1. To take the vital signs of a 4monthold
child, which order provides the most accurate
results?
A. Respiratory rate, heart rate, then rectal
... [Show More] temperature.
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate.
D. Rectal temperature, respiratory rate, then heart rate.
2. A 16yearold
is brought to the Emergency Center with a crushed leg after falling off a
horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the
nurse take?
A. Dispense a tetanus antitoxin.
B. Prepare human tetanus immune globulin.
C. Administer tetanus toxoid booster.
D. Delay the tetanus toxoid booster until due.
Correct
Correct
The respiratory rate should be taken first (A) in infants, since touching them or performing
unpleasant procedures usually makes them cry, elevating the heart rate and making
respirations difficult to count (B). Rectal temperature is the most invasive procedure, and is
most likely to precipitate crying, so should be done last (C and D).
Awarded 1.0 points out of 1.0 possible points.
After the completion of the initial tetanus immunization schedule, the recommended booster for
an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated
by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from
missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound
requiring prophylactic therapy, so the tetanus toxoid booster should be administered (C). (A, B,
and D) are not indicated.
Awarded 1.0 points out of 1.0 possible points.
3. The mother of a 6monthold
asks the nurse when her baby will get the first measles,
mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule
published by the Centers for Disease Control, which response is accurate?
A. 3 to 6 months.
B. 12 to 15 months.
C. 18 to 24 months.
D. 4 to 6 years.
4. A 2yearold
child with Down syndrome is brought to the clinic for his regular physical
examination. The nurse knows which problem is frequently associated with Down syndrome?
A. Congenital heart disease.
B. Fragile X chromosome.
C. Trisomy 13.
D. Pyloric stenosis.
Correct
Correct
The first measles, mumps, and rubella (MMR) vaccine should be given no sooner than 12
months of age, and ideally between 12 and 15 months of age (B). (A) should not receive the
MMR vaccine due to the presence of maternal antibodies. MMR is not routinely administered at
(C), but other immunizations, such as DTaP and Hepatitis B may be given at that time. The
second dose of MMR is routinely administered at (D), provided that at least 4 weeks have
elapsed since the first dose, and if both doses were administered beginning at or after 12
months.
Awarded 1.0 points out of 1.0 possible points.
Congenital heart disease (A) is the most common associated defect in children with Down
syndrome. (C) might have seemed possible since Down syndrome is a trisomal chromosomal
abnormality of chromosome 21. (B) is a sexlinked
abnormality also causing mental retardation.
(D) is not associated with Down syndrome.
Awarded 1.0 points out of 1.0 possible points.
5. A 14yearold
female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide?
A. Remove all blackheads and follow with an alcohol scrub.
B. Use medicated cosmetics only to help hide the blemishes.
C. Wash the hair and skin frequently with soap and hot water.
D. Encourage her to see a dermatologist as soon as possible.
6. The nurse is caring for a 12yearold
with Syndrome of Inappropriate Antidiuretic
Hormone (SIADH). This child should be carefully assessed for which complication?
A. Poor skin turgor resulting from dehydration.
B. Changes in level of consciousness.
C. Premature aging as the disease progresses.
D. Severe edema from an excess of water and sodium.
Correct
Incorrect
Correct
Incorrect
Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and
helps prevent and treat acne. Oily skin is especially bothersome during adolescence when
hormones cause enlargement of sebaceous glands and increased glandular secretions which
predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should
be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at
a later time, if healthcare recommendations are not successful.
Awarded 0.0 points out of 1.0 possible points.
The child must be monitored for signs and symptoms of hyponatremia, which creates secondary
central nervous system alterations such as changes in level of consciousness, seizure, and
coma (B). Fluid overload occurs with SIADH, not (A) (which occurs with diabetes insipidus). (C)
is caused by hypersecretion of growth hormone, not SIADH. (D) is not found in children with
SIADH because edema is caused by an excess of both water and sodium.
Awarded 0.0 points out of 1.0 possible points.
7. A threemonth
old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The
nurse determines the daily caloric need for this child is approximately
A. 400 calories per day.
B. 500 calories per day.
C. 600 calories per day.
D. 700 calories per day.
8. A 6yearold
is admitted to the pediatric unit after falling off a bicycle. Which intervention
should the nurse implement to assist the child's adjustment to hospitalization?
A. Explain hospital schedules to the child, such as mealtimes.
Correct
Correct
10 lbs 15 oz = 10.9 lbs. Convert lbs to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954 kg,
rounded to 5 kg. An infant requires 108 calories/kg/day (108 × 5 = 540 calories/day). However,
this infant requires 10% more calories because he has one degree temperature elevation. 10%
of 540 is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day. Tough
question! You know that 400 calories are too few and 700 are too much, and a temperature
elevation necessitates consumption of more calories, so choose the higher of the two choices
left!
Awarded 1.0 points out of 1.0 possible points.
B. Use terms, such as "honey" and "dear," to show a caring attitude.
C. Provide a list of rules that limits visitation of siblings in the hospital.
D. Orient the parents to the hospital unit and refreshment areas.
9. A child falls on the playground and is brought to the school nurse with a small laceration on
the forearm. Which action should the nurse implement first?
A. Slowly pour hydrogen peroxide over the open wound.
B. Apply ice to the area before rinsing with cold water.
C. Wash the wound gently with mild soap and water.
D. Gently cleanse with a sterile pad using povidoneiodine.
10. What preoperative nursing intervention should be included in the plan of care for an infant
with pyloric stenosis?
A. Monitor for signs of metabolic acidosis.
B. Esti
mat
e
the
involvement of the schoolaged
child incorporates the child's sense of initiate and cooperation.
Awarded 1.0 points out of 1.0 possible points.
Correct
Incorrect
Altered daily schedules and loss of rituals are upsetting to children and increase separation
anxiety, and active sensitivity to the needs of children can minimize the negative effects of
hospitalization. Explaining the hospital schedules (A) and establishing an individual schedule
familiarizes the child to the hospital environment and decreases anxiety. (B) depersonalizes the
child who should be addressed by name. Family and sibling visitation should be recommended
and encouraged without limitation (C). Although (D) should be implemented, the direct
A small, superficial laceration to the skin should be washed gently with mild soap and water (C)
for several minutes, followed by thorough rinsing. (A and D) are antiseptics that can be
traumatic (painful) when cleaning fresh, open wounds. Applying ice (B) may reduce or prevent
further edema, but the wound should be washed with mild soap and water first.
Awarded 0.0 points out of 1.0 possible points.
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ID: 310951938
Correct
Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the classic sign of pyloric
stenosis. (B) is not indicated. (C) is dangerous, due to the potential for aspiration with frequent
vomiting.
Awarded 1.0 points out of 1.0 possible points.
11. Which class of antiinfective drugs is contraindicated for use in children under 8 years of
age?
A. Aminoglycosides.
B. Tetracyclines.
C. Penicillins.
D. Quinolones.
12. The nurse is preparing a health teaching program for parents of toddlers and
preschoolers and plans to include information about prevention of accidental poisonings. It is most
important for the nurse to include which instruction?
A. Tell children they should not taste anything but food.
B. Store all toxic agents and medicines in locked cabinets.
C. Provide special play areas in the house and restrict play in other areas.
D. Punish children if they open cabinets that contain household [Show Less]