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Tx Plan Nursing Care of Children Exam
The infant should begin vocalizing vowel sounds at the age of 7 months, and by the age of 10 months, be able to say at least one word. A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to his body after death. - A school-age child is interested in post-death services and what happens to the body after death due to an improved ability to comprehend what is happening. C. The child recognizes that death is permanent. - Preschool-age children have difficulty understanding the concept of time and are therefore not likely to believe that death is permanent. They perceive death as reversible. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. - ✔✔A. The child views death as similar to sleep. - Preschool-age children might make this comparison. D. The child believes his thoughts can cause death. - Preschool-age children believe that their thoughts and wishes can make things happen since they are egocentric. This is one reason why the death of a family member can be very difficult for a child at this age.
E. The child thinks death is a punishment. - Preschool-age children sometimes believe that death is the result of guilt or punishment due to something they have done, said, or thought. A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication. - A PCA device allows the adolescent to be in charge of pain management and is an effective method to control pain. It is inappropriate for the nurse to suggest discontinuing the PCA. B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain. - One of the principles of PCA is that no one other than the client or nurse pushes the button to deliver the medication. An adolescent is capa - ✔✔D. Reinforce teaching with the client about how to push the button to deliver the medication. The appropriate action at this time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, verify that the client knows how to use the equipment, and emphasize the importance of using it regularly to manage pain effectively. A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head to toe sequence. - It is recommended to start with the least invasive interventions and proceed to the more invasive. The head to toe approach is recommended for preschool-age and older children.
Preschool play centers on imitative activities. Providing a stethoscope allows the child an opportunity for therapeutic play. Imitating health care personnel helps to ease the fear of unfamiliar equipment. A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper- Most 2-year-old children do not have the coordination abilities to cut with scissors. This activity is appropriate for a 3-year-old child. B. Drawing stick figures using crayons - The ability to draw stick figures is an appropriate activity for a 4-year-old child. The 2-year-old child will draw vertical lines and make circular strokes. C. Riding a tricycle - Riding a tricycle is an appropriate activity for a 3-year-old child. Most 2- year-old children do not have the strength or the gross motor ability to ride a tricycle. D. Building towers of blocks - ✔✔D. Building towers of blocks Building towers of blocks is an appropriate activity for a 2-year-old child. It promotes fine-motor development, and knocking blocks down provides a means of dealing with the stress of hospitalization. A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance?
A. Give the toddler milk.- The nurse should instruct the parents that it might be recommended to give the toddler milk to drink, but this will depend on the poison that is ingested. Evidence- based practice indicates that the nurse should take a different action first. B. Go to an emergency department. - The nurse should instruct the parents that it might be recommended that they take the toddler to the emergency department, but this will depend on the poison and amount that is ingested. Evidence-based practice indicates that the nurse should take a different action first. C. Call the poison control center. D. Induce vomiting. - The nurse should instruct the parents that - ✔✔C. Call the poison control center. According to evidence-based practice, the nurse should instruct the parents to first call the poison control center, which will then identify what further actions the parents should take. A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero. - Vitamin C does not influence absorption or excretion of lead, and intake does not need to be reduced for a child who has a blood lead level of 3 mcg/dL. Over time, this can result in a vitamin C deficiency.
E. Play music videos during scheduled meal times. - A quiet, stimulation-free environment should be provided at meal times to avoi - ✔✔A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake. Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. A nutritional goal for the child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake. A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing.- The nurse should remove the child's contaminated clothing to prevent further exposure to the substance; however, a different action is the priority. B. Check the child's respiratory status. C. Administer an antidote to the child. - The nurse may administer an antidote if one is available for the substance ingested; however, a different action is the priority.
D. Establish IV access for the child. - The nurse should establish IV access because shock is a complication of some poisons; however, a different action is the priority. - ✔✔B. Check the child's respiratory status. The nurse should apply the ABC priority-setting framework when answering this item. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The nurse observes that the child's lips are edematous and inflamed and that he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway. A nurse is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "I am not going to let my child play with other children for 2 days." - The child is not contagious to others after receiving the MMR immunization. B. "I will need to return in 2 weeks for my child to receive the varicella immunization." - MMR and varicella immunizations are either administered during the same visit, or at least 1 month apart. C. "I can give my child acetaminophen for discomfort associated with the immunization."
milk is not recommended until after age 2 since it lacks essential fatty acids which are needed for growth and development. A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying - The side-lying position may be used during a lumbar puncture. B. Semi-recumbent - A semi-recumbent position is used when performing a gavage feeding. The client's head and chest should be elevated. C. Flexed sitting - The flexed sitting position may be used during a lumbar puncture. D. Supine - ✔✔D. Supine The client is placed in the supine position, with the client's legs in a frog position. A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include? A. Follow a nightly routine and established bedtime. B. Encourage active play prior to bedtime. - Active play at bedtime is likely to promote the preschool-age child's resistance to sleep rather than to promote fatigue.
C. Let the child remain awake until tired enough to go to sleep. - This approach is likely to result in an overtired child who is awake and unpleasant. Children taught to maintain a bedtime routine at an early age will make the evening more pleasant for everyone, including themselves, and avoid sleep disturbances. D. Reward the child with a food treat just prior to sleep if the child goes to bed on time. - Part of a preschool-age child's bedtime routine should be nightly oral care. Following this with a food treat is inappropriate. - ✔✔A. Follow a nightly routine and established bedtime. Preschool-age children test limits. Consistency in approach to bedtime is very important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night. A nurse is assessing a 3 - year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? A. Ask the parents. - Pain is a subjective experience even for a 3-year-old child. Asking the parents is not appropriate as pain is considered a personal experience. B. Use the FACES scale. C. Use the numeric rating scale. - The numeric rating scale is appropriate for children who are 5 years of age or older. D. Check the child's temperature. - The child's temperature is not an indicator of pain. While changes in heart rate, BP, and respiratory rate can be indicators of pain, these are not reliable, because pain is a subjective manifestation. - ✔✔B. Use the FACES scale.
A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. Human papillomavirus (HPV) and hepatitis A - The HPV immunization series is started at the age of 11 years, and the hepatitis A immunization series is started at the age of 12 months. B. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) - The first dose of the MMR immunization is administered at 12 to 15 months of age, and the TDaP immunization is administered at 11 to 12 years of age. C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAIV) - Varicella is not administered to children younger than 12 months, and the LAIV immunization is not administered to children under 2 years of age. - ✔✔C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) The recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization series consists of 3 to 4 doses, depending on the immunization used, and at a minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months. The IPV immunization series consists of 4 doses and is administered at the ages of 2 months, 4 months, 6 to 18 months, and 4 to 6 years. A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker. - A stationary infant walker is recommended. Wheeled infant walkers can quickly move across uneven surfaces and result in injury.
B. Place soft pillows around the edge of the infant's crib. - Soft pillows and cushions should not be used in cribs due to the increased risk of suffocation. C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49° C (120° F). - ✔✔C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49° C (120° F) Infants and children should remain in the rear-facing position when in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines As the infant begins to crawl and becomes more mobile, the risk of falls increases. To prevent a burn injury, the temperature of the water heater should not exceed 49° C (120° F).
A. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine - DTaP is used to provide immunity against diphtheria, tetanus, and pertussis in infants and children under the age of 7 years. DTaP is not recommended for wound prophylaxis. B. A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT) - TIG and DT may be given concurrently for wound prophylaxis, but the nurse should administer these separately using different muscles. DT is given as wound prophylaxis to children under the age of 7 years. C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine - Tdap is given to adults/adolescents who have completed the initial DTaP immunization series, - ✔✔D. Adult tetanus booster (Td) Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age. A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination - Playing peek-a-boo does not further refine the infant's fine-motor skills unless the infant is using his hands to locate the hidden object himself. Hand-eye coordination is necessary for fine motor skills. B. Sense of trust - Playing peek-a-boo does not serve to establish a sense of trust. Trust is developed by the consistent care given in the first year of life. C. Object permanence
D. Egocentrism - Egocentrism refers to the fact that infants are self-centered and cannot see things from a point of view other than their own. An 8-month-old infant is considered egocentric. - ✔✔C. Object permanence A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide- The pneumococcal polysaccharide immunization is administered to children between the ages of 2 and 18 years who have a specific high-risk condition that places them at risk for an infection with Streptococcus pneumococci, a bacterium that causes meningitis, otitis media, and pneumonia in clients who have chronic illnesses. B. Meningococcal polysaccharide C. Rotavirus- The final dose of the rotavirus immunization is administered prior to the age of 8 months. An additional booster dose is not recommended. D. Herpes zoster- The herpes zoster immunization is recommended for adults over the age of 60 to prevent an episode of shingles. - ✔✔B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis, which affects the brain, and meningococcemia, which affects the blood. Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention has issued a recommendation that all incoming college students receive the meningococcal immunization.
C. Extrusion - The extrusion reflex, which causes the infant to spit out food placed on the tongue rather than moving it to the back of the mouth, is absent by the age of 4 months. D. Moro - The Moro reflex should disappear at the age of 3 to 4 months. It is an extension of the arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities. - ✔✔B. Baninski The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits. A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? A. Wash and dry the infant's genitalia and perineum thoroughly. B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area. - The adhesive on the collection device will not stick to the infant's skin if it is moistened with lubricant. Oil and powder should not be used. C. Avoid placing the scrotum inside the collection bag. - It is acceptable for the nurse to place the infant's penis and scrotum inside the collection bag in order to ensure a snug fit and prevent leaking. D. Wait several hours after positioning the device before checking it. - The urine collector should be checked frequently and removed when urine is obtained. If the infant is active, the adhesive might loosen. - ✔✔A. Wash and dry the infant's genitalia and perineum thoroughly.
This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained. The skin should be washed and dried to promote application of the adhesive of the collection device. A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group? A. Copies a circle B. Cuts foods using a table knife - The nurse should explain that cutting food using a table knife is a fine-motor skill expected of 7-year-old children. C. Begins writing in cursive - Initial use of cursive writing is an expected skill for an 8- to 9-year- old child. D. Prints first and last name clearly - The nurse should explain that children will print their first name around the age of 5 years. - ✔✔A. Copies a circle The nurse should explain that copying a circle is a skill achieved by the age of 4 years. A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
