Nursing Care of Children 2
1) A nurse in an emergency department is caring for a 4-year-old child who has burns to
the neck and face following a house fire. Which of the following actions should the nurse
take first?
A. Cover the child's wounds with a clean, dry cloth.
The nurse should cover the child’s wounds with a clean, dry cloth;
however, there is a different action the nurse should take first.
B. Establish IV access for the child with a large-bore catheter.
The nurse should establish IV access for the child using a large-bore
catheter; however, there is a different action the nurse should take
first.
C. Provide reassurance to the child's parents.
The nurse should provide reassurance to the child’s parents; however,
there is a different action the nurse should take first.
D. Determine the child's breathing pattern.
The nurse should apply the ABC priority setting framework. This
framework emphasizes the basic core of human functioning: having an
open airway, being able to breathe in adequate amounts of oxygen,
and circulating oxygen to the body's organs via the blood. An alteration
in any of these can indicate a threat to life, and is therefore the nurse’s
priority concern. When applying the ABC priority setting framework,
airway is always the highest priority because the airway must be clear
and open for oxygen exchange to occur. Breathing is the second
highest priority in the ABC priority setting framework because
adequate ventilatory effort is essential in order for oxygen exchange to
occur. Determining the child’s breathing pattern is the first action the
nurse should take. Circulation is the third highest priority in the ABC
priority setting framework because delivery of oxygen to critical organs
only occurs if the heart and blood vessels are capable of efficiently
carrying oxygen to them.
,2) A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition.
Which of the following statements by the parent indicates an understanding of the
teaching?
A. "My child should consume 1,000 calories per day."
Toddlers who are 2 years old should consume 1,000 calories daily.
B. "My child should have 4 ounces of protein per day."
Toddlers who are 2 years old should have 2 oz of protein daily.
C. "I should give my child 32 ounces (4 cups) of milk per day."
Toddlers who are 2 years old should have no more than 24 oz (3 cups)
of milk per day.
D. "I should feed my child 4 ounces (1/2 cup) of vegetables per day."
Toddlers who are 2 years old should consume 8 oz (1 cup) of
vegetables per day.
3) A nurse is providing discharge teaching to the parent of a school-age child who has
leukemia and is receiving chemotherapy. Which of the following statements by the parent
indicates an understanding of the teaching?
A. "I will take my child's rectal temperature daily."
The parent should avoid taking rectal temperatures to prevent trauma
to the child.
B. "I will make sure my child gets his MMR vaccine this week."
A child who has leukemia will have a compromised immune system
and should not receive the MMR vaccine.
C. "I will inspect my child's mouth every day for sores."
A child who has leukemia is at an increased risk for mucositis;
therefore, the parent should inspect the child’s mouth daily for lesions
or ulcerations.
, D. "I will allow my child to ride his bicycle tomorrow."
The nurse should advise the parents to avoid any activities that could
cause injury or bleeding, such as riding bicycles or climbing on
playground equipment.
4) A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has
acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the
test. Which of the following responses should the nurse make?
A. "The test determines the level of antibiotics in your child's blood."
A therapeutic blood level indicates a medication, such as an antibiotic,
is effective.
B. "The test tells us if your child ever had the measles."
A rubella titer will indicate the presence of measles.
C. "The test verifies the amount of albumin in your child's blood."
A serum albumin level is monitored in a child who has nephrotic
syndrome.
D. "The test shows us if your child had a recent strep infection."
An ASO titer indicates that the child has had a recent strep infection. In
determining a definitive diagnosis for acute glomerulonephritis, this
must be documented as it is usually the result of this type of infection.
5) A nurse is providing nutritional teaching to an adolescent client who has celiac disease.
Which of the following breakfast foods should the nurse recommend?
A. Plain flour pastry
The client who has celiac disease should be on a low-gluten diet.
Gluten is found primarily in wheat and rye, but also is found in smaller
quantities in barley and oats; therefore, plain flour pastries are an
inappropriate breakfast item for the nurse to recommend to the client.
1) A nurse in an emergency department is caring for a 4-year-old child who has burns to
the neck and face following a house fire. Which of the following actions should the nurse
take first?
A. Cover the child's wounds with a clean, dry cloth.
The nurse should cover the child’s wounds with a clean, dry cloth;
however, there is a different action the nurse should take first.
B. Establish IV access for the child with a large-bore catheter.
The nurse should establish IV access for the child using a large-bore
catheter; however, there is a different action the nurse should take
first.
C. Provide reassurance to the child's parents.
The nurse should provide reassurance to the child’s parents; however,
there is a different action the nurse should take first.
D. Determine the child's breathing pattern.
The nurse should apply the ABC priority setting framework. This
framework emphasizes the basic core of human functioning: having an
open airway, being able to breathe in adequate amounts of oxygen,
and circulating oxygen to the body's organs via the blood. An alteration
in any of these can indicate a threat to life, and is therefore the nurse’s
priority concern. When applying the ABC priority setting framework,
airway is always the highest priority because the airway must be clear
and open for oxygen exchange to occur. Breathing is the second
highest priority in the ABC priority setting framework because
adequate ventilatory effort is essential in order for oxygen exchange to
occur. Determining the child’s breathing pattern is the first action the
nurse should take. Circulation is the third highest priority in the ABC
priority setting framework because delivery of oxygen to critical organs
only occurs if the heart and blood vessels are capable of efficiently
carrying oxygen to them.
,2) A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition.
Which of the following statements by the parent indicates an understanding of the
teaching?
A. "My child should consume 1,000 calories per day."
Toddlers who are 2 years old should consume 1,000 calories daily.
B. "My child should have 4 ounces of protein per day."
Toddlers who are 2 years old should have 2 oz of protein daily.
C. "I should give my child 32 ounces (4 cups) of milk per day."
Toddlers who are 2 years old should have no more than 24 oz (3 cups)
of milk per day.
D. "I should feed my child 4 ounces (1/2 cup) of vegetables per day."
Toddlers who are 2 years old should consume 8 oz (1 cup) of
vegetables per day.
3) A nurse is providing discharge teaching to the parent of a school-age child who has
leukemia and is receiving chemotherapy. Which of the following statements by the parent
indicates an understanding of the teaching?
A. "I will take my child's rectal temperature daily."
The parent should avoid taking rectal temperatures to prevent trauma
to the child.
B. "I will make sure my child gets his MMR vaccine this week."
A child who has leukemia will have a compromised immune system
and should not receive the MMR vaccine.
C. "I will inspect my child's mouth every day for sores."
A child who has leukemia is at an increased risk for mucositis;
therefore, the parent should inspect the child’s mouth daily for lesions
or ulcerations.
, D. "I will allow my child to ride his bicycle tomorrow."
The nurse should advise the parents to avoid any activities that could
cause injury or bleeding, such as riding bicycles or climbing on
playground equipment.
4) A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has
acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the
test. Which of the following responses should the nurse make?
A. "The test determines the level of antibiotics in your child's blood."
A therapeutic blood level indicates a medication, such as an antibiotic,
is effective.
B. "The test tells us if your child ever had the measles."
A rubella titer will indicate the presence of measles.
C. "The test verifies the amount of albumin in your child's blood."
A serum albumin level is monitored in a child who has nephrotic
syndrome.
D. "The test shows us if your child had a recent strep infection."
An ASO titer indicates that the child has had a recent strep infection. In
determining a definitive diagnosis for acute glomerulonephritis, this
must be documented as it is usually the result of this type of infection.
5) A nurse is providing nutritional teaching to an adolescent client who has celiac disease.
Which of the following breakfast foods should the nurse recommend?
A. Plain flour pastry
The client who has celiac disease should be on a low-gluten diet.
Gluten is found primarily in wheat and rye, but also is found in smaller
quantities in barley and oats; therefore, plain flour pastries are an
inappropriate breakfast item for the nurse to recommend to the client.
