PEDS: Nursing Care of Children 1 Exam Retake(answered/rationales)

A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster - B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis, which affects the brain, and meningococcemia, which affects the blood. Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention has issued a recommendation that all incoming college students receive the meningococcal immunization. A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeps on hands and knees B. Inability to vocalize vowel sounds C. Uses crude pincer grasp D. Stands by holding onto support - B. Inability to vocalize vowel sounds The infant should begin vocalizing vowel sounds at the age of 7 months, and by the age of 10 months, be able to say at least one word. A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to his body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. - D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. Preschool-age children believe that their thoughts and wishes can make things happen since they are egocentric. This is one reason why the death of a family member can be very difficult for a child at this age. Preschool-age children sometimes believe that death is the result of guilt or punishment due to something they have done, said, or thought. A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication. B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain. C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10. D. Reinforce teaching with the client about how to push the button to deliver the medication. - D. Reinforce teaching with the client about how to push the button to deliver the medication. The appropriate action at this time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, verify that the client knows how to use the equipment, and emphasize the importance of using it regularly to manage pain effectively. A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head to toe sequence.