CAPSTONE – PEDS PREASSESSMENT
A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the following is an
expected finding? Suspended from school several times in the past year - Conduct disorder is an impulse-control disorder which
includes a long-term pattern of violating the rights of others and performing violent or hostile acts.
◦ Death of client's father two months ago Risk factors for conduct disorder include harsh discipline with inconsistent parenting
or growing up in an institutional environment. Death of the client's father two months ago could trigger a stress/trauma
disorder, such as acute stress disorder, but does not put the client at risk for conduct disorder.
◦ Experiences frequent facial tics A client who has Tourette's disorder often experiences facial and verbal tics and other motor
difficulties.
◦ Adheres strictly to routines A client who has autism spectrum disorder experiences difficulty with communication and
interaction with others, might also become fixated with certain objects, and adheres strictly to routines.
A nurse is planning care for a 6yo child who has bacterial meningitis. Which of the following interventions is UNNECESSARY in
the client PoC? Measure head circumference every shift. - The head circumference of a 6-year-old can't increase since the fontanels
and sutures have been closed since the child was 18 months old. Therefore, it is unnecessary to measure the child's head
circumference.
◦ Place the client in a semi-Fowler's position. A semi-Fowler's position, with the head of bed elevated to between 30° and 45°,
will help to reduce edema in the brain.
◦ Admit the client to a private room. Isolation for the first 24 hr is indicated for a client who has bacterial meningitis due to the
highly contagious nature of some types of bacterial meningitis. Decreasing the environmental stimuli is also an important action
in the care of a client who has meningitis.
◦ Implement seizure precautions. Seizure precautions are appropriate because the child has an increased risk for seizure
activity. The meningitis itself and corresponding brain edema and meningeal irritation can result in seizure activity. Meningitis
typically causes a very high fever, which increases the risk of febrile seizure.
A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the
nurse include in the teaching? "Restrict your child's intake of caffeine while she is taking this medication." - The nurse should
instruct the parents that the child should avoid caffeine while taking methylphenidate as it increases the stimulating effects of the
medication. Caffeine can also lead to irritability in the child.
◦ "Administer the medication at bedtime." The nurse should instruct the parents to administer methylphenidate no later than
1600. Early morning dosing is often recommended to enhance the child's ability to focus during school hours. Administration late
in the day can cause the child to experience insomnia.
◦ "Your child might gain weight while taking this medication." The nurse should instruct the parents that their child might lose
weight while taking methylphenidate. This medication is a stimulant and increases metabolism while suppressing the appetite.
◦ "This medication might increase the amount of saliva your child produces." The nurse should inform the parents that dry
mouth is a common adverse effect of methylphenidate. Other common adverse effects include restlessness, insomnia, weight loss,
and tachycardia.
A nurse is caring for a 6mo client who has sudden abdominal pain, vomiting, distended abdomen and red current jelly-like stools.
The nurse should know that these are signs for which of the following. Manifestations of appendicitis include: Abdominal pain;
generalized pain that typically begins at the peri-umbilical area and localizes to the right lower quadrant (pain may be most intense
at McBurney’s point, located about halfway between the anterior superior iliac crest and the umbilicus.); pain that increases with
movement; rigid abdomen; Fever, tachycardia, possible vomiting, constipation and/or diarrhea, anorexia, pallor, lethargy, and/or
irritability
◦ Hernia The manifestations presented indicate intussusception not a hernia.
Intussusception
Intussusception is the telescoping of the intestine over itself. This usually occurs in infants and young children up to 5 years of age, but
it is most common between 5 and 9 months of age. Manifestations include:
• Normal comfort interrupted by periods of sudden and acute pain
• Palpable, sausage-shaped mass in the right upper quadrant of the abdomen and/or a tender, distended abdomen
• Stools that are mixed with blood and mucus that resemble the consistency of red currant jelly
Pyloric stenosis
Manifestations of pyloric stenosis include:
◦ Vomiting that often occurs 30 to 60 min after a meal and becomes projectile as obstruction worsens
◦ Constant hunger
◦ Olive-shaped mass in the right upper quadrant of the abdomen and possible peristaltic wave that moves from left to right
when lying supine
, ◦ Failure to gain weight and signs of dehydration, such as skin that is dry and/or pale, cool lips, dry mucous membranes,
decreased skin turgor, diminished urinary output, concentrated urine, thirst, rapid pulse, sunken eyes, and decreased
blood pressure
a nurse is preparing to perform an abdominal assessment on a child. identify the sequence the nurse should follow (move the
steps into the box on the right, placing them in the selected order of performance. use all the steps) Inspection, Auscultation,
Superficial palpitation, Deep palpitation When performing an abdominal assessment on a child, the nurse should first inspect the
abdomen without touching and observe for anything that could indicate a medical concern. Because palpation prior to auscultation
can alter the bowel sounds, the nurse should auscultate the abdomen for bowel sounds next. Then, the nurse should palpate the
abdomen superficially so the child won’t tense her abdominal muscles. Finally, the nurse should perform a deep palpation of the
abdomen, making sure to palpate any painful areas last.
A nruse is caring for a 4yo child who has a new diagnosis of DM and is distressed after an insulin injection. Which of the following
play activities should the nurse recognize is therapeutic in helping the child deal with the injection? A needleless syringe and a doll
Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child, because they will allow the child to act
out feelings of anger and helplessness.
◦ A video game Playing a video game is a distraction and is useful for a child who is bored.
◦ A story book about a child who has diabetes This activity does not provide an outlet for working out the feelings that the child
is unable to verbalize at the age of 4.
◦ A period of play in the playroom Playing in the playroom is not a therapeutic activity in this situation.
A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the ff
developmental tasks should the nurse include as being expected of a preschooler? Participates in imaginary play - By 5 years of
age, a preschooler should participate in imaginary and creative play, play cooperatively with peers, and speak in complete
sentences.
◦ Controls impulsive feelings By 12 years of age, a school-age child's psychosocial development should include the ability to
control impulsive feelings.
◦ Builds a collection of cards By 12 years of age, a school-age child’s psychosocial development should include the ability to
collect small items, such as cards, stamps, rocks, and buttons.
◦ Expresses need for privacy By 12 years of age, a school-age child usually expresses a need for privacy when performing personal
hygiene, such as bathing or showering.
A nurse is providing care to a child who has an allergy to eggs. The nurse should question a prescription for which of the
following immunizations? Influenza, live attenuated (LAIV) - An egg allergy is a contraindication for receiving the LAIV vaccine.
Severe anaphylactic reactions can occur and pose life-threatening conditions for the child.
◦ Inactivated poliovirus (IPV) An egg allergy is not a contraindication for receiving the IPV vaccine. A severe allergic reaction to a
previous dose or to a component of the vaccine is a contraindication for receiving the IPV vaccine. The nurse can delay
administering the vaccine if the child has a moderate or severe acute illness with or without a fever.
◦ Haemophilus influenza type b (Hib) An egg allergy is not a contraindication for receiving the Hib vaccine. A severe allergic
reaction to a previous dose or to a component of the vaccine is a contraindication for receiving the Hib vaccine. The nurse can
delay administering the vaccine if the child has a moderate or severe acute illness with or without a fever.
◦ Hepatitis B (HepB) The HepB vaccine is contraindicated in individuals who have an allergy to baker's yeast.
A nurse is caring for a 10mo infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the strategies should
the nurse implement to promote the infant’s growth and development? Allow the infant to stand in the crib. - Allowing the child
to participate in normal developmental activities promotes growth and development. The infant can be held and allowed to walk in
a cast or orthotic device.
◦ Tie colorful latex balloons to the side of the crib. Toys that are tied to the side or strung across the crib are a safety hazard
that could cause the infant to suffocate. The nurse should keep latex balloons out of the infant’s reach.
◦ Provide a small electronic toy. Small electronic toys are a safety hazard. Electronic toys often have small batteries that can be
ingested. Electronic toys can also have heating elements and sharp edges that can cause injury to the skin.
◦ Change the infant's diaper as soon as soiling occurs. Maintaining hygiene is important because it promotes health, but it does
not promote growth and development. The nurse should keep the diaper area and cast clean without using lotions or powders.
These actions help maintain integrity of the skin.
.
A nurse is caring for a 6mo infant following surgery. Which of the ff should the nurse use to measure pain in this client? FLACC pain
scale - The FLACC scale is used for infants and children 2 months to 7 years. It is based on assessment of the following behavior
indicators: Facial expressions, Position of legs, Activity, Crying, Ability to be consoled.
◦ Oucher numeric scale. The client must be able to count to 100 by ones or tens to use this scale.
A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the following is an
expected finding? Suspended from school several times in the past year - Conduct disorder is an impulse-control disorder which
includes a long-term pattern of violating the rights of others and performing violent or hostile acts.
◦ Death of client's father two months ago Risk factors for conduct disorder include harsh discipline with inconsistent parenting
or growing up in an institutional environment. Death of the client's father two months ago could trigger a stress/trauma
disorder, such as acute stress disorder, but does not put the client at risk for conduct disorder.
◦ Experiences frequent facial tics A client who has Tourette's disorder often experiences facial and verbal tics and other motor
difficulties.
◦ Adheres strictly to routines A client who has autism spectrum disorder experiences difficulty with communication and
interaction with others, might also become fixated with certain objects, and adheres strictly to routines.
A nurse is planning care for a 6yo child who has bacterial meningitis. Which of the following interventions is UNNECESSARY in
the client PoC? Measure head circumference every shift. - The head circumference of a 6-year-old can't increase since the fontanels
and sutures have been closed since the child was 18 months old. Therefore, it is unnecessary to measure the child's head
circumference.
◦ Place the client in a semi-Fowler's position. A semi-Fowler's position, with the head of bed elevated to between 30° and 45°,
will help to reduce edema in the brain.
◦ Admit the client to a private room. Isolation for the first 24 hr is indicated for a client who has bacterial meningitis due to the
highly contagious nature of some types of bacterial meningitis. Decreasing the environmental stimuli is also an important action
in the care of a client who has meningitis.
◦ Implement seizure precautions. Seizure precautions are appropriate because the child has an increased risk for seizure
activity. The meningitis itself and corresponding brain edema and meningeal irritation can result in seizure activity. Meningitis
typically causes a very high fever, which increases the risk of febrile seizure.
A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the
nurse include in the teaching? "Restrict your child's intake of caffeine while she is taking this medication." - The nurse should
instruct the parents that the child should avoid caffeine while taking methylphenidate as it increases the stimulating effects of the
medication. Caffeine can also lead to irritability in the child.
◦ "Administer the medication at bedtime." The nurse should instruct the parents to administer methylphenidate no later than
1600. Early morning dosing is often recommended to enhance the child's ability to focus during school hours. Administration late
in the day can cause the child to experience insomnia.
◦ "Your child might gain weight while taking this medication." The nurse should instruct the parents that their child might lose
weight while taking methylphenidate. This medication is a stimulant and increases metabolism while suppressing the appetite.
◦ "This medication might increase the amount of saliva your child produces." The nurse should inform the parents that dry
mouth is a common adverse effect of methylphenidate. Other common adverse effects include restlessness, insomnia, weight loss,
and tachycardia.
A nurse is caring for a 6mo client who has sudden abdominal pain, vomiting, distended abdomen and red current jelly-like stools.
The nurse should know that these are signs for which of the following. Manifestations of appendicitis include: Abdominal pain;
generalized pain that typically begins at the peri-umbilical area and localizes to the right lower quadrant (pain may be most intense
at McBurney’s point, located about halfway between the anterior superior iliac crest and the umbilicus.); pain that increases with
movement; rigid abdomen; Fever, tachycardia, possible vomiting, constipation and/or diarrhea, anorexia, pallor, lethargy, and/or
irritability
◦ Hernia The manifestations presented indicate intussusception not a hernia.
Intussusception
Intussusception is the telescoping of the intestine over itself. This usually occurs in infants and young children up to 5 years of age, but
it is most common between 5 and 9 months of age. Manifestations include:
• Normal comfort interrupted by periods of sudden and acute pain
• Palpable, sausage-shaped mass in the right upper quadrant of the abdomen and/or a tender, distended abdomen
• Stools that are mixed with blood and mucus that resemble the consistency of red currant jelly
Pyloric stenosis
Manifestations of pyloric stenosis include:
◦ Vomiting that often occurs 30 to 60 min after a meal and becomes projectile as obstruction worsens
◦ Constant hunger
◦ Olive-shaped mass in the right upper quadrant of the abdomen and possible peristaltic wave that moves from left to right
when lying supine
, ◦ Failure to gain weight and signs of dehydration, such as skin that is dry and/or pale, cool lips, dry mucous membranes,
decreased skin turgor, diminished urinary output, concentrated urine, thirst, rapid pulse, sunken eyes, and decreased
blood pressure
a nurse is preparing to perform an abdominal assessment on a child. identify the sequence the nurse should follow (move the
steps into the box on the right, placing them in the selected order of performance. use all the steps) Inspection, Auscultation,
Superficial palpitation, Deep palpitation When performing an abdominal assessment on a child, the nurse should first inspect the
abdomen without touching and observe for anything that could indicate a medical concern. Because palpation prior to auscultation
can alter the bowel sounds, the nurse should auscultate the abdomen for bowel sounds next. Then, the nurse should palpate the
abdomen superficially so the child won’t tense her abdominal muscles. Finally, the nurse should perform a deep palpation of the
abdomen, making sure to palpate any painful areas last.
A nruse is caring for a 4yo child who has a new diagnosis of DM and is distressed after an insulin injection. Which of the following
play activities should the nurse recognize is therapeutic in helping the child deal with the injection? A needleless syringe and a doll
Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child, because they will allow the child to act
out feelings of anger and helplessness.
◦ A video game Playing a video game is a distraction and is useful for a child who is bored.
◦ A story book about a child who has diabetes This activity does not provide an outlet for working out the feelings that the child
is unable to verbalize at the age of 4.
◦ A period of play in the playroom Playing in the playroom is not a therapeutic activity in this situation.
A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the ff
developmental tasks should the nurse include as being expected of a preschooler? Participates in imaginary play - By 5 years of
age, a preschooler should participate in imaginary and creative play, play cooperatively with peers, and speak in complete
sentences.
◦ Controls impulsive feelings By 12 years of age, a school-age child's psychosocial development should include the ability to
control impulsive feelings.
◦ Builds a collection of cards By 12 years of age, a school-age child’s psychosocial development should include the ability to
collect small items, such as cards, stamps, rocks, and buttons.
◦ Expresses need for privacy By 12 years of age, a school-age child usually expresses a need for privacy when performing personal
hygiene, such as bathing or showering.
A nurse is providing care to a child who has an allergy to eggs. The nurse should question a prescription for which of the
following immunizations? Influenza, live attenuated (LAIV) - An egg allergy is a contraindication for receiving the LAIV vaccine.
Severe anaphylactic reactions can occur and pose life-threatening conditions for the child.
◦ Inactivated poliovirus (IPV) An egg allergy is not a contraindication for receiving the IPV vaccine. A severe allergic reaction to a
previous dose or to a component of the vaccine is a contraindication for receiving the IPV vaccine. The nurse can delay
administering the vaccine if the child has a moderate or severe acute illness with or without a fever.
◦ Haemophilus influenza type b (Hib) An egg allergy is not a contraindication for receiving the Hib vaccine. A severe allergic
reaction to a previous dose or to a component of the vaccine is a contraindication for receiving the Hib vaccine. The nurse can
delay administering the vaccine if the child has a moderate or severe acute illness with or without a fever.
◦ Hepatitis B (HepB) The HepB vaccine is contraindicated in individuals who have an allergy to baker's yeast.
A nurse is caring for a 10mo infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the strategies should
the nurse implement to promote the infant’s growth and development? Allow the infant to stand in the crib. - Allowing the child
to participate in normal developmental activities promotes growth and development. The infant can be held and allowed to walk in
a cast or orthotic device.
◦ Tie colorful latex balloons to the side of the crib. Toys that are tied to the side or strung across the crib are a safety hazard
that could cause the infant to suffocate. The nurse should keep latex balloons out of the infant’s reach.
◦ Provide a small electronic toy. Small electronic toys are a safety hazard. Electronic toys often have small batteries that can be
ingested. Electronic toys can also have heating elements and sharp edges that can cause injury to the skin.
◦ Change the infant's diaper as soon as soiling occurs. Maintaining hygiene is important because it promotes health, but it does
not promote growth and development. The nurse should keep the diaper area and cast clean without using lotions or powders.
These actions help maintain integrity of the skin.
.
A nurse is caring for a 6mo infant following surgery. Which of the ff should the nurse use to measure pain in this client? FLACC pain
scale - The FLACC scale is used for infants and children 2 months to 7 years. It is based on assessment of the following behavior
indicators: Facial expressions, Position of legs, Activity, Crying, Ability to be consoled.
◦ Oucher numeric scale. The client must be able to count to 100 by ones or tens to use this scale.
