-"talks" to an imaginary friend - ANS-A 4 year old girl returns to the pediatricians office for a post
op visit following hospitalization for minor surgery. When observing the child in the waiting area,
which behavior should the nurse consider normal for this age child?
-a sore throat last week - ANS-The nurse is assessing a 9-year-old boy who has been admitted
to the hospital with possible acute post-streptococcal glomerulonephritis (APSGN). In obtaining
his history, what information is most significant?
-absolute neutrophil count of 400/mm3 - ANS-A nine-year-old with leukemia is admitted with a
ruptured appendix. An NG tube is inserted and attached to low intermittent section. Which
finding is most important for the nurse to report to the healthcare provider?
-administer the injection into the middle of the lateral aspect of the thigh - ANS-The nurse is
giving an im injection of antibiotic to a 16 month old toddler with pneumonia. Toddler does not
have any known allergies and has been walking without assistance for one month. Which
technique should the nurse select for administration?
-Administers a scheduled dose - ANS-A two-year-old child with heart failure is admitted for a
replacement of graft for cortication of the aorta. Prior to administering the next dose of digoxin,
the nurse obtains an apical heart rate of 128 BPM what action should the nurse implement?
-ask if the right tests has been seen in the scrotum before. - ANS-A mother brings her 2 month
old son to the clinic for a well baby exam. During the assessment the nurse finds that the right
testicle is not descended into the scrotum but the left is palpable. Which action should the nurse
take?
-BP: 70/40 - ANS-The HR of a 3 year old with CHF has steadily decreased over the last few
hours, now is 76 bpm, the previous reading 4 hours ago was 110bpm. Which additional finding
should be reported immediately to a healthcare provider?
-careful bathing in handling that avoids abdominal manipulation - ANS-An infant is admitted for
surgery who has wilms tumor. Which nursing intervention should the nurse implement during a
preop period?
-Carefully recording the height and weight of children to detect inappropriate growth rates -
ANS-Which nursing intervention is most important to assist in detecting, hypo, pituitary, ism, and
hyperpituitarism in children?
-cover the infants mouth and assist the mother to take the infant back to the room - ANS-A male
infant is admitted to the pediatric unit with pertussis and is exhibiting a "whooping-like cough."
The mother brings the infant to the nurse's station to seek assistance. Which intervention should
the nurse implement first?
-crackers - ANS-A 9 year old with celiac disease is admitted to the pediatric unit following an
appendectomy. Which food should the nurse remove from this child's tray?
-Decreased cardiac murmur - ANS-When administering indomethacin (Indocin) to a premature
infant who has patent ductus arteriosus, the nurse should anticipate which outcome?
-demonstrate startle reflex - ANS-The nurse is assessing a 6-month old infant. Which response
requires further evaluation by the nurse?
, -echocardiogram - ANS-The nurse is caring for a preschool aged child with a congenital heart
defect who is admitted with intermittent low grade fever, fatigue, and weight loss. Further
physical assessment findings include a new murmur, splinter hemorrhages under the nails, and
painless red lesions on the palms of the hands. Which diagnostic procedure should the nurse
prepare the parents to expect the healthcare provider to prescribe?
-Emphasize emotions with facial expressions - ANS-The nurse is communicating with a
12-year-old who is hearing impaired. Which action is best for the nurse to use when attempting
to communicate with this child?
-give the infant a pacifier during feedings - ANS-A 6 month old, diagnosed with short bowel
syndrome, began enteral feedings yesterday. To maintain growth and development of the child
during this period, what action should the nurse include in the infants plan of care?
-giving pain meds around the clock helps control the pain - ANS-The mother of an 11 year old
boy who has juvenile idiopathic arthritis tells the nurse, "I really don't want my son to become
dependent on pain medication, so I only allow him to take it when he is really hurting." Which
information is most important for the nurse to provide to the mother?
-growth failure is a concern, but development delays are not likely to occur - ANS-A 10 year old
girl is diagnosed with inflammatory bowel disease. Her mother is concerned that she will
experience delays as the result of this disorder. How should the nurse respond?
-III - ANS-during the physical exam of an 11-year-old girl, the nurse observes, budding breast
and scant pubic hair. Which Tanger stage should the nurse choose when documenting these
findings?
-In olive shaped mass in the abdominal area - ANS-A one month old male infant is brought to
the clinic for his mother, who states that her son has been vomiting forcefully after each meal for
the last three days. The infant is a febrile, dehydrated, and pyloric stenosis is suspected. What
other findings should the nurse identify that are consistent with pyloric stenosis?
-inspect hair follicle shafts for adherence of nits - ANS-The school nurse is assessing a child
who reports having an itchy scalp. The nurse has sent home instructions for pediculosis capitis
for several children in the school. Which assessment should the nurse implement to this child?
-Inspect the child oropharynx - ANS-Well, administering the final dose of oral amoxicillin to a
preschool age. Boy, he tells the nurse said his throat hurts. Which intervention is most important
for the nurse to implement?
-it is recommended for infants who meet established high risk criteria - ANS-A nurse is teaching
a class for mothers of premature infants, and is asked about "a shot for respiratory virus" what
information about palivizumab us correct?
-Jaundice - ANS-The nurse is caring for a child with sickle cell disease who is experiencing
sickle cell crisis. Which findings should the nurse report to the healthcare provider immediately?
-lemonade - ANS-What drink choice on a hot day indicates to the nurse that a teenager with
sickle cell anemia understands dietary considerations related to the disease?
-make plans for growth hormone injections to enhance growth - ANS-The caregiver of a
preschooler learns about long term endocrine dysfunctions resulting from their child's
craniospinal radiation. Which statement made by the caregiver should the nurse recognize as
needing additional education?