Growth & Development
A nurse is assessing a 9 month old infant. Which finding requires further evaluation?
The infant is unable to sit without support.
A child with croup presents with a barking cough and stridor. What is the priority nursing intervention?
Administer humidified oxygen.
Which vaccine is contraindicated in immunocompromised children?
MMR (live attenuated vaccine)
A child with a congenital heart defect squats during play. What does this indicate?
Tetralogy of Fallot; squatting improves oxygenation during a hypercyanotic spell
A child with type 1 diabetes is pale, shaky, and diaphoretic. What is the priority intervention?
Administer a fast acting carbohydrate.
A toddler insists on doing everything independently and says no frequently. Which developmental stage is this?
Autonomy vs. Shame & Doubt (Erikson)
Which assessment finding indicates worsening respiratory distress in a child?
Nasal flaring and intercostal retractions.
A child with measles presents with Koplik spots. Where are they located?
Inside the cheeks (buccal mucosa)
A child is suspected of having intussusception. Which assessment finding is most characteristic?
Currant jelly stools.
A child with cystic fibrosis requires which dietary modification?
High calorie, high protein diet with pancreatic enzymes.
The nurse plans care for a hospitalized preschooler. Which intervention is most appropriate?
Use therapeutic play to reduce fear and anxiety.
A child with epiglottitis is drooling and sitting in the tripod position. What is the nurse's priority action?
Prepare for emergency airway management.
A nurse prepares immunizations for a 12 month old. Which vaccines are expected?
MMR and Varicella.
A 2 year old ingests an unknown household cleaner. What is the nurse's priority action?
Call poison control and avoid inducing vomiting.
A child with sickle cell disease reports severe pain. What is the nurse's priority action?
Administer prescribed analgesics and provide hydration.
A parent is concerned their 15 month old is not walking independently. What is the nurse's best response?
Independent walking can develop as late as 18 months.
A child with asthma has a silent chest. What does this indicate?
Severe airway obstruction and impending respiratory failure.
A child with bacterial meningitis is admitted. What is the priority nursing intervention?
Initiate droplet precautions.
A child presents with dehydration. Which finding indicates severe dehydration?
Sunken fontanelle and minimal urine output.
A child with Kawasaki disease is at risk for which complication?
Coronary artery aneurysms.
A school age child fears hospitalization due to potential disability. Which Erikson stage does this reflect?
Industry vs Inferiority
A toddler with RSV has oxygen saturation of 89%. What is the priority intervention?
Initiate supplemental oxygen.
A child with suspected meningitis presents with photophobia, fever, and nuchal rigidity. What is the nurse's priority action?
Administer prescribed IV antibiotics promptly.
A 2 year old child is brought to the emergency department with severe dehydration from vomiting and diarrhea. The child is lethargic, has sunken eyes, dry mucous membranes, and minimal urine output. What is the nurse's priority action?
Initiate intravenous isotonic fluid replacement (saline)
A child with nephrotic syndrome presents with edema and proteinuria. What is the priority nursing focus?
Monitor for infection and manage fluid balance.