NSG 3600 Exam 3 – Questions With Appropriate
Solutions
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Terms in this set (246)
The nurse judges teaching as 3, 4.
successful when the parent of a child 1. Children with myasthenia gravis should not
with myasthenia gravis states which of play strenuous sports. The increased stress from
the following? Select all that apply. being in a competitive sport tends to negatively
1. “My child should play on the impact children, and they should learn strategies to
school’s basketball team.” decrease stress.
2. “My child should meditate every 2. It is important that children with myasthenia gravis
day.” have activities they can participate in without causing
3. “My child should be allowed to do stress. Activities such as board games, horseback
what other kids do.” riding, and hiking should be encouraged. Some
4. “My child should be watched children would benefit from meditation but may take
carefully for signs of illness.” time to appreciate the results.
5. “My child should sleep in my room 3. Children with myasthenia gravis can do many
so that I can watch him better.” things other children do. They should be advised
not to play strenuous sports, and they should learn
how to control stress.
4. Children are watched for signs of illness because
of the exacerbation of signs of myasthenia gravis.
5. It’s not recommended that children sleep in the
same bedroom as their parents unless it can’t be
avoided.
TEST-TAKING HINT: The test taker must know the
physiology of the illness and consider that this is a
chronic disease. The child is first a child, so he will
have all the growth and development issues
children without a chronic disease have.
,The parent of a newborn asks, "Will 1. Swallowing is a reflex in neonates; infants younger
my baby spit out the formula if it is too than 6 weeks cannot voluntarily control swallowing.
hot or too cold?" Which is the nurse's 2. Swallowing is a reflex in neonates; infants younger
best response? than 6 weeks cannot voluntarily control swallowing.
1. "Babies have a tendency to reject 3. The infant is not capable of selectively rejecting
hot fluids but not cold fluids, which fluid because swallowing is a reflex until 6 weeks.
could result in abdominal discomfort." 4. Swallowing is a reflex in infants younger than 6
2. "Babies have a tendency to reject weeks.
cold fluids but not hot fluids, which TEST-TAKING HINT: Swallowing is a reflex that is
could result in esophageal burns." present until the age of 6 weeks. The test taker
3. "Your baby would most likely spit should eliminate answers 1, 2,and 3 because they
out formula that was too hot, but your suggest that the infant is capable of selectively
baby could swallow some of it, which rejecting fluids.
could result in a burn."
4. "Your baby is too young to be
physically capable of spitting out
fluids and will automatically swallow
anything."
The mother of a newborn asks the 1. The caloric content of breast milk and formula
nurse why the infant has to nurse so tends to be similar.
frequently. Which is the best 2. Peristalsis in infants is greater than in older
response? children.
1. Formula tends to be more 3. The small-stomach capacity and rapid movement
calorically dense, and formula-fed of fluid through the digestive system account for
babies require fewer feedings than the need for small, frequent feedings.
breastfed babies. 4. Breastfed babies and formula-fed babies do not
2. The newborn's stomach capacity is necessarily have a difference in feeding time.
small, and peristalsis is slow. TEST-TAKING HINT: The test taker should eliminate
3. The newborn's stomach capacity is answers 1 and 4 because they both form
small, and peristalsis is more rapid generalizations that are not supported by current
than in older children. literature.
4. Breastfed babies tend to take
longer to complete a feeding than
formula-fed babies.
,A 4-month-old has had vomiting and 1. The information obtained from a urinalysis of an
diarrhea for 24 hours. The infant is infant is not as helpful as serum electrolytes. The
fussy, and the anterior fontanel is infant has limited ability to concentrate urine, so the
sunken. The nurse notes the infant specific gravity is not usually affected.
does not produce tears when crying. 2. The information obtained from a urinalysis of an
Which task will help confirm the infant is not as helpful as serum electrolytes. The
diagnosis of dehydration? infant has limited ability to concentrate urine, so the
1. Urinalysis obtained by bagged specific gravity is not usually affected. A urinalysis
specimen. does not need to be obtained by catheterization.
2. Urinalysis obtained by sterile 3. The analysis of serum electrolytes offers the
catheterization. most information and assists with the diagnosis of
3. Analysis of serum electrolytes. dehydration.
4. Analysis of cerebrospinal fluid. 4. Although critical in diagnosing meningitis, a lumber
puncture and analysis of cerebrospinal fluid are not
done to confirm dehydration.
TEST-TAKING HINT: Infants have limited ability to
concentrate urine, so answers 1 and 2 can be
eliminated immediately.
A 4-month-old is brought to the 1. Dehydration is corrected with the administration
emergency department with severe of an isotonic solution, such as normal saline or
dehydration. The heart rate is 198, and lactated Ringer solution.
her blood pressure is 68/38. The 2. Solutions containing dextrose should never be
infant's anterior fontanel is sunken. The administered in bolus form because they may result
nurse notes that the infant does not in cerebral edema.
cry when the intravenous lineis 3. Solutions containing dextrose should never be
inserted. The child's parents state that administered in bolus form because they may result
she has not "held anything down" in 18 in cerebral edema.
hours. The nurse obtains a finger-stick 4. Severe dehydration is not usually corrected with
blood sugar of 94. Which would the oral solutions; children with altered levels of
nurse expect to do immediately? consciousness should be kept NPO.
1. Administer a bolus of normal saline. TEST-TAKING HINT: The test taker should
2. Administer a bolus of D10W. immediately eliminate answers 2 and 3 because
3. Administer a bolus of normal saline they both suggest administering glucose in bolus
with 5% dextrose added to the form, which is always contraindicated in pediatric
solution. clients. Answer 4 should be eliminated because the
4. Offer the child an oral rehydrating infant is severely dehydrated and not responding
solution such as Pedialyte. to painful stimulation, which is suggested by the
lack of a cry on intravenous insertion.
, The nurse is caring for a 2-year-old 1. Fluid boluses of normal saline are administered
child who was admitted to the according to the child’s body weight. It is not unusual
pediatric unit for moderate to have to repeat the bolus multiple times in order to
dehydration due to vomiting and see an improvement in the child’s condition.
diarrhea. The child is restless with 2. It is important to monitor serum electrolytes
periods of irritability. The child is frequently in the dehydrated child.
afebrile with a heart rate of 148 and a 3. Potassium is contraindicated because the child
blood pressure of 90/42. Baseline has not yet urinated. Potassium is not added to the
laboratory tests reveal the following: maintenance fluid until kidney function has been
Na 152, Cl 119, and glucose 115. The verified.
parents state that the child has not 4. The child with dehydration secondary to vomiting
urinated in 12 hours. After establishing and diarrhea is placed on a clear liquid diet.
a saline lock, the nurse reviews the TEST-TAKING HINT: Be aware of the usual ways in
physician's orders. Which order should which dehydration is treated. Answer 3 should be
the nurse question? selected because the description states that the
1. Administer a saline bolus of 10 child has not urinated.
mL/kg, which may be repeated if the
child does not urinate.
2. Recheck serum electrolytes in 12
hours.
3. After the saline bolus, begin
maintenance fluids of D5 1⁄4 NS with
10 mEq KCl/L.
4. Give clear liquid diet as tolerated.
Solutions
Save Groups
Terms in this set (246)
The nurse judges teaching as 3, 4.
successful when the parent of a child 1. Children with myasthenia gravis should not
with myasthenia gravis states which of play strenuous sports. The increased stress from
the following? Select all that apply. being in a competitive sport tends to negatively
1. “My child should play on the impact children, and they should learn strategies to
school’s basketball team.” decrease stress.
2. “My child should meditate every 2. It is important that children with myasthenia gravis
day.” have activities they can participate in without causing
3. “My child should be allowed to do stress. Activities such as board games, horseback
what other kids do.” riding, and hiking should be encouraged. Some
4. “My child should be watched children would benefit from meditation but may take
carefully for signs of illness.” time to appreciate the results.
5. “My child should sleep in my room 3. Children with myasthenia gravis can do many
so that I can watch him better.” things other children do. They should be advised
not to play strenuous sports, and they should learn
how to control stress.
4. Children are watched for signs of illness because
of the exacerbation of signs of myasthenia gravis.
5. It’s not recommended that children sleep in the
same bedroom as their parents unless it can’t be
avoided.
TEST-TAKING HINT: The test taker must know the
physiology of the illness and consider that this is a
chronic disease. The child is first a child, so he will
have all the growth and development issues
children without a chronic disease have.
,The parent of a newborn asks, "Will 1. Swallowing is a reflex in neonates; infants younger
my baby spit out the formula if it is too than 6 weeks cannot voluntarily control swallowing.
hot or too cold?" Which is the nurse's 2. Swallowing is a reflex in neonates; infants younger
best response? than 6 weeks cannot voluntarily control swallowing.
1. "Babies have a tendency to reject 3. The infant is not capable of selectively rejecting
hot fluids but not cold fluids, which fluid because swallowing is a reflex until 6 weeks.
could result in abdominal discomfort." 4. Swallowing is a reflex in infants younger than 6
2. "Babies have a tendency to reject weeks.
cold fluids but not hot fluids, which TEST-TAKING HINT: Swallowing is a reflex that is
could result in esophageal burns." present until the age of 6 weeks. The test taker
3. "Your baby would most likely spit should eliminate answers 1, 2,and 3 because they
out formula that was too hot, but your suggest that the infant is capable of selectively
baby could swallow some of it, which rejecting fluids.
could result in a burn."
4. "Your baby is too young to be
physically capable of spitting out
fluids and will automatically swallow
anything."
The mother of a newborn asks the 1. The caloric content of breast milk and formula
nurse why the infant has to nurse so tends to be similar.
frequently. Which is the best 2. Peristalsis in infants is greater than in older
response? children.
1. Formula tends to be more 3. The small-stomach capacity and rapid movement
calorically dense, and formula-fed of fluid through the digestive system account for
babies require fewer feedings than the need for small, frequent feedings.
breastfed babies. 4. Breastfed babies and formula-fed babies do not
2. The newborn's stomach capacity is necessarily have a difference in feeding time.
small, and peristalsis is slow. TEST-TAKING HINT: The test taker should eliminate
3. The newborn's stomach capacity is answers 1 and 4 because they both form
small, and peristalsis is more rapid generalizations that are not supported by current
than in older children. literature.
4. Breastfed babies tend to take
longer to complete a feeding than
formula-fed babies.
,A 4-month-old has had vomiting and 1. The information obtained from a urinalysis of an
diarrhea for 24 hours. The infant is infant is not as helpful as serum electrolytes. The
fussy, and the anterior fontanel is infant has limited ability to concentrate urine, so the
sunken. The nurse notes the infant specific gravity is not usually affected.
does not produce tears when crying. 2. The information obtained from a urinalysis of an
Which task will help confirm the infant is not as helpful as serum electrolytes. The
diagnosis of dehydration? infant has limited ability to concentrate urine, so the
1. Urinalysis obtained by bagged specific gravity is not usually affected. A urinalysis
specimen. does not need to be obtained by catheterization.
2. Urinalysis obtained by sterile 3. The analysis of serum electrolytes offers the
catheterization. most information and assists with the diagnosis of
3. Analysis of serum electrolytes. dehydration.
4. Analysis of cerebrospinal fluid. 4. Although critical in diagnosing meningitis, a lumber
puncture and analysis of cerebrospinal fluid are not
done to confirm dehydration.
TEST-TAKING HINT: Infants have limited ability to
concentrate urine, so answers 1 and 2 can be
eliminated immediately.
A 4-month-old is brought to the 1. Dehydration is corrected with the administration
emergency department with severe of an isotonic solution, such as normal saline or
dehydration. The heart rate is 198, and lactated Ringer solution.
her blood pressure is 68/38. The 2. Solutions containing dextrose should never be
infant's anterior fontanel is sunken. The administered in bolus form because they may result
nurse notes that the infant does not in cerebral edema.
cry when the intravenous lineis 3. Solutions containing dextrose should never be
inserted. The child's parents state that administered in bolus form because they may result
she has not "held anything down" in 18 in cerebral edema.
hours. The nurse obtains a finger-stick 4. Severe dehydration is not usually corrected with
blood sugar of 94. Which would the oral solutions; children with altered levels of
nurse expect to do immediately? consciousness should be kept NPO.
1. Administer a bolus of normal saline. TEST-TAKING HINT: The test taker should
2. Administer a bolus of D10W. immediately eliminate answers 2 and 3 because
3. Administer a bolus of normal saline they both suggest administering glucose in bolus
with 5% dextrose added to the form, which is always contraindicated in pediatric
solution. clients. Answer 4 should be eliminated because the
4. Offer the child an oral rehydrating infant is severely dehydrated and not responding
solution such as Pedialyte. to painful stimulation, which is suggested by the
lack of a cry on intravenous insertion.
, The nurse is caring for a 2-year-old 1. Fluid boluses of normal saline are administered
child who was admitted to the according to the child’s body weight. It is not unusual
pediatric unit for moderate to have to repeat the bolus multiple times in order to
dehydration due to vomiting and see an improvement in the child’s condition.
diarrhea. The child is restless with 2. It is important to monitor serum electrolytes
periods of irritability. The child is frequently in the dehydrated child.
afebrile with a heart rate of 148 and a 3. Potassium is contraindicated because the child
blood pressure of 90/42. Baseline has not yet urinated. Potassium is not added to the
laboratory tests reveal the following: maintenance fluid until kidney function has been
Na 152, Cl 119, and glucose 115. The verified.
parents state that the child has not 4. The child with dehydration secondary to vomiting
urinated in 12 hours. After establishing and diarrhea is placed on a clear liquid diet.
a saline lock, the nurse reviews the TEST-TAKING HINT: Be aware of the usual ways in
physician's orders. Which order should which dehydration is treated. Answer 3 should be
the nurse question? selected because the description states that the
1. Administer a saline bolus of 10 child has not urinated.
mL/kg, which may be repeated if the
child does not urinate.
2. Recheck serum electrolytes in 12
hours.
3. After the saline bolus, begin
maintenance fluids of D5 1⁄4 NS with
10 mEq KCl/L.
4. Give clear liquid diet as tolerated.
