pediatric hesi part 1
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine
evaluation. Which assessment finding suggests the presence of a common complication often
experienced by those with Down syndrome? -
Presence of a systolic murmur
Rationale: Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down
syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most
common heart defects associated with this congenital anomaly.
Which preoperative nursing intervention should be included in the plan of care for an infant with
pyloric stenosis? -
Observe for projectile vomiting.
Rationale: Projectile vomiting (D), the classic sign of pyloric stenosis, contributes to metabolic
alkalosis.
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place.
He has an endotracheal tube and is ventilator-dependent but will be extubated soon following
recovery from anesthesia. Which nursing intervention should be included in this child's plan of
care? -
Remove restraints one at a time and provide range-of-motion exercises.
Rationale: Removing restraints one at a time is safer than simultaneously. The infant should have
the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and
range-of-motion exercises should be performed with these assessments. Under no circumstances
should restraints be applied to the client continuously. Documentation of assessment findings
regarding the restrained extremities must occur much more frequently than every 72 hours;
however, the reason for using restraints must be justified and should be stated in the medical record.
The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further
assessment reveals that he is concerned about his edematous facial features. Based on these
assessment findings, the nurse should plan interventions related to which nursing diagnosis? -
Social isolation
Rationale: Peer acceptance and body image are significant issues in the growth and development of
adolescents. The answer addresses the problem of a lack of contact with peers stemming from his
desire to protect his ego.
Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains 250
mg/5 mL. How many milliliters should the nurse administer in one dose? -
15
Rationale: Take 22lbs / 2.2 = 10kg
10kg X 75mg/kg = 750mg
750/250 mg = 3mg X 5mL = 15
A child comes to the school nurse complaining of itching. Further assessment reveals that the child
has impetigo. What action should the nurse take? -
Send the child home with the parents to see the health care provider before returning
to school.
1
,Rationale: Impetigo is a staphylococcal infection and is transmitted by person-to-person contact.
The child should be sent home with a note to the parents explaining the condition
The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect
this child to exhibit? -
Boasts aggressively when telling a story
Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a
tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings,
what action should the nurse take? -
Ask if the child has had a cold, runny nose, or any ear pain lately.
Rationale: The tympanic membrane is normally pearly gray, not bulging, and moves when a client
blows against resistance or when a small puff of air is blown into the ear canal. Because these
findings are not completely normal, further assessment of history and related signs and symptoms
are needed to interpret the findings accurately.
Following the administration of immunizations to a 6-month-old girl, the nurse provides the family
with home care instructions. Which statement by the mother indicates that further teaching is
needed? -
"I will give her a baby aspirin every 4 hours as needed for fever."
Rationale: Although fever may occur, non-aspirin-containing medications should be used because
of the risk of Reye's syndrome
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which
intervention should the nurse implement first? -
Insert an intravenous (IV) line and begin IV fluids.
Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to
initiate IV fluids
The nurse is preparing a child with an intussusception for a prescribed barium enema. What is the
main purpose of conducting this procedure prior to surgical intervention? -
Reduce the invaginated bowel segment.
Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into
another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of
age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation,
which often reduces the area of bowel intussusception, thereby negating the need for surgical
intervention.
In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to
suspect a congenital heart defect? -
Diminished femoral pulses
Rationale: Diminished femoral pulses (D) could indicate coarctation of the aorta.
Which assessment finding(s) should the nurse expect when caring for a child with cystic fibrosis?
(Select all that apply.) -
Steatorrhea
Foul-smelling stools
Delayed growth
2
,Pulmonary congestion
Which nursing intervention(s) is (are) therapeutic when caring for a hospitalized toddler? (Select all
that apply.) -
Allow the toddler to choose a colored Band-Aid after an injection & Give brief but
simple explanations to the child before procedures.
Rationale: Giving the toddler a choice may increase autonomy in the hospitalized setting. Brief but
simple explanations are beneficial with the toddler. Separation from the parent can cause emotional
distress. Regression is expected, and bedwetting is not an indication for a urinary catheter. The
nurse should encourage age-appropriate toys to be brought in from home.
The nurse should teach the parents of a child with a cyanotic heart defect to perform which action
when a hypercyanotic spell occurs? -
Allow the child to assume a knee-chest position, with the head and chest slightly
elevated.
Rationale: Assuming a knee-chest position with the head and chest slightly elevated will help
restore hemodynamic equilibrium.
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis.
Which intervention is most important for the nurse to implement? -
Assess the child's mucous membranes and skin turgor
Rationale: An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume
deficit. The nurse should first assess for indications of fluid volume deficit
A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS)
is being discharged following the birth of her second child. The mother tells the nurse that she is
fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this
woman? -
"The fear of losing another child to SIDS is very realistic. Have you thought about
what support you may need?"
Rationale: The most effective way to provide emotional support is to acknowledge what clients may
be feeling, be a sounding board for them so they can listen to themselves, and allow them to
discover their own solutions
A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the
first time tomorrow. During the school day, which intervention should be implemented for this
child? -
Place suctioning supplies on the back of the wheelchair when transporting.
Rationale: Suctioning supplies should always be readily available for use with any client who has a
tracheostomy.
A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment
with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit? -
Persistent cold
Rationale: Respiratory tract infections commonly occur in the pediatric population, but the child
with AIDS has a decreased ability to defend the body against these common infections. Thus, the
most typical presenting symptom of a child who contracted AIDS through vertical transmission
(i.e., from the mother during delivery) is a persistent cold or respiratory infection
3
, The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans
to include information about the prevention of accidental poisonings. It is most important for the
nurse to include which instruction? -
Store all toxic agents and medicines in locked cabinets.
Rationale: The only reliable way to prevent poisonings in young children is to make the items
inaccessible
A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic.
Which statement by the parent warrants immediate intervention by the nurse? -
"My son often chokes while I am feeding him."
Rationale: Airway obstruction is always a priority when caring for any client
Which intervention(s) should the nurse include in the teaching plan for the mother of a 6-year-old
who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) -
Administer mineral oil daily.
Eliminate dairy products.
Initiate consistent toileting routine.
Rationale: Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an
enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining
with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber
diet and increased daily fluids are components of care for a child with encopresis.
A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory
infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally.
Which intervention has the highest priority? -
Tell the parent to take the child to the emergency department.
Rationale: The child is exhibiting symptoms that may indicate possible meningitis, and the parents
should be encouraged to get immediate evaluation
When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing
intervention is most important to implement? -
Monitor the infant's heart rate
The nurse expects a 2-year-old child to exhibit which behavior? -
Display possessiveness with toys.
Rationale: Two-year-old children are egocentric and unable to share with other children.
When caring for a child with congenital heart disease and polycythemia, which nursing intervention
has the highest priority? -
Maintaining adequate hydration
Rationale: The key word in this question is polycythemia. Hydration decreases blood viscosity and
the risk for thrombus formation, the most common complication of polycythemia.
An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated
femoral artery site. Which intervention should the nurse implement? -
Show the parents how to hold the child with the extremity extended.
Rationale: The extremity should be extended to prevent trauma to the femoral catheterization site
4
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine
evaluation. Which assessment finding suggests the presence of a common complication often
experienced by those with Down syndrome? -
Presence of a systolic murmur
Rationale: Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down
syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most
common heart defects associated with this congenital anomaly.
Which preoperative nursing intervention should be included in the plan of care for an infant with
pyloric stenosis? -
Observe for projectile vomiting.
Rationale: Projectile vomiting (D), the classic sign of pyloric stenosis, contributes to metabolic
alkalosis.
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place.
He has an endotracheal tube and is ventilator-dependent but will be extubated soon following
recovery from anesthesia. Which nursing intervention should be included in this child's plan of
care? -
Remove restraints one at a time and provide range-of-motion exercises.
Rationale: Removing restraints one at a time is safer than simultaneously. The infant should have
the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and
range-of-motion exercises should be performed with these assessments. Under no circumstances
should restraints be applied to the client continuously. Documentation of assessment findings
regarding the restrained extremities must occur much more frequently than every 72 hours;
however, the reason for using restraints must be justified and should be stated in the medical record.
The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further
assessment reveals that he is concerned about his edematous facial features. Based on these
assessment findings, the nurse should plan interventions related to which nursing diagnosis? -
Social isolation
Rationale: Peer acceptance and body image are significant issues in the growth and development of
adolescents. The answer addresses the problem of a lack of contact with peers stemming from his
desire to protect his ego.
Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains 250
mg/5 mL. How many milliliters should the nurse administer in one dose? -
15
Rationale: Take 22lbs / 2.2 = 10kg
10kg X 75mg/kg = 750mg
750/250 mg = 3mg X 5mL = 15
A child comes to the school nurse complaining of itching. Further assessment reveals that the child
has impetigo. What action should the nurse take? -
Send the child home with the parents to see the health care provider before returning
to school.
1
,Rationale: Impetigo is a staphylococcal infection and is transmitted by person-to-person contact.
The child should be sent home with a note to the parents explaining the condition
The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect
this child to exhibit? -
Boasts aggressively when telling a story
Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a
tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings,
what action should the nurse take? -
Ask if the child has had a cold, runny nose, or any ear pain lately.
Rationale: The tympanic membrane is normally pearly gray, not bulging, and moves when a client
blows against resistance or when a small puff of air is blown into the ear canal. Because these
findings are not completely normal, further assessment of history and related signs and symptoms
are needed to interpret the findings accurately.
Following the administration of immunizations to a 6-month-old girl, the nurse provides the family
with home care instructions. Which statement by the mother indicates that further teaching is
needed? -
"I will give her a baby aspirin every 4 hours as needed for fever."
Rationale: Although fever may occur, non-aspirin-containing medications should be used because
of the risk of Reye's syndrome
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which
intervention should the nurse implement first? -
Insert an intravenous (IV) line and begin IV fluids.
Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to
initiate IV fluids
The nurse is preparing a child with an intussusception for a prescribed barium enema. What is the
main purpose of conducting this procedure prior to surgical intervention? -
Reduce the invaginated bowel segment.
Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into
another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of
age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation,
which often reduces the area of bowel intussusception, thereby negating the need for surgical
intervention.
In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to
suspect a congenital heart defect? -
Diminished femoral pulses
Rationale: Diminished femoral pulses (D) could indicate coarctation of the aorta.
Which assessment finding(s) should the nurse expect when caring for a child with cystic fibrosis?
(Select all that apply.) -
Steatorrhea
Foul-smelling stools
Delayed growth
2
,Pulmonary congestion
Which nursing intervention(s) is (are) therapeutic when caring for a hospitalized toddler? (Select all
that apply.) -
Allow the toddler to choose a colored Band-Aid after an injection & Give brief but
simple explanations to the child before procedures.
Rationale: Giving the toddler a choice may increase autonomy in the hospitalized setting. Brief but
simple explanations are beneficial with the toddler. Separation from the parent can cause emotional
distress. Regression is expected, and bedwetting is not an indication for a urinary catheter. The
nurse should encourage age-appropriate toys to be brought in from home.
The nurse should teach the parents of a child with a cyanotic heart defect to perform which action
when a hypercyanotic spell occurs? -
Allow the child to assume a knee-chest position, with the head and chest slightly
elevated.
Rationale: Assuming a knee-chest position with the head and chest slightly elevated will help
restore hemodynamic equilibrium.
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis.
Which intervention is most important for the nurse to implement? -
Assess the child's mucous membranes and skin turgor
Rationale: An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume
deficit. The nurse should first assess for indications of fluid volume deficit
A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS)
is being discharged following the birth of her second child. The mother tells the nurse that she is
fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this
woman? -
"The fear of losing another child to SIDS is very realistic. Have you thought about
what support you may need?"
Rationale: The most effective way to provide emotional support is to acknowledge what clients may
be feeling, be a sounding board for them so they can listen to themselves, and allow them to
discover their own solutions
A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the
first time tomorrow. During the school day, which intervention should be implemented for this
child? -
Place suctioning supplies on the back of the wheelchair when transporting.
Rationale: Suctioning supplies should always be readily available for use with any client who has a
tracheostomy.
A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment
with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit? -
Persistent cold
Rationale: Respiratory tract infections commonly occur in the pediatric population, but the child
with AIDS has a decreased ability to defend the body against these common infections. Thus, the
most typical presenting symptom of a child who contracted AIDS through vertical transmission
(i.e., from the mother during delivery) is a persistent cold or respiratory infection
3
, The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans
to include information about the prevention of accidental poisonings. It is most important for the
nurse to include which instruction? -
Store all toxic agents and medicines in locked cabinets.
Rationale: The only reliable way to prevent poisonings in young children is to make the items
inaccessible
A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic.
Which statement by the parent warrants immediate intervention by the nurse? -
"My son often chokes while I am feeding him."
Rationale: Airway obstruction is always a priority when caring for any client
Which intervention(s) should the nurse include in the teaching plan for the mother of a 6-year-old
who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) -
Administer mineral oil daily.
Eliminate dairy products.
Initiate consistent toileting routine.
Rationale: Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an
enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining
with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber
diet and increased daily fluids are components of care for a child with encopresis.
A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory
infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally.
Which intervention has the highest priority? -
Tell the parent to take the child to the emergency department.
Rationale: The child is exhibiting symptoms that may indicate possible meningitis, and the parents
should be encouraged to get immediate evaluation
When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing
intervention is most important to implement? -
Monitor the infant's heart rate
The nurse expects a 2-year-old child to exhibit which behavior? -
Display possessiveness with toys.
Rationale: Two-year-old children are egocentric and unable to share with other children.
When caring for a child with congenital heart disease and polycythemia, which nursing intervention
has the highest priority? -
Maintaining adequate hydration
Rationale: The key word in this question is polycythemia. Hydration decreases blood viscosity and
the risk for thrombus formation, the most common complication of polycythemia.
An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated
femoral artery site. Which intervention should the nurse implement? -
Show the parents how to hold the child with the extremity extended.
Rationale: The extremity should be extended to prevent trauma to the femoral catheterization site
4
