RN VATI Nursing Care of Children 2019 Assessment
2. "Your child will be exposed to a moderate amount of radiation during the procedure."
MY ANSWER
An MRI produces radiofrequency emissions from nonradioactive elements; therefore, there is no
exposure to radiation involved during this procedure.
"Your child might experience pain during the procedure."
An MRI does not cause pain, as it is a noninvasive procedure that emits radiofrequencies to
produce an image.
"This is considered an invasive procedure."
An MRI is a noninvasive procedure, unless an IV is prescribed when contrast is used. No contrast
is indicated for this child, so no IV is needed.
"You can remain in the room with your child during the procedure."
The parent may remain in the room with the child to provide comfort and reassurance during
the procedure.
3. Nausea
The nurse should identify that nausea is an early sign of increased intracranial pressure in a child.
Papilledema
The nurse should identify that papilledema is a late sign of increased intracranial pressure in a
child.
Dilated pupils
The nurse should identify that dilated pupils along with a decreased pupillary response are late
signs of increased intracranial pressure in a child.
Bradycardia
MY ANSWER
The nurse should identify that bradycardia is a late sign of increased intracranial pressure in a
child.
4. Initiate contact precautions.
The nurse should initiate contact, droplet, and standard precautions for RSV because exposure to
contaminated secretions can transmit the virus. RSV can live on objects for several hours and on
hands for 30 min.
Perform chest percussion and postural drainage.
The nurse should perform periodic suctioning of the nose or nasopharynx to clear nasal
secretions. Chest percussion and postural drainage are not routinely recommended for an infant
who has RSV.
Encourage clear liquids by mouth.
MY ANSWER
The nurse should not encourage clear liquids by mouth, because the infant has tachypnea. Oral
fluids are contraindicated in the presence of tachypnea due to the risk for aspiration.
Administer IV antibiotics.
The nurse should not plan to administer IV antibiotics, because RSV is a viral infection.
Antibiotics may be prescribed if a secondary bacterial infection occurs.
5. Warm extremities
Heart failure involves an inability of the heart to pump effectively, limiting perfusion to major
organs and the extremities. The nurse should expect a child who has heart failure to exhibit pale,
cool extremities.
Frequent headaches
The child who has heart failure can exhibit neurologic manifestations, such as increased
restlessness or irritability as a result of hypoxia and impaired cardiac function; however, frequent
headaches are not an expected manifestation associated with heart failure.
Distended neck veins
The child who has heart failure will exhibit manifestations of increased blood volume, such as
distended neck veins. This occurs because the hormone ADH is excreted, which holds onto
sodium and water in response to decreased cardiac output and renal perfusion.
Weight loss
MY ANSWER
The child who has heart failure will exhibit weight gain as a result of sodium and water retention.
As the heart failure progresses, dependent and periorbital edema, ascites, and pulmonary
effusions result.
6. The infant falls to a sitting position while learning how to walk.
The infant falling to a sitting position while learning how to walk is not a manifestation of
hemophilia, as this is an expected part of growth and development.
The infant bleeds slightly when scratched by a cat.
Bleeding slightly when a minor scratch occurs is not a manifestation of hemophilia; however, if
the bleeding is not easily controlled, the parent should notify the provider.
The infant's skinned knee drains serosanguineous fluid.
MY ANSWER
The drainage of serosanguineous fluid from a skinned knee is not a manifestation of hemophilia.
This is an expected finding after a skin injury and does not warrant evaluation.
The infant's knees are reddened and edematous.
The nurse should identify that the infant might be experiencing hemarthrosis if redness, edema,
and warmth of the joints are noted. Bleeding into the joints is the most frequent form of internal
bleeding in children who have hemophilia.
"I should eat extra food on busy days when I am more active" is correct. The nurse should
instruct the child to increase her intake of allowable foods when she is more active. Exercise
lowers blood glucose levels during and after activity. Food intake should be adjusted to
compensate for the release of insulin into the circulatory system and prevent episodes of
hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate
play or activity.
"I should wait 2 hours after eating before playing with my friends" is incorrect. The child should
play or exercise within 2 hr of eating because exercise requires her to have more carbohydrates
in her system. Waiting 2 hr after eating before play or exercise increases the likelihood of a
hypoglycemic episode. A carbohydrate snack will most likely be needed during prolonged play or
exercise and another a few hours after the activity.
"I should increase my intake of sugar-free fluids when I am sick" is correct. The nurse should
instruct the child to increase her intake of sugar-free fluids when she is sick. Fluids flush out
ketones to prevent dehydration. The nurse should recommend sugar-free liquids, such as water,
broth, and tea to the child. The child should continue with her usual intake at mealtimes and
follow her recommended meal plan as much as possible.
"I should eat a snack 30 minutes before my baseball game starts" is correct. The nurse should
instruct the child to eat a recommended snack 30 min prior to a planned activity, such as a
baseball game. If the game is prolonged, she should have a snack every 45 min to an hour. If for
some reason the child cannot tolerate the extra food, the next intervention is to decrease the
child's insulin dose before baseball games.
"I should have a 16 ounce sports drink if I start feeling weak or shaky" is incorrect. The child
should consume 8 oz of a sports drink if she feels hypoglycemic, rather than 16 oz. Clinical
manifestations of hypoglycemia include dizziness, headache, irritability, weakness, shakiness,
and confusion. An 8-oz sports drink contains 15 g of carbohydrate. If the child consumes 16 oz, it
would contain a minimum of 30 g of carbohydrate and most likely cause the child to become
hyperglycemic and require a dose of insulin.
8. "Your child's skin will appear flushed."
MY ANSWER
The nurse should inform the parents that their child will have pale skin near the end of his life.
The skin is cool to the touch and might appear grayish-blue as death nears. Mottling might occur
in the extremities and move toward the body core because of a decrease in cardiac output and
perfusion to the extremities.
"Your child will lose movement in his legs."
The nurse should inform the parents that their child will lose movement of the lower
extremities. This progressive loss of movement will move up the body as death nears.
"Your child will first lose his ability to hear."
The nurse should inform the parents that the sense of hearing is the last sense to fail as death
nears. Loss of sensation develops before hearing loss, and the child might become more
sensitive to light.
"Your child's blood pressure will start to increase."
The nurse should inform the parents that their child will experience decreased cardiac output,
leading to a drop in blood pressure and decreased pulses.
Koplik spots
The nurse should not expect a child who has viral meningitis to have Koplik spots. Koplik spots
are small red spots with a white center that are found on the oral mucosa in children who have
measles.
Decreased protein in the cerebrospinal fluid
The nurse should expect a child who has viral meningitis to exhibit either a normal or slightly
elevated protein level in the cerebrospinal fluid due to increased permeability of the blood-brain
barrier.
Nuchal rigidity
MY ANSWER
The nurse should expect a child who has viral meningitis to have nuchal rigidity, which is caused
by meningeal irritation. The child might also have fever and photophobia.
Decreased glucose in the cerebrospinal fluid
The nurse should expect a child who has viral meningitis to exhibit a glucose level in the
cerebrospinal fluid within the expected reference range. Bacterial meningitis can decrease the
glucose in the cerebrospinal fluid.
11. Restrict the child's potassium intake.
MY ANSWER
The nurse should not instruct the parents to restrict the child's potassium intake; however, the
parents should restrict the child's sodium intake by avoiding the addition of salt to the child's
food and eliminating high-sodium foods from the diet. The child may resume a regular salt intake
after the acute phase of nephrotic syndrome has passed.
Provide quiet activities for the child.
The nurse should instruct the parents to provide quiet activities, such as reading and coloring,
during the edema phase of nephritis to minimize oxygen consumption and preserve energy.
Weigh the child once a week.
The nurse should instruct the parents to weigh the child at the same time each day with the
child wearing the same clothing. The nurse should instruct the parents to notify the provider if
the child's weight increases.
Administer acetaminophen to the child daily.
The nurse should not instruct the parents to administer acetaminophen to the child daily, as
nephrotic syndrome does not cause pain. Daily administration of acetaminophen could also
cause additional stress to the child's kidneys.
12. "I will cook foods that are low in fat and carbohydrates."
The parent should serve nutritious foods that are high in calories, protein, and fats. A child who
has cystic fibrosis experiences intestinal malabsorption and is at risk for nutritional deficiencies
and inadequate growth.
"My child can chew his enzyme medication with meals."
The parent should have the child swallow the capsules whole or sprinkle them on his food within
30 min of her meals and snacks. The child should not chew or crush the enteric-coated tablets,
because destroying the enteric coating can lead to inactivation of the enzymes and excoriation of
the oral mucosa.
"I will give my child stool softeners for constipation."
Constipation can occur in the child who has cystic fibrosis because of a failure to properly break
down foods, a slowing of the intestinal motility, and the thickened enzymatic secretions due to
the disease process itself. The parent should administer an osmotic solution, such as
polyethylene glycol, stool softeners, or laxatives to treat constipation.
"My child will be excused from physical education class."
MY ANSWER
The parent should encourage the child to participate in physical exercise to mobilize secretions
and increase blood flow to the lungs. Exercise can stimulate mucus excretion and provides a
sense of good health and positive self-esteem for the child.
13. Administer factor VIII is correct. Hemophilia A is a bleeding disorder caused by a factor VIII
deficiency; therefore, the nurse should plan to administer factor VIII prophylactically to prevent
or minimize bleeding.
Assess for changes in level of consciousness is correct. Hemophilia A can cause cerebral
bleeding; therefore, the nurse should assess the child for headaches and decreased level of
consciousness.
Apply a warming blanket over the child is incorrect. The nurse should apply ice or cold packs to
the child to vasoconstrict the child's blood flow.
Perform passive range of motion hourly is incorrect. The nurse should rest the joints during the
acute phase of bleeding to prevent stretching the joint or bleeding to recur.
Refrigerate the reconstituted antihemophilic factor solution until used. While the factor VIII
concentrate (unreconstituted) should be stored in the refrigerator, once it is mixed with the
diluent, it should not be returned to the refrigerator.
Administer factor IX is incorrect. The nurse should identify that children who have hemophilia B
have a deficiency in factor IX and the nurse should plan to administer factor IX prophylactically to
prevent or minimize bleeding.
14. "My child should have 4 ounces of protein per day."
MY ANSWER
A toddler who is 2 years old should consume 2 oz of protein daily. The nurse should instruct the
parents to follow recommendations for dietary guidelines from the Dietary Guidelines for
Americans, 2010 to achieve adequate caloric and nutrient needs.
"I should feed my child 1 cup of vegetables per day."
A toddler who is 2 years old should have 1 cup (8 oz) of vegetables per day. A variety of
vegetables should be introduced to the toddler. The nurse should instruct the parents to follow
recommendations for dietary guidelines from the Dietary Guidelines for Americans, 2010 to
achieve adequate caloric and nutrient needs.
"I should give my child 6 cups of milk a day."
A toddler who is 2 years old should have no more than 24 oz (3 cups) of milk per day to prevent
iron deficiency anemia. This occurs in the toddler who consumes large amounts of dairy and
then fails to consume adequate amounts of iron-containing proteins. To enhance growth of the
toddler's brain and body, whole milk products are recommended instead of low-fat or fat-free
varieties.
"My child should consume 800 calories per day."
A toddler who is 2 years old should consume approximately 1,000 to 1,300 calories daily, divided
into three meals and one or two snacks. The nurse should instruct the parents to follow
recommendations for dietary guidelines from the Dietary Guidelines for Americans, 2010 in
order to achieve adequate caloric and nutrient needs.
15. BUN 32 mg/dL
The nurse should identify this finding as above the expected reference range of 5 to 18 mg/dL
for a child. A child who has glomerulonephritis will have an elevated BUN because of the
impaired glomerular filtration rate, which results in retention of urea in the blood.
Negative urine protein
MY ANSWER
The nurse should identify a negative urine protein as an expected finding in a child who does not
have glomerulonephritis. A child who has glomerulonephritis will have proteinuria, which is an
increase in urinary protein due to impaired glomerular filtration.
Urine specific gravity 1.020
The nurse should identify this finding as within the expected reference range of 1.016 to 1.022
for a child who has normal fluid intake. An expected finding for a child who has
glomerulonephritis would be an increased urine specific gravity.
Potassium 3.3 mEq/L
The nurse should identify this potassium level as below the expected reference range of 3.4 to
4.7 mEq/L for a child. A child who has glomerulonephritis will have a potassium level that is
either increased or within the expected range.
17. Albumin
MY ANSWER
Adolescents who have anorexia nervosa can have protein-calorie malnutrition due to nutritional
deficit; however, another test is the priority.
Complete metabolic panel
The greatest risk to the client who has anorexia nervosa is alterations in electrolytes, which can
lead to cardiac arrhythmias; therefore, obtaining a complete metabolic panel is the priority.
Human chorionic gonadotropin level
Adolescents who have anorexia nervosa can experience amenorrhea and pregnancy needs to be
ruled out; however, another test is the priority.
Total cholesterol
Adolescents who have anorexia nervosa can have increased cholesterol levels due to nutritional
deficits; however, another test is the priority.
Flat anterior fontanel
The nurse should identify a flat anterior fontanel as an expected finding in an infant who has
mild to moderate dehydration. An infant who has severe dehydration will exhibit a sunken
anterior fontanel.
Dry, hot skin
The nurse should observe that an infant who is severely dehydrated has skin that is cool to the
touch and mottled in appearance with the presence of tenting.
Loss of 5% of weight
The nurse should identify a loss of 5% of weight as a manifestation of mild dehydration. An
infant experiencing a 6% to 9% weight loss has moderate dehydration, while a loss of 10% or
more indicates severe dehydration.
Absence of tears when crying
MY ANSWER
The nurse should identify the absence of tears when crying as a manifestation of severe
dehydration. Other manifestations of severe dehydration include sunken eyeballs, parched
mucous membranes, oliguria, sunken fontanels, and hyperpnea.
19. "Your child needs mechanical ventilation."
The nurse should not tell the parent the child needs mechanical ventilation, as the child is awake
and alert. A child who is not breathing on her own or is experiencing respiratory distress requires
mechanical ventilation.
"We need to observe your child for cerebral swelling."
MY ANSWER
The nurse should inform the parents that the child needs observation because she is still at risk
for a complication from the submersion injury. Complications can include respiratory
compromise and cerebral edema during the first 24 hr after the submersion.
20. "I will ensure that my child takes a 1 hour nap each day."
A child who has JIA should be discouraged from sleeping during the day because it can cause
joint stiffness and interfere with nighttime sleep. The child should instead rest daily with
activities such as reading, watching television, and listening to music.
"I will give my child prednisone as needed for pain."
Prednisone is a glucocorticoid that acts as an anti-inflammatory agent and is given on a
scheduled basis during exacerbations.
"I will apply cool compresses to my child's painful joints during exacerbations."
MY ANSWER
The parent should apply moist heat, rather than cool compresses, to relieve pain and stiffness in
affected joints. Having the child soak in a bathtub of warm water is an effective strategy for
relieving pain and stiffness in multiple joints.
"I will have my child wear splints during the night."
The parent should have the child wear splints during the night to prevent joint deformities and
reduce and minimize pain from inactivity
22. Initiate chelation therapy.
The nurse should not initiate chelation therapy for a child who has ingested kerosene. Chelation
therapy removes iron from circulating blood and is not useful for the treatment of hydrocarbon
ingestion.
Prepare for intubation with a cuffed endotracheal tube.
The nurse should anticipate that the child will require intubation with a cuffed endotracheal
tube because of the high risk of aspiration. This child is at risk for aspiration because she is
lethargic, grunting, and gagging.
Inject deferoxamine subcutaneously.
Deferoxamine is an antidote used in the treatment of iron toxicity. It is not used in the treatment
of hydrocarbon ingestion.
Administer activated charcoal.
MY ANSWER
The nurse should administer activated charcoal to treat a child who has ingested excess aspirin.
Add supplemental calcium to the child's diet.
The nurse should not instruct the parents to increase the child's calcium intake. Immobilization
increases the risk for hypercalcemia, leading to renal stones, muscle fatigue, and diminished
reflexes.
Decrease dietary fiber intake.
The nurse should not instruct the parents to decrease the child's intake of fiber. Immobilization
increases the risk for constipation and fecal impaction; therefore, the nurse should instruct the
parents to increase the child's fiber intake.
Encourage small, frequent meals high in protein.
MY ANSWER
The nurse should instruct the parents to provide small, frequent meals that are high in protein
while their child is healing from surgery. Immobilization causes a decrease in appetite; therefore,
small, frequent meals will be more readily tolerated. Adequate protein intake is needed for
energy and tissue healing.
Encourage foods that are low in calories.
The nurse should not instruct the parents to provide foods that are low in calories.
Immobilization decreases the metabolic rate and appetite. However, adequate healing requires
calories to prevent undernutrition, nutrient deficiencies, and a negative nitrogen balance. The
nurse should instruct the parents to provide nutrient-dense foods that are high in protein.
25. lement seizure precautions.
The nurse should identify this potassium level as below the expected reference range of 4.1 to
5.3 mEq/L for infants. The nurse should monitor for cardiac abnormalities for an infant who has a
potassium level outside the expected reference range.
Offer the infant 15 mL of formula.
The nurse should insert an NG tube to maintain gastric decompression prior to surgical
correction of the stenosis. The nurse should keep the infant NPO.
Check the infant's serum creatinine.
The nurse should check the infant's serum creatinine and BUN levels prior to and during the
administration of IV potassium to ensure renal function is adequate and avoid the development
of hyperkalemia should renal failure occur. The nurse should also closely monitor intake and
output to ensure adequate urinary output prior to and during the administration of IV
potassium.
Administer sodium polystyrene.
MY ANSWER
The nurse should identify this potassium level as below the expected reference range of 4.1 to
5.3 mEq/L for infants. Sodium polystyrene stimulates the body to excrete potassium through the
large intestine and would worsen the infant's condition.
"My child will be awake for this procedure."
The child requires sedation for an endoscopy and bronchoscopy to prevent complications from
this procedure; therefore, the child will not be awake during the procedure.
"I can take my child home as soon as the procedure is over."
The nurse will observe the child for complications, such as laryngeal edema, after the procedure.
The child can go home when his vital signs are stable and he has a gag/cough reflex, which
usually returns within a few hours.
"The provider will remove the object during this procedure."
MY ANSWER
The provider is able to make a definitive diagnosis of objects in the larynx and trachea during a
bronchoscopy and can subsequently remove the foreign body.
"After this procedure, I have to wait 48 hours before I can give my child solid foods."
Once the gag/cough reflex returns, the child can consume fluids and solid foods. This usually
occurs within a few hours following the procedure.
"Your child can eat and drink up to 2 hours prior to the test."
In the event that bleeding or accidental perforation of an abdominal organ occurs, the child will
need to be taken to surgery. The NPO status will decrease the risk of aspiration if surgery is
necessary.
"Your child will need to be on bed rest for 6 hours following the test."
The nurse should instruct the parents that the child will need to be on bed rest for 24 hr
following the test. The activity restriction is necessary to prevent bleeding following the
procedure.
"Your child will have a pressure dressing on the biopsy site following the test."
MY ANSWER
The nurse should instruct the parents that the child will have a pressure dressing on the site of
the biopsy following the test to minimize bleeding. The nurse might also use a sandbag to
maintain pressure to the puncture site.
"Your child will receive contrast dye via an IV during the test."
The nurse should instruct the parents that the child may receive oral pre-procedure medication
for sedation for a renal biopsy; however, contrast dye is not used for this diagnostic test.
28. Anemia is incorrect. Tetralogy of Fallot is four defects that alter hemodynamics to widely
varying degrees. Shunting can be in either direction depending on the degree of the defects and
the differences between the pulmonary and the systemic vascular resistance. The chronic
hypoxemia stimulates erythropoiesis, resulting in polycythemia, which is an increased number of
RBCs.
Stridor is incorrect. Stridor, a noisy, high-pitched respiration, is not a clinical manifestation of
Tetralogy of Fallot.
Bounding peripheral pulses is incorrect. Bounding peripheral pulses are not a clinical
manifestation of Tetralogy of Fallot.
A heart murmur is correct. Infants who have Tetralogy of Fallot exhibit a systolic murmur that is
moderate in intensity.
Cyanotic spells is correct. Infants who have Tetralogy of Fallot experience anoxic spells when the
infant's oxygen requirements exceed the oxygen available in the blood supply, such as when the
infant is crying or following a feeding.
30. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale."
Breathing in through the mouthpiece and holding the breath for 5 seconds is an incorrect
method of using the PEFM. The correct method of using the PEFM is to forcefully exhale for 1
second as quickly as possible to measure the amount of air exhaled.
"If I get a reading in the green zone, I will tell my parents right away so they can call the doctor."
Values in the green zone represent 80% to 100% of the child's personal best. This indicates that
asthma is under good control and does not warrant calling the provider.
"I will slowly exhale through the mouthpiece over a 10-second interval."
MY ANSWER
Slowly exhaling through the mouthpiece over a 10-second interval is an incorrect method of
using the PEFM. The correct method of using the PEFM is to forcefully exhale for 1 second as
quickly as possible to measure the amount of air exhaled.
"I will record the highest reading of the three attempts."
The child should forcefully exhale for 1 second as quickly as possible to measure the amount of
air exhaled and repeat this process three times. The child should wait 30 seconds between
attempts and record the highest of the three readings.
31. Administer the medication on an empty stomach.
MY ANSWER
The nurse should instruct the parents to administer the medication with meals or just before
eating to prevent gastrointestinal upset.
Encourage the child to brush his teeth after each meal.
The nurse should recommend consistent dental hygiene to the parents of a child who has a
prescription for phenytoin. This medication can cause gingival hyperplasia, and good oral
hygiene reduces the risk of this occurring.
Crush the child's medication to mix with applesauce.
The nurse should instruct the parents to administer the extended-release capsule whole to
ensure proper absorption and therapeutic plasma drug levels.
Observe the child for diarrhea.
The nurse should instruct the parents to monitor the child for constipation as an adverse effect
of phenytoin.
33. Capillary refill greater than 4 seconds
MY ANSWER
The nurse should identify that a capillary refill time greater than 4 seconds indicates severe
dehydration. An infant experiencing moderate dehydration will exhibit a capillary refill time of 2
to 4 seconds.
Bradycardia
The nurse should identify that bradycardia is not a manifestation of dehydration. An infant
experiencing dehydration will exhibit a heart rate that is either within or above the expected
range, depending upon the severity of fluid loss.
Tachypnea
The nurse should identify that tachypnea is a manifestation of moderate dehydration. As
dehydration worsens, breathing becomes hyperpneic.
Lethargy
The nurse should identify that an infant who is lethargic has severe dehydration. An infant
experiencing moderate dehydration will exhibit increased irritability.
Face, Legs, Activity, Cry, Consolability (FLACC) scale
MY ANSWER
The nurse should use the FLACC scale to assess the toddler's pain level. The FLACC scale is used
for infants and children from 2 months to 7 years.
Color Tool scale
The nurse should not use the Color Tool scale to assess pain in a toddler. The Color Tool scale is
used for children ages 4 years old and older that are able to identify colors.
FACES scale
The nurse should not use the FACES pain rating scale to assess pain in a toddler. The FACES scale
is used for children ages 3 years old and older and requires the child to identify pain by pointing
to a face that represents the level of pain the child is experiencing.
Visual Analog Scale (VAS)
The nurse should not use the VAS pain scale to assess pain in a toddler. The VAS scale is used for
children older than 4.5 years old and requires the child to make a written mark on a pain scale
that represents the level of pain the child is experiencing.
Vomiting is correct. The clinical manifestations of a brain tumor vary with the size and location of
the tumor. Vomiting unrelated to feeding is a common finding. It tends to become progressively
more projectile and is most severe in the morning. It can be accompanied by nausea and is a
result of increased intracranial pressure.
Easy bruising is incorrect. Anticoagulation is not associated with brain tumors. It is more likely to
be seen with hematologic malignant disease (leukemia).
Clumsiness is correct. Clumsiness, lack of coordination, and loss of balance are common
manifestations of brain tumors. Manifestations result from pressure and interference with
circulation within the brain.
Irritability is correct. Irritability is a common behavioral manifestation of brain tumors. Other
manifestations include anorexia, fatigue, lethargy, and bizarre behavior such as staring.
Persistent headaches is correct. Headache is probably the most common symptom of brain
tumors. Headaches result from pressure on pain-sensitive areas, such as large blood vessels and
cranial nerves. Headaches tend to be worse in the morning and subside as the day progresses.
The infant cannot turn pages in a book.
The nurse should not expect an infant to turn pages in a book until the age of 12 months.
The infant cannot build a tower of three cubes.
The nurse should not expect an infant to build a tower of three cubes until the age of 18 months.
The infant cannot sit steadily without support.
MY ANSWER
An infant who is 8 months old should be able to sit steadily without support; therefore, the
nurse should report this finding to the provider because it might indicate developmental delay
for a 10-month-old infant.
The infant cannot imitate animal sounds.
The nurse should not expect an infant to imitate animal sounds until the age of 12 months.
40.
Apply a transparent dressing to the blood sample site.
The nurse should hold pressure or place a pressure dressing on the venipuncture site after
obtaining the blood sample. The removal of a transparent dressing can cause increased trauma
to the child who has hemophilia.
Apply a cold compress to the site prior to obtaining the sample.
MY ANSWER
The nurse should not apply a cold compress to the extremity prior to obtaining the blood
sample, because this will cause vasoconstriction, making it more difficult to obtain the blood
sample.
Perform an Allen test prior to obtaining the blood sample.
An Allen test is a procedure used to assess arterial circulation prior to obtaining arterial blood
samples. An aPTT requires venous blood sampling.
Obtain the sample using venipuncture.
The nurse should obtain the blood sample by venipuncture because this method allows for less
bleeding than a finger puncture.
41. Administer ibuprofen for pain.
The nurse should not instruct the parents to administer ibuprofen to the toddler, because
nonsteroidal anti-inflammatory drugs increase the risk of bleeding. The nurse should instruct the
parents to administer acetaminophen if the child experiences pain.
Place knee pads on the child.
As toddlers grow and explore, it is important that parents of a child who has hemophilia take
measures to make the environment safe. This can include measures such as installing carpeting
over ceramic tiled floors or placing knee and elbow pads on the child to protect the child's joints
from injury and bleeding.
Limit the child's physical activity.
MY ANSWER
The nurse should instruct the parents to allow the child to participate in age-appropriate
activities to foster motor development. The parents should provide close supervision during
playtime to decrease the likelihood of accidental injury.
Use a firm-bristled toothbrush for dental care.
The nurse should instruct the parents of the child to use a soft-bristled toothbrush when
providing oral care to the toddler to avoid bleeding and minimize oral trauma. Soft, foam
toothettes that are disposed of after use can also be used.
42. Accompany verbal instructions with visual references.
The nurse should instruct the teachers to use visual references along with verbal instructions for
children who have ADHD. Using both verbal and written instruction provides clear
communication of expectations for the children.
Vary the classroom routine to keep the children interested.
MY ANSWER
The nurse should not instruct the teachers to vary their classroom routine to maintain the
interest of children who have ADHD. Children who have ADHD require a consistent environment
that is predictable to assist with focus and the ability to complete expected tasks.
Limit presentation of subjects of interest to the children to the afternoons.
The nurse should encourage the teachers to alternate topics of high interest to the children with
topics of less interest. This will help retain the attention of the children.
Increase classroom assignments to stimulate learning.
The nurse should not instruct the teachers to increase classroom assignments for children who
have ADHD. Teachers might need to decrease classroom assignments to allow the children time
to complete the work.
43. Expiratory wheeze
An expiratory wheeze is an expected finding for a child who is experiencing an asthma attack and
should be reported to the provider to allow for effective treatment; however, there is another
finding that is the nurse's priority to report to the provider.
Heart rate 100/min
A heart rate of 100/min is an expected finding for a child who is experiencing an asthma attack
and should be reported to the provider to allow for effective treatment; however, there is
another finding that is the nurse's priority to report to the provider.
Profuse sweating
Profuse sweating indicates that this child is at greatest risk for severe respiratory distress and
requires immediate intervention; therefore, this is the nurse's priority finding to report to the
provider. Other manifestations include refusal to lie down and sudden agitation or drowsiness.
The nurse should report any of these manifestations to the provider and remain with the child in
case intubation becomes necessary.
Oxygen saturation 91%
MY ANSWER
An oxygen saturation of 91% is an expected finding for a child who is experiencing an asthma
attack and should be reported to the provider to allow for effective treatment; however, there is
another finding that is the nurse's priority to report to the provider.
44. The infant exhibits a fear of strangers.
The nurse should expect a 6-month-old infant to exhibit a fear of strangers when the ability to
recognize his parents develops.
The infant understands the word "no."
The nurse should expect a 9-month-old infant to understand the word "no" and to respond to
basic commands from the parents.
The infant has an absent grasp reflex.
The nurse should expect a 4-month-old infant to have an absent grasp reflex because this
primitive reflex disappears at 3 months of age. The nurse should expect the infant to grasp
objects with both hands at this stage of development.
The infant rolls from his back to his abdomen.
MY ANSWER
The nurse should expect a 6-month-old infant to reposition himself to a prone position from a
supine one. At 4 months of age, the infant should be able to roll from his back to his side.
45. Shallow respirations
MY ANSWER
The nurse should not expect the toddler to have shallow respirations, as this is a manifestation
of hypoglycemia. A toddler who is experiencing hyperglycemia exhibits deep, rapid (Kussmaul)
respirations.
Moist mucous membranes
The nurse should not expect the toddler to have moist mucous membranes. A toddler who is
experiencing hyperglycemia exhibits dry mucous membranes.
Skin pallor
The nurse should not expect the toddler to have skin pallor, as this is a manifestation of
hypoglycemia. A toddler who is experiencing hyperglycemia exhibits flushed skin and might have
signs of dehydration.
Lethargic mood
The nurse should expect the toddler to be lethargic. A toddler who is experiencing hypoglycemia
will be irritable and have a labile mood.
46. Applying heat to the affected areas
MY ANSWER
The nurse should apply heat to the affected areas to increase circulation and decrease pain;
however, another action is the priority.
Administering prophylactic antibiotics
The nurse should administer prophylactic antibiotics to prevent bacterial infection because the
adolescent's body has a decreased ability to fight infection; however, another action is the
priority.
Infusing blood products
The nurse should administer blood products to correct anemia and reduce blood viscosity;
however, another action is the priority.
Promoting rest
The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to increase tissue oxygenation. An adolescent who has sickle cell anemia and is
experiencing a vasoocclusive crisis has a higher requirement for cellular oxygenation; therefore,
the nurse should reduce the client's metabolic demands for oxygen and limit cardiac oxygen
consumption by encouraging rest.
Elevate the child's residual limb for 48 hr.
The nurse should plan to elevate the child's residual limb for the first 24 hr following surgery.
Elevating the leg longer than 24 hr can cause hip contractures and lead to difficulties with future
ambulation.
Apply a loose-fitting bandage onto the child's residual limb.
The nurse should plan to apply an elastic bandage in a figure-eight pattern to apply pressure to
the residual limb. A pressure dressing controls edema, decreases the likelihood of hemorrhage,
and assists in contouring the residual limb for future prosthetic placement.
Perform active and isotonic range-of-motion exercises.
MY ANSWER
The nurse should plan to perform both active and isotonic range-of-motion exercises of the
joints above the amputation site several times per day. This will maintain joint mobility, which is
necessary for future ambulation.
Clean the incision using half-strength hydrogen peroxide every 8 hr.
The nurse should not plan to clean the incision with half-strength hydrogen peroxide, as this can
irritate the tissue. The nurse should clean the incision with soap and water each day while
assessing the limb for manifestations of infection or skin breakdown.
Hot dogs
MY ANSWER
Acute glomerulonephritis is a renal disorder resulting in edema, hypertension, hematuria, and
proteinuria. If required, dietary changes require limitation of foods that are high in sodium
because of the edema and hypertension. The nurse should recommend the elimination of hot
dogs from the child's diet, as processed meats are high in sodium.
Canned mixed fruit
The nurse should identify that canned mixed fruit is very low in sodium and is permissible for the
child who has acute glomerulonephritis.
Steamed green beans
The nurse should identify that steamed green beans are very low in sodium and are permissible
for the child who has acute glomerulonephritis. Beans are also an excellent source of complex
carbohydrates, which are recommended for this client.
Whole wheat macaroni
The nurse should identify that whole wheat macaroni is very low in sodium and is permissible for
the child who has acute glomerulonephritis. In addition, whole wheat macaroni is an excellent
source of complex carbohydrates, which are recommended for this client.
50.
Insert the tip of the thermometer 5 cm (2 in) into the rectum.
The nurse should insert the tip of the thermometer no more than 2.5 cm (1 in) into the child's
rectum to prevent injury.
Place the child in prone position.
The nurse should place the child in a side-lying, supine, or prone position to obtain a rectal
temperature.
Stabilize the thermometer at the distal end.
The nurse should stabilize the thermometer close to the child's rectum to prevent injury.
Direct the tip of the thermometer toward the spine during insertion.
MY ANSWER
The nurse should direct the tip of the probe toward the umbilicus during insertion because this
is the direction of the rectum. Pointing the tip of the thermometer toward the spine can increase
the risk of rectal perforation.
52.
6 months
MY ANSWER
The nurse should expect infants to begin adding consonants to simple syllables (da-da, wa-wa)
and begin to imitate sounds at around 6 months of age.
12 months
The nurse should expect an infant to begin speaking three to five words with meaning at around
12 months of age.
18 months
The nurse should expect a toddler to speak ten or more words at around 18 months of age. The
toddler should also form simple word combinations.
24 months
The nurse should expect a toddler to speak approximately three-hundred words at around 24
months of age. The toddler should also use two- and three-word
53. "Your child should not receive the measles, mumps, and rubella vaccine."
MY ANSWER
The CD4 count is a measurement of lymphocytes, which plays a role in cellular immune function.
Adequate immune function is indicated by a CD4 count of 600 to 1,500 cells/µL. At levels less
than 200 cells/µL, the child is at increased risk for opportunistic infections. A child who has HIV
and a CD4 level within the expected reference range should receive immunizations against
common childhood illnesses, such as MMR and varicella.
"Your child should receive the pneumococcal vaccine."
Immunizations are an important factor in maintaining a child's health. A child who has HIV and a
CD4 level within the expected reference range should receive the pneumococcal vaccine.
"Household members should avoid receiving the varicella vaccine."
It is not necessary for household members living with a child who has HIV and a CD4 level within
the expected reference range to avoid receiving the varicella vaccine, because there is no
evidence of immunosuppression.
"Your child will need IV gamma globulin prophylaxis if exposed to pediculosis."
IV gamma globulin prophylaxis is administered to children who are exposed to or develop
recurrent bacterial infections. Pediculosis, or lice, is treated with medicated shampoo and
manual removal of nits. A child who has HIV and a CD4 level within the expected reference range
does not require an alternative treatment for pediculosis.
Place a throw rug under the crib.
MY ANSWER
The nurse should instruct the parent to place a throw rug under the crib because the toddler can
fall out of the crib. The nurse should also instruct the parent to move the toddler to a youth bed
when he is able to climb out of the crib.
Select a toy box with a heavy, hinged lid.
The nurse should instruct the parent to select a toy box with a lid the toddler can easily open. A
toy box with a heavy, hinged lid places the toddler at risk for injury or suffocation if entrapment
occurs.
Offer marshmallows as a snack food.
The nurse should instruct the parent not to offer marshmallows as a snack food, because they
are a choking hazard. If the toddler does not chew the marshmallow completely, it can occlude
his airway.
Set the water heater temperature to 54.4° C (130° F).
The nurse should instruct the parent to set the temperature on the hot water heater at no more
than 49° C (120° F) to prevent scalding of the toddler.
A is correct. To document the appropriate area on the growth chart, obtain a chart designated
for the infant's age and gender. Next, the nurse should find the marker for age at the bottom of
the chart. Then, on the right side of the page, the nurse should determine the marker for weight
in either kg or lb and plot them on the graph accordingly. If the points plotted are within the two
bolded lines, representing the 5th and 95th percentiles, the child's development in terms of
these parameters is appropriate. This is the correct documentation of the infant's weight.
B is incorrect. To document the appropriate area on the growth chart, obtain a chart designated
for the infant's age and gender. Next, the nurse should find the marker for age at the bottom of
the chart. Then, on the right side of the page, the nurse should determine the markers for
weight in either kg or lb and plot them on the graph accordingly. According to this point on the
chart, the infant is 13 months old and weighs 11.3 kg (24.9 lb).
C is incorrect. To document the appropriate area on the growth chart, obtain a chart designated
for the infant's age and gender. Next, the nurse should find the marker for age at the bottom of
the chart. Then, on the right side of the page, the nurse should determine the markers for
weight in either kg or lb and plot them on the graph accordingly. According to this point on the
chart, the infant is 11 months old and weighs 9.5 kg (20.9 lb).
D is incorrect. To document the appropriate area on the growth chart, obtain a chart designated
for the infant's age and gender. Next, the nurse should find the marker for age at the bottom of
the chart. Then, on the right side of the page, the nurse should determine the markers for
weight in either kg or lb and plot them on the graph accordingly. According to this point on the
chart, the infant is 13 months old and weighs 10.2 kg (22.5 lb).
56. Chill the medication prior to administration.
The nurse should instruct the parents that the otic solution should be at room temperature
before instilling in the ear to minimize discomfort.
Pull the pinna up and back during medication administration.
MY ANSWER
The nurse should instruct the parents to gently pull the pinna downward and straight back
during administration of the medication to the infant. This positions the ear canal and
eustachian tube to ensure correct placement of the medication.
Hyperextend the infant's neck during medication administration.
The nurse should not instruct the parents to hyperextend the infant's neck when administering
ear drops, as this is the position used to administer nasal medications. The nurse should instruct
the parents to turn the infant's head to the appropriate side while in the prone or supine
position. After instilling the medication, the parents should keep the infant in a lateral position
for a few minutes to ensure the medication reaches the target area.
Massage the anterior area of the ear following administration.
The nurse should instruct the parents to massage the anterior area of the ear, just in front of the
tragus, following administration to facilitate instillation of the medication into the ear canal. This
action assists the medication in reaching the target area.
58. Indomethacin
The nurse should not plan to administer indomethacin to a child who has cerebral palsy and is
experiencing muscle spasms. Indomethacin is an anti-inflammatory medication used in the
treatment of gout.
Baclofen
The nurse should plan to administer baclofen to a child who has cerebral palsy and muscle
spasms because it is a centrally acting skeletal muscle relaxant that will decrease muscle spasm
and severe spasticity.
Methotrexate
The nurse should not plan to administer methotrexate to a child who has cerebral palsy and is
experiencing muscle spasms. Methotrexate is an antineoplastic medication used to treat various
cancers and rheumatoid arthritis.
Carbamazepine
MY ANSWER
The nurse should not plan to administer carbamazepine to a child who has cerebral palsy and is
experiencing muscle spasms. Carbamazepine is an anticonvulsant used to treat seizures.
Maintain clean technique during the child's dressing changes.
The nurse should perform dressing changes using sterile technique to prevent infection. Delayed
wound healing can occur due to infection, which can also cause partial-thickness wounds to
develop into full-thickness wounds.
Provide low calorie snacks for the child several times each day.
Burn injuries create a hypermetabolic state, requiring an increase of up to three times the
normal calorie requirements. The nurse should provide high-calorie, high-protein snacks to
promote healing and replace calories and proteins that are expended due to the child's
increased metabolism.
Apply continuous passive motion devices to lower the child's extremities during periods of rest.
The nurse should apply splints to the child's lower extremities during periods of rest and sleep to
minimize the development of flexion contractions.
Administer pain medication to the child 30 min before physical therapy.
MY ANSWER
The nurse should administer pain medication to the child 30 to 45 min prior to painful
procedures, such as physical therapy or dressing changes. Adequate pain control is needed so
the child will actively participate and cooperate during physical therapy.
60. "I will give lansoprazole 30 minutes after her feeding."
The mother should give lansoprazole to her infant 30 min before feeding. Administering
lansoprazole, a proton pump inhibitor, 30 min prior to meals ensures the peak plasma
concentration of the medication occurs during mealtimes. This medication reduces gastric
hydrochloric acid secretion and can stimulate an increase in lower esophageal sphincter tone,
which can prevent reflux of stomach contents into the esophagus.
"I will lay my baby on her side after feedings."
MY ANSWER
The parent should not lay her infant down following a feeding, as this position will worsen
gastroesophageal reflux. The parent should place the infant upright in an infant seat or raise the
head of the bed 30° for 1 hr after feedings.
"I will add rice cereal to my baby's feedings."
The mother can add rice cereal to formula or expressed breast milk to thicken the feedings.
Thickened feedings can decrease the number of vomiting episodes the infant experiences.
"I will use a nipple that has a wide base to feed her."
The parent should create a larger hole within the nipple to help the infant suck more easily. A
wide-based nipple is used for feeding infants who have a cleft lip.