A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions by the nurse is
... [Show More] appropriate?
Place the child on NPO status
A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (select all that apply)
A. Negative gram stain
B. Normal glucose content
E. Normal protein content
A nurse is caring for a 4-month-old infant who has meningitis. Which of the following finding is associated with this diagnosis?
High-pitched cry
A nurse is caring for a school age client who possibly has Reye syndrome. Which of the following is a risk factor for developing Reye syndrome?
Recent history of gastroenteritis
A nurse is developing an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (select all that apply)
B. Pneumococcal conjugate vaccine (PCV) D. Haemophilus influenzae type B (Hib) vaccine
A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (select all that apply
A. Loss of consciousness
B. Appearance of daydreaming
C. Dropping held objects
A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take?
A. Maintain the child in a side-lying position
A nurse is providing teaching to the parent of a child who is to have an electroencephalogram (EEG). Which of the following responses should the nurse include in the teaching?
A. Decaffeinated beverages should be offered on the morning of the procedure
A nurse is teaching a group of parents about the risk factors for seizures. Which of the following factors should the nurse include in the teaching? (select all that apply)
A. Febrile episodes
B. Hypoglycemia
C. Sodium imbalances
A nurse is reviewing treatment options with the parent of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? (select all that apply
A. Vagal nerve stimulator
B. Additional antiepileptic medications
C. Corpus callosotomy
D. Focal resection
A nurse is in the emergency department is assessing a child following a motor vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take first?
A. Stabilize the child's neck
A nurse is caring for an adolescent who has a closed head injury. Which of the following findings are indications of increased intracranial pressure (ICP)? (select all that apply)
A. Report of headache
B. Alteration in pupillary response
D. Increased sleeping
A nurse is caring for a child who has ICP. Which of the following actions should the nurse take? (select all that apply)
B. Maintain a quiet environment
D. Administer a stool softener
E. Maintain body alignment
A nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? (select all that apply)
A. Amnesia
C. Bradycardia
D. Respiratory depression
E. Confusion
A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the following adverse effects should the nurse monitor the child for and report to the provider?
C. Confusion
A nurse is planning to perform a peripheral vision test on a child. Which of the following actions should the nurse take?
C. Cover the child's eye while performing the test on the other eye
A nurse is teaching a group of parents about possible manifestations of Down's syndrome. Which of the following findings should the nurse include in the teaching? (select all that apply)
C. Protruding abdomen
D. Broad, short feet, and hands
E. Hypotonia
A nurse is assessing a child who has myopia. Which of the following findings should the nurse expect? (select all that apply)
A. Headaches
C. Difficulty reading
E. Poor school performance
A nurse is assessing a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? (select all that apply)
A. Uses monotone speech
B. Speaks loudly
D. Appears shy
A nurse is teaching the parent of an infant who has Down syndrome. Which of the following statements by the parent indicates an understanding of the teaching?
B. I should place a cool mist humidifier in his room
A nurse is completing a pain assessment of an infant. Which of the following pain scales should the nurse use?
B. FLACC
A nurse is planning care for a child following a surgical procedure. Which of the following interventions should the nurse include in the plan of care?
D. Administer IV analgesics on a schedule
A nurse is assessing an infant. Which of the following are manifestations of pain in an infant? (select all that apply)
B. Loud cry
C. Lowered eyebrows
D. Rigid body
A nurse is planning care for an infant who is experiencing pain. Which of the following interventions should the nurse include in the plan of care? (select all that apply)
A. Offer a pacifier
C. Use swaddling
E. Encourage kangaroo care
A nurse is preparing a toddler for an intravenous catheter insertion using atraumatic care. Which of the following actions should the nurse take? (select all that apply)
A. Explain the procedure using the child's favorite toy
D. Allow the child to make one choice regarding the procedure
E. Apply lidocaine and prilocaine cream to three potential insertion sites
A nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool-age child?
B. Relating fears to magical thinking
A nurse on a pediatric unit is caring for a toddler. Which of the following behaviors is an effect of hospitalization? (select all that apply)
B. Experiences separation anxiety
C. Displays intense emotions
D. Exhibits regressive behaviors
A nurse is teaching a parent about parallel play in children. Which of the following statements should the nurse include in the teaching?
D. The child plays independently when in a group
A nurse is teaching a group of parents about separation anxiety. Which of the following information should the nurse include in the teaching?
D. Kicking a stranger is an example
A nurse is caring for a child who is dying. Which of the following are findings of impending death? (select all that apply)
C. Difficulty swallowing
E. Cheyne-stokes respirations
A nurse is teaching a parent about complicated grief. Which of the following statements should the nurse make?
B. Personal activities are affected when experiencing complicated grief
A nurse is teaching a parent of a preschool child about factors that affect a child's perception of death. Which of the following factors should the nurse include in the teaching?
B. Preschool children perceive death as temporary
A nurse often cares for children who are dying. Which of the following are appropriate actions for the nurse to take to maintain professional effectiveness? (select all that apply)
A. Remain in contact with the family after their loss
B. Develop a professional support system
C. Take time off from work
A nurse is caring for a child who has a terminal illness and review palliative care with an assistive personnel (AP). Which of the following statements indicated understanding of the review?
D. I will listen and respond as the family talks about their child's life
A nurse is preparing to administer immunizations to a 4-month-old infant. Which of the following is an appropriate action for the nurse to take in providing atraumatic care?
D. Provide sucrose solution on the pacifier
A nurse is planning to administer recommended immunizations to a 2 month old infant. Which of the following vaccines should the nurse plan to give? (select all that apply)
A. Rotavirus (RV)
B. Diphtheria, tetanus, and acellular pertussis (DTaP)
C. Haemophilus influenza
E. Pneumococcal conjugate (PCV13)
F. Inactivated poliovirus
A nurse is planning to administer recommended immunizations to a 4 year old child. Which of the following vaccines should the nurse plan to give? (select all that apply)
A. Inactivated poliovirus (IPV)
C. Measles, mumps, rubella (MMR)
D. Varicella (VAR)
F. Diphtheria, tetanus, and acellular pertussis (DTaP)
A nurse is preparing to administer the varicella vaccine to an adolescent. Which of the following questions should the nurse ask to determine whether there is a contraindication to administering the vaccine?
C. Are you currently taking corticosteroid medication?
A nurse is teaching a group of parents about complications of communicable diseases. Which of the following communicable diseases can lead to pneumonia? (select all that apply)
B. Rubeola (measles)
C. Pertussis (whooping cough)
D. Varicella (chickenpox)
A nurse is providing teaching for an adolescent client who has mononucleosis. The client has a fever, fatigue, swollen lymph nodes, sore throat, and a sore upper abdomen. Which of the following instructions should the nurse include in the teaching? (select all that apply)
A. Take antibiotics until symptoms subside
B. Drink plenty of liquids
C. Avoid participating in strenuous activities
D. Allow for periods of rest
F. Gargle with saltwater every 2 to 3 hr.
A nurse is assessing a client who has pertussis. Which of the following findings should the nurse expect? (select all that comply)
A. Runny nose
B. Mild fever
C. Cough with whooping sound
A nurse is teaching a group of parents about communicable diseases. The nurse should include that which of which of the following is the best method to prevent a communicable disease?
D. Obtaining immunizations
A nurse is teaching an adolescent to self-administer a corticosteroid medication using a metered dose inhaler (MDI). Which of the following instructions should the nurse include? (select all that apply)
A. Shake the device prior to use
B. Rinse and expectorate after administration
C. Inhale slowly with medication administration
A nurse is caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that has a reading of 89%. Which of the following actions should the nurse take first?
C. Ensure proper placement of the sensor probe
A nurse in the emergency department is assessing a newly admitted infant. Which of the following is an early indication of hypoxemia?
C. Cyanosis
A nurse is caring for a child who is receiving oxygen. Which of the following findings indicates oxygen toxicity?
D. Unconsciousness
A nurse is caring for a child who is receiving a bronchodilator medication by nebulized aerosol therapy. Which of the following actions should the nurse take? (select all that apply)
B. Obtain vital signs prior to the procedure
C. Tell the child to take deep breaths
D. Determine if the child should use a mask
E. Attach the device to an air source
A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? (select all that apply)
C. Administer humidified oxygen
D. Suction the nasopharynx as needed
A nurse is teaching a group of parents about influenza. Which of the following information should the nurse include in the teaching?
D. Oseltamivir should be given within 48 hours of onset of symptoms
A nurse is caring for a child who is in the postoperative period following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding?
C. Frequent swallowing and clearing of the throat
A nurse is caring for a child in the postoperative period following a tonsillectomy. Which of the following actions should the nurse take?
B. Administer analgesics on a schedule
A nurse is assessing a child who has epiglottitis. Which of the following findings should the nurse expect? (select all that apply)
A. Hoarseness and difficulty speaking
B. Difficulty swallowing
D. Drooling
F. Stridor
A nurse is assessing a child who has asthma. Which of the following findings are indications of deterioration in the child's respiratory status? (select all that apply)
B. Wheezing
C. Retraction of the sternal muscles
E. Nasal flaring
A nurse is teaching an adolescent about the appropriate use of his asthma medications should the nurse instruct the client to use as needed before exercise?
D. Albuterol
A nurse is planning care for a child who has asthma. Which of the following interventions should the nurse include in the plan of care? (select all that apply)
B. Place the child in an upright position
C. Monitor oxygen saturation
D. Administer bronchodilators
A nurse is teaching a child who has asthma how to use a peak flow meter. Which of the following information should the nurse include in the teaching? (select all that apply)
A. Zero the meter before each use
C. Perform three attempts
A nurse is discussing risk factors for asthma with a group of newly licensed nurses. Which of the following conditions should the nurse include in the teaching? (select all that apply)
A. Family history of asthma
B. Family history of allergies
C. Exposure to smoke
D. Low birth weight
A nurse is reviewing the diagnostic findings for a preschool age child who is suspected of having cystic fibrosis. Which of the following findings should the nurse identify as an indication of cystic fibrosis?
A. Sweat chloride content 85 mEq/L
A nurse is admitting a child who has cystic fibrosis. Which of the following medications should the nurse anticipate including in the plan of care? (select all the apply)
A. Tobramycin
C. Fat-soluble vitamins
D. Albuterol
E. Dornase alfa
A nurse is performing an admission assessment for a child who has cystic fibrosis. Which of the following findings should the nurse expect? (select all that apply)
A. Wheezing
B. Clubbing of fingers and toes
C. Barrel-shaped chest
A nurse is providing discharge teaching for a child who has cystic fibrosis. Which of the following instructions should the nurse include?
B. Administer pancreatic enzymes with meals and snacks
A nurse is assessing an infant who has coarctation of the aorta, Which of the following findings should the nurse expect? (select all that apply)
A. Weak femoral pulses
B. Cool skin of lower extremities
E. Heart failure
A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (select all that apply)
B. Cool extremities
C. Peripheral edema
E. Nasal flaring [Show Less]