RN Nursing Care of Children 2019 with NGN
Total Questions : 67
Showing 25 questions, Sign in for moreA nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?
Explanation
A.While an elevated cholesterol level is a concern in diabetes, it is not the priority in this case. The elevated HbA1c level indicates a more pressing issue that requires immediate attention.
B. The correct answer is B. HbA1c 11.5%. HbA1c is a measure of the average blood glucose level over the past 2 to 3 months. A high HbA1c indicates poor glycemic control and increased risk of complications from diabetes. The nurse's priority is to address the factors that are contributing to the high HbA1c and provide education and support to improve the adolescent's self-management.
C. Glycosuria, while important to monitor, is a common finding in uncontrolled diabetes.
It indicates elevated blood glucose levels and may require adjustments in the treatment plan. However, it is not as critical as addressing the elevated HbA1c level.
D. A preprandial blood glucose level of 124 mg/dL is within a reasonable range for an adolescent with diabetes. It is important to monitor blood glucose levels, but the elevated HbA1c level takes precedence in this situation.
A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?
Explanation
A. A child with impetigo has a contagious skin infection. It would not be appropriate to room them with a preschooler who has just had surgery, as this could increase the risk of post-operative infection.
B. Correct. A child with a fractured left femur does not have a contagious condition that would pose a risk to the preschooler following Wilms' tumor removal. This would be an appropriate roommate.
C. A child with viral pneumonia has a contagious respiratory infection. This could put the preschooler at risk of developing a respiratory infection, which could be especially dangerous after surgery.
D. A child with cellulitis of the right radius has a contagious skin infection. It would not be appropriate to room them with a preschooler who has just had surgery, as this could increase the risk of post-operative infection.
A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?
Explanation
A. Nightmares are common in children and may not be directly related to the brain tumor. While they should be addressed, they are not the priority in this case.
B. Hyperactivity can be a normal behavior in preschoolers. It may or may not be related to the brain tumor. Other symptoms should take precedence.
C. Pruritus (itching) is a common symptom that can have various causes, and it may not be directly related to the brain tumor. It should be addressed but is not the priority in this case.
D. Correct. Diplopia (double vision) can be a neurological symptom associated with increased
intracranial pressure or other complications related to a brain tumor. It is important to report this finding promptly to the provider for further evaluation and intervention.
A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?
Explanation
A. An upper respiratory infection 2 days ago is not a contraindication for the MMR vaccine. The vaccine can be administered once the child has recovered from the acute illness.
B. Correct. An allergy to neomycin, which is an antibiotic, is a contraindication for
receiving the MMR vaccine. Neomycin is present in trace amounts in the MMR vaccine, and individuals with a severe allergy to this antibiotic should not receive the vaccine.
C. A temperature of 37.2° C (99° F) is a low-grade fever and is not a contraindication for the MMR vaccine. Mild illness without fever is not a contraindication.
D. A family history of seizures is not a contraindication for the MMR vaccine. The vaccine can be safely administered to children with a family history of seizures.
A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?
Explanation
A. A respiratory rate of 28 breaths per minute indicates increased respiratory effort, which can be a sign of moderate dehydration. The infant may be trying to compensate for fluid
loss.
B. Capillary refill of 1 second is within the normal range (less than 2 seconds). It is not indicative of moderate dehydration.
C. Weight loss of 7% is a significant amount of weight loss and is indicative of severe dehydration, not moderate dehydration. Moderate dehydration is usually defined as 5- 10% weight loss.
D. Bradycardia (slow heart rate) is not typically associated with dehydration. In fact, tachycardia (fast heart rate) is a more common sign of dehydration.
A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.
History and Physical
A 15-year-old adolescent is admitted for a vaso-occlusive crisis. The parent reports that the adolescent has a low-grade fever and has vomited for 3 days. The adolescent reports having right-sided and low back pain. They also report hands and right knee are painful and swollen. The client reports pain as 8 on a scale of 0 to 10.
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
Explanation
A. Instruct the parent to ensure the pneumococcal vaccine is current.
This is a preventive measure to reduce the risk of infections in individuals with sickle cell disease.
B. Give oral hydroxyurea.
Hydroxyurea is used to decrease the frequency of pain episodes in sickle cell disease.
C. Monitor oxygen saturation continuously.
Continuous monitoring of oxygen saturation is important to detect any potential respiratory complications.
D. Place the client on strict bed rest.
Bed rest helps to reduce the metabolic demands on the body and promotes healing.
E. Restrict oral intake.
During a sickle cell crisis, it's generally not necessary to restrict oral intake unless there are specific indications to do so, such as severe abdominal pain or vomiting that prevents the child from tolerating oral feeds.
F. Apply cold compresses to the affected joints. Administer meperidine IV for pain.
Cold compresses may exacerbate vaso-occlusion, and meperidine is not the first-line choice for pain management in sickle cell crisis due to potential neurotoxicity.
G. Administer meperidine IV for pain.
Meperidine has a relatively short duration of action, which may necessitate frequent dosing. This can lead to more fluctuations in pain control.
H. Administer folic acid as prescribed.
Folic acid supplementation is often recommended for individuals with sickle cell disease to support red blood cell production.
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?
Explanation
A. Pinpoint pupils are a characteristic sign of opioid overdose, not inhalation of gasoline.
B. Correct. Ataxia (lack of coordination) can be a neurological symptom associated with inhalation of gasoline or other volatile substances. These substances can affect the central nervous system and lead to impaired coordination.
C. Hyperactive reflexes are not a typical finding associated with inhalation of gasoline.
This is more characteristic of conditions like hyperthyroidism or certain neurological disorders.
D. Hypothermia is not a typical finding associated with inhalation of gasoline. It is more likely to cause symptoms related to the central nervous system and respiratory system.
A nurse in the emergency department is preparing to discharge a 3-year- old child.
Nurses' Notes
The child's guardian states the child has been unable to sleep recently and has been very irritable. Guardian expresses concern about the child's atopic dermatitis worsening and the child
scratching excessively, which results in the areas bleeding. Guardian states the child has a history of allergic rhinitis.
Which of the following statements should the nurse plan to include in the discharge instructions for the child's guardian? (Select all that apply.)
No explanation
A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling. Which of the following reactions is an age-appropriate response to death?
Explanation
A. A preschool-age child is not expected to give a logical explanation for death. They may not fully understand the concept of death in the same way an older child or adult does.
B. Correct. It is common for preschool-age children to be curious about what happens to the body after death. This curiosity is an age-appropriate response to death.
C. A preschool-age child may not fully grasp the concept of death as permanent. They may have limited understanding of the irreversibility of death.
D. Feeling responsible for a sibling's death would be an inappropriate and potentially concerning response for a preschool-age child. It may indicate a need for further assessment and support.
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?
Explanation
A. Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) and may not require immediate reporting unless it is severe or associated with other concerning symptoms.
B. Correct. Tachypnea (rapid breathing) in an infant with RSV can be a sign of
respiratory distress and may require immediate intervention or further evaluation by the provider.
C. Pharyngitis (sore throat) is a possible symptom of RSV, but it may not be as immediately concerning as tachypnea.
D. Coughing is a common symptom of RSV and may not require immediate reporting unless it is severe or associated with other concerning symptoms.
A nurse is caring for an adolescent who has a major depressive disorder. Which of the following actions should the nurse take first?
Explanation
A. Administering an antidepressant is an important intervention for a client with major depressive disorder. However, before initiating any treatment, it is crucial to assess the client's risk for self-harm or suicidal ideation.
B. Assisting the client in completing activities of daily living (ADLs) is important for their overall well-being, but the most immediate concern for a client with major depressive disorder is to assess their safety and risk for self-harm.
C. Correct. Assessing the client's risk for self-harm or suicidal ideation is the first priority.
This information will help determine the level of intervention and support needed.
D. Encouraging the client to attend group therapy is a valuable intervention, but it is not the first priority. Safety concerns must be addressed before implementing other
therapeutic interventions.
A charge nurse is teaching a group of nurses about identifying child abuse. Which of the following findings should the nurse identify as a potential indicator of child abuse?
Explanation
A. A toddler's repeated refusal to let a nurse perform a routine medical assessment may indicate fear or discomfort around adults, which could be a potential indicator of child abuse or neglect.
B. A mother's hesitation to comfort her 6-month-old infant may be due to various reasons, such as cultural differences, lack of confidence, or personal preferences. It is not necessarily indicative of child abuse.
C. Bruises on a toddler's knees are a common finding in active children who are learning to walk and explore their environment. While bruises should always be assessed, they are not automatically indicative of child abuse.
D. An 8-month-old infant crying when a parent leaves the room is a normal separation anxiety response for an infant of this age and is not indicative of child abuse. This behavior is part of normal infant development.
A nurse is teaching a parent of a toddler about administering digoxin. Which of the following statements by the parent indicates an understanding of the teaching?
Explanation
A. This statement indicates understanding. Giving water after administering digoxin helps ensure that the medication is swallowed and reaches the stomach, which is important for proper absorption.
B. Giving digoxin with foods high in fiber is not a specific instruction for administering this medication. It is important to follow the healthcare provider's specific dosing
instructions.
C. If a child vomits after taking digoxin, the parent should not give another dose. They should wait until the next scheduled dose. Double dosing can lead to overdose.
D. Mixing digoxin with juice is not recommended, as it may affect the absorption of the medication. It is best to give digoxin with a small amount of water.
A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?
Explanation
A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.
B. A respiratory rate of 30 breaths per minute in a 3-month-old infant is higher than the expected range (typically 25-40 breaths per minute). This finding should be reported to the provider for further evaluation.
C. A heart rate of 68 beats per minute in an 18-month-old toddler is within the normal range (typically 70-110 beats per minute). It does not require immediate reporting to the provider.
D. A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.
A nurse is providing teaching to the guardians of an infant who requires a Pavlik harness.
Which of the following instructions should the nurse include?
Explanation
A. Applying baby powder under the harness straps may cause irritation and should be avoided.
B. Massaging lotion into the skin under the harness is not necessary and may lead to skin irritation or interfere with the harness's function.
C. Adjusting the harness straps daily is important to ensure a proper fit as the infant grows.
D. Placing the diaper under the straps of the harness helps to prevent irritation and allows for a more secure fit of the harness. It also helps to keep the diaper in place.
A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines.
Which of the following instructions should the nurse include in the teaching?
Explanation
A. Drinking milk on an empty stomach is not recommended for individuals with lactose intolerance, as it can lead to more pronounced symptoms.
B. Flavored yogurts may contain additional sugars or additives that can exacerbate
symptoms in individuals with lactose intolerance. It is generally recommended to choose plain, unsweetened yogurt.
C. This is a correct instruction. There are various nondairy sources of calcium, such as fortified soy milk, almond milk, leafy green vegetables, and certain types of fish (like salmon and sardines).
D. Tolerability of plain milk versus flavored milk can vary from person to person. Some individuals may find one easier to tolerate than the other, but it is not a universal rule for everyone with lactose intolerance.
A nurse is assessing a toddler who is 8 hr postoperative following a cardiac catheterization procedure. Which of the following findings should the nurse report to the provider?
Explanation
A. Bilateral cool extremities can indicate decreased peripheral perfusion, which may be a sign of a complication following a cardiac catheterization procedure. This finding should be reported to the provider.
B. A blood pressure of 102/58 mm Hg is within the normal range for a toddler. It does not require immediate reporting to the provider.
C. A serum glucose level of 90 mg/dL is within the normal range for a toddler. It does not require immediate reporting to the provider.
D. A weak pedal pulse distal to the site may be expected after a cardiac catheterization procedure, especially in the immediate postoperative period. However, it should still be monitored and documented, and any significant changes should be reported to the provider.
A nurse is teaching a group of parents about childhood immunizations. The nurse should identify that infants should receive the first dose of which of the following immunizations at 12 months of age?
Explanation
A. The first dose of the Hepatitis B vaccine is typically administered shortly after birth, not at 12 months of age.
B. Correct. The first dose of the Varicella (chickenpox) vaccine is recommended at 12 months of age.
C. The Human Papillomavirus (HPV) vaccine is not typically started until the preadolescent or adolescent years, typically around ages 11-12.
D. The first dose of the Inactivated Polio Virus (IPV) vaccine is usually given at 2 months of age, with additional doses at 4 months and 6-18 months.
A nurse is caring for a school-age child who is 1 hr postoperative following a tonsillectomy.
Which of the following actions should the nurse take? (Select all that apply.)
Explanation
A. Maintaining the child in a supine position is not recommended after a tonsillectomy.
The child should be positioned on their side to prevent aspiration.
B. Cranberry juice is acidic and may be irritating to the surgical site. Clear, non-acidic fluids are usually recommended after a tonsillectomy.
C. While coughing should be minimized to prevent irritation to the surgical site, the child should not be discouraged from coughing if needed to clear secretions.
D. Administering an analgesic on a scheduled basis is important for managing pain after a tonsillectomy. This helps to maintain a consistent level of pain control.
E. Observing the child for frequent swallowing is important, as it may indicate bleeding or discomfort. This is a key assessment after a tonsillectomy.
A nurse is caring for a school-age child who is experiencing a sickle cell crisis. Which of the following actions should the nurse take
Explanation
A. Applying warm compresses can help to improve blood flow and relieve pain in areas affected by a sickle cell crisis. This is a beneficial intervention.
B. Decreasing fluid intake is not recommended. Maintaining hydration is important in the management of sickle cell disease, as it helps to prevent dehydration and reduces the risk of sickling.
C. Furosemide is a diuretic and is not typically used in the treatment of a sickle cell crisis.
It is not an appropriate intervention in this situation.
D. Contact precautions are not necessary for a sickle cell crisis. This crisis is not a contagious condition. Standard precautions for infection control should be followed.
A nurse is assessing a toddler who has a history of lead poisoning. Which of the following actions should the nurse take?
Explanation
A. Toddlers with a history of lead poisoning are at risk for developmental delays.
Developmental testing can help identify any delays that may require intervention or support.
B. Lead absorption is not related to iron intake. However, a diet rich in iron can help reduce the absorption of lead.
C. Blood testing, not stool testing, is the primary method for assessing lead levels. Blood lead levels provide the most accurate information about lead exposure.
D. While lead poisoning can cause changes in skin color in severe cases, it is not the primary assessment for lead exposure. Blood lead levels and developmental testing are more indicative of lead poisoning.
A nurse is teaching the parent of a toddler who has phenylketonuria about meal planning.
Which of the following information should the nurse include in the teaching?
Explanation
A. Toddlers with phenylketonuria (PKU) need to limit their intake of phenylalanine, an amino acid found in protein. Therefore, the toddler's protein consumption should be carefully controlled and monitored.
B. Foods high in iron do not need to be specifically limited for a child with PKU. Iron-rich foods are important for overall health and should be included in the diet.
C. Aspartame contains phenylalanine and should be avoided by individuals with PKU. PKU is a metabolic disorder that impairs the body's ability to break down phenylalanine, so it is important to limit phenylalanine intake.
D. This is correct. Foods containing milk products should be avoided, as they are a source of phenylalanine and can contribute to an excessive intake of this amino acid in a child with PKU. Instead, specialized medical foods low in phenylalanine are recommended.
A nurse is planning care for an adolescent who has sickle cell anemia which of the following immunizations should the nurse include in the plan?
Explanation
A. Rotavirus vaccine is not typically indicated for adolescents. It is usually administered to infants.
B. Correct. Adolescents with sickle cell anemia are at increased risk for infections,
including those caused by Streptococcus pneumoniae. The pneumococcal conjugate vaccine (PCV) helps protect against certain types of pneumococcal bacteria.
C. The MMR vaccine provides immunity against measles, mumps, and rubella, but it is not specifically indicated for adolescents with sickle cell anemia. They should receive
this vaccine as recommended for their age group.
D. The RSV vaccine is primarily recommended for infants and young children at high risk for severe respiratory syncytial virus (RSV) infection. It is not typically indicated for adolescents with sickle cell anemia.
A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12-month-old infant. Which of the following actions should the nurse plan to take?
Explanation
A. In infants, the foot is a commonly used site for IV insertion due to the size of the veins and accessibility. However, it's important to ensure proper immobilization of the
extremity to prevent dislodgement.
B. A 24-gauge catheter may be too small for effective IV therapy in an infant. A larger gauge catheter is typically used for IV access in infants.
C. The IV site should be changed according to facility policy and based on assessment of the site. There is no specific guideline for changing the IV site every 3 days.
D. An opaque dressing is not typically used for IV insertion sites. A transparent dressing allows for continuous assessment of the site without removal.
A nurse is assessing an adolescent client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect?
Explanation
A. Unexplained weight gain is not a typical finding in Hodgkin's lymphoma. Weight loss is more commonly associated with this condition.
B. Night sweats are a common symptom of Hodgkin's lymphoma. They can be indicative of the body's response to the cancer.
C. Flushed skin is not typically associated with Hodgkin's lymphoma. Pallor or jaundice may be more commonly observed.
D. Decreased body temperature is not a typical finding in Hodgkin's lymphoma. Infection or fever may lead to an elevated body temperature.
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