QUESTIONS AND DETAILED SOLUTIONS
EXPERT REVIEWED RESOURCE
●● Further evaluation need for an adolescent who has spina bifida
Answer: Cath themselves 4-5 times a day, watch for bed sores, wounds
●● Who could be in a room with a child with leukemia
Answer: No infection, nephrotic syndrome is om
●● Most reliable indicator of fluid loss
Answer: Obtaining daily weight, wet diapers, fluid outtake
●● Who should the nurse see first of 4 clients
Answer: ABC priority
●● Adolescent refusing treatment
Answer: Assess for reason why, educate and report to HCP
●● Who would an anti-streptolysin titer be ordered
Answer: Presence of streptococcal antibodies, shows that may have
already had strep
,●● 6 month old growth and development
Answer: Double their birth weight
Grow one in per month during first 6 mo
Begin teething
Begin to roll over
Sit with support
Posterior fontanelles closed
Raking grasp
●● School age child
Answer: industry vs inferiority
Focus on giving children opportunities to develop skills and achieve a
sense of accomplishment like participating in structured activities,
fostering independence
●● Findings for aortic stenosis
Answer: S4 heart sounds, chest pain, SOB, fatigue, difficulty walking,
rapid fluttering heartbeat, HYPOTENSION.
●● Nursing priority for rheumatic fever
Answer: Administer ordered antibiotics and monitor for signs of carditis
, ●● Findings for toddler who has heart failure
Answer: poor feeding, dyspnea, peripheral edema, TACHYCARDIA,
increase venous return to lungs and heart, pulmonary congestion-
crackles, orthopnea, weight gain.
●● Nursing instructions following a cardiac catheterization
Answer: give acetaminophen or ibuprofen for pain, stay home from
school for several days. Give child excess fluid to get rid of dye.
●● Plan of care for an infant needing lumbar puncture
Answer: Have patient in C position
●● Pulse rate needed to give digoxin
Answer: Newborn :110 and above
Infant: 90 and above
Toddler: 80 and above
Preschooler: 70 and above
School age : 60 and above
●● Nursing priority for patient seizing and vomiting
Answer: Ensure airway is clear, position patient on their side
●● Health promotion for adolescent