HESI RN PEDIATRIC QUESTION AND ANSWERS

HESI RN PEDIATRIC QUESTION AND ANSWERS 1. The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider? Points Earned: 0.0/1.0 Correct Answer(s): A 2. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 3. Which finding in a 19-year-old female client should trigger further assessment by the nurse? Points Earned: 0.0/1.0 Correct Answer(s): A 4. A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder? Points Earned: 0.0/1.0 Correct Answer(s): A 5. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 6. 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? 7. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 8. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 9. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 10. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 11. To take the vital signs of a 4-month-old child, which order provides the most accurate results? Points Earned: 0.0/1.0 Correct Answer(s): A 12. Preoperative nursing care for a child with Wilms' tumor should include which intervention? 13. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 14. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 15. When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it Points Earned: 0.0/1.0 Correct Answer(s): D 16. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 17. A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? Points Earned: 0.0/1.0 Correct Answer(s): A 18. A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior? Points Earned: 0.0/1.0 Correct Answer(s): C 19. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 20. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 21. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 22. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 23. A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? Points Earned: 0.0/1.0 Correct Answer(s): A 24. The nurse observes a 4-year-old boy in a daycare setting. Which behavior would the nurse consider normal for this child? Points Earned: 0.0/1.0 Correct Answer(s): C 25. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 26. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 27. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 28. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 29. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 30. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 31. Which restraint should be used for a toddler after a cleft palate repair? Points Earned: 0.0/1.0 Correct Answer(s): C 32. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 33. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 34. During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement? Points Earned: 0.0/1.0 Correct Answer(s): C 35. When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children? Points Earned: 0.0/1.0 Correct Answer(s): D 36. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 37. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 38. During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing? Points Earned: 0.0/1.0 Correct Answer(s): B 39. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 40. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 41. A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child? Points Earned: 0.0/1.0 Correct Answer(s): B 42. 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 . Points Earned: 0.0/1.0 Correct Answer(s): B 43. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 44. Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant? . Points Earned: 0.0/1.0 Correct Answer(s): B 45. To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? Points Earned: 0.0/1.0 Correct Answer(s): A 46. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 47. Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.) Points Earned: 0.0/3.0 Correct Answer(s): A, C, F 48. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 49. The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits? Points Earned: 0.0/1.0 Correct Answer(s): D 50. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 51. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 52. Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations? Points Earned: 0.0/1.0 Correct Answer(s): A 53. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 54. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 55. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 56. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 57. The nurse is planning care for school-aged children at a community care center. Which activity is best for the children? Points Earned: 0.0/1.0 Correct Answer(s): B 58. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 59. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 60. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 61. What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? Points Earned: 0.0/1.0 Correct Answer(s): D 62. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 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? Points Earned: 0.0/1.0 Correct Answer(s): B 64. Which behavior should the nurse expect a two-year-old child to exhibit? Points Earned: 0.0/1.0 Correct Answer(s): C 65. The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication? Points Earned: 0.0/1.0 Correct Answer(s): A 66. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 67. 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? Points Earned: 0.0/1.0 Correct Answer(s): A When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline? Points Earned: 0.0/1.0 Correct Answer(s): A 69. 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? Points Earned: 0.0/1.0 Correct Answer(s): D 70. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 71. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 72. 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? Points Earned: 0.0/1.0 Correct Answer(s): C Which action by the nurse is most helpful in communicating with a preschool-aged child? Points Earned: 0.0/1.0 Correct Answer(s): B 74. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 75. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 76. 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? Points Earned: 0.0/1.0 Correct Answer(s): A 77. When assessing a child with asthma, the nurse should expect intercostal retractions during Points Earned: 0.0/1.0 Correct Answer(s): A 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? Points Earned: 0.0/1.0 Correct Answer(s): B 79. Which class of antiinfective drugs is contraindicated for use in children under 8 years of age? Points Earned: 0.0/1.0 Correct Answer(s): B 80. 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 Points Earned: 0.0/1.0 Correct Answer(s): C 81. 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? Points Earned: 0.0/1.0 Correct Answer(s): C 82. 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? Points Earned: 0.0/1.0 Correct Answer(s): B 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.) Points Earned: 0.0/4.0 Correct Answer(s): A, B, D, E 84. 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? Points Earned: 0.0/1.0 Correct Answer(s): C HESI RN PEDIATRICS QUESTIONS & ANSWERS 1. The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child's crying during the recovery period? A. Tear formation increases salivation. B. This behavior increases respirations. C. Excessive hysteria can lead to vomiting. D. Crying stresses the suture line Rationale: Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes options A, B, and C, these conditions do not create a problem for the child with a cleft lip repair. 2. An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab stat. Rationale: Sinus bradycardia (heart rate 90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority. Option A is not indicated at this time. Option C provides helpful assessment data but does not address the cause of the problem and delays needed intervention. Option D is indicated for a serious, life-threatening overdose with digoxin. 3. The nurse admits a child to the intensive care unit with a possible diagnosis of Wilms tumor - What is the most safety precaution for child? A. maintain NPO status B. Limit visitors to the immediate family C. Place a do not palpate abdomen sign on head of bed D. Encourage ambulation in the pre-operative period Rationale: Protect child from injury; place a sign on bed stating "no abdominal palpation" (to prevent accidental fragmentation and dislodging into the abdominal cavity). The other option choices are not relevant at this time. 4. The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease? A. Turkey salad, milk, and oatmeal cookies B. Baked chicken, coleslaw, soda, and frozen fruit dessert C. Tuna salad sandwich on whole wheat bread, milk, and ice cream D. Turkey sandwich on rye bread, orange juice, and fresh fruit Rationale: A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats, wheat, rye, or barley. 5. A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. Which nursing intervention should be included in this child's plan of care? A. Keep restraints on at all times to prevent unplanned extubation. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities. D. Document the reason for application of the restraints every 72 hours. Rationale: Removing restraints one at a time is safer than option C. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously. Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in the medical record. 6. The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP? A. Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care. D. Report any pain that the child experiences. Rationale: All these are important measures to review with the UAP, but the most important is option A. Improper use of isolation precautions can place other staff and clients at risk for infection. Options B, C, and D promote client comfort and reduce anxiety but are of a lower priority than option A. 7. The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a surgical procedure. Which action should the nurse take first? A. Evacuate the bowel of impacted feces B. Admnister magnesium sulfate C. Place the child on a clear liquid diet D. Assess the stool for white color Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day; then magnesium sulfate is administered for bowel evacuation. A barium enema is likely to cause option A. After the enema, white stool may be seen as the body naturally removes any remaining barium. 8. A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical examination. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors commonly associated with DDH. Which response is accurate? A. Vertex delivery B. Male gender C. Breech presentation D. Second-born child Rationale: Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech position, not the vertex (head-first) position. Twice as many females as males present in the breech position; thus, 80% of children with DDH are females, not males. Of breech presentations, 60% occur with first-born children, not subsequent siblings, possibly because of the unstretched uterus and compaction of the surrounding abdominal contents, which tend to increase compression on the uterus in the nulliparous woman. 9. The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider? A. Sits or squats frequently when playing outdoors B. Exhibits a sudden and unexplained weight gain C. Is not completely toilet-trained and has some accidents D. Demonstrates irritation and fatigue 1 hour before bedtime Rationale: Sudden and unexplained weight gain can indicate fluid retention and is a sign of congestive heart failure. Option A is used by the child to reduce chronic hypoxia, especially during exercise. Option C is common; 2-year-olds are not expected to be toilet-trained. Option D is normal. 10. A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit? A. Shortness of breath B. Joint pain C. Persistent cold D. Organomegaly Rationale: Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection. Options A, B, and D are symptoms of AIDS complications that may occur later as the disease progresses. 11. Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed? A. "I will give her a baby aspirin every 4 hours as needed for fever." B. "I will call the clinic if her cry becomes high- pitched or unusual." C. "I know I can expect her to be irritable over the next 2 days." D. "I will exercise her legs regularly to decrease the soreness." Rationale: Although fever may occur, non–aspirin-containing medications should be used because of the risk of Reye syndrome. Option B indicates a severe reaction, whereas option C is a common side effect. Option D decreases soreness in the thigh injection site. 12. Which preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? A. Monitor for signs of metabolic acidosis. B. Estimate the quantity of diarrhea stools. C. Place in a supine position after feeding. D. Observe for projectile vomiting. Rationale: Projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic alkalosis. Metabolic acidosis is the opposite imbalance from alkalosis and is not an expected finding. An antidiarrheal agent is not indicated. Option C is dangerous because of the potential for aspiration with frequent vomiting. 13. A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which intervention should the nurse implement first? A. Place a mask on the child before transporting the child outside the room. B. Immunize exposed family members with the varicella vaccine. C. Place the child in strict isolation to prevent an outbreak on the unit. D. Determine which staff have had varicella before making assignments. Rationale: The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only personnel assigned to care for this client. Option A is not sufficient to prevent exposure to others. Option B must be done prior to exposure. 14. The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this child to exhibit? A. Throws a temper tantrum when told he must share the toys. B. Plays by himself for most of the day. C. Boasts aggressively when telling a story. D. Cries and is fearful when separated from his parents. Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales. Options A and D are typical toddler behaviors. A preschooler's play is usually cooperative, so playing alone is not typical. 15. 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. Based on these findings, what action should the nurse take? A. No action is required because this is an expected finding for a school-aged child. B. Ask if the child has had a cold, runny nose, or any ear pain lately. C. Send a note home advising parents to have the child evaluated by a health care provider. D. Call the parents and have them take the child home from school for the rest of the day. Rationale: More information is needed to interpret these findings. The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Because these findings are not completely normal, further assessment of history and related signs and symptoms are needed to interpret the findings accurately. Based on the data obtained from the otoscope examination, options A, C, and D are not indicated. 16. When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority? A. Administering oxygen therapy continuously B. Restricting fluids as ordered C. Maintaining adequate hydration D. Maintaining digoxin levels Rationale: The key word in this question is polycythemia. Hydration decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia. Options A and D are nursing interventions for the cardiac client but do not treat polycythemia. Fluid intake should be increased, not restricted. 18. The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement? A. Assess the child's mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child's food likes and dislikes. D. Ask the parents about the child's recent dietary intake. Rationale: An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit and then implement options B, C, and D. 19. When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement? A. Use a blanket as a mummy restraint. B. Monitor the infant's heart rate. C. Lubricate the catheter with saline. D. Explain the procedure to the parents. Rationale: All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant's heart rate, which may decrease because of vagal nerve stimulation and can occur when the tube is inserted. Options A, C, and D are of lower priority than option B. 20. In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses Rationale: Diminished femoral pulses could indicate coarctation of the aorta. In the normal transition period, options A and B occur during the 4 to 6 hours after birth (second period of reactivity). Option C is a normal finding in the newborn. 21. At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions? A. Inspiration B. Coughing C. Apneic episodes D. Expiration Rationale: Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring. During apnea, the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent. 22. Which interventions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) A. Provide a low-fiber diet. B. Administer mineral oil daily. C. Decrease the daily fluids. D. Eliminate dairy products. E. Initiate consistent toileting routine. Rationale: Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet, not option A, and increased daily fluids, not option C, are components of care for a child with encopresis. 23. The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is the most likely cause of the child's impaired mobility? A. Pathologic fractures B. Poor alignment of joints C. Dyspnea on exertion D. Joint inflammation Rationale: Joint inflammation and pain are the typical manifestations of an exacerbation of JRA. Options A, B, and C are not specifically related to JRA. 24. A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning. D. Apply water-soluble lubricant to the suture line Rationale: The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring. 25. A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first? A. Obtain a scale to weigh the infant's diapers. B. Instruct the mother to offer Pedialyte regularly. C. Insert an intravenous (IV) line and begin IV fluids. D. Obtain a stool specimen for analysis. Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids to rehydrate the infant. Options A, B, and D can then be implemented as needed. 26. The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse? A. "Tell me what you know about birth control." B. "Do you know how to apply a condom?" C. "Teen pregnancy should not be taken lightly." D. "You need to visit with your guidance counselor." Rationale: Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception. It would be best for the nurse to ask a more general question, such as option A. Option B is narrow in focus. Options C and D are blocks to any further communication. 27. A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need? A. 400 calories/day B. 500 calories/day C. 600 calories/day D. 700 calories/day Rationale: An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to 10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1° F temperature elevation. Ten percent of 540 (calories/day) is 54, and 540 + 54 = 594. This infant will require approximately 600 calories/day. Options A, B, and D are incorrect. 28. The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs? A. Place the child's head flat, with the knees on pillows above the level of the heart. B. Have the child lie on the right side, with the head elevated on one pillow. C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated. D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths. Rationale: Assuming a knee-chest position with the head and chest slightly elevated will help restore hemodynamic equilibrium. Options A and B are incorrect positions and may hinder the child's condition. Option D may cause chest pain or a vasovagal response, with resulting hypotension. 29. A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome? A. Presence of a systolic murmur B. New onset of patchy alopecia C. Complaints of long bone pain D. Recent projectile vomiting Rationale: Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly. Options B, C, and D are not recognized as common complications of trisomy 21. 30. The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client? A. Remove the brace 1 hour each day for bathing only. B. Remove the brace only for back range-of-motion exercises. C. Wear the brace against the bare skin to ensure a good fit. D. Wearing the brace will cure the spinal curvature. Rationale: The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis. 31. Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A. Adjustment of orthodontic appliances or braces B. Loss of deciduous teeth (baby teeth) C. Urinary catheterization D. Insect bites Rationale: Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization is an invasive procedure. Options A, B, and D are not invasive and do not require administration of prophylactic antibiotics. 32. A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse? A. "My son often chokes while I am feeding him." B. "Is it normal for my child's legs to cross each other?" C. "He gets stiff when I pull him up to a sitting position." D. "My 4-year-old son is jealous of his little brother." Rationale: Airway obstruction is always a priority when caring for any client. Options B and C are characteristics of spastic cerebral palsy and may involve one or both sides. These children have difficulty with fine motor skills, and attempts at motion increase abnormal postures. Option D is an expected behavior and may need to be addressed, but it is not a priority over choking. 33. Which nursing diagnosis has the highest priority when planning care for an infant with eczema? A. High risk for altered parenting related to feelings of inadequacy B. Altered comfort (pruritus) related to vesicular skin eruptions C. Altered health maintenance related to knowledge deficit of treatment D. Risk for impaired skin integrity related to eczema Rationale: Altered comfort (pruritus) has the highest priority because itching will cause the infant to scratch, creating complications such as scarring or infection. Options A, C, and D are all important nursing diagnoses and should be considered when developing the infant's plan of care, but they do not have the priority of option B. 34. The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further assessment reveals that he is concerned about his edematous facial features. Based on these assessment findings, the nurse should plan interventions related to which nursing diagnosis? A. Social isolation B. Altered health maintenance C. Knowledge deficit D. Ineffective coping Rationale: Peer acceptance and body image are significant issues in the growth and development of adolescents. Option A addresses the problem of a lack of contact with peers stemming from his desire to protect his ego. Options B, C, and D are not supported by the assessment finding. 35. A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit? A. Bone pain, pallor B. Weakness, tremors C. Nystagmus, anorexia D. Fever, abdominal distention Rationale: Option A lists the most common presenting symptoms of leukemia. Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor. Options B and C could be associated with central nervous system disorders. Option D commonly occurs in children but is not specific for leukemia. 36. A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally. Which intervention has the highest priority? A. Determine if the child has any allergies to antibiotics. B. Instruct the parent to give the child tepid baths. C. Instruct the parent to increase the child's fluid intake. D. Tell the parent to take the child to the emergency department. Rationale: The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation. Options A, B, and C are all valuable interventions after the client is assessed and diagnosed. 37. A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the first time tomorrow. During the school day, which intervention should be implemented for this child? A. Cover the tracheostomy site with clothing so that other children will not notice. B. Apply suction for 30 seconds when inserting a catheter into the stoma. C. Discourage the child from coughing deeply to remove mucous secretions. D. Place suctioning supplies on the back of the wheelchair when transporting. Rationale: Suctioning supplies should always be readily available for use with any client who has a tracheostomy. Options A, B, and C do not describe safe practices for this child with a tracheostomy. 38. An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement? A. Teach the parents how to ambulate the child in the room safely. B. Show the parents how to hold the child with the extremity extended. C. Restrain the child's lower extremities for a minimum of 4 hours. D. Place the child in a prone position to apply pressure to the site. Rationale: The extremity should be extended to prevent trauma to the femoral catheterization site. Options A and D increase the risk for complications and are contraindicated. Option C is not necessary. Only the extremity that was catheterized requires immobilization. 39. A burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. When calculating the percentage of burn, which parts of the child's body are proportionally larger than an adult's? A. Head and neck B. Arms and chest C. Legs and abdomen D. Back and abdomen Rationale: The standard rule of nines is inaccurate for determining burned body surface areas with children because a child's head and neck are proportionately larger than an adult's. Specially designed charts are commonly used to measure the percentage of burn in children. Options B, C, and D are not proportionately different. 40. The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about the prevention of accidental poisonings. It is most important for the nurse to include which instruction? A. Tell children that they should not taste anything but food. B. Store all toxic agents and medicines in locked cabinets. C. Provide special play areas in the house and restrict play in other areas. D. Punish children if they open cabinets that contain household chemicals. Rationale: The only reliable way to prevent poisonings in young children is to make the items inaccessible. Teaching children not to taste anything but food is important but ineffective for young children. Options C and D will not control a child's curiosity. 41. Which nursing interventions are therapeutic when caring for a hospitalized toddler? (Select all that apply.) A. Require parents to leave the room when performing invasive procedures. B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures. D. Insert a urinary catheter if bedwetting occurs during hospitalization. E. Do not allow any toys to be brought in from the child's home. Rationale: Giving the toddler a choice may increase autonomy in the hospitalized setting. Brief but simple explanations are beneficial with the toddler. Separation from the parent can cause emotional distress. Regression is expected, and bedwetting is not an indication for a urinary catheter. The nurse should encourage age-appropriate toys to be brought in from home. 42. A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother? A. Watch the boy a few more days and see if the cough begins to produce sputum. B. The full 10-day course of antibiotics must be completed before effectiveness can be evaluated. C. Give the child plenty of fluids and an over-the- counter cough suppressant. D. Bring the child to the clinic today for an examination related to the cough. Rationale: The child should be evaluated as soon as possible for pneumonia. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production. Option B delays evaluation too long. Although giving fluids is advisable, cough suppressants might mask symptoms of a serious condition. 42. A nurse is preparing to end the shift and receives a laboratory report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take? A. Communicate the result to the oncoming nurse and document. B. Tell the oncoming nurse that the level is dangerously high. C. Ask the laboratory to redo the test because the result is faulty. D. Hold the next dose of theophylline based on this finding. Rationale: The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report. Based on the laboratory finding, options B, C, and D are not indicated. 43. Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains 250 mg/5 mL. How many milliliters should the nurse administer in one dose? A. 10 B. 15 C. 20 D. 25 Rationale: 2.2 lb/1 kg = 22 lb/x kg x = 10 kg 1 kg/75 mg = 10 kg/x mg x = 750 mg 250 mg/5 mL = 750 mg/x mL x = 15 mL 44. Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery? A. Crying that is unrelieved by comforting measures B. Presence of an inguinal bulge after gentle palpation C. Refusal to take oral feedings D. Straining during defecation Rationale: The parents should notify the health care provider if the hernia remains irreducible after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release. Options A and D may cause the hernia to protrude but do not necessitate notification of the health care provider. Option C may not be specific to the hernia. 45. A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take? A. Send the child home with the parents to see the health care provider before returning to school. B. Send the child home with the parents and report this to the health department. C. Cover the lesion with a dry gauze dressing and send the child back to class. D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class. Rationale: Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition. Option B is not necessary because this is not a public health hazard. Option C slows the healing process and can contribute to spread of the infection. The lesions should be washed with soap and water, topical ointment applied, and left open to the air to dry. This will occur at the child's home. 46. The nurse expects a 2-year-old child to exhibit which behavior? A. Build a house with blocks. B. Ride a small tricycle 6 feet. C. Display possessiveness with toys. D. Look at a picture book for 15 minutes. Rationale: Two-year-old children are egocentric and unable to share with other children. Options A, B, and D are behaviors of a preschooler. 47. A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman? A. "You can prevent SIDS if your baby sleeps on the side or back. You will have to monitor the baby carefully." B. "The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?" C. "An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind that you need." D. "My neighbor's baby died of SIDS last year, and she went to a SIDS support group. That really helped her." Rationale: The most effective way to provide emotional support is to acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions. Option A implies to the mother that she can prevent SIDS from occurring, which is an unrealistic expectation. Offering a personal opinion about what will help this client or about what has helped a neighbor is not as effective as helping the client discover what would be best for her. 48. A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is the nurse addressing when teaching inhalation therapy? A. Autonomy B. Industry C. Trust D. Initiative Rationale: Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson theory of psychosocial development. They enjoy being active and participating in role playing. "Autonomy vs. Shame and Doubt" occurs at 1 to 3 years of age. "Industry vs. Inferiority" occurs at 6 to 11 years; "Trust vs. Mistrust" occurs from birth to 1 year of age. 49. Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) Select option(s), then click Submit. A. Steatorrhea B. Obesity C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion Rationale: Options A, C, D, and E are all common assessment findings in the client with cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis. 50. The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child? A. "Our first child was born with a cleft lip." B. "We are very careful not to get sunburns in our family." C. "My first child sometimes got a diaper rash." D. "My husband and our daughter are both lactose- intolerant." Rationale: Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis because milk allergies can contribute to the child's outbreaks. Option A is not a contributing factor. Option B is an environmental factor in other skin diseases but does not have a strong correlation with eczema in children. Option C is not unusual and occurs in the diaper area, whereas atopic dermatitis occurs most often on the face and extensor aspects of the arms and legs