ATI RN Nursing Care of Children Form B Which of the following actions indicates to a nurse that the parent of a preschooler is using an age-appropriate disciplinary technique? ... Explains to the child why her behavior is unacceptable Places the child in time out after misbehaving Allows the child to choose the consequence for her misbehavior Assigns an extra chore for the misbehavior 1 A nurse is performing a neurological examination on a 15-month-old child. Which of the following is an expected normal finding? Negative Babinski reflex Presence of Moro reflex Absence of corneal reflexes Positive palmar grasp 2 A nurse is reviewing the morning laboratory results for an infant who is receiving digoxin (Lanoxin) and furosemide (Lasix) for the treatment of heart failure. Which of the following values should be reported to the primary care provider? Sodium 140 mEq/L Calcium 10.2 mg/dL Chloride 100 mEq/L Potassium 3.2 mEq/L 3 A nurse is caring for an infant with AIDS who is being treated for candidiasis. Which of the following findings in the infant indicates to the nurse that treatment has been effective? Heart rate of 170/min 4 to 5 wet diapers per day Oxygen saturation of 92% Consumes 3 oz of formula per feeding 4 A nurse is caring for a school-age child who is dying. In which of the following ways can the nurse appropriately meet the child's needs? Discourage the child's aggressive behavior. Share her feelings with the child. Encourage the child to talk about his feelings. Whisper when talking to the child. 5 An adolescent is undergoing a lumbar puncture to confirm a diagnosis of meningitis. Following the procedure, which of the following interventions should the nurse anticipate implementing to prevent postprocedure complications? Administer an antibiotic. Give the adolescent an IV bolus of normal saline. Apply analgesic cream to the puncture site. Instruct the adolescent to lie flat for several hours. 6 A nurse is caring for a child with a tracheostomy. Which of the following techniques should the nurse use to suction the child? Insert catheter to 2 cm beyond end of tracheostomy tube. Remove catheter while applying intermittent suction. Instill saline to loosen secretions while suctioning. Continue suctioning until secretions are removed. 7 A nurse is speaking to a child who is hearing impaired. To assist the child in communication, which of the following actions should the nurse take? Exaggerate pronunciation of words. Change positions frequently to maintain attention. Use touch to initiate conversation. Speak in a monotone voice. 8 A nurse is caring for a school-age child who had an arm cast applied 8 hr ago. Which of the following findings should alert the nurse to a complication related to the casting? Child rates pain as a 5 on a scale from 0 to 10 Child’s hands are cool bilaterally Child reports tightness at the wrist Child's grasp is weak 9 A nurse is planning a teaching session for parents regarding infant development. Which of the following parent activities regarding play should the nurse include in the teaching? Watch educational videos with the infant. Promote play with other infants. Engage with the infant in one-on-one play. Give the infant a large-piece puzzle. 10 An infant is scheduled for surgery for pyloric stenosis at 0700. Which of the following nursing interventions is appropriate prior to transferring the infant to surgery? Apply cardiac monitor. Complete a bowel prep. Insert an NG tube. Apply oxygen via nasal cannula. 11 A school-age child has returned from surgery and is placed in skeletal traction. Which of the following orders should the nurse question? Encourage use of trapeze to release pressure. Check neurovascular status of affected extremity. Adjust traction as needed if child is in pain. Maintain alignment of traction. 12 A school-age child with type 1 diabetes mellitus presents to the emergency department with an admitting blood glucose of 478 mg/dL and a pH of 7.30. Which of the following actions should the nurse anticipate taking? Obtain hematocrit and hemoglobin. Initiate IV fluid therapy. Insert an indwelling urinary catheter. Administer 1 mg of IM glucagon. 13 An adolescent diagnosed with mononucleosis is brought to the primary care provider by her parent. When assessing the adolescent's current condition, which of the following should the nurse expect to find? Splenomegaly Koplik spots Maculopapular rash Paroxysmal coughing 14 A newborn who has been experiencing diarrhea for the past 72 hr is brought to the emergency department by her parent. Which of the following assessment findings is the highest priority for the nurse? Irritated perianal area Decreased skin turgor Irritable behavior Absent tears 15 A nurse is caring for a school-age child who has sustained a closed-head injury from a bicycle accident. Which of the following nursing actions is appropriate? Elevate the head of the child's bed to a 30 degree angle. Provide opioid analgesics every 3 hr. Turn the child every 4 hr. Secure the child's head with sandbags. 16 A nurse is providing teaching to a parent about how to manage ringworm in his preschooler. Which of the following should the nurse include in the teaching? Apply 1:20 Burow's solution compresses to the lesions. Wash clothing and linens in hot water. Seal nonwashable toys in a plastic bag for 2 weeks. Apply topical ointment to the lesions for 1 to 2 weeks. 17 A toddler is brought to the clinic by his parent for a well-child exam. Which of the following should the nurse include in anticipatory guidance when teaching the parents? Toddlers who graze have difficulty maintaining adequate nutrition. Toddlers seen masturbating should be left alone. Toddlers prefer to play with other children. Toddlers can be expected to trace shapes with a crayon. 18 A nurse is assessing a client with appendicitis. Which of the following are expected findings? (Select all that apply.) Projectile vomiting Jaundice Bloody stools Right, lower-quadrant abdominal pain Fever 19 A child is brought to the emergency department after sustaining a burn injury from scalding water. The burn is determined to be a partial thickness (second degree) burn. The nurse identifies which of the following areas of the skin as being the deepest layer of tissue involved? (Move your cursor over the artwork until it changes – usually into a hand – indicating a “Hot Spot,” or selectable area. Click on the Hot Spot that corresponds to the correct answer.) 20 A nurse is planning care for a toddler admitted with acute gastroenteritis. Which of the following should the nurse expect to give? Oral rehydration solution Bananas or applesauce Chicken or beef broth Hypertonic IV solution 21 A nurse is teaching postoperative colostomy care to the family of an infant with Hirschsprung's disease. Which of the following statements by the family indicates a need for further teaching? "I will call the primary care provider if my infant has skin breakdown." "My infant's stoma should be pink and moist." "My infant's appliance has some room to move around." "My infant will wear a one-piece outfit to protect the bag." 22 When teaching a school-age child newly diagnosed with diabetes mellitus about following a food plan, the nurse should anticipate which of the following based on the child's expected cognitive development? Believes that inanimate objects are alive Understands the concept of cause and effect Evaluates quality of own thinking Makes judgments based on egocentric thinking 23 A nurse is assessing an adolescent female. The adolescent's mother tells the nurse she is concerned that her daughter is "too thin." Which of the following assessment findings is consistent with anorexia nervosa? Hyperactive deep tendon reflexes Lanugo over the back Oily skin with acne Elevated body temperature 24 A nurse is caring for a child following an IV pyelogram. Which of the following findings indicates a complication of this procedure? Polyuria Dysuria Low-grade fever Itching 25 A nurse is caring for a child with sickle cell anemia. Which of the following signs of acute chest syndrome should a nurse report to the primary care provider immediately? Congested cough Dilute urine Hgb 10 g/dL Systolic murmur 26 A nurse is planning care for an adolescent following insertion of Harrington rods for treatment of scoliosis. Which of the following should the nurse include in the plan of care? Encourage the family to perform the adolescent’s personal care. Use a log rolling technique to change the adolescent’s position. Begin ambulation on the adolescent's first postoperative day. Administer pain medication per the adolescent’s request. 27 A nurse is caring for a toddler who is postoperative after repair of a cleft palate. Which of the following interventions by the nurse is appropriate? Restrain arms at the elbows. Feed with a spoon. Monitor oral temperature. Provide a pacifier for comfort. 28 A nurse is providing discharge teaching to the parent of a child with cystic fibrosis. Which of the following statements by the parent indicates a need for further instruction? "My child will have chest physiotherapy after each meal." "I will be sure that my child receives a yearly flu shot." "I will ensure that my child has a high-calorie diet." "My child will participate in daily exercise." 29 A nurse is preparing to teach an adolescent client about a procedure. Which of the following techniques is most appropriate? Arrange for a support group. Involve the adolescent in the plan of care. Use simple words that describe the procedure. Have the adolescent's parents explain the procedure. 30 Which of the following assessment findings in an infant should indicate to a nurse that suctioning of the nasopharynx is needed? The infant is beginning to cough. The infant's respiratory rate is 30 to 32/min. The infant is becoming irritable. The infant's heart rate is 120 to 130/min. 31 A nurse is providing developmentally appropriate nutritional guidelines at a community center. Which of the following should the nurse include in the teaching? Provide 36 ounces of milk per day to a toddler. Provide 2 tablespoons of solid food per year of age to a preschooler. Introduce popcorn as a healthy snack at 12 months of age. Encourage a 15 year old to increase calcium intake to prevent osteoporosis 32 Which of the following is an appropriate nursing intervention for a child who is unconscious following a closed-head injury? Perform chest percussion as needed. Initiate seizure precautions. Turn the child side-to-side every 2 hr. Keep the child's neck in flexed position. 33 A parent brings her 6-month-old infant to the clinic for her scheduled immunizations. Which of the following reports by the parent regarding the child's last set of immunizations indicates that precautions should be considered? The infant was lethargic for 8 hr. The infant was unwilling to move her leg for 24 hr. The infant had an elevated temperature. The infant cried uncontrollably for 3 hr. 34 An adolescent with hydrocephalus and ventriculoperitoneal shunt malfunction has been admitted to the unit with an external ventricular drain. Which of the following assessment findings should indicate to the nurse that the client is experiencing increased intracranial pressure? The client is drowsy and irritable. The client is oriented but reports extreme fatigue. The client has paradoxic chest movement and apnea. The external ventricular drain has had a 10 to 20 mL shift increase. 35 A school-age child has sustained a head injury and developed increased intracranial pressure. Which of the following vital signs should the nurse recognize as being consistent with increased intracranial pressure? A respiratory rate of 12 to 14/min A respiratory rate of 23 to 25/min A heart rate of 80/min A heart rate of 90/min 36 A nurse is caring for a 10-month-old child brought to the emergency department by his parents following a head injury. Prioritize the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.) Assess respiratory status. Check pupil reactions. Examine scalp for lacerations. Palpate extremities for fractures. 37 An infant has had a cardiac catheterization with right femoral entry to diagnose a possible congenital heart defect. Following this procedure, the nurse should be concerned about which of the following? Cool toes on the right foot Weak pedal pulses on both feet Positive Babinski's on both feet Erythema on the right foot 38 A nurse is called to the room of a child who is having a tonic-clonic seizure. To prevent injury to the child, which of the following actions should the nurse take? Turn the child onto her side. Administer an IM antiepileptic medication. Insert an oral airway. Begin rescue breathing. 39 A nurse is assessing a toddler with potential lead poisoning. Which of the following is an appropriate assessment? Performing developmental testing for delays Auscultating heart sounds for dysrhythmias Obtaining a stool specimen for lead levels Inspecting the skin for discoloration 40 A nurse is caring for an infant with bronchiolitis. The infant's oxygen saturation reading is 88%. Which of the following actions should the nurse take first? Administer a nebulizer treatment. Sit the infant up. Notify the primary care provider. Suction the infant's nares. 41 A child with strabismus is brought to the clinic by her mother. The nurse confirms that the mother understands management of strabismus when she states she will place the patch over the child's place the patch over the child's right eye for 1 hr and then her left eye for the next hour. right eye one night and then her left eye the next night. weaker eye. stronger eye. 42 A nurse is caring for a child with acute glomerulonephritis. Which of the following laboratory values indicates progression of the disease? 4+ proteinuria 3+ glucosuria Elevated serum sodium Decreased serum BUN 43 For which of the following child laboratory values should a nurse contact the primary care provider? A school-age child with cystic fibrosis with an HCO3 of 24 mEq/L A child with suspected lead poisoning who has a lead level of 15 ug/dL An adolescent with type 1 diabetes mellitus with an HbA1c of 5% A school-age child with renal failure who has a specific gravity of 1.005 44 To prevent complications, which of the following instructions should a nurse provide to a school-age child who has spina bifida? Manage chronic pain with use of distraction. Perform clean intermittent catheterization. Check blood glucose before each meal. Consume a diet high in vitamin C. 45 A nurse is caring for a school-age child with chronic asthma. Which of the following nursing interventions is most appropriate for preventing asthma exacerbations in this child? Promote breathing exercises in the child. Teach the child what triggers symptoms. Assist the child in accepting his illness and limitations. Have the child demonstrate use of an inhaler. 46 A preschooler is admitted to the emergency department with full thickness (third degree) burns over 45% of his body. Which of the following actions should the nurse take first? Administer IV morphine. Administer IV antibiotics. Administer IV solutions. Administer total parenteral nutrition. 47 A nurse is providing teaching to the parents of a school-age child diagnosed with seizure disorder. The parents are concerned that the child will have a seizure and they will not know what to do. Which of the following should the nurse include in the teaching? Remove hard objects close to the child. Place the child on his back during a seizure. Administer an extra dose of his medication. Insert a tongue blade between the child’s teeth. 48 A nurse is providing teaching regarding toilet training to a parent of a 16-month-old child. Which of the following statements made by the parent indicates an understanding of the teaching? "My child is ready to toilet train now." "My child must be able to remove her clothing to train." "It's okay for my child to get on and off the toilet during training." "My child will need a free-standing potty chair to begin training." 49 A nurse is giving a child an injection of influenza vaccine. Which of the following common side effects should the nurse instruct the child's parent to expect within the next 24 to 48 hr? Nausea Headache Fever Dizziness 50 A 10-month-old infant is undergoing a well-infant check up. Which of the following assessment findings should concern the nurse? The infant is unable to walk alone. The infant's Moro reflex is absent. The infant's anterior fontanel is open. The infant needs assistance to sit up. 51 A preschooler who has just returned from cardiac catheterization experiences bleeding at the site. Which of the following nursing interventions should the nurse implement? Reinforce the dressing. Apply a 5 lb sandbag to the site. Elevate the head of the bed to a 45 degree angle. Apply direct pressure 1 inch above the site. 52 A nurse is interviewing the parent of a school-age child with asthma. Which of the following statements by the parent indicates to the nurse a need for further teaching? "My child uses fluticasone propionate (Flovent) with a spacer daily." "My child uses albuterol (Proventil) once a day." "My child is currently using montelukast (Singulair) at bedtime." "My child uses cromolyn sodium (Intal) before going to gym class." 53 A nurse is providing teaching to an adolescent who is prescribed tretinoin (Retin-A) gel to treat acne. Which of the following should the nurse include in the teaching? Apply sunblock with a minimum SPF-15 when outdoors. Take vitamin A supplements each day. Use alcohol to remove gel before a fresh application. Wash hair on alternate days. 54 A nurse is providing discharge teaching to the parents of a child who is receiving digoxin (Lanoxin). Which of the following is an adverse reaction to this medication that the parents should report to the primary care provider? Change in mood Vomiting Hearing loss Diaphoresis 55 A toddler is receiving albuterol via nebulizer for treatment of asthma. Which of the following assessment findings indicates to the nurse that the treatment has been effective? Increased heart rate Productive cough Decreased air movement Expiratory wheeze 56 A 2 month old is brought to the clinic by her parent for a well-child visit. When assessing this child, the nurse notes a severe case of diaper dermatitis. Which of the following interventions should the nurse recommend to promote skin integrity during diaper changes? Apply cornstarch. Cleanse the area with disinfectant wipes. Remove skin barrier ointment. Dry skin with a hair dryer. 57 A child is postoperative following a tonsillectomy. Which of the following findings by a nurse indicates bleeding? Vomiting with dark flecks of blood Continuous swallowing High fever Decreased respiratory rate 58 Which of the following statements by a nurse is helpful in assisting parents in handling a toddler who is exhibiting negativism during meal times? "Tell her she is having her favorite sandwich for lunch." "Ask her if she is ready to eat her sandwich for lunch." "Tell her that she may have a sandwich or soup for lunch." "Ask her if she would like to have her favorite sandwich for lunch." 59 A child receiving IV penicillin G develops flushing, urticarial rash, and severe laryngeal edema. Which of the following interventions should the nurse take next after stopping the infusion? Administer diphenhydramine (Benadryl). Prepare for intubation. Initiate continuous ECG monitoring. Give epinephrine IV push. 60 A nurse is caring for a toddler who is receiving droplet precautions for meningitis. Which of the following should the parents be encouraged to do to promote normal development in the toddler? Give the toddler safety scissors and paper. Encourage the toddler to interact with other children. Bring the toddler’s favorite toy from home. Bring balloons to the toddler's room. 61 A nurse is planning a class for parents regarding managing an infestation of lice in school-age children. Which of the following instructions should a nurse include in the teaching? Bag the child’s nonwashable items and discard. Monitor the child's scalp for 2 to 3 days. Apply medication twice daily until symptoms subside. Remove nits from hair using a fine-tooth comb. 62 A nurse is providing discharge teaching to the parent of an infant with congenital heart disease who will bottle feed. Which of the following statements by the parent indicates a need for further teaching? "I will feed my baby smaller feedings every 3 hr." "My baby will feed better if we are in a quiet place." "I will use a soft nipple with a larger opening to feed my baby." "My baby's feeding will last about 10 min.". 63 When caring for a school-age child with juvenile rheumatoid arthritis, which of the following instructions regarding pain management should the nurse provide the family? Administer opioid medications for breakthrough pain. Promote active range of motion during acute inflammation. Provide a soft mattress with extra pillows. Provide NSAIDs on a routine schedule. 64 A nurse is caring for four clients. Which of the following clients is at the highest risk for failure to thrive? A 1-week-old neonate who has lost 10% of his birth weight A 2-year-old child who will only eat two food items A 4-year-old child diagnosed with cerebral palsy A 6-year-old child diagnosed with asthma [Show More]
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