Peds ATI 2019 B

A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use?

a. FACES
b. Numeric
c. CRIES
d. Visual analog
Click the card to flip 👆
1 / 56
Terms in this set (56)
A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use?

a. FACES
b. Numeric
c. CRIES
d. Visual analog
A
A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?

a. "allow your child to play outside during the hours between 10:00am and 2:00pm."
b. "choose a waterproof sunscreen with a minimum SPF of 15."
c. "dress you child in loose weave polyester fabric prior to sun exposure."
d. "reapply sunscreen every 4 hours."
B
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?

a. an 18 month old toddler who has unintelligible speech
b. a 3 month old infant who has exaggerated startle response
c. a 4 year old preschooler who prefers playing with others rather than alone
d. an 8 month old infant who is not yet making babbling sounds
D
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?

a. HR 124
b. increased tear production
c. sunken anterior fontanel
d. capillary refill 2 seconds
C
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching?

a. "limit movement of the child's large joints"
b. "encourage the child to perform independent self-care."
c. "provide the child with a soft mattress for sleeping."
d. "schedule a 2 hour daily nap for the child in the afternoon."
B
A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan?

a. use sterile scissors to remove the dressing from the site
b. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in use
c. access the site suing a noncoring angle needle
d. use a semipermeable transparent depressing to cover the site
D
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include?

a. controls impulsive feelings
b. understands right from wrong
c. easily separates from parents for long periods of time
d. expresses likes and dislikes
D
A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include?

a. "you should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing."
b. "you should monitor your child's weight weekly while they are receiving inhaled corticosteroids therapy."
c. "pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy."
d. "when using the peak expiratory flow meter, record your child's average of three readings."
C
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?

a. reports an absence of nausea and vomiting
b. reports experiencing an onset of loose stools within 15 minutes of administration
c. serum potassium level 4.1 mEq/L
d. blood pressure 86/52 mm Hg
C
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider?

a. nasal flaring
b. WBC count 11,300/mm^3
c. diarrhea
d. abdominal distension
A
A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? a. "my child can resume usual activities since this year just an outpatient surgery." b. "my child will be able to drink the chocolate milkshake I promised to get for them tonight." c. "I will notify the doctor if I notice that my child is swallowing frequently." d. "I will have my child gargle with warm salt water to relieve their sore throat."CA nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? a. inform the parents that written consent is required prior to organ donation b. provide written information to the parents about organ donation c. ask the provider to explain misconceptions of organ donation to the parents. d. explore the parents feelings and wishes regarding organ donationDA nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? a. Desmopressin b. Luteinizing hormone-releasing hormone c. Recombinant growth hormone d. LevothyroxineCA nurse is providing discharge teaching to he parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include? a. "clean your baby's sutures daily with a mixture of chlorhexidine and water." b. "expect your baby to swallow more than usual over the next few days." c. "inspect your baby's tongue for white patches using a tongue depressor every 8 hours." d. "apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."DA nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? a. palpate the dorsum of the child's feet b. weigh the child daily using the same scale c. assess the child's skin turgor d. observe the child for periorbital swellingAA nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes incipidus? a. urine specific gravity 1.045 b. sodium 155 mEq/L c. blood glucose 45 mg/dL d. urine output 35 mL/hrBA school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? a. "I will plan to increase the amount of homework I assign to students who have ADHD." b. "I will give students who have ADHD the same amount of time as other students to complete tests." c. "I will allow students who have ADHD one rest break throughout the day." d. "I will teach challenging academic subjects to students who have ADHD in the morning."DA nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will offer my child small amounts of fruit juice frequently." b. "I will avoid giving my child solid foods until the diarrhea has stopped." c. "I will monitor my child's number of wet diapers." d. "I will give my child polyethylene glycol daily for 7 days."CA nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? a. "Stay home from school for 1 week following the procedure." b. "follow a diet that is low in fiber for 1 week." c. "wait 3 days before taking a tub bath." d. "apply a pressure dressing to the site for 3 days."CA nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? a. administer pancreatic enzymes 2 hours after meals b. discontinue the use of pancreatic enzymes if steatorrhea develops c. limit fluid intake to 750 mL per day d. increase fat content in the child's diet to 40% of total calories.DA nurse is admitting an infant who has intussesception. Which of the following findings should the nurse expect? (select all that apply) a. steatorrhea b. vomiting c. lethargy d. constipation e. weight gainB, CA nurse is assessing an 8 year old child who has early indication of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? a. insert an indwelling urinary catheter b. measure weight and height c. initiate IV access d. maintain ECG monitoringCA nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? a. "I should buy plastic shoes to wear at the swimming pool." b. "I should wear sandals as much as possible." c. "I should place the permethrin cream between my toes twice daily." d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."BA nurse is caring for a school age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? a. deep respirations of 32/min b. shallow respirations of 10/min c. paradoxic respirations of 26/min d. periods of apnea lasting for 20 secondsAA nurse is assessing a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? a. presence of a central incisor tooth b. presence of strabismus c. presence of an open anterior fontanel d. presence of external cerumenBA charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority? a. length of stay b. treatment schedule c. disease process d. self-care abilityCA school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? a. check the child for a head injury b. observe for oral bleeding c. check the child's respiratory rate d. observe for extremity weaknessCA nurse is caring for a toddler who has acute otitis media and a temperature of 40 degree C (104 degrees F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? a. apply a cooling blanket to the toddler b. dress the toddler in minimal clothing c. give the toddler a tepid bath d. administer diphenhydramine to the toddlerBA nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? a. until the adolescent is afebrile b. for 7 days following admission to the facility c. until the adolescent has a negative blood culture d. for 24 hrs following initiation of antimicrobial therapyDA nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? a. have the adolescent sign a consent form for treatment b. instruct the adolescent to return with a guardian c. obtain consent from the adolescent's guardian over the phone d. treat the adolescent without a consent formAA nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize that infant's pain? a. Use a manual lancet to obtain the heel blood sample b. apply an ice pack to the infant's heel prior to obtaining the sample c. allow the mother to breastfeed while the sample is being obtained d. apply a topical lidocaine cream prior to obtaining the sampleCA nurse is receiving change of shift report for four children. Which of the following children should the nurse assess first? a. a toddler who has a concussion and an episode of forceful vomiting b. an adolescent who has infective endocarditis and reports having a headache c. an adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0-10 d. a school age child who has acute glomerulonephritis and brown-colored urineAA community health nurse is assessing an 18 month old toddler in a community day care. Which of the following findings should a nurse identify as a potential indication of physical neglect? a. resists having an axillary temperature taken b. exhibits withdrawal behaviors when their parent leaves c. has multiple bruises on their knees d. poor personal hygieneDA nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? a. avoid palpating the abdomen when bathing the child before surgery b. refrain form auscultating the child's bowel sounds during the postoperative assessment c. encourage the child to play with other children on the unit prior to surgery d. explain to the child that their pain will be managed after the surgeryAA nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a. "When your child no longer has an increased temperature." b. "Three days after you first noticed the rash appear on your child." c. "When you child's lesions are crusted, usually 6 days after they appear." d. "Two to three weeks, when your child's lesions completely disappear."CA nurse is providing dietary teaching to the guardian of a school age child who has cystic fibrosis. Which of the following statements should the nurse make? a. "You should offer your child high protein meals and snacks throughout the day." b. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." c. "You should restrict your child's calorie intake to 1200 per day." d. "you should give your child a multivitamin once weekly."AA nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? a. 1/2 cup whole milk b. 1 cup orange juice c. 1/2 cup raisins d. 1 cup raw carrotsCA nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? a. decreased edema b. increased abdominal girth c. decreased appetite d. increased protein in the urineAA nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? a. "Use a kitchen teaspoon to measure the medication." b. "Brush the child's teeth after giving the medication." c. "double the next dose if the child misses a dose." d. "repeat the dose if the child vomits."BA nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hours ago. The nurse should instruct the guardians to report which of the following findings to the provider? a. capillary refill time less than 2 seconds b. restricted ability to move the toes c. swelling of the casted foot when the leg is dependent d. pedal pulse +3 bilateralBA nurse in an emergency department is caring for a school age child who has epiglottitis. Which of the following actions should the nurse take? a. obtain a throat culture form the child b. monitor the child's oxygen saturation c. put a warm mist humidifier in the child's room d. place the child in the supine positionBA nurse is providing discharge teaching to the parents of a 6 month old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? a. "you may bathe your infant in an infant bathtub when you go home." b. "apply hydrocortisone cream to your infant's penis daily." c. "you should clamp your infant's stent twice daily." d. "allow the stent to drain directly into your infant's diaper."DA nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? a. wrist b. great toe c. index finger d. heelBA nurse is reviewing the laboratory results of a school age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? a. erythrocyte sedimentation rate 10mm/hr b. WBC count 6200/mm^3 c. c-reactive protein 1.4mg/L d. RBC count 4.7 million/mm^3AA nurse in an emergency department is caring for a school age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? a. administer the tetanus toxoid vaccine if more than 1 year since the prior dose b. apply an antimicrobial ointment to the affected area c. leave the burn area open to air d. place an ice pack on the affected areaBA nurse is an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (select all that apply.) a. increased temperature b. gingival hyperplasia c. xerophthalmia d. bradycardia e. cervical lymphadenopathyA, C, EA nurse is planning developmental activities for a newly admitted 10 year old child who has neutropenia. Which of the following actions should the nurse plan to take? a. provide the child with a book about adventure b. arrange frequent visits from family members and peers c. give the child a large piece puzzle d. use puppets to entertain the childAA nurse is planning an educational program for school age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? a. the child should be able to stand on the balls of their feet when sitting on the bike b. the child should ride their bike 2 feet to the side of other bike riders c. the child should wear dark colored clothing with a fluorescent stripe when riding at night d. the child should ride the bike facing traffic when it is necessary to tide in the streetAA nurse is assessing a school age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. hypotension b. reports insomnia c. difficulty concentrating d. tachycardiaCA nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching? a. "Mononucleosis is caused by an infection with the Epstein-Barr virus." b. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." c. "A monospot is a throat culture used to diagnosis mononucleosis." d. "Children who get mononucleosis will need to refrain form sports for 6 months."AA nurse is planning care for a newly admitted school age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? a. ensure that a padded tongue blade is at the child's bedside b. allow the child to play video games on a tablet computer c. allow the child to take a tub bath independently d. ensure the oxygen source is functioning in the child's roomDA nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take? a. place the infant in a knee-chest position b. administer a dose of meperidine IV c. discontinue administration of IV fluids d. apply oxygen at 2L/min via nasal cannulaAA nurse is creating a plan of care for a child who has varicella. which of the following interventions should the nurse include? a. maintain the child's room temperature at 80 degrees F b. prepare the child for a lumbar puncture c. administer aspirin to the child for a temperature greater than 38.3 degrees C (101 degrees F) d. initiate airborne precautions for the childDA nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching a. "scold your child when they have toileting accident." b. "award your child with a sticker when they sit on the potty chair." c. "play your child's favorite song while teaching them to use the potty chair." d. "teach multiple steps of the skill at the same time."BA nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? a. furosemide b. captopril c. regular insulin d. potassium chlorideDA nurse is teaching the guardian of a 6 month old infant about teething. Which of the following statements should the nurse make? a. "your baby might pull at their ears when they are teething." b. "rub your baby's gums with an aspirin to decrease discomfort." c. "place a beaded teething necklace around your baby's neck." d. "Your baby's upper middle teeth will erupt first."A