Nursing Care of Children Final ATI

Nursing Care of Children Final A 1) A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. When the child’s blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur. B. Give potassium as a rapid IV bolus. Giving potassium as a rapid IV bolus is contraindicated because it can result in cardiac arrest. C. Administer 3 units of ultralente insulin subcutaneously. Ultralente is long-acting insulin that takes 6 to 14 hr to begin working. Regular insulin will be given via IV infusion until the blood sugar reaches 250 to 300 mg/dL. If the regular insulin infusion continues, hypoglycemia can occur. D. Obtain an HbA1c level stat. An HbA1c level measures the blood glucose level over the last 2 to 3 months and will not give useful information for the client’s current status. 2) A nurse is caring for a child who has Tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm3 A platelet count of 20,000/mm3 is below the expected range. A child who has Tetralogy of Fallot will not have a decreased platelet count. B. WBC 4,000/mm3 A WBC count of 4,000/mm3 is below the expected reference range. A child who has Tetralogy of Fallot will not have neutropenia. C. Thyroid stimulating hormone 7.0 microunits/mL This TSH level is above the expected reference range. A child who has Tetralogy of Fallot will not have changes in the thyroid function levels. D. RBC 6.8 million/uL A child who has Tetralogy of Fallot causes cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts. 3) A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring in the child's stuffed animal. Encouraging parents to bring in a child’s favorite stuffed animal helps lessen the disruptiveness of hospitalization. B. Give the child choices when planning daily activities. Children who have autism have difficulty organizing behaviors; therefore, it is best to not give choices. C. Administer phenytoin three times per day. Phenytoin is taken by children who have seizure disorders. D. Provide a shared room with another child his age. Children who have autism need decreasing stimulation and avoidance of auditory or visual distraction. These children should have a private room. 4) A nurse is caring for a child who has a vesicular rash. The parents of the child asks the nurse what illness can cause this rash for 6 days. The nurse should expect that the child has which of the following conditions? A. Measles A child who has measles might develop Koplik spots, a transient cephalocaudal rash of maculopapular eruptions of the upper trunk and face, becoming more confluent as it spreads to the lower areas of the body. B. Fifth disease A child who has fifth disease usually begins with bright red cheeks producing a "slapped-cheek" appearance. Following this, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance to the rash. C. Tetanus A child who has tetanus will develop lockjaw and muscle rigidity; however, there is no rash associated with tetanus. Nurses recommend the DTaP immunization to aid in prevention of this disease. D. Varicella Children who have varicella might commence with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over. 5) A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelet count 500,000 mm3 A platelet count of 500,000 mm3 is above the expected reference range. A child who has acute lymphocytic leukemia has a low platelet count. B. RBC 2.5 million/uL An RBC of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC. C. WBC 4,000/mm3 A WBC of 4,000/mm3 is below the expected reference range. A child who has acute lymphocytic leukemia has a very high WBC. D. Hct 60% An Hct of 60% is above the expected reference range. A child who has acute lymphocytic leukemia has a low Hct level. 6) A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale A word graphic rating scale uses a line with words identifying a scale of no pain to worst possible pain. Children ages 4 to 17 place a line on the scale that describes their pain. Children who are 3 years old will have difficulty understanding the words. B. Color tool The color tool uses four markers for the child to represent pain at various levels. Children ages 4 and older can use this tool. Children who are 3 years old might have difficulty remembering what each marker represents. C. FACES pain rating scale The FACES scale is a scale that looks at various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels. D. Numeric scale Using a numeric scale from 0 to 10 to rate pain requires the child to understand numbers. This tool is helpful for children ages 5 and older. 7) A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a preoperative visit to the facility. A preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure. B. Inform the child he will be put to sleep during the procedure. After 9 years of age, a child understands concepts of death. The nurse should inform the child that he is taking a "special sleep" not that he is being "put to sleep". Children who have pets might refer to being "put to sleep" as death. C. Read the child a story about a cartoon character having a similar operation. Reading a cartoon book is developmentally appropriate for a preschoolage child or toddler. Participating in therapeutic play has benefits for those age groups. D. Tell the child the appointment is to have his throat checked. Children need factual information and explanations about what will happen during hospitalizations. 8) A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? A. "If you take too much insulin, drink a sugar-free cola." Sugar-free cola will not increase the blood sugar, because it does not contain sugar. Encourage the child to drink juice or milk and eat a complex carbohydrate. B. "You will need to decrease your insulin dosage when you become a teenager." Insulin requirements increase during puberty due to a decreased sensitivity to insulin, resulting in an increase in the child’s insulin dosage. C. "You can use a vial of insulin for up to 30 days." The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator. D. "Stop taking your insulin if you are vomiting