HESI RN PEDIATRICS EXAM
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most
... [Show More] important for the nurse to implement?
A. Assess the child's mucous membranes and skin turgor.
B. Contact food services about needed menu restrictions.
C. Determine the child's food likes and dislikes.
D. Ask the parents about the child's recent dietary intake.
Rationale:
An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit and then implement options B, C, and D.
Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery?
A. Crying that is unrelieved by comforting measures
B. Presence of an inguinal bulge after gentle palpation
C. Refusal to take oral feedings
D. Straining during defecation
Rationale:
The parents should notify the health care provider if the hernia remains irreducible after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release. Options A and D may cause the hernia to protrude but do not necessitate notification of the health care provider. Option C may not be specific to the hernia.
A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take?
A. Send the child home with the parents to see the health care provider before returning to school.
B. Send the child home with the parents and report this to the health department.
C. Cover the lesion with a dry gauze dressing and send the child back to class.
D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class.
Rationale:
Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition. Option B is not necessary because this is not a public health hazard. Option C slows the healing process and can contribute to spread of the infection. The lesions should be washed with soap and water, topical ointment applied, and left open to the air to dry. This will occur at the child's home.
The nurse expects a 2-year-old child to exhibit which behavior?
A. Build a house with blocks.
B. Ride a small tricycle 6 feet.
C. Display possessiveness with toys.
D. Look at a picture book for 15 minutes.
Rationale:
Two-year-old children are egocentric and unable to share with other children. Options A, B, and D are behaviors of a preschooler.
A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman?
A. "You can prevent SIDS if your baby sleeps on the side or back. You will have to monitor the baby carefully."
B. "The fear of losing another child to SIDS is very realistic. Have you thought about what support
you may need?"
C. "An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind that you need."
D. "My neighbor's baby died of SIDS last year, and she went to a SIDS support group. That really helped her."
Rationale:
The most effective way to provide emotional support is to acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions. Option A implies to the mother that she can prevent SIDS from occurring, which is an unrealistic expectation. Offering a personal opinion about what will help this client or about what has helped a neighbor is not as effective as helping the client discover what would be best for her.
A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is the nurse addressing when teaching inhalation therapy?
A. Autonomy
B. Industry
C. Trust
D. Initiative
Rationale:
Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson theory of psychosocial development. They enjoy being active and participating in role playing. "Autonomy vs. Shame and Doubt" occurs at 1 to 3 years of age. "Industry vs. Inferiority" occurs at 6 to 11 years; "Trust vs. Mistrust" occurs from birth to 1 year of age.
Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.)
Select option(s), then click Submit.
A. Steatorrhea
B. Obesity
C. Foul-smelling stools
D. Delayed growth
E. Pulmonary congestion
Rationale:
Options A, C, D, and E are all common assessment findings in the client with cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis.
The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child?
A. "Our first child was born with a cleft lip."
B. "We are very careful not to get sunburns in our family."
C. "My first child sometimes got a diaper rash."
D. "My husband and our daughter are both lactose- intolerant."
Rationale:
Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis because milk allergies can contribute to the child's outbreaks. Option A is not a contributing factor. Option B is an environmental factor in other skin diseases but does not have a strong correlation with eczema in children. Option C is not unusual and occurs in the diaper area, whereas atopic dermatitis occurs most often on the face and extensor aspects of the arms and legs
When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement?
A. Use a blanket as a mummy restraint.
B. Monitor the infant's heart rate.
C. Lubricate the catheter with saline.
D. Explain the procedure to the parents.
Rationale:
All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant's heart rate, which may decrease because of vagal nerve stimulation and can occur when the tube is inserted. Options A, C, and D are of lower priority than option B.
In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect?
A. Irregular respiration and heart rate
B. Gagging
C. Blue feet and hands
D. Diminished femoral pulses
Rationale:
Diminished femoral pulses could indicate coarctation of the aorta. In the normal transition period, options A and B occur during the 4 to 6 hours after birth (second period of reactivity). Option C is a normal finding in the newborn.
At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions?
A. Inspiration
B. Coughing
C. Apneic episodes
D. Expiration
Rationale:
Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring. During apnea, the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent.
Which interventions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.)
A. Provide a low-fiber diet.
B. Administer mineral oil daily.
C. Decrease the daily fluids.
D. Eliminate dairy products.
E. Initiate consistent toileting routine.
Rationale:
Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet, not option A, and increased daily fluids, not option C, are components of care for a child with encopresis.
The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is the most likely cause of the child's impaired mobility?
A. Pathologic fractures
B. Poor alignment of joints
C. Dyspnea on exertion
D. Joint inflammation
Rationale:
Joint inflammation and pain are the typical manifestations of an exacerbation of JRA. Options A, B, and C are not specifically related to JRA.
A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period?
A. Place the infant upright in an infant seat position.
B. Provide mittens with the use of elbow restraints.
C. Use soft rubber catheters for nasal suctioning.
D. Apply water-soluble lubricant to the suture line
Rationale:
The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first?
A. Obtain a scale to weigh the infant's diapers.
B. Instruct the mother to offer Pedialyte regularly.
C. Insert an intravenous (IV) line and begin IV fluids.
D. Obtain a stool specimen for analysis.
Rationale:
An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids to rehydrate the infant. Options A, B, and D can then be implemented as needed.
The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse?
A. "Tell me what you know about birth control."
B. "Do you know how to apply a condom?"
C. "Teen pregnancy should not be taken lightly."
D. "You need to visit with your guidance counselor."
Rationale:
Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception. It would be best for the nurse to ask a more general question, such as option A. Option B is narrow in focus. Options C and D are blocks to any further communication.
A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9°
F. What caloric amount does this child need?
A. 400 calories/day
B. 500 calories/day
C. 600 calories/day
D. 700 calories/day
Rationale:
An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to
10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1° F temperature elevation. Ten percent of 540 (calories/day) is 54, and 540 + 54 = 594. This infant will require approximately 600 calories/day. Options A, B, and D are incorrect.
The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs?
A. Place the child's head flat, with the knees on pillows above the level of the heart.
B. Have the child lie on the right side, with the head elevated on one pillow.
C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated.
D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths.
Rationale:
Assuming a knee-chest position with the head and chest slightly elevated will help restore hemodynamic equilibrium. Options A and B are incorrect positions and may hinder the child's condition. Option D may cause chest pain or a vasovagal response, with resulting hypotension.
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome?
A. Presence of a systolic murmur
B. New onset of patchy alopecia
C. Complaints of long bone pain
D. Recent projectile vomiting
Rationale:
Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly.
Options B, C, and D are not recognized as common complications of trisomy 21.
The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client?
A. Remove the brace 1 hour each day for bathing only.
B. Remove the brace only for back range-of-motion exercises.
C. Wear the brace against the bare skin to ensure a good fit.
D. Wearing the brace will cure the spinal curvature.
Rationale:
The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis.
Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence?
A. Adjustment of orthodontic appliances or braces
B. Loss of deciduous teeth (baby teeth)
C. Urinary catheterization
D. Insect bites
Rationale:
Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization is an invasive procedure. Options A, B, and D are not invasive and do not require administration of prophylactic antibiotics.
A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse?
A. "My son often chokes while I am feeding him."
B. "Is it normal for my child's legs to cross each other?"
C. "He gets stiff when I pull him up to a sitting position."
D. "My 4-year-old son is jealous of his little brother."
Rationale:
Airway obstruction is always a priority when caring for any client. Options B and C are characteristics of spastic cerebral palsy and may involve one or both sides. These children have difficulty with fine motor skills, and attempts at motion increase abnormal postures. Option D is an expected behavior and may need to be addressed, but it is not a priority over choking.
The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child's crying during the recovery period?
A. Tear formation increases salivation.
B. This behavior increases respirations.
C. Excessive hysteria can lead to vomiting.
D. Crying stresses the suture line
Rationale:
Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes options A, B, and C, t [Show Less]