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The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside?
a. Emergency cart
b. Tracheotomy set
c. Padded tongue blade
d. Suctioning equipment and oxygen
d. Suctioning equipment and oxygen
The nurse is caring for a patient who has sustained a gunshot shot wound to the leg. The wound is actively bleeding and the patient reports 10/10 pain. Which factor should the nurse consider a priority when assessing the severity of the patient's injury?
a. The age of the patient
b. The size of the patient
c. Location of the penetration
d. Time that the injury occurred
c. Location of the penetration
The nurse is caring for a 5-year-old child with a congenital heart defect. The nurse is reviewing with the parents the actions that would be necessary if the child experiences cardiopulmonary arrest and needs resuscitation. Which of the following statements by the parents indicate to the nurse that the teaching has been understood? Select all that apply.
a. "I have to use compressions to circulate the blood."
b. “I should compress to the depth of ½ her chest”
c. “I will compress at a rate of 60-100 bpm”
d. "I will give two breaths for every 30 compressions."
e. "I will check for responsiveness before starting CPR."
a. "I have to use compressions to circulate the blood."
d. "I will give two breaths for every 30 compressions."
e. "I will check for responsiveness before starting CPR."
The nurse discusses child-proofing the home for safety with the mother of a 9-month-old. The statement made by the mother that indicates an unsafe behavior is:
a. "I put covers on all of the electrical outlets."
b. "In the car, she rides in a front-facing car seat."
c. "There are locks on all of the cabinets in the house."
d. "I have a gate at the top and bottom of the stairs."
b. "In the car, she rides in a front-facing car seat."
Which physical findings would be of most concern in an infant with respiratory distress?
a. Tachypnea.
b. Retractions.
c. Wheezing.
d. Breathing through the mouth.
b. Retractions.
The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.
a. Time the seizure.
b. Restrain the child.
c. Stay with the child.
d. Place the child in a prone position.
e. Move furniture away from the child.
f. Insert a padded tongue blade in the child's mouth.
a. Time the seizure.
c. Stay with the child.
e. Move furniture away from the child.
A nurse is teaching a group of parents about assessing the ABCDE's in children with toxic exposure. Which two assessment components should the nurse discuss in addition to the traditional ABC's of CPR?
Select all that apply.
a. Diuresis
b. Disability
c. Exposure
d. Exudates
e. Diaphoresis
b. Disability
c. Exposure
The nurse is caring for residents in a behavioral health setting for school age children. Which of the following activities based on Erickson’s theory will be most effective in meeting the growth and development needs of a person in this age group?
a. Group board game
b. Solitary coloring
c. Independent reading time
d. Playing with a yo-yo
a. Group board game
What is the most important piece of information that the nurse must ask the parent of a child in status asthmaticus?
a. "What time did your child eat last?"
b. "Has your child been exposed to any of the usual asthma triggers?"
c. "When was your child last admitted to the hospital for asthma?"
d. "When was your child's last dose of medication?"
d. "When was your child's last dose of medication?"
How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child's weakness and fatigue? Select all that apply.
a. Feeding more frequently with smaller feedings
b. Using a slow flow nipple
c. Holding and cuddling the child during feeding
d. Substituting glucose water for formula
e. Offering high-caloric formula
a. Feeding more frequently with smaller feedings
c. Holding and cuddling the child during feeding
e. Offering high-caloric formula
A neural tube defect that is not visible externally in the lumbosacral area would be called
A. meningocele.
B. myelomeningocele.
C. spina bifida cystica.
D. spina bifida occulta
D. spina bifida occulta
A 2-year-old child comes to the emergency department with a substantial acetaminophen overdose. Which drug-specific medication should the nurse anticipate administering to this patient?
a. Naloxone
b. N-acetylcysteine
c. Activated charcoal
d. Diluted oil of wintergreen
b. N-acetylcysteine
Your patient is a 9-year-old female who experienced syncope. During your assessment, you observe she is pale, slow to answer questions, and exhibits poor muscle tone. Radial pulses are present and very weak and thready. The ECG monitor reveals a wide complex tachycardia at 180 beats per minute. What should you do?
a. Start compressions
b. Perform synchronized cardioversion
c. Prepare for intubation
d. Ask the patient to bear down
b. Perform synchronized cardioversion
A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply.
a. A 4-month old infant whose HR is 190 bpm
b. A 3-year old whose blood pressure is 118/80
c. A 9-year old whose temperature is 39°C (102.2°F)
d. An adolescent whose pulse rate is 70 bpm
e. An infant with a respiratory rate of 55 bpm
f. A 11-month old whose HR is 156
d. An adolescent whose pulse rate is 70 bpm
e. An infant with a respiratory rate of 55 bpm
f. A 11-month old whose HR is 156
The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is:
a. "He is always hungry."
b. "He tires out during feedings."
c. "He is fussy for several hours every day."
d. "He sleeps all the time."
b. "He tires out during feedings."
The nurse is caring for a patient hospitalized after a crushing chest injury, leading to development of blood surrounding the pericardium. The nurse notes tachycardia, tachypnea, muffled heart sounds, weakened peripheral pulses, and delayed capillary refill. Which form of shock is the patient likely experiencing?
a. Septic shock
b. Cardiogenic shock
c. Distributive shock
d. Hypovolemic shock
b. Cardiogenic shock
Hospital management of near-drowning victims includes all of the following EXCEPT:
A. measurement of arterial blood gas values.
B. rewarming if the patient is hypothermic.
C. measurement of venous blood gas values.
D. chest radiography.
C. measurement of venous blood gas values.
A 6-week-old is admitted to the hospital with influenza. The child is crying, and the father tells the nurse that his son is hungry. The nurse explains that the baby is not to have anything by mouth. The parent does not understand why the child cannot eat. Which is the nurse's best response to the parent?
a. "We are giving your child intravenous fluids, so there is no need for anything by mouth."
b. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now."
c. "When your child eats, he burns too many calories; we want to conserve the child's energy."
d. "Your child has too much nasal congestion; if we feed the child by mouth, the distress will likely increase."
b. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now."
What describes a toddler's cognitive development at age 20 months?
a. Searches for an object only if he or she sees it being hidden
b. Realizes that "out of sight" is not out of reach
c. Puts objects into a container but cannot take them out
d. Understands the passage of time such as "just a minute" and "in an hour"
b. Realizes that "out of sight" is not out of reach
An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse understands dyspnea occurs because blood is:
a. circulated through the lungs again, causing pulmonary circulatory congestion.
b. shunted past the pulmonary circulation, causing pulmonary hypoxia.
c. shunted past cardiac arteries, causing myocardial hypoxia.
d. circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.
a. circulated through the lungs again, causing pulmonary circulatory congestion.
The nurse is assessing a patient who fell two stories from a window. An artificial airway is in place, and the cervical spine has been stabilized. Which action is the most appropriate for the nurse to take next?
a. Assess capillary refill
b. Listen to lung sounds
c. Obtain a blood pressure
d. Evaluate the patient's Glasgow Coma Scale score
b. Listen to lung sounds
Warming techniques for a cold-water near-drowning victim include all of the following EXCEPT:
A. cooling the extremities and warming the body core.
B. warming the inspired oxygen.
C. heated intravenous solutions.
D. heated lavage of the pericardial space.
A. cooling the extremities and warming the body core.
The nurse is assessing a seven-month-old child. Which developmental skills are normal and should be expected?
a. Pulling up to a standing position
b. Can feed self with a spoon
c. Sits alone
d. Speaks in short sentences
c. Sits alone
A nurse is assessing a 4 month old infant as a wellness check-up. Which of the following should be reported to the care team?
a. Open posterior fontanelle
b. Unable to respond to name
c. No formation of teeth
d. Unable to roll to stomach
a. Open posterior fontanelle
Which child with asthma should the nurse see first?
a. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 93%.
b. A 5-year-old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 93%.
c. A 9-year-old who is quiet, is pale in color, and is wheezing bilaterally with an oxygen saturation of 92%.
d. A 16-year-old who is speaking in short sentences, is wheezing, is sitting upright, and has an oxygen saturation of 93%.
a. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 93%.