Respiratory and GI
A 2-year-old boy is seen for acute laryngotracheobronchitis. What observation would lead the nurse to suspect airway occlusion?
A. He states he is tired and wants to sleep.
B. His respiratory rate is gradually increasing.
C. His cough is becoming harsher.
D. His nasal discharge is increasing.
B. His respiratory rate is gradually increasing.
The nurse is planning care for an 8-month-old infant with a ventricular septal defect. Which nursing diagnosis should the nurse use to help guide the care for this patient?
A. Impaired gas exchange related to a right-to-left shunt
B. Impaired skin integrity related to poor peripheral circulation
C. Ineffective airway clearance related to altered pulmonary status
D. Ineffective tissue perfusion related to inefficiency of the heart as a pump
D. Ineffective tissue perfusion related to inefficiency of the heart as a pump
The nurse is instructing the mother of a school-age child with a leg cast about cast care at home. What should the nurse include in this teaching? (Select all that apply.)
A. Cover the cast with a plastic bag to bathe.
B. Remind that nothing is to be put down the cast.
C. Recommend using magic markers for autographs.
D. Use the cool setting on a hair dryer to ease itchy skin.
E. Encourage usual activities but restrict strenuous actions.
A. Cover the cast with a plastic bag to bathe.
B. Remind that nothing is to be put down the cast.D. Use the cool setting on a hair dryer to ease itchy skin.
E. Encourage usual activities but restrict strenuous actions.The nurse is completing the teaching for parents of a toddler recovering from a fracture. Which outcome should the nurse identify to help determine if teaching has been effective?
A. The child resumes normal activity level at home.
B. The parents encourage the child to be independent.
C. The parents place a locked gate at the top of the stairs.
D. The child waits for the parent to assist before walking down a set of stairs.
D. The child waits for the parent to assist before walking down a set of stairs.
A nurse should recognize that which laboratory result would be most consistent with a diagnosis of diabetes mellitus?
A. proteinuria
B. a fasting blood glucose less than 126 mg/dL
C. a fasting blood glucose greater than 126 mg/dL
D. glucose in the urine
C. a fasting blood glucose greater than 126 mg/dL
The nurse is making a follow-up visit to the home of a family with a baby newly diagnosed with cystic fibrosis. Which outcome indicates that the parents are adjusting to the child's care needs?
A. Baby has gained weight.
B. Baby's foul-smelling stool.
C. Baby produces large stool twice a day.
D. Baby appears flushed and is warm to touch.
A. Baby has gained weight.
A toddler is diagnosed with a functional heart murmur. What should the nurse explain to the child's parents about this murmur?
A. This type of murmur is innocent.
B. Mild activity restrictions are indicated.
C. More frequent health appraisals are indicated.
D. Corrective surgery may be required later in life.
A. This type of murmur is innocent.
The nurse is caring for a child who is having a seizure. What is the appropriate action by the nurse?
A. Attempt to place oxygen on the child so they don't become cyanotic.
B. Hold the child's arms and legs still so they aren't injured.
C. Attempt to turn the child on their side to prevent aspiration.
D. Place a bite block or oral airway into the child's mouth to prevent biting of the tongue.
C. Attempt to turn the child on their side to prevent aspiration.
A. change the child’s position infrequently to minimize the chance of increased ICP.
B. avoid using narcotics or sedatives to provide comfort and pain relief.
C. monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
D. give tepid sponge baths to reduce fever because antipyretics are contraindicated.
C. monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
The nurse is preparing teaching materials for a family whose child is prescribed somatropin for a growth hormone deficiency. What should the nurse instruct the parents about the administration of this medication?
A. This medication must be given by injection.
B. This medication must be given in the morning before school.
C. Hip or knee pain is an expected adverse effect of this medication.
D. This medication does not interact with any other types of medication.
A. This medication must be given by injection.
The nurse is caring for a preschool-age child with acute nasopharyngitis. Which information should the nurse include when teaching the parents about this health problem?
A. Healthy children rarely have more than one cold per year.
B. Typically, the child will pull the ear when a cold is present.
C. A cough that accompanies a cold should rarely be suppressed.
D. An antibiotic is prescribed for children younger than 5 years of age.
C. A cough that accompanies a cold should rarely be suppressed.
At 3 years of age, a child has a cardiac catheterization. After the procedure, which interventions would be most important?
A. Assuring the child that the procedure is now over
B. Allowing the child to adapt to the light room gradually
C. Taking pedal pulses for the first 4 hours
D. Allowing the child to talk about the procedure
C. Taking pedal pulses for the first 4 hours
An 8-year-old child is being treated for tonic-clonic seizures. What should the nurse emphasize when teaching the parents about this disorder?
A. The child should maintain an active lifestyle.
B. Immediately provide medication if a seizure begins.
C. Have the child carry a padded tongue blade with her at all times.
D. Ensure quiet time late in the day, when seizure activity is most likely to occur.
A. The child should maintain an active lifestyle.
A. A school-age child in a coma with stable vital signs
B. A preschool child with a head injury and decreasing level of consciousness
C. An adolescent admitted after a motor vehicle accident is oriented to person and place
D. A toddler in a persistent vegetative state with a low-grade fever
B. A preschool child with a head injury and decreasing level of consciousness
After hospital discharge, the mother of a child newly diagnosed with type 1 diabetes mellitus telephones you because her daughter is acting confused and very sleepy. Which emergency measure would the nurse suggest the mother carry out before she brings the child to see her doctor?
A. Give her one unit of regular insulin.
B. Give her a glass of orange juice.
C. Give her nothing by mouth so that a blood sugar can be drawn at the doctor's office.
D. Give her a glass of orange juice with one unit regular insulin in it.
B. Give her a glass of orange juice.
The nurse is advising a group of new parents on how to care for their infant at home if the baby develops mild diarrhea. Which statement indicates that teaching has been effective?
A. “I should offer milk after each episode of diarrhea.”
B. “I should take the baby's temperature and call my physician.”
C. “I could give Kaopectate as long as I follow the directions on the bottle.”
D. “I should offer Pedialyte after 1 hour and frequently thereafter to prevent dehydration.”
D. “I should offer Pedialyte after 1 hour and frequently thereafter to prevent dehydration.”
The nurse is instructing the parents of a child with sickle-cell anemia on safety precautions. What should the nurse emphasize during this teaching?
A. Suggest the child participate in sports activities without restriction.
B. Treat upper respiratory infections with over-the-counter medication.
C. Ensure a consistent and daily intake of adequate fluids to prevent dehydration.
D. Remind to avoid immunizations to prevent the introduction of bacteria into the body.
C. Ensure a consistent and daily intake of adequate fluids to prevent dehydration.
An 18-month-old child is admitted with signs of increased intracranial pressure. What should the nurse observe when assessing this patient?
A. Numbness of fingers and decreased temperature
B. Increased pulse rate and decreased blood pressure
C. Increased temperature and decreased respiratory rate
D. Decreased level of consciousness and increased respiratory rate
C. Increased temperature and decreased respiratory rate
A. diabetic coma.
B. brainstem injury.
C. upper respiratory tract infection.
D. leaking of cerebrospinal fluid (CSF).
D. leaking of cerebrospinal fluid (CSF).
A 4-year-old boy with nephrotic syndrome has extensive edema. The best implementation to reduce periorbital edema would be to
A. apply cool, sterile soaks to his head.
B. encourage him to eat low-protein foods.
C. apply warm compresses to his eyes at bedtime.
D. elevate the head of the bed.
D. elevate the head of the bed.
A 1-month-old infant is diagnosed with gastroesophageal reflux. Which intervention should the nurse teach the mother to help with the symptoms of this disorder?
A. Hold in a horizontal position while feeding.
B. Place on the back immediately after feeding.
C. Feed with formula thickened with rice cereal.
D. Administer prescribed medications before each feeding.
C. Feed with formula thickened with rice cereal.
The nurse is assessing a school-age child with sickle-cell anemia. Which assessment finding is consistent with this child's diagnosis?
A. Slightly yellow sclera
B. Enlarged mandibular growth
C. Increased growth of long bones
D. Depigmented areas on the abdomen
A. Slightly yellow sclera
A preadolescent girl with scoliosis is prescribed a body brace. What should the nurse teach the child about the purpose of the brace?
A. Prevents torticollis
B. Improves spinal stability
C. Corrects spinal curvature
D. Prevents herniation of a spinal disk
B. Improves spinal stability
A. Child should be hospitalized for close observation.
B. No treatment is necessary if thorough wound cleaning is done.
C. Antirabies prophylaxis must be initiated.
D. Antirabies prophylaxis must be initiated if clinical manifestations appear.
C. Antirabies prophylaxis must be initiated.
A. fat.
B. fruit juice.
C. several glasses of water.
D. complex carbohydrate and protein.
D. complex carbohydrate and protein.