1
,Rationale - The FACES pain rating scale can be used with children as young as 3 years of age,
and pain should be investigated with every nursing assessment.
A 7-year-old child is hospitalized for a tonsillectomy. What are priority nursing actions when
caring for this child after surgery? Select all that apply.
A) Advancing diet as tolerated.
B) Encouraging coughing to clear the throat.
C) Monitoring PT and PTT.
D) Administering pain medication around the clock.
E) Suctioning mouth and throat frequently. A) Advancing diet as tolerated.
C) Monitoring PT and PTT.
D) Administering pain medication around the clock.
Rationale -
Following tonsillectomy, the child may begin oral intake after surgery, beginning with ice chips
and progressing as tolerated to avoid vomiting, which could injure the surgical site.
Increased bleeding times put the child at risk for hemorrhage at the tonsillectomy site, which
could compromise the airway.
The nurse should expect that the child will have pain from the tonsillectomy. Pain control is best
achieved with around-the-clock dosing. Without adequate pain control, the child may cry,
putting stress on the surgical site.
,A 12-month-old child with infantile eczema is seen at the clinic for several open lesions on the
arms and legs. What should a nurse caution the child's parents against?
A) Initiating a diet free of milk products.
B) The use of topical hydrocortisone cream.
C) Adding cornstarch to bath water.
D) Immunization during eczema exacerbations. D) Immunization during eczema
exacerbations.
Rationale - The child should not receive immunizations during an acute exacerbation of eczema
(atopic dermatitis), as this may lead to complications such as allergic reaction. The child with
atopic dermatitis is experiencing an inflammatory response. Care should be directed at relieving
inflammation and avoiding exposure to substances thought to trigger an immune response.
A 13-year-old client diagnosed with beta-thalassemia is hospitalized for blood transfusion. What
are the priority nursing diagnoses related to this child's care? Select all that apply.
A) Risk for infection.
B) Impaired elimination.
C) Risk for injury.
D) Disturbed body image.
E) Chronic pain.
F) Activity intolerance. A) Risk for infection.
C) Risk for injury.
, D) Disturbed body image.
F) Activity intolerance.
Rationale -
Children with beta-thalassemia are at increased risk for infection due to the impaired oxygen-
carrying capacity of their blood.
These children are at risk for injury from an increased destruction of red blood cells. As red
blood cells die, iron is released with deposits in the liver and spleen, enlarging these organs and
impairing their function while also causing vomiting from abdominal pressure.
These children may experience bone deformities, growth retardation, and delayed maturation of
the sexual organs. These symptoms (e.g., broad forehead, short stature, immature appearance)
may be troubling for an adolescent, whose main concern is to fit in with the peer group.
Chronic hypoxia results from the production of abnormal red blood cells. If the body does not
have sufficient red blood cell production, oxygen is not supplied to the tissues adequately,
leading to activity intolerance and fatigue.
A charge nurse is creating nursing assignments for a pediatric unit when one of the oncoming
nurses calls to say, "Sorry, I'll be a few minutes late since I have a child home ill with the
chickenpox." What type of assignment would be most acceptable for the nurse who will be late?
A) Any assignment is fine as long as the nurse wears a mask.
B) The nurse needs an assignment that does not include children with neutropenia.
C) The nurse should not be given an assignment and should be called off.
,Rationale - The FACES pain rating scale can be used with children as young as 3 years of age,
and pain should be investigated with every nursing assessment.
A 7-year-old child is hospitalized for a tonsillectomy. What are priority nursing actions when
caring for this child after surgery? Select all that apply.
A) Advancing diet as tolerated.
B) Encouraging coughing to clear the throat.
C) Monitoring PT and PTT.
D) Administering pain medication around the clock.
E) Suctioning mouth and throat frequently. A) Advancing diet as tolerated.
C) Monitoring PT and PTT.
D) Administering pain medication around the clock.
Rationale -
Following tonsillectomy, the child may begin oral intake after surgery, beginning with ice chips
and progressing as tolerated to avoid vomiting, which could injure the surgical site.
Increased bleeding times put the child at risk for hemorrhage at the tonsillectomy site, which
could compromise the airway.
The nurse should expect that the child will have pain from the tonsillectomy. Pain control is best
achieved with around-the-clock dosing. Without adequate pain control, the child may cry,
putting stress on the surgical site.
,A 12-month-old child with infantile eczema is seen at the clinic for several open lesions on the
arms and legs. What should a nurse caution the child's parents against?
A) Initiating a diet free of milk products.
B) The use of topical hydrocortisone cream.
C) Adding cornstarch to bath water.
D) Immunization during eczema exacerbations. D) Immunization during eczema
exacerbations.
Rationale - The child should not receive immunizations during an acute exacerbation of eczema
(atopic dermatitis), as this may lead to complications such as allergic reaction. The child with
atopic dermatitis is experiencing an inflammatory response. Care should be directed at relieving
inflammation and avoiding exposure to substances thought to trigger an immune response.
A 13-year-old client diagnosed with beta-thalassemia is hospitalized for blood transfusion. What
are the priority nursing diagnoses related to this child's care? Select all that apply.
A) Risk for infection.
B) Impaired elimination.
C) Risk for injury.
D) Disturbed body image.
E) Chronic pain.
F) Activity intolerance. A) Risk for infection.
C) Risk for injury.
, D) Disturbed body image.
F) Activity intolerance.
Rationale -
Children with beta-thalassemia are at increased risk for infection due to the impaired oxygen-
carrying capacity of their blood.
These children are at risk for injury from an increased destruction of red blood cells. As red
blood cells die, iron is released with deposits in the liver and spleen, enlarging these organs and
impairing their function while also causing vomiting from abdominal pressure.
These children may experience bone deformities, growth retardation, and delayed maturation of
the sexual organs. These symptoms (e.g., broad forehead, short stature, immature appearance)
may be troubling for an adolescent, whose main concern is to fit in with the peer group.
Chronic hypoxia results from the production of abnormal red blood cells. If the body does not
have sufficient red blood cell production, oxygen is not supplied to the tissues adequately,
leading to activity intolerance and fatigue.
A charge nurse is creating nursing assignments for a pediatric unit when one of the oncoming
nurses calls to say, "Sorry, I'll be a few minutes late since I have a child home ill with the
chickenpox." What type of assignment would be most acceptable for the nurse who will be late?
A) Any assignment is fine as long as the nurse wears a mask.
B) The nurse needs an assignment that does not include children with neutropenia.
C) The nurse should not be given an assignment and should be called off.
