1. A nurse is providing discharge teaching to parents whose infant had a
ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which
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of the following statements by the parents indicates an understanding of the
teaching?
A. "We will chech his abdomen daily for signs of fluid accumulation."
B. "We will notifiy the doctor right away if he has a fever."
C. "We should keep a helmet on him when he's awake"
D. "We can expect him to have occasional seizure episodes." - B.
Rationale: Infection is a risk after ventriculoperitoneal shunt insertion, esp 1 to 2
months after placement. The parents should report fevers, vomiting, seizure
activity, and decreased responsiveness, as these findings can indicate infections.
2. A nurse is providing teaching to the guardians of a 4 month old infant on how to
play with the infant. Which of the following play activities should the nurse sugget
for this infant?
A. Show the infant a board book with large pictures.
B. Imitate the sounds of different farm animals for the infant.
C. Give the infant a large push-pull toy.
D. Allow the infant to splash in the bathtub. - D.
Rationale: Splashing is appropriate for the developmental age of the infant and
provides tactile stimulation. However, the nurse shoud emphasize and teach bath
safety to prevent injury.
3. A nurse is caring for a child with a vesicular rash that has been present for 6
days. The nurse should expect that the child has which of the followig
conditions?
A. Measles
B. Fifth disease
C. Tetanus
D. Varicella - D.
Rationale: Children who has varicella may present first with a maculopapular
rash that progresses to vesicles on erythematous bases, which eventually
rupture and crust over.
4. A nurse is caring for a school-age child who has glomerulonephritis. The child
has decreased urinary output and a blood pressure of 160/78 mmHg and is
receiving hydralazine. Which of the following lunch choices should the nurse
recommend?
A. 1 hotdog, 22 potato chips, and 120 ml (4oz) of orange juice
B. 1 sandwich with lettuce, tomato, and 4 slices of bacon; a small apple,; and
240 mL (8oz) of milk
C. 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4oz) of apple juice.
D. 1 cup of cottage cheese, a small banana, and 240 mL (8oz) of soda - C.
Rationale: Children with glomerulonephritis has moderate sodium restriction, and
further restriction is given to foods that are high in potassium for children who
have decreased urinary output. These restrictions are because the kidneys of
these children are not funtioning appropriately. This menu consist of 571 g of
potassium and 268g of sodium.
5. A nurse is assessing a 6-year old child who began treatment for pneumococcal
pnemonia 4 days ago. Which of the following findings should the nurse identify
as an indication the treatment is effective?
A. Dullness with chest percussion
B. Heart rate 118/min
C. Conjunctival discharge
D. Respiratory rate 28/min - B.
Rationale: Heart rate of 118/min is within the expected range for a 6-year-old
child. A child who has an acute pneumococcal pneumonia infection will exhibit
tachycardia.
6. A nurse is caring for a child who has exacerbation of cystic fibrosis. Which of the
following laboratory findings should the nurse report to the provider immediately?
A. Blood glucose 140 mg/dl
B. Oxygen saturation 85%
C. RBC 3.2 million/uL
D. Serum sodium 156 mEq/L - B.
Rationale: Apply ABC priority-setting framework
7. A nurse is assessing a 6 month-old infant during a well-child visit. Which of the
following motor activities should the nurse expect the infant to have achieved?
A. Sitting alone
B. Attempting to stack objects
C. Picking up small objects with a crude pincer grasp
D. Turning from back to stomach - D.
Rationale: A 6 month old infant should be able to turn over completely, sit
momentarily without support, and reach to be picked up
8. A nurse in an acute pediatric unit is caring for a 2-year-old child who has
separation anxiety when her parents leave for work. The nurse should identify
which of the following behaviors as a manifestation of the stage of despair?
A. The child tries to bite the nurse
B. The child is withdrawn and refuses to talk
C. The child attempts to run away to find her parents
D. The child screams and cries loudly - B.
Rationale: Separation anxiety manifests in 3 stages: protest, despair, and
detatchment. Withdrawal and lack of communication are manifestations of the
stage of despair.
9. A nurse is reviewing the medical record of a 2-month-old infant who has
rotavirus. The nurse notes a hemoglobin level of 12g/dL and a hematocrit of
51%. Which of the following statements by the nurse indicates an understanding
of the lab values?
A. "The infant might be dehyrdated"
B. "The infant might be anemic"
C. "The infant might have received too much fluid"
D. "The infant might have leukemia" - A.
Rationale: An increased hematocrit level indicates dehydration. Hematocrit levels
rise when blood volume is decreased during dehydration.
10.A nurse is planning to implement relaxation strategies with a young child prior to
a painful procedure. Which of the following actions should the nurse take?
A. Ask the child to hold a breath and blow it out slowly
B. Ask the child to describe a pleasurable event
C. Bounce the child gently while holding him upright
D. Rock the child using long, rhythmic movements. - D.
Rationale: The nurse can implement relaxation strategies by sitting with the child
in a well-supported position such as against the chest and rocking or swaying
back and forth in long, wide movements. [Show Less]