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A nurse is assessing the pain level of a 3 year old toddler. Which of the following
assessment scales should the nurse use?
A. FACES
B. Numeric
C. CRIES
D. Visual analog -
E. Answer-A. FACES
The nurse should use the FACES pain rating scale for pediatric clients who are 3 years
old and older. this scale allows the toddler to point to the face that depicts their current
level of pain. the nurse can then determine the need for pain management.
A nurse is planning an educational program to teach parents about protecting
their children from sunburns. Which of the following instructions should the
nurse plan to include?
A. "allow your child to play outside during the hours between 10:00am and 2:00pm."
B. "choose a waterproof sunscreen with a minimum SPF of 15."
C. "dress you child in loose weave polyester fabric prior to sun exposure."
D. "reapply sunscreen every 4 hours." -
E. Answer-B. "choose a waterproof sunscreen with a minimum SPF of 15."
The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF
of 15 for children. the parents should apply the sunscreen prior to sun exposure to
reduce the risk of sunburn.
A nurse is performing hearing screenings for children at a community health fair.
Which of the following children should the nurse refer to a provider for a more
extensive hearing evaluation?
A. an 18 month old toddler who has unintelligible speech
B. a 3 month old infant who has exaggerated startle response
C. a 4 year old preschooler who prefers playing with others rather than alone
D. an 8 month old infant who is not yet making babbling sounds -
E. Answer-D. An 8- month-old who is not yet making babbling sounds.
The nurse should refer an infant who is not making babbling sounds by the age of 7 mo
to a provider for amore extensive eval of hearing
A nurse in an emergency department is assessing a 3 month old infant who has
rotavirus and is experiencing acute vomiting and diarrhea. Which of the following
manifestations should the nurse identify as an indication that the infant has
moderate to severe dehydration?
,A. HR 124
B. increased tear production
C. sunken anterior fontanel
D. capillary refill 2 seconds -
E. Answer-C. sunken anterior fontanel
The nurse should recognize that a sunken anterior fontanel is an indication of moderate
to severe dehydration due to the acute loss of fluid.
A nurse is providing teaching to the family of a school-age child who has juvenile
idiopathic arthrisis. Which of the following instructions should the nurse include
in the teaching?
A. "limit movement of the child's large joints"
B. "encourage the child to perform independent self-care."
C. "provide the child with a soft mattress for sleeping."
D. "schedule a 2 hour daily nap for the child in the afternoon." -
E. Answer-B. "encourage the child to perform independent self-care."
The nurse should teach the family the importance of encouraging the child to perform
independent self-care. This will minimize the child's pain while maximizing mobility.
encouraging an praising the child's effort for independence will also increase their self-
esteem.
A nurse is planning care for a school age child who has a tunneled central
venous access device. Which of the following interventions should the
nurse include in the plan?
A. use sterile scissors to remove the dressing from the site
B. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in
use
C. access the site suing a noncoring angle needle
D. use a semipermeable transparent depressing to cover the site -
E. Answer-D. use a semipermeable transparent depressing to cover the site
The nurse should cover the site with a semipermeable transparent dressing to reduce
the risk of infection.
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the
following expected behavior characteristics of toddlers should the nurse include?
A. controls impulsive feelings
B. understands right from wrong
C. easily separates from parents for long periods of time
D. expresses likes and dislikes -
E. Answer-D. expresses likes and dislikes
This is the time in life when a toddler is developing autonomy and self-concept. they will
try to assert themselves and frequently refuse to comply. the parent should allow the
child to have some control, but also set limits for them so they learn from their behavior
and learn to control their actions.
, A nurse is providing discharge teaching to the parent of a school age child who
has moderate persistent asthma. Which of the following instructions should the
nurse include?
A. "you should give your child their salmeterol inhaler every 4 hours when they are
having an acute episode of wheezing."
B. "you should monitor your child's weight weekly while they are receiving inhaled
corticosteroids therapy."
C. "pulmonary function tests will be performed every 12-24 months to evaluate how your
child is responding to therapy."
D. "when using the peak expiratory flow meter, record your child's average of three
readings." -
E. Answer-C. "pulmonary function tests will be performed every 12-24 months to
evaluate how your child is responding to therapy."
AThe nurse should include this to evaluate the presence of lung disease and how the
child is responding to the current treatment regimen. as children grow, sometimes their
manifestations can improve or decline, and treatment needs to change accordingly.
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate
enema. Which of the following findings indicates effectiveness of the medication?
A. reports an absence of nausea and vomiting
B. reports experiencing an onset of loose stools within 15 minutes of administration
C. serum potassium level 4.1 mEq/L
D. blood pressure 86/52 mm Hg -
E. Answer-C. serum potassium level 4.1 mEq/L
The nurse should monitor the serum potassium (K) level following the administration of
sodium polystyrene sulfonate. this med is used to treat hyperkalemia by exchanging
sodium ions for K ions in the intestine. therefore, a K level w/in the expected reference
range of 3.4-4.7 indicates the effectiveness of the med
A nurse is assessing an infant who has pneumonia. Which of the following
findings is the priority for the nurse to report the provider?
A. nasal flaring
B. WBC count 11,300/mm^3
C. diarrhea
D. abdominal distension -
E. Answer-A. nasal flaring
The nurse should determine that the priority finding to report to the provider is nasal
flaring, nasal flaring indicates the infant is experiencing acute respiratory distress.
A nurse is providing discharge teaching to the guardian of a school age child
who has undergone a tonsillectomy. Which of the following statements by the
guardian indicates an understanding the teaching?
A. "my child can resume usual activities since this year just an outpatient surgery."
B. "my child will be able to drink the chocolate milkshake I promised to get for them
tonight."