Developmental
4.A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider?
A. Inability to raise head when in prone position
B. Inability to sit without support
C. Inability to pick up an object with her fingers
D. Inability to bring an object to her mouth
A. Inability to raise head when in prone position
Rationale:A 3-month-old infant should be able to raise her head and shoulders from prone position;
A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take?
A. Teach the parents about cortisol replacement therapy.
B. Place the child on a low-sodium diet.
C. Monitor the child for fluid volume excess.
D. Discuss the manifestations of hyperglycemia with the parents.
A. Teach the parents about cortisol replacement therapy.
Rationale: The nurse should plan to teach the child's parents about cortisol replacement therapy.
Administration of glucocorticoids and mineralocorticoids is necessary because inadequate supplies or a sudden cessation of the medications can cause acute adrenal crisis.
A nurse is assessing a toddler who has suspected lead poisoning. Which of the following findings should the nurse expect the client to manifest with acute lead poisoning?
A. Increased urinary output
B. Anorexia
C. Diarrhea
D. Jaundice
B -
Rationale: Manifestations of acute lead poisoning include anorexia, nausea, vomiting, abdominal pain, glycosuria and aminoaciduria and constipation.
A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?
110 /min
Correct Rationale: Bradycardia is an adverse effect of digoxin. Expected apical heart rates vary considerably according to age. The nurse should withhold the digoxin dose for heart rate of 60/min or below in an adult, 70/min or below in a child, and 110/min or below in an infant.
Digoxin (Digitek, lanoxin) blood pressure and anti-arrhythmic medication.
Class: Cardiac glycoside - improves the filling of ventricles and lowers HR
A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?
A. Maintain NPO status.
B. Monitor oral temperature every 4 hr.
C. Medicate the client for pain every 4 hr as needed.
D. Administer sodium biphosphate/sodium phosphate.
Rationale: Enemas and laxatives are contraindicated because they increase the volume in the bowel and can cause the inflamed appendix to rupture, increasing the risk for peritonitis.
A chronically ill school-age child is most vulnerable to which stressor?
1. Mutilation anxiety
2. Anticipatory grief
3. Anxiety over school absences
4. Fear of hospital procedures
3. Anxiety over school absences
RATIONALE: The school-age child is becoming industrious and attempts to master school-related activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child who's chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children.
A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of thefollowing warnings over the child's bed?
A. Do not palpate abdomen.
B. No venipuncture or blood pressure in left arm
C. Contact precautions
D. Collect all urine.
A. Do not palpate abdomen - Rationale: Wilms' tumor is a neoplasm of the kidney (nephroblastoma). This tumor is encapsulated, and palpation can cause it to rupture, which would allow seeding of the tumor into the pelvic cavity.
A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with thesefindings?
A. Tracheoesophageal fistul
B. Inguinal hernia
C. Hypertrophic pyloric stenosis
D. Intussusception
Rationale: These findings are associated with a diagnosis of intussusception. Other associated findings include vomiting, lethargy, periods of screaming and drawing the knees to the chest followed by periods of normal behavior, and eventual fever and signs of peritonitis.
An infant who weighs 7.5 kg is to receive ampicillin (Omnipen) 25 mg/kg I.V. every 6 hours. How many milligrams should the nurse administer per dose? Record your answer using one decimal place.
187.5 milligrams
RATIONALE: The nurse should calculate the correct dose using the following equation:
25 mg/kg × 7.5 kg = 187.5 mg
A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority?
A. Insert an IV catheter.
B. Obtain blood culture specimens.
C. Administer an antipyretic.
D. Prepare for nasotracheal intubation.
Prepare for nasotracheal intubation.
Rationale: The client's manifestations suggest epiglottitis, which is a respiratory emergency. Airway obstruction is imminent, and that is the greatest risk to the client's safety at this time, so the priority action is to prepare for intubation to maintain airway patency.
When developing a care plan for an adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on:
1. becoming industrious.
2. establishing an identity.
3. achieving intimacy.
4. developing initiative.
2. establishing an identity.
RATIONALE: According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers, and strives to attain a personal identity by becoming more independent from his family. Becoming industrious is the developmental task of the school-age child; achieving intimacy is the task of the young adult; and developing initiative is the task of the preschooler.
A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?
A. "Withhold insulin dose if feeling nauseous."
B. "Notify the provider if blood glucose levels are over 350 milligrams/deciliter."
C. "Test the urine for ketones."
D. "Limit fluid intake during meal time."
Rationale: The parent or child should test the urine for ketones and report the presence of them in the urine. Ketonuria can indicate that the child does not have enough glucose for energy and is breaking down fats to provide glucose to cells.
A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?
A. Avoid a diet that consists primarily of milk.
B. Administer fat-soluble vitamins daily.
C. Include fluoridated water in the toddler's diet.
D. Limit intake of high-protein foods.
Avoid a diet that consists primarily of milk.
Rationale: Milk is a poor source of iron and a diet that consists primarily of milk places the toddler at risk for iron deficiency anemia
A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg P.O. every 12 hours. If the child weighs 22 lb (10 kg), what it his daily mg dosage?
1. 50 mg
2. 100 mg
3. 110 mg
4. 220 mg
100mg
A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?
A. Respiratory rate
B. Burns of the mouth
C. Bowel sounds
D. Visual acuity
A. Respiratory rate
Rationale: Using the airway, breathing, circulation approach to client care, the nurse should prioritize assessing the client's respiratory rate. Small amounts of kerosene can enter the lungs and damage them directly, causing a severe aspiration pneumonia. Because the pneumonia is caused by chemical irritation rather than bacteria, antibiotics aren't useful for prevention or treatment. Breathing becomes rapid and gasping, and vomiting and persistent coughing can follow. In severe cases, brain damage can occur.
What is a normal systolic blood pressure for a 3-year-old child?
1. 60 mm Hg
2. 93 mm Hg
3. 120 mm Hg
4. 150 mm Hg
93 mm Hg
RATIONALE: The normal range for systolic blood pressure in preschoolers is 82 to 110 mm Hg. The normal range for diastolic blood pressure is 50 to 78 mm Hg.
A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse initiate?
A. Airborne
B. Contact
C. Protective environment
D. Droplet
Airborne -
Rationale: The nurse should initiate airborne precautions for a child who has measles, which is transmitted via droplet nuclei smaller than 5 microns. The nurse should place the child in a negative-pressure airflow room and wear a mask when providing client care.
A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?
A. Dry, flushed skin
B. Deep, rapid respirations
C. Tachycardia
D. Polyuria
C. Tachycardia
Rationale:A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to have tachycardia due to increased circulating catecholamines and increased adrenergic activity.
An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb. The physician orders ceftriaxone (Rocephin), 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial containing 500 mg, to which the nurse adds 2 ml of preservative-free normal saline solution. The nurse should administer how many milliliters?
1. None because this isn't a safe dosage
2. 0.08 ml
3. 1.08 ml
4. 1.8 ml
3. 1.08 ml
RATIONALE: Because the infant weighs 17 lb (7.7 kg), the safe dosage range is 385 to 578 mg daily. The ordered dosage, 540 mg daily, is safe. To calculate the amount to administer, the nurse may use the following fraction method:
500 mg/2 ml = 270 mg/X ml
500X = 270 × 2
500X = 540
X = 540/500
X = 1.08 ml
A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?
A. Offer fluids through a straw.
B. Apply bilateral wrist restraints.
C. Administer opioids for pain.
D. Implement a soft diet.
C. Administer opioids for pain.
Rationale:Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.
A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?
A. "This is within the expected range for your baby."
B. "The fever is causing an increase in your baby's heart rate."
C. "As your baby begins to fall asleep, his heart rate will decrease."
D. "Your baby's heart is beating fast in an attempt to cool down his body."
B. "The fever is causing an increase in your baby's heart rate."
Rationale: The expected reference range for the temperature of an infant from birth to 1 year is 36.5° C (97.7° F) to 37.2° C (98.9° F). This infant has a fever that is causing the infant's heart rate to increase. The expected reference range for heart rate in a 2 month-old infant is 121 to 179/min.
A nurse is assessing an adolescent who has an exacerbation of Graves' disease. Which of the following findings should the nurse expect?
A. Weight gain
B. Bradycardia
C. Lethargy
D. Heat intolerance
D. Heat intolerance
Rationale:An exacerbation of Graves' disease can cause heat intolerance due to an increased metabolic rate, which leads to warm flushed moist skin and extreme diaphoresis.
88.A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?
A. Dry, sticky mucous membranes
B. Polyuria
C. Negative Chvostek's sign
D. Muscle tremors
B- hyperglycemia
C- hypocalcemia - tapping on the facial nerve would create a positive chvosteks
D- hypocalcemia has muslce tremors and cramps which can lead to convulsion
You have a 2 month old patient who is 17kg. The doctor ordered Acetaminophen 120mg (160mg/5mL) every 6 hours, and Ibuprofen 100mg (200mg/10mL) every 4 hours.
What's incorrect about these medications.
1. Acetaminophen is Tylenol - that dose is 10-15mg/kg. Therefore dosing should be 170mg to 255mg.
2. Ibuprofen should not be given to patients under 6 months old
A nurse is caring for a toddler who has a fractured right femur and is in Bryant traction. When determining that the traction is appropriately assembled, the nurse should observe which of the following?
A. Skin straps maintain the leg in an extended position.
B. Weights are attached to a pin that is inserted into the femur.
C. A padded sling is under the knee of the affected leg.
D. The buttocks is elevated slightly off of the bed.
D. The buttocks is elevated slightly off of the bed.
Rationale: Having the buttocks elevated slightly off of the bed is appropriate for Bryant traction. The child's hips are flexed at a 90-degree angle with the legs suspended by pulleys and weights. The weights must hang freely from the bed to maintain alignment.