Respiratory
The nurse is caring for a preschool-aged child diagnosed with acute otitis media. What is the priority intervention for the nurse caring for this patient?
Relieving pain
The nurse is teaching a school-age child about asthma medications. Which medication will the nurse teach to be used as needed for shortness of breath or before exercise to prevent dyspnea?
Albuterol
An adolescent with epilepsy is experiencing a generalized seizure. What is the nurse's priority when providing safety for the client?
Position the client on their side
This keeps the airway open and prevents client's from swallowing their tongue back causing airway obstruction
A child comes into the emergency room with complaints of nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. The nurse knows these signs indicate what condition?
Meningitis
The nurse is assessing an infant, the mother reports the infant has not gained weight and is having foul smelling stools. What diagnosis would the nurse except the infant to have?
Cystic Fibrosis
A child is admitted to the hospital with asthma. What assessment findings would support this diagnosis?
Nonproductive cough, wheezing, chest tightness, dyspnea, coarse lung sounds
If severe: restlessness, anxiety, use of accessory muscles (retractions), low O2, Tripod position, inaudible breath sounds
A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which finding is a manifestation of this postoperative complication?
Frequent swallowing and throat clearing
An infant is admitted with bacterial meningitis. What is the highest priority for the nurse?
A. Establish droplet precautions
B. Administer acetaminophen
C. Obtain history from caregivers
D. Orient caregivers to the unit
A
The nurse is caring for a patient with brain tumor-related hydrocephalus who is scheduled to undergo placement of a ventriculoperitoneal (VP) shunt. Which information is most important for the nurse to include when explaining the purpose of the procedure?
A VP shunt redirects the cerebrospinal fluid (CSF) from the ventricles to the peritoneum.
The nurse enters a room of a toddler who is in the crib. The side rail is down and the mother is sitting in the chair. What is a priority action for the nurse?
Raise the siderail of the crib and educate the mother about safety
The nurse is assessing a child's respiratory status and notes the child is anxious, sitting forward to breath, drooling and has stridor. The nurse understands the patient is showing signs of which respiratory issue?
Epiglottitis
Which of the following assessment findings indicate that a toddler is experiencing respiratory distress? (Select All That Apply)
A. Coughing
B. Respiratory rate of 45 breaths/min
C. Heart rate of 100 beats/min
D. Restlessness
E. Retractions
A, B, D, E
The school nurse is observing in a classroom, when she notices a child who is speaking suddenly stop and stare for about 5 seconds and the continues speaking. What seizure type would the nurse note this as?
Absence seizure
The nurse is monitoring for signs of increased intracranial pressure (ICP) in an infant. What signs would the nurse be assessing for?
Bulging fontanel, Changes in LOC, Irritability, Vomiting, Poor Feeding, Seizures, Abnormal posturing, Changes in vital signs (HR & BP)
When communicating with the pediatric client, what techniques should the nurse use? Select all that apply.
A. Make communication developmentally appropriate
B. Always be truthful
C. Include play whenever possible
D. Stand above the child when talking so they know you are an authority figure
A, B, C
A child is admitted for treatment of an asthma attack. Which of the following indicates immediate intervention is needed?
A. Thin, copious mucous secretions
B. Productive cough
C. Intercostal retractions
D. Respiratory rate of 20 breaths/min
C. Intercostal retractions
A child has been diagnosed with streptococcal pharyngitis and has been put on antibiotics. What is a priority teaching for the parents?
Complete the entire course of the antibiotics as prescribed
The nurse is caring for an infant with a myelomeningocele. The parents ask the nurse why the nurse keeps measuring the baby's head circumference. Which of the following would be the best response?
A. Infants' heads are measured to ensure growth is on track
B. Infants with a myelomeningocele are at risk for hydrocephalus which shows up as an increase in head size.
C. Because the infant has an opening on the spinal cord, the infant is at risk for meningitis which can show up as an increase in head size
D. Many infants with myelomeningocele have microcephaly which can show up as a decrease in head size.
B.
The nurse is caring for a 4-year-old with meningitis. A primary nursing goal would be to:
A. increase stimulation opportunities to prevent coma
B. provide an opportunity for therapeutic play.
C. reduce the pain related to nuchal rigidity.
D. inspect the teeth for obvious caries.
C
A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media?
The eustachian tube is short, straight, and wide.
When is the best time to assess an infant's respiratory rate?
Worst time- when the infant is crying, makes the count inaccurate
The nurse is obtaining report on 4 patients on the pediatric unit. Which patient would the nurse assess first?
A. A toddler admitted with croup and is drinking and afebrile and playing in the crib
B. A teenager admitted with asthma and has respiratory rate of 25 and O2 of 91%
C. A preschool admitted with bronchitis in cool mist humidification and has a respiratory rate of 18
D. An infant admitted for a work up for RSV with a respiratory rate of 30 and pulse ox of 98%
B. The patient has an increased respiratory rate and has an O2 less than 92%
A parent of a child with a concussion injury asks the nurse "how will you know if my child is getting worse?" The nurse should tell the parents that which is the best indicator of a change in brain function?
A. Taking the child's pulse rate every hour
B. Assessing if the child knows who they are
C. Monitoring pupil response every 30 minutes
D. Asking the child to squeeze the parent's fingers
B
When assessing a six-month old infant in the clinic, the nurse notes hyperactive deep tendon reflexes, spasticity of extremities, and arching of the back. What is the most likely cause of these symptoms in this infant?
Cerebral palsy
A nurse is caring for a pre-school age child who has croup. Which of the following normal assessment findings should the nurse expect?
Barky cough (seal like)