Ati nur223g paediatrics sect 2 final exam
Total Questions : 92
Showing 25 questions, Sign in for moreA nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?
Explanation
Rationale:
A. Assessing the erythematous rash is important, as it can indicate the presence of erythema marginatum, a common symptom of rheumatic fever, but it is not the priority.
B. Auscultating the rate and characteristics of the child's heart sounds is the priority assessment because acute rheumatic fever can cause carditis, which affects the heart valves and can lead to serious complications. Early detection of any cardiac involvement is crucial for timely intervention and management.
C. Assessing joint pain is necessary for comfort and symptom management but does not take precedence over potential cardiac complications.
D. Identifying parental anxiety is important for providing emotional support but is not the immediate priority in managing the child's acute condition.
A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?
Explanation
Rationale:
A. Shaking the inhaler for 3 to 5 seconds ensures that the medication is properly mixed and will be delivered effectively during inhalation.
B. The correct waiting time between inhalations is usually 1 minute, not 2 minutes, to allow for optimal bronchodilation.
C. Pressing down twice on the MDI canister is incorrect. The client should press down once and inhale the medication deeply.
D. Rinsing the mouth after using the MDI is recommended to prevent oral thrush, but using water, not mouthwash, is generally advised to avoid potential irritation.
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
Rationale:
A. Gastritis in the father is unrelated to rheumatic fever, which is linked to streptococcal infections, not gastrointestinal issues.
B. Chickenpox, caused by the varicella-zoster virus, is not related to rheumatic fever.
C. A sibling who had a sore throat 3 weeks ago is significant because rheumatic fever often follows an untreated or inadequately treated streptococcal throat infection. Recognizing a recent history of streptococcal infection is key to understanding the source of the child's rheumatic fever.
D. Fifth disease, caused by parvovirus B19, is also unrelated to rheumatic fever.
A nurse is teaching the parents of a child with frequent nosebleeds how to care for the child. Which statement by the parents indicate that the parents have understood the teaching?
Explanation
Rationale:
A. Sitting the child upright and forward while applying pressure to the sides of the nose is the correct approach to managing a nosebleed. This position prevents blood from flowing down the throat and helps stop the bleeding by applying direct pressure.
B. Turning the child's head to the side and pressing on the nasal ridge is incorrect because it does not effectively control the bleeding and may cause blood to flow into the throat.
C. Lying the child in bed and pressing on the forehead is not effective in controlling a nosebleed.
D. Lying flat and applying pressure to the cheeks does not address the source of the bleeding and may worsen the situation.
A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Explanation
Rationale:
A. Positioning the infant on the abdomen is contraindicated after cleft lip repair because it could put pressure on the surgical site, risking injury or dehiscence.
B. Offering a pacifier is not advised as it could disrupt the surgical site and delay healing.
C. Ibuprofen is not typically recommended for infants younger than 6 months due to the risk of adverse effects; acetaminophen is usually preferred for pain management in this age group.
D. Encouraging the parents to rock the infant provides comfort and soothes the baby without risking harm to the surgical site. Parental involvement also helps with bonding and emotional support during recovery.
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
Rationale:
A. Loosening restrictive clothing is important for ensuring the child’s comfort and preventing injury, but it is not the immediate priority.
B. Placing a pillow under the child’s head can help prevent head injury during a seizure, but positioning the child is more urgent to prevent aspiration.
C. Positioning the child side-lying is the priority because it helps maintain an open airway and reduces the risk of aspiration of vomit during the seizure. Protecting the airway is the most critical intervention in this scenario.
D. Clearing the area of hazards is important to prevent injury during the seizure, but it is secondary to ensuring the child's airway is protected.
A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?
Explanation
Rationale
A. Testing urine for ketones is important during illness as it can indicate the presence of ketoacidosis, a potentially life-threatening complication in children with type 1 diabetes.
B. Withholding insulin during illness is dangerous, as the body may require more insulin due to increased stress and glucose production.
C. While notifying the provider for high blood glucose levels is essential, it is not the first action to take. Monitoring for ketones is crucial during illness.
D. Limiting fluid intake is not advised during illness, as adequate hydration is important to prevent dehydration and assist in glucose regulation.
A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?
Explanation
Rationale:
A. Deep, rapid respirations, known as Kussmaul respirations, are typically associated with hyperglycemia and ketoacidosis, not hypoglycemia.
B. Tachycardia is a common symptom of hypoglycemia, as the body releases adrenaline in response to low blood glucose levels, leading to an increased heart rate.
C. Polyuria is associated with hyperglycemia, not hypoglycemia.
D. Dry, flushed skin is typically a sign of dehydration or hyperglycemia, not hypoglycemia.
A nurse is assessing a 2-year-old child at a well-child visit. The child's parent expresses concern about the child's increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?
Explanation
Rationale:
A. While diet can influence behavior, the concern here is the child’s developmental stage, making this response less relevant.
B. Discussing discipline is important, but understanding normal developmental behaviors is more appropriate in this context.
C. Explaining that temper tantrums are normal for toddlers, who are starting to develop a sense of autonomy, helps reassure the parent that this behavior is typical and part of the child's development.
D. Suggesting parenting books might be helpful, but it does not directly address the parent's immediate concern about the behavior.
A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?
Explanation
Rationale:
A. Testing urine for ketones is crucial during illness because it helps in early detection of diabetic ketoacidosis, which can be life-threatening.
B. Withholding insulin is dangerous during illness, as the body may require more insulin, not less.
C. While it is important to notify the provider if blood glucose levels are elevated, monitoring for ketones takes precedence to prevent complications.
D. Limiting fluid intake is not recommended, as fluids are essential for maintaining hydration and helping to manage blood glucose levels during illness.
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?
Explanation
Rationale:
A. Constipation is not a typical manifestation of a sickle cell crisis.
B. High fever may occur if an infection is present, but it is not a hallmark symptom of a sickle cell crisis.
C. Bradycardia is not expected during a sickle cell crisis; if anything, tachycardia may be seen due to pain or anemia.
D. Pain is the most common and significant symptom of a sickle cell crisis, caused by the obstruction of blood flow by sickled red blood cells, leading to ischemia and severe pain. This requires immediate attention and pain management.
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
Rationale:
A. Isosorbide dinitrate is a nitrate that helps to dilate blood vessels and reduce the workload on the heart. It is generally safe for clients with asthma.
B. Carvedilol is a beta-blocker used to manage heart failure, but it can also cause bronchoconstriction, which is dangerous for clients with asthma. Beta-blockers can exacerbate asthma symptoms, so clarification is needed before administration.
C. Fluticasone is a corticosteroid commonly used to manage asthma and other respiratory conditions; it is not contraindicated for this client.
D. Captopril is an ACE inhibitor used to treat heart failure and does not pose a risk for clients with asthma.
The nurse is instructing the parents of a child with sickle cell anemia on safety precautions. What should the nurse emphasize during this teaching?
Explanation
Rationale:
A. Children with sickle cell anemia should receive all recommended immunizations to protect against infections, which can trigger a sickle cell crisis.
B. Participating in sports should be done with caution, and activities that lead to dehydration or overexertion should be avoided.
C. Over-the-counter medications should be used cautiously and under the guidance of a healthcare provider, as some medications may not be suitable for children with sickle cell anemia.
D. Ensuring adequate hydration is crucial for preventing sickle cell crises. Dehydration can increase blood viscosity, leading to sickling of the red blood cells and subsequent pain and complications.
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)
Explanation
Rationale:
A. Removing objects from the bed is necessary to prevent injury during the seizure.
B. Placing the client in a side-lying position helps to maintain an open airway and reduces the risk of aspiration.
C. Assessing airway patency is crucial to ensure the client can breathe adequately during and after the seizure.
D. Placing a tongue depressor or any object in the client's mouth is contraindicated, as it can cause injury or obstruct the airway.
E. Restraining the client is also contraindicated because it can cause harm or increase agitation during a seizure.
A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?
Explanation
Rationale:
A. Telling the child that temper tantrums are unacceptable may not be effective, as toddlers may not fully understand this concept.
B. Ignoring temper tantrums is often recommended because giving attention to the tantrum can reinforce the behavior. Consistently ignoring the tantrum can help decrease their frequency over time.
C. While distraction can sometimes be effective, it may not work in the middle of a tantrum when the child is already upset.
D. Physically restraining the child is not recommended as it can escalate the situation and lead to further distress.
A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?
Explanation
Rationale:
A. Switching formula is not the first intervention, as projectile vomiting in an infant can indicate a more serious condition such as pyloric stenosis, which requires medical evaluation.
B. Oral rehydration solution may be needed if the infant is dehydrated, but the cause of vomiting must be assessed first.
C. While burping can reduce gas and discomfort, it is unlikely to resolve projectile vomiting, which may be due to a more serious underlying condition.
D. Bringing the baby to the clinic is the most appropriate action, as projectile vomiting can be a sign of pyloric stenosis or another serious condition that requires prompt medical attention.
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
Rationale:
A. The knee-chest position increases systemic vascular resistance, which helps to divert more blood to the pulmonary circulation, improving oxygenation in a child experiencing a "tet spell" or hypercyanotic episode.
B. The prone position does not help in relieving cyanosis and dyspnea in Tetralogy of Fallot.
C. The supine position with the head turned does not assist in improving oxygenation during a cyanotic episode.
D. The semi-Fowler's position may aid breathing but is less effective than the knee-chest position in managing cyanotic spells.
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
Rationale:
A. Genetics plays the most significant role in a child’s growth and development, determining many physical and psychological traits. However, it cannot be altered.
B. Socialization impacts development, but it is influenced by environmental factors and can be guided by caregivers.
C. The environment affects development, but it can be modified to support growth.
D. The family is crucial in a child's development, but its influence can also be shaped through intervention and support.
A nurse is assessing a 3-year-old child and suspects the child may have a developmental delay. Which of the following actions is a priority for the nurse to take?
Explanation
Rationale:
A. The priority is to discuss the findings with the primary care provider to determine the next steps in diagnosis and intervention. Early identification and referral are crucial for addressing developmental delays.
B. Referring to early intervention is important but should follow the discussion with the primary care provider to ensure an appropriate and coordinated response.
C. Providing pamphlets is supportive but secondary to initiating a formal evaluation and intervention process.
D. Educating the parents is essential, but it should be based on a confirmed diagnosis and plan developed in collaboration with healthcare providers.
A school-aged child is diagnosed with streptococcal pharyngitis. What of the following clinical manifestations should the nurse expect?
Explanation
Rationale:
A. Rest is recommended until the child recovers, as exertion can worsen symptoms and delay healing.
B. While streptococcal infections can lead to complications, a tooth abscess is not a typical concern.
C. Completing the entire course of antibiotics is crucial to prevent complications such as rheumatic fever and glomerulonephritis.
D. Swollen lymph nodes are common, but they typically do not obstruct the airway in streptococcal pharyngitis.
A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?
Explanation
Rationale:
A. Distended neck veins are not associated with pyloric stenosis.
B. A ridged abdomen is not typical of pyloric stenosis; rather, an olive-shaped mass may be palpated in the right upper quadrant.
C. Projectile vomiting is a hallmark sign of pyloric stenosis due to the obstruction at the pylorus, preventing food from passing into the small intestine.
D. Red currant jelly stools are associated with intussusception, not pyloric stenosis.
The nurse is caring for a preschooler with acute nasopharyngitis. Which information should the nurse include when teaching the parents about this health problem?
Explanation
Rationale:
A. Coughing helps to clear mucus from the airways, and suppressing it can lead to complications such as mucus buildup and infection.
B. Antibiotics are not prescribed for viral infections like the common cold unless there is a secondary bacterial infection.
C. Ear pulling may indicate ear discomfort or infection, but it is not a typical response to nasopharyngitis alone.
D. It is normal for young children to have multiple colds per year due to their developing immune systems.
A school-aged child develops a nosebleed (epistaxis). Which action should the nurse take?
Explanation
Rationale:
A. Turning the head to the side is not recommended, as it can cause blood to drain into the throat.
B. Applying pressure to the forehead does not help control nasal bleeding.
C. Sitting upright and applying pressure to the sides of the nose is the correct action to stop the bleeding and prevent blood from going down the throat.
D. Keeping the child flat can increase the risk of blood entering the airway, which can lead to aspiration.
A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant?
Explanation
Rationale:
A. Sitting on a nurse's lap leaning forward is a safe position for postural drainage as it promotes drainage from the upper lobes of the lungs.
B. The Trendelenburg position, where the body is laid flat on the back with the feet higher than the head, is contraindicated for infants with cystic fibrosis because it can increase the risk of gastroesophageal reflux and aspiration.
C. The supine position is generally safe but does not facilitate effective postural drainage compared to other positions.
D. Sitting on a nurse's lap leaning backward is safe and can be used for drainage from the anterior lung segments.
A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?
Explanation
Rationale:
A. A storybook may provide comfort and information but is less interactive in helping the child process the experience of injections.
B. Playing in the playroom is beneficial for normalizing hospital stays but does not directly address the child’s distress regarding injections.
C. A video game can be a good distraction but does not provide therapeutic engagement with the fear or anxiety related to injections.
D. Allowing the child to play with a needleless syringe and a doll is therapeutic as it gives the child a sense of control and understanding of the injection process, helping to reduce fear and anxiety.
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