When checking a toddler's vital signs, the nurse initially assesses the:
A. Heart rate
B. Respiratory rate
C. Blood pressure
D.
... [Show More] Temperature
B
The nurse assesses the least invasive vital sign first and then progresses to most invasive. Thus, RR, HR, temperature, and then BP.
(James et al., Ch 9 - physical assessment)
When appropriately assessing an infant's heart rate, it is important for the nurse to: (Select all that apply)
A. Count for 15 seconds and multiply by 4
B. Count the heart rate for one full minute
C. Count the brachial pulse with one finger
D. Ask the parent to look at her watch while counting the pulse
E. Assess the apical pulse using a stethoscope
B, E
The HR is most accurate when it is assessed with a stethoscope, for one full minute by the nurse, especially for children less than 2 years old
To obtain an appropriate pain assessment of a preschool aged child, the nurse uses which of the following tools?
A. Numeric rating scale
B. FLACC
C. CRIES pain scale
D. FACES pain rating scale
D
Most appropriate - FACES pain rating scale is for 3 years old and older. Numeric-Child 9 years and older. FLACC-infants, preverbal or nonverbal child. CRIES-neonates, 0-6 months old
To assess the Point of Maximum Impulse (PMI) of a child who is 10 years old, the nurse assesses the apical pulse at the:
A. Third intercostal space, lateral to the midclavicular line
B. Fourth intercostal space, lateral to the midclavicular line
C. Fifth intercostal space at the midclavicular line
D. Space anywhere around the left nipple
C
The PMI in a child older than 7 years old is located in the fifth intercostal space in the midclavicular line
For which of the following reasons are infants and children at greater risk for infection? (Select all that apply)
A. Their immune systems are not as robust as adults' immune systems
B. Their parents do not give them chewable multi-vitamins every day
C. They have a proportionately greater body surface area in relation to mass
D. They do not drink enough Gatorade, Powerade, and energy drinks
E. They have increased exposure to infections in daycares and schools
A, C, E
In comparison to adults, infants and children have a proportionately greater body surface in relation to body mass, resulting in a greater potential for fluid loss through the skin and GI tract. Their immune systems are not as robust as adults, rendering young children more susceptible to infectious diseases, fever, gastroenteritis, and respiratory infections, all of which result in fluid and electrolyte disturbances and fluid-volume deficit. They are also at higher risk because of increased exposure to infections in a daycare, nursery, and school settings.
(James et al., pg 337)
While an adolescent is hospitalized, a source of anxiety for him is the:
A. Separation from his computer
B. Separation from his siblings
C. Separation from his parents
D. Separation from his friends
D
While the adolescent is hospitalized, separation from his friends is a source of anxiety as he feels his peer group is important
A hospitalized two year old child is crying because his mother is leaving. The most appropriate nursing action is to:
A. Give the child some stuffed animals for play
B. Ask the child life specialist to play with him
C. Ask the mother what time she will be back
D. Allow the child two minutes to stop crying
B
The most appropriate nursing action is to ask the child life specialist to play with the toddler. The child life specialist is specially trained and educated to play with hospitalized children within their developmental levels and with the appropriate play therapies. Separation anxiety is a significant stressor in the hospitalized toddlers and infants
The nurse understands caring for a child means the nurse is caring for the:
A. Family dog and the child
B. Child and his siblings
C. Child only
D. Whole family as the client
D
In 2003, family centered care was adopted as a philosophy of care for pediatric nursing by the Society of Pediatric Nurses.
A child who is unable to verbalize his feelings may express feelings and thoughts through which of the following?
A. Diet
B. Clothing
C. Play
D. Watching television
C
Play can greatly facilitate communication with children. Children are less likely to be inhibited when participating in play interactions.
During assessment, the nurse notes an infant's head circumference has increased almost 6 cm since the last hospitalization six months ago. The nurse understands the increase in head circumference in this infant indicates which of the following?
A. Higher IQ
B. Increased hearing acuity
C. Increased sense of sight
D. Brain growth
D
One parameter of the growth of the developing child is the head circumference; this indicated brain growth. The average head growth occurs in the pattern of 12 cm during the first year
During hospitalization, a school-age child sucks his thumb and wets his bed every day. Which of the following nursing actions is most appropriate?
A. Place the child in "time out."
B. Clean the patient's bed and give him emotional support
C. Call the patient's parents so the child can be disciplined
D. Notify the pediatrician and request medication
B
In a stressful situation such as hospitalization, a child with undue anxiety can regress and reactivate a behavior more appropriate to an earlier stage of development
The most appropriate communication skill [Show Less]