue, need to increase to 30 oz a day
C. Allow the infant to rest and refeed on demand or every 2 hours.- child is always fatigue, this will ensure adequate feeding.
D. Use a softer nipple or increase the size of the nipple opening.- this will save energy
A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide?
Explain that menarche varies and occurs between the ages of 12 and 18 years.
Which finding in a 19-year-old female client should trigger further assessment by the nurse?
Menstruation has not occurred- menarche usually occur between the ages of 12 and 18 years old
At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first?
Administer PRN prescription of nifedipine (Procardia) sublingually.
-CA channel blocker
-always assess physiological needs
A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis?
Answer: Sequestration.- pooling of blood causes and pain and anemia d/t blockage of blood in the spleen
1. Aplastic anemia- anemia d/t drugs
2. Hyperhemolytic anemia- anemia d/t the breakdown of RBC
3.Vaso-occlusive anemia- sickle cells are clogging up small capillaries- and pain but not enlarged spleen and liver
A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?
pre school age children are conceded about lost of body mutilation or body integrity.
nurse should explain- they did not cause the illness, procedure is not punishment, restoring body image with a band-aid.
The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first?
Start an IV infusion of normal saline- patient is experiencing fluid vole deficit
A 6-month-old boy and his mother are at the healthcare provider's office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today?
2. HEP -B (1st dose: birth, 2nd dose: 1-2 months, 3rd dose 6-9 months)
5. INFLUENZA~ adminster at a different site
A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first?
Determine the child's pulse and respiration~ always remember ABC
assess: respiratory, cardiac, and neuro
The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain?
Description of vomiting episodes in past 24 hours.- assessment of what cause vomiting episodes leaning towards treatment
The nurse is planning care for school-aged children at a community care center. Which activity is best for the children?
erikson: industry vs inferiority
achieve independence and productivity
The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother?
Walk away from him and ignore the behavior
-temper tantrums are normal, just ignore the behavior.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan?
Consistently follow a set mealtime routine
- always follow a consistent home schedule
As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider?
A 6-month-old with failure to thrive that has a closed anterior fontanel.
closed fontanel earlier > a fontanel that has not closed yet, it is just delayed
Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate?
A trial of human chorionic gonadotrophic hormone
Frequent stimulation of the cremasteric reflex~ causes the testes to ascend, but descend.
When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement?
Record weight daily = nutrition for infants
The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview?
Are you experiencing any type of nervousness? - physiological answers: nervousness, apprehension, palpitations, hyper excitability
side note: hyperthrydoism will have exothalamus but not double vision
Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations?
Oven-baked potato chips and cola
avoid: oats, wheat, rey and barley
Which action by the nurse is most helpful in communicating with a preschool-aged child?
Use a doll to play and communicate. Correct
To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?
Use a happy-face/sad-face pain scale.
-faces pain scale
minimm of age 3 years old
when to use numeric pain scale
minimum of 9 years old
when to use verbal report
3 year old can point out location and degree of pain
nonverbal signs of pain
-difficultiy in sleeping or feeding
vital signs of pain
-decreased 02 levels
when to use cries
pain rating scale (PRS)
1-36 months of age
A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization?
Explain hospital schedules to the child, such as mealtimes.
-always keep a consistent schedule, if possible try to copy house schedule. this will decrease separation anxiety
The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question?
Do not give if the child has chickenpox, the flu, or any other viral illness. Correct
-pepto bismol: contains aspirin, aspirin + any viral, flue or infection = reye syndrome
-->reye syndrome (encephalophy + hepatic dysfunction)
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
Serum BUN and creatinine levels.
add potassium = need adequate renal function + urine output
The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit?
Clubbed fingers d/t hypoxia
-tachycardia > bradycardia
An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?
Prevent the return of oxygenated blood to the lungs
The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?
Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there. Correct
When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?
Cessation of growth in a child that had been normal.
hypothyrodism-->d/t metabolism--> decrease metabolism--> cessation of the growth
The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family?
growth hormone causes increase in blood sugar-->monitor for diabetes (Polyuria and polydipsia)
The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication?
Changes in level of consciousness.
fluid retention + DILUTED hyponatremia
A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information?
Children need to retain a sense of initiative without impinging on the rights and privileges of others. Correct
-Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others
develop a conscience and learn a sense of initiative without being rude to the rights of others-->vigorous, intrusive havior, enterprise and strong imagination
A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?
Wash the hair and skin frequently with soap and hot water.
teenage growth hormones causes increase in sebaceous glands and increased glandular secretions which predispose the teenager to acne.
During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?
JRA= EYE EXAM
The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits?
Half of child's speech is understandable (15-24 months)
-Is able to name four colors & Can count five blocks = 3-5 years old
-Is capable of making a three word sentence. = accomplished by 18 months
A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?
Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?
-Tetracyclines causes destruction of enamel and tooth discoloration
able to give: aminoglycodides, penicillins, Quinolones.
A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan?
Use sunscreen when lying by the pool.
also avoid taking with milk because it interferes with absoprtion
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit?
Choking, coughing, and cyanosis.
The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?
12 to 15 months.
second dose: 4- 6 years old
Preoperative nursing care for a child with Wilms' tumor should include which intervention?
Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." Correct
-prevent spreading the encapsulated tumor to other organs
An 18-month-old is admitted to the hospital with possible Hirschsprung's disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?
Ribbon-like and brown.
Bile-colored and watery = gastroenteritis
Foul-smelling and fatty = cystic fibrosis
Semi-solid and yellow= normal in breast fed neonates
The nurse is planning the care of a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis?
Place elbow restraints on the child's arms
lbow restraints prevent arm flexion and scratching of involved areas, but do not inhibit use of the hands for play activities
The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift?
Tympanic and oral temperatures are equally accurate. Correct
hypothalamus and eardrum are perfused by the same circulation causes the same core temp by ear and oral
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention?
Apical heart rate of 60. Correct
In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first?
5 year old = glucose reading (think of it as playing a game)
9 year old = can self administer the medication with proper demonstration
The nurse observes a 4-year-old boy in a daycare setting. Which behavior would the nurse consider normal for this child?
Demonstrates aggressiveness by boasting when telling a story.
A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is calculated as a larger percentage of total body surface than an adult's?
child= head + neck
adult= chest + arms
The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take?
theophylline: 10-20 mcg/dl
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?
Have a bulb syringe readily available to remove secretions. Correct
Humidification will liquefy the nasal secretions
All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old child?
by 20 months, the fontanels are suppose to be closed already.
The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that
a tympanic measurement of temperature will provide the most accurate reading.
A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The nurse determines the daily caloric need for this child is approximately
600 calories per day.
10.9 divide by 2.2 = 5kg x 108 kg/cal/day = x 5 = 540. since there is a 10% increase, 54 +540= 594, 600 calories per day.
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?
Store all toxic agents and medicines in locked cabinets.
The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?
I understand that I will be in a body cast and I will show you how you taught me to turn
To take the vital signs of a 4-month-old child, which order provides the most accurate results?
Respiratory rate, heart rate, then rectal temperature.
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next?
Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?
Observe for projectile vomiting leads to metabolic alkalosis, not acidosis
A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child?
Remove restraints one at a time and provide range of motion exercises.
-child still needs to have exercise movement and passive range of motion exercises.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?
most common examination is congenital heart disease
When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it
stresses the suture line--> need to maintain the skin integrity
Which behavior would the nurse expect a 2-year-old child to exhibit?
Display possessiveness of toys. Correct
-egocentric thinking:vigiours, want to show boat, tell information but still respect the rights of others
When assessing a child with asthma, the nurse should expect intercostal retractions during
inspiration! inspiraiton causes show the presence of intercostal retractions
A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client's social interaction, what intervention is best for the nurse to initiate?
Arrange for an Internet connection in the client's room for email communication. Correct
adolescent: body image and peer acceptance are the main concerns. the stem of the question is stating that he is concerned about his distorted appearance. allowing email communication will still allow peer communication and acceptance while preserving his body image
A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?
Tell the student to proceed directly to his regularly scheduled class. Correct
-the kid just came from football practice, which increases his muscle activity. 100.4 is a regular temp.
-taking the child to drink cold fluids, then retake temp--> this would give false assurance.
A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?
Wash the wound gently with mild soap and water.
-hydrogen peroxide +povidone-iodine = will irritate the wound.
clean the wound first to prevent infection then put ice
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take?
Administer tetanus toxoid booster.
Detanus is part of DTAP vaccine.
-first dose: 6 months
-booster shoot: adolescent or adults
-booster shot: traumatic injury-->contaminated with by dirt, feces, soil or saliva
puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite
During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?
Stop the infusion immediately and notify the healthcare provider. Correct
-adjust IV fluids
-TPN- cannot d/c or increase fluids--> hypoglycemia
-blood transfusion--> can d/c it -->anaphylic reaction
The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider?
Pale bluish coloration of the toes.
-skin traction: force is applied to the skin
-skeletal traction: pin or wire applies pull directly to the distal bone fragment
A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?
The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her. Correct
-room air is 21%, since the oxygen hood is at 35% the baby needs the oxygen hood. offer an alternative like stroke the patient and offer reassurance
The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand?
aersol therapy then postural drainage before meals or 1 hour after
aerosl therapy loosens up the secretions, then psutral drainage moves it up
The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain?
Type of reaction to loud noises. Correct
ototoxicity can cause tinnitus and vertigo in children if the mother uses aspirin during pregnancy. aspirin side effect of tinnitus only occurs during utero.
-NO RISK FOR BLEEDING FOR THE INFANT, ONLY THE MOTHER
The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's repeated hospitalizations. Which is the best response that the nurse should offer?
Encourage the mother to have the children visit the hospitalized sibling. Correct
-remember: incorporate a house environment, prevent separation anxiety and allow sibling visitors to decrease stress and anxiety
seperation anxiety- toddler or pre school
toddler greatest threat
The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?
Engage the child through drawing pictures.
-since babies are egocentric, they do things on their own and draw. this will allow the nurse to assess the picture
The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching?
Using a teaspoon will help me measure this correctly. Correct
Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.)
1. child height + weight
2. body surface area of the child
3. nomogram determined mathematical consent
Which restraint should be used for a toddler after a cleft palate repair?
Elbow restraints post op
during procedure: use mummy restraint
When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline?
Parental control should be consistent.
consistent parenting will prevent misbehaver of children.
consistent parents will prevent misinterpretation of rules.
A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?
Steatorrhea is foul smelling stools and float because of excess grease on the poop
The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child's cooperation?
remember: iron causes staining of the teeth, allow the child to drink the a straw
Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant?
A thin stratum corneum that increases topical absorption. Correct
infaints have a thin skin called the stratum corneum--> this will increase topical absorption
A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?
treat with RICE
A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child's care?
-hydration #1 priority to prevent viscosity of blood.
-since the sickle cell can impact the spleen, liver, kidney, bones and CNS--> can increase for for infection d/t no function of the spleen. need to administer immunization shots
The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?
low neutrophil count = risk for infection because body is no longer fighting the infection
high neutrophil count= you have an infection and body is fighting it off
A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?
any burn patient: always remember ABC!
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