Ati nur 223a sect 4 pediatrics final exam
Total Questions : 82
Showing 25 questions, Sign in for moreA child is admitted with a suspected diagnosis of Wilms tumor. The nurse should place a sign with which of the following warnings over the child’s bed?
Explanation
Choice A rationale
Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. It is crucial not to palpate the abdomen of a child with a suspected Wilms tumor because this can cause the tumor to rupture and spread cancerous cells to other parts of the body.
Choice B rationale
This choice is incorrect because there is no specific restriction on venipuncture or blood pressure measurements in the left arm for children with Wilms tumor. This precaution is typically associated with conditions like lymphedema or after a mastectomy.
Choice C rationale
Collecting all urine is not a specific precaution for Wilms tumor. While monitoring urine output can be important in various conditions, it is not a primary concern for Wilms tumor.
Choice D rationale
Contact precautions are not necessary for Wilms tumor as it is not an infectious disease. Contact precautions are typically used for conditions that are contagious or spread through direct contact.
The nurse would teach the mother of a boy with Tetralogy of Fallot that if the child suddenly becomes cyanotic and dyspneic, the mother should:
Explanation
Choice A rationale
Placing the child in a knee-chest position helps increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation during a cyanotic spell in children with Tetralogy of Fallot.
Choice B rationale
Having the child lie supine with the head turned to one side does not help in managing a cyanotic spell and may not improve oxygenation.
Choice C rationale
Lying prone does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.
Choice D rationale
Placing the child in a semi-Fowler’s position in an infant seat does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.
A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information, the nurse documents that the infant has:
Explanation
Choice A rationale
Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.
Choice B rationale
Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.
Choice C rationale
Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.
Choice D rationale
Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.
When planning care for children, the nurse knows that which factor has the largest impact but is not able to be altered to influence the growth and development of children?
Explanation
Choice A rationale
Environment plays a significant role in a child’s growth and development, including factors like socioeconomic status, access to education, and living conditions. However, it can be altered to some extent.
Choice B rationale
Genetics is the largest factor impacting growth and development that cannot be altered. Genetic factors determine physical characteristics, susceptibility to certain diseases, and overall growth patterns.
Choice C rationale
Socialization influences a child’s development, including social skills and behavior. While important, it can be influenced and altered through various interventions.
Choice D rationale
Nutrition is crucial for growth and development, affecting physical and cognitive development. However, it can be modified through dietary changes and interventions.
A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client’s plan of care?
Explanation
Choice A rationale
Measuring head circumference every shift is unnecessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants where head circumference changes can indicate increased intracranial pressure.
Choice B rationale
Implementing seizure precautions is necessary as bacterial meningitis can cause seizures due to increased intracranial pressure and inflammation.
Choice C rationale
Admitting the client to a private room is necessary to prevent the spread of infection, as bacterial meningitis can be highly contagious.
Choice D rationale
Placing the client in a semi-Fowler’s position helps reduce intracranial pressure and promotes comfort.
A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention?
Explanation
Choice A rationale
A positive Babinski reflex is normal in infants up to 2 years old and indicates normal neurological development.
Choice B rationale
A negative Doll’s eye reflex is concerning as it may indicate a neurological problem. However, it is not as critical as a positive Moro reflex in a 9-month-old.
Choice C rationale
A negative Crawl reflex may indicate developmental delays, but it is not as critical as a positive Moro reflex in a 9-month-old.
Choice D rationale
A positive Moro reflex is abnormal in a 9-month-old and may indicate neurological issues. This reflex typically disappears by 2 months of age.
A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure?
Explanation
Choice A rationale
Increased crying episodes are a common indicator of pain in infants. Crying is a behavioral response to discomfort and can be more intense or frequent when the infant is in pain. This response is due to the activation of the infant’s nervous system, which signals distress through crying.
Choice B rationale
Decreased respiratory rate is not typically associated with pain in infants. Pain usually causes an increase in respiratory rate due to the body’s stress response, which involves the release of adrenaline and other stress hormones that stimulate the respiratory system.
Choice C rationale
Decreased heart rate is also not a common sign of pain in infants. Pain generally leads to an increased heart rate as part of the body’s fight-or-flight response, which is mediated by the sympathetic nervous system.
Choice D rationale
Increased formula consumption is not an indicator of pain. In fact, pain might reduce an infant’s appetite and lead to decreased feeding. Pain can cause discomfort during feeding, leading to fussiness and refusal to eat.
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?
Explanation
Choice A rationale
High fever is a common finding in children experiencing sickle cell crisis. The crisis is often triggered by infections, which can cause fever. The sickled red blood cells can block blood flow, leading to tissue ischemia and necrosis, which can also contribute to fever.
Choice B rationale
Bradycardia, or a slow heart rate, is not typically associated with sickle cell crisis. The crisis usually causes an increased heart rate due to pain and the body’s stress response.
Choice C rationale
Constipation is not a common finding in sickle cell crisis. The primary symptoms are related to pain and vaso-occlusion, which can cause severe pain and other complications.
Choice D rationale
Decreased respiratory rate is not a typical finding in sickle cell crisis. The crisis can cause respiratory distress due to pain and hypoxia, leading to an increased respiratory rate.
A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider?
Explanation
Choice A rationale
The inability to stand upright without support at 15 months is a developmental delay that should be reported to the provider. By this age, most toddlers can stand and walk independently. Delays in motor skills can indicate underlying neurological or musculoskeletal issues.
Choice B rationale
Building a tower of six to seven cubes is a skill typically developed by 24 months. At 15 months, a toddler may only be able to stack two to three cubes.
Choice C rationale
Jumping with both feet is a skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to be able to jump with both feet.
Choice D rationale
Turning a doorknob is a fine motor skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to have this skill.
Which of the following conditions is commonly associated with tetralogy of Fallot?
Explanation
Choice A rationale
Asthma is a chronic respiratory condition characterized by airway inflammation and bronchoconstriction. It is not commonly associated with tetralogy of Fallot.
Choice B rationale
Polycythemia, or an increased number of red blood cells, can occur as a compensatory mechanism in response to chronic hypoxia in tetralogy of Fallot. However, it is not a primary condition associated with tetralogy of Fallot.
Choice C rationale
Pulmonary hypertension is a condition characterized by increased blood pressure in the pulmonary arteries. While it can occur secondary to congenital heart defects, it is not a primary condition associated with tetralogy of Fallot.
Choice D rationale
Tetralogy of Fallot is a congenital heart defect that includes four heart abnormalities: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. These defects cause altered blood flow and reduced oxygen levels in the blood.
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse’s priority?
Explanation
Choice A rationale
Obtaining blood cultures is important for identifying the causative organism, but it should be done immediately before or concurrently with the administration of antibiotics.
Choice B rationale
Administering an intravenous antibiotic is the priority action for a child with suspected bacterial meningitis. Early administration of antibiotics is crucial to treat the infection and prevent complications such as brain swelling and seizures.
Choice C rationale
Preparing the child for a lumbar puncture is necessary for diagnosing meningitis, but it should not delay the administration of antibiotics.
Choice D rationale
Placing the child in isolation is important to prevent the spread of infection, but it is not the immediate priority over administering antibiotics.
A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.)
Explanation
Choice A rationale
Daytime symptoms occurring more than twice a week is an expected finding in mild persistent asthma. This indicates that the asthma is not well-controlled and requires regular use of a controller medication.
Choice B rationale
Nighttime symptoms occurring approximately twice a month is more characteristic of intermittent asthma, not mild persistent asthma.
Choice C rationale
Minor limitations with normal activity are expected in mild persistent asthma. This indicates that the asthma is affecting the child’s daily activities to some extent.
Choice D rationale
Symptoms that are continuous throughout the day are indicative of severe persistent asthma, not mild persistent asthma.
Choice E rationale
A peak expiratory flow (PEF) greater than or equal to 80% of the predicted value is an expected finding in mild persistent asthma. This indicates that the child’s lung function is relatively well-preserved.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
Explanation
Choice A rationale
Restraining the child’s arms during a seizure is not recommended. Restraint can cause injury to the child and does not prevent the seizure from occurring. Instead, the focus should be on ensuring the child’s safety by removing any nearby objects that could cause harm.
Choice B rationale
Positioning the child laterally (on their side) is the correct action. This position helps maintain an open airway and allows any secretions to drain out of the mouth, reducing the risk of aspiration. It also facilitates better breathing and prevents the tongue from obstructing the airway.
Choice C rationale
Attempting to stop the seizure is not advisable. Seizures typically run their course and attempting to stop them can cause more harm than good. The nurse should focus on ensuring the child’s safety and monitoring the seizure’s duration and characteristics.
Choice D rationale
Using a padded tongue blade is outdated and not recommended. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or airway. It is better to ensure the child’s safety by positioning them laterally and monitoring their airway.
A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take?
Explanation
Choice A rationale
Obtaining a throat culture is contraindicated in suspected epiglottitis. This procedure can cause further irritation and potentially lead to airway obstruction. Epiglottitis is a medical emergency, and the priority is to maintain a patent airway.
Choice B rationale
Placing the child in an upright position is the correct action. This position helps improve breathing and reduces the risk of airway obstruction. It also allows for better visualization and assessment of the child’s respiratory status.
Choice C rationale
Visualizing the epiglottis with a tongue depressor is not recommended in suspected epiglottitis. This action can cause further irritation and potentially lead to airway obstruction. The priority is to maintain a patent airway and avoid any procedures that could exacerbate the condition.
Choice D rationale
Transporting the child to radiology for a throat x-ray is not the immediate priority. While imaging may be necessary for diagnosis, the primary focus should be on maintaining a patent airway and ensuring the child’s respiratory status is stable.
A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?
Explanation
Choice A rationale
A low-carbohydrate, low-protein diet is not appropriate for a child with acute glomerulonephritis. Carbohydrates and proteins are essential nutrients, and restricting them can lead to malnutrition and other complications.
Choice B rationale
A regular diet with no added salt is not sufficient for managing acute glomerulonephritis with peripheral edema. Sodium restriction is necessary to help reduce fluid retention and edema.
Choice C rationale
A low-protein, low-potassium diet is not the best choice for managing acute glomerulonephritis. While protein and potassium intake may need to be monitored, the primary focus should be on sodium and fluid restriction.
Choice D rationale
A low-sodium, fluid-restricted diet is the correct choice. Sodium restriction helps reduce fluid retention and edema, while fluid restriction helps manage fluid balance and prevent further complications.
A nurse is preparing to measure an infant’s vital signs. The nurse should use which of the following sites to assess a heart rate?
Explanation
ChoiceA rationale
Theapexoftheheart(apicalpulse)isthepreferredsiteforassessingtheheartrateininfants.It is located at the point of maximal impulse (PMI) and provides the most accuratemeasurementof theheartrateinthisagegroup.
ChoiceB rationale
The brachial artery is not the preferred site for assessing the heart rate in infants. While it canbeused forbloodpressuremeasurement,itisnotasaccurateastheapicalpulseforheartrateassessment.
ChoiceCrationale
Theradialarteryisnottypicallyusedforassessingthe heartrateininfants.Itismorecommonlyusedinolderchildren andadults.
ChoiceD rationale
Thecarotidarteryisnotrecommendedforassessingtheheartrateininfantsduetotheriskofcompressingtheairwayandcausingdiscomfort.
A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms?
Explanation
Choice A rationale
Budesonide via dry-powder inhaler is a corticosteroid used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
Choice B rationale
Cromolyn via metered-dose inhaler is a mast cell stabilizer used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
Choice C rationale
Albuterol via jet nebulizer is a short-acting beta-adrenergic agonist that provides rapid bronchodilation. It is the medication of choice for immediate relief of acute asthma exacerbations.
Choice D rationale
Montelukast orally is a leukotriene receptor antagonist used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?
Explanation
Choice A rationale
The influenza vaccine is recommended annually for all individuals, including adolescents, to protect against the flu. However, it is not specifically required for pre-college physical assessments.
Choice B rationale
The pneumococcal polysaccharide vaccine is typically administered to older adults and individuals with certain medical conditions. It is not a standard requirement for adolescents.
Choice C rationale
The Bacille Calmette-Guérin (BCG) vaccine is used in countries with a high prevalence of tuberculosis. It is not commonly administered in the United States or required for pre-college physical assessments.
Choice D rationale
The meningococcal polysaccharide vaccine is recommended for adolescents, especially those entering college, to protect against meningococcal disease, which can spread in close living quarters.
A nurse is caring for a child who has rheumatic fever. When obtaining the child’s medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child’s infection?
Explanation
Choice A rationale
Rheumatic fever is often preceded by a streptococcal infection, such as strep throat. A sibling with a sore throat 3 weeks ago could have had a strep infection, which is a significant risk factor for developing rheumatic fever.
Choice B rationale
Chickenpox is caused by the varicella-zoster virus and is not related to rheumatic fever, which is a complication of streptococcal infections.
Choice C rationale
Gastritis is an inflammation of the stomach lining and is not associated with rheumatic fever.
Choice D rationale
Fifth disease is caused by parvovirus B19 and is not related to rheumatic fever.
The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider’s orders and recognizes that clarification is needed for which of the following medications?
Explanation
Choice A rationale
Isosorbide dinitrate is a nitrate used to treat angina and heart failure. It does not have contraindications for patients with asthma.
Choice B rationale
Carvedilol is a beta-blocker that can exacerbate asthma symptoms because it blocks beta-2 receptors in the lungs, leading to bronchoconstriction.
Choice C rationale
Captopril is an ACE inhibitor used to treat hypertension and heart failure. It does not have contraindications for patients with asthma.
Choice D rationale
Fluticasone is a corticosteroid used to manage asthma and does not have contraindications for patients with heart failure.
A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider?
Explanation
Choice A rationale
At 10 months, infants are typically able to imitate simple sounds, including animal sounds. This is a normal developmental milestone.
Choice B rationale
Turning pages in a book is a fine motor skill that develops later, around 12 months of age.
Choice C rationale
Building a tower of three or four cubes is a skill that typically develops around 15-18 months of age.
Choice D rationale
By 10 months, infants should be able to sit steadily without support. Inability to do so may indicate a developmental delay.
A nurse is developing a health program for the parents of school-age boys. Which of the following information about pubescent changes should the nurse include in the program?
Explanation
Choice A rationale
Puberty might be delayed if scrotal changes have not occurred by the age of 13½ to 14 years, not 11 years.
Choice B rationale
Changes in the voice occur during puberty but do not signal its beginning. Enlargement of the testicles is the first sign of puberty in boys.
Choice C rationale
Growth spurts in height typically occur toward the end of mid-puberty, making this the correct answer.
Choice D rationale
Gynecomastia, or the development of breast tissue in boys, commonly occurs during mid- puberty, not late puberty
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse’s priority?
Explanation
Choice A rationale
Loosening restrictive clothing can help ensure the child is comfortable and can breathe easily during a seizure. However, it is not the priority action. The primary concern during a tonic- clonic seizure is to maintain the child’s airway and prevent aspiration, especially if the child is vomiting.
Choice B rationale
Positioning the child side-lying is the priority action. This position helps maintain an open airway and allows any vomit or secretions to drain out of the mouth, reducing the risk of aspiration.
Choice C rationale
Placing a pillow under the child’s head can provide comfort and prevent head injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
Choice D rationale
Clearing the area of hazards is important to prevent injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler’s mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions?
Explanation
Choice A rationale
Developing autonomy is a normal developmental milestone for toddlers. However, the behaviors described in the question (sitting quietly, sucking thumb, turning away) are more indicative of regression rather than autonomy.
Choice B rationale
Resentment toward the mother is not a typical developmental reaction for an 18-month-old toddler. The behaviors described are more indicative of regression due to the stress of hospitalization.
Choice C rationale
Anxiety reaction can occur in toddlers who are hospitalized, but the behaviors described (sitting quietly, sucking thumb, turning away) are more indicative of regression.
Choice D rationale
Regression is a common reaction in toddlers who are hospitalized. The behaviors described (sitting quietly, sucking thumb, turning away) are typical signs of regression, where the child reverts to earlier developmental behaviors as a coping mechanism.
A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?
Explanation
Choice A rationale
Administering an inhaled glucocorticoid can help reduce inflammation in the airways, but it is not the priority intervention in an acute asthma exacerbation. The primary concern is to provide rapid bronchodilator.
Choice B rationale
Obtaining a peak flow reading can help assess the severity of the asthma exacerbation, but it is not the priority intervention. The primary concern is to provide rapid bronchodilator.
Choice C rationale
Administering a short-acting beta-agonist (SABA) is the priority intervention. SABAs, such as albuterol, provide rapid bronchodilation and relieve bronchospasm, which are the main features of status asthmatics.
Choice D rationale
Determining the cause of the acute exacerbation can help guide long-term management, but it is not the priority intervention in an acute asthma exacerbation. The primary concern is to provide rapid bronchodilation.
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