1. 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?
A. Place the client on NPO status.
B. Prepare the client for a liver biopsy.
C. Position the client dorsal recumbent.
D. Put the client in a protective environment. - A
A. Due to the client's decreased level of consciousness, placing the client on NPO status is
an appropriate action by the nurse.
2. A nurse is caring for a 4-month-old infant who has meningitis. Which of the following findings is
associated with this diagnosis?
A. Depressed anterior fontanel
B. Constipation
C. Presence of the rooting reflex
D. High-pitched cry - D
D. A high-pitched cry is a finding associated with meningitis in a 4-month-old infant.
3. A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of
the
following results indicate viral meningitis? (Select all that apply.)
A. Negative gram stain
B. Normal glucose content
C. Cloudy color
D. Decreased WBC count
E. Normal protein content - A B E
A. A negative gram stain indicates viral meningitis.
B. Normal glucose content indicates viral meningitis.
E. Normal protein content indicates viral meningitis.
4. 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.)
A. Inactivated polio vaccine (IPV)
B. Pneumococcal conjugate vaccine (PCV)
C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
D. Haemophilus influenzae type B (Hib) vaccine
E. Trivalent inactivated influenza vaccine (TIV) - B
B. The introduction of the PCV decreased the incidence of bacterial meningitis in
children, as it provides immunity against bacteria that causes the illness.
D.
5. 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?
A. Recent history of infectious cystitis caused by Candida
B. Recent history of bacterial otitis media
C. Recent episode of gastroenteritis
D. Recent episode of Haemophilus influenzae meningitis - C
C. A recent episode of gastroenteritis, a viral illness, is a risk factor for Reye syndrome.
Reye syndrome typically follows a viral illness, such as influenza, gastroenteritis, or varicella.
5. A nurse is providing teaching about the management of epistaxis to a child and his family. Which of
the
following positions should the nurse instruct the child to take when experiencing a nosebleed?
A. Sit up and lean forward.
B. Sit up and tilt the head up.
C. Lie in a supine position.
D. Lie in a prone position. - A
A. The nurse should instruct the child to sit up and lean to prevent aspiration when
experiencing a nosebleed.
6. A nurse is providing teaching about epistaxis to the parent of a school-age child. Which of the
following
should the nurse include as an appropriate action to take when managing an episode of epistaxis?
(Select all that apply.)
A. Press the nares together at least 10 min.
B. Breathe through the nose until bleeding stops.
C. Pack cotton or tissue into the naris that is bleeding.
D. Apply a warm cloth across the bridge of the nose.
E. Insert petroleum into the naris after the bleeding stops. - A C E
A. Pressing the nares together for at least 10 min is an appropriate action to take when
managing an episode of epistaxis.
C. Packing cotton or tissue into the naris that is bleeding is an appropriate action when
managing an episode of epistaxis.
E. Inserting petroleum into the naris after the bleeding stops is an appropriate action
when managing an episode of epistaxis.
3. A nurse is providing teaching to the parent of a child who has a new prescription for liquid oral iron
supplements. Which of the following statements by the parent indicates an understanding of the
teaching?
A. "I should take my child to the emergency department if his stools become dark."
B. "My child should avoid eating citrus fruits while taking the supplements."
C. "I should give the iron with milk to help prevent an upset stomach."
D. "My child should take the supplement through a straw." - D
D. The child should take the supplement through a straw to prevent or minimize staining of
the teeth.
4. A nurse is preparing to administer iron dextran (Proferdex) IM to a school-age child who has iron
deficiency anemia. Which of the following actions by the nurse is appropriate?
A. Administer the dose in the deltoid muscle.
B. Use the Z-track method when administering the dose.
C. Avoid injecting more than 2 mL with each dose.
D. Massage the injection site for 1 min after administering the dose. - B
B. The nurse should use the Z-track method when administering the dose.
5. A nurse is caring for an infant whose screening test reveals that he may have sickle cell disease. Which
of the following tests should be performed to distinguish if the infant has the trait or the disease?
A. Sickle solubility test (Sickledex)
B. Hemoglobin electrophoresis
C. Complete blood count
D. Transcranial Doppler - B
B. The hemoglobin electrophoresis test should be performed to distinguish if the infant
has the trait or the disease.
1. A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action
for the nurse to take?
A. Provide emotional support to the family.
B. Educate the family on care of the child.
C. Prevent clinical complications.
D. Administer analgesics. - D
D. The priority action the nurse should take when using Maslow's hierarchy of needs is
to meet the toddler's physiological need first. Therefore, administering analgesics to alleviate or
decrease physical pain is the priority action for the nurse to take.
2. A nurse is caring for a 2-year-old child who has had three ear infections in the past 5 months. The
nurse
should know that the child is at risk for developing which of the following as a long-term complication?
A. Balance difficulties
B. Prolonged hearing loss
C. Speech delays
D. Mastoiditis - C
C. Speech delay is a common complication of otitis media.
3. An infant who has clinical manifestations of acute otitis media (AOM) is brought to an outpatient
facility by his parent. The nurse should recognize that which of the following factors places the infant at
risk for otitis media? (Select all that apply.)
A. Breastfeeding without formula supplementation.
B. Attends day care 4 days per week.
C. Immunizations are up to date.
D. History of a cleft palate repair.
E. Parents smoke cigarettes outside. - B D E
B. Infants who attend day care have an increased risk of OM because of the exposure to
multiple people.
D. Infants born with cleft palate are more prone to AOM because micro-organisms can
easily enter the eustachian tubes.
E. Exposure to secondhand smoke increases an infant's risk for AOM.
4. A nurse is caring for a toddler who has rhinitis, cough, and diarrhea for 2 days. Upon assessment, it is
noted that the tympanic membrane has a orange discoloration and decreased movement. Which of the
following is an appropriate statement for the nurse to make?
A. "Your child has an ear infection that requires antibiotics."
B. "Your child could experience transient hearing loss."
C. "Your child will need to be on a decongestant until this clears."
D. "Your child will need to have a myringotomy." - B
B. Rhinitis, cough, diarrhea, and an orange discoloration of the tympanic membrane are
clinical findings of OME. Transient hearing loss is a complication of OME.
5. A nurse is assessing an infant. Which of the following findings are clinical manifestations of acute otitis
media? (Select all that apply.)
A. Decreased pain in the supine position
B. Rolling head side to side
C. Loss of appetite
D. Increased sensitivity to sound
E. Crying - B C E
B. Infants who have acute otitis media will roll their head side to side because of the pain
and pressure in the ear.
C. Infants who have acute otits media will exhibit a loss of appetite due to the pain and
pressure in the ear.
E. Infants who have acute otitis media will exhibit crying and irritability from the pain.
1. A nurse is teaching the parent of a child who has a neuroblastoma. Which of the following statements
should the nurse include in the teaching? (Select all that apply.)
A. "Half of the children who have neuroblastoma have metastatic disease."
B. "Your child will need a bone marrow biopsy."
C. "Your child will be paralyzed because of this tumor."
D. "Most children are diagnosed around age 12."
E. "Your child will need surgery for resection of the tumor." - A B E
A. Half of the children who have neuroblastoma have metastatic disease. Therefore, this
should be included in the teaching.
B. Diagnostic testing for neuroblastoma includes a bone marrow biopsy. Therefore, this
should be included in the teaching.
E. Resection of the tumor is the treatment of choice. Therefore, this should be included in
the teaching.
2. A nurse is caring for a toddler who has a Wilms' tumor. Which of the following should be included in
the plan of care?
A. Abdominal palpation to identify the size of the tumor
B. Preparation for surgery
C. Teaching about dialysis
D. Obtaining 24-hr urine specimen - B
B. Removal of the tumor occurs within 24 to 48 hr of admission. Therefore, preparation
for surgery should be included in the plan of care [Show Less]